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introduction the world population is aging steadily 1 for many years the prevailing ideal in public policy has been aging in place ie enabling older people to remain living independently in the place of their choice for as long as possible nevertheless transitions in housing commonly occur with aging for example moving to housing that provides a greater level of support due to declining mobility andor cognition the field of environmental gerontology has been garnering intense research interest in recent years focusing on the interactions between older people and their environment and how this relationship evolves with advancing age 2 a large body of research has focused on the features of the built environment that are important to aging elders 3 4 5 while numerous other works have investigated experiences of older adults aging in place or outofplace 6 7 8 9 10 11 however 2 of 10 most of these studies generally focused exclusively on either communitydwelling people or nursing home residents and investigated the relation with one particular aspect of their home or environment it remains unclear whether there is a common vision among older people regarding the arena in which their life plays out or their socalled life territory and what the features of the older persons life territory might be no studies to date have used a qualitative approach to explore the perceptions that older people have of their life territory investigating this idea could help to broaden our understanding of how older people see themselves fit into their environment and the meaning of place for older people both in the community and in supportive housing this in turn could guide public policy for elders with a view to enhancing the features of the environment that are determinant in the wellbeing and autonomy of older people in the context of skilled elder care delivery by multinational groups it is important to identify the common features that are important to older people regardless of their nationality so that these key aspects may be integrated into housing solutions for seniors against this background the objective of this study was to explore the relationship between the participants and their life territory in order to define a working definition of this concept which could then be used to orient policy decisions methods setting we performed a qualitative study in four european countries by means of individual semistructured interviews in each country an average of 14 interviews were conducted namely 7 in urban areas and 7 in rural areas participants and recruitment the 7 interviews in each urban or rural area were performed with 4 older people and the other was someone who had moved to that community from elsewhere 2 professionals from the korian nursing homes or people responsible for organizing activities and 1 representative of local institutions these representatives were from the local area but not necessarily exactly the same town or village where the nursing home was situated for the older people the sample was constituted to maximise heterogeneity by including participants of different age and sex different degrees of autonomy people living maritally and people living alone people who can drive and those who cannot different lengths of time living in the area the local nursing home resident was a person whose previous home was within 10 km of the nursing home the relocated resident was a person whose previous home was more than 30 km from the nursing home and who relocated to the nursing home for various reasons the profiles of participants and the interview guides were developed by the market research company ipsos france in collaboration with the korian foundation interviews and analysis social science researchers from ipsos trained the interview teams from the korian foundation to perform the interviews in each country and in the local language ipsos was responsible for project management in collaboration with the local korian team in each country the interview questions focused mainly on the local territory integration into the territory activities that contribute to the integration of seniors and projections for an ideal world the interview guide was adapted to each participant profile and the details of the interview guides are provided in the supplementary material the interview guide was not pilot tested informed consent was obtained from all participants the interviews from all four participating countries were recorded transcribed translated and centrally analysed by ipsos using thematic analysis 12 thematic analysis aims to identify and categorize themes common to the majority of participants in a crosssectional manner across all interviews each theme is then considered as a meaningful independent unit of discursive language the themes are classified into major themes and secondary themes the first level of analysis was performed individually by each researcher in the team then meetings were held to harmonize and decide on the major and secondary themes to be retained and their regrouping into subject categories the analysis was validated by 3 authors ss sg the final report was written by fe and ss and approved by all authors differences in interpretation were resolved by discussion and consensus results were not returned to the participants results in total 54 interviews were performed 25 in urban and 29 in rural areas representing a total of 10 nursing homes in the four participating european countries interviews lasted between 26 min and 1 h 10 min the details of the interview participants per country are given in table 1 five main themes emerged from the analysis of the interviews namely the working definition of your life territory the importance of the built environment interactions between nursing homes and the outside community a sense of integration and the use of new technologies each of these points is detailed hereafter a conceptual framework denoting the most salient relationships is shown in figure 1 illustrative quotes on each of the themes are provided in the supplementary material nursing home professionals 2 the working definition of your life territory the importance of the built environment interactions between nursing homes and the outside community a sense of integration and the use of new technologies each of these points is detailed hereafter a conceptual framework denoting the most salient relationships is shown in figure 1 illustrative quotes on each of the themes are provided in the supplementary material conceptual framework illustrating the interactions between the notions of home place the built environment integration interactions with the community and the use of technology the working definition of ones life territory the arena in which older people see their life being played out is a multidimensional concept that covers both individuallevel and collective aspects on an individual level the concept clearly includes the actual dwelling place and the notion of home as well as the level of personal autonomy and interactions with a social network of family and friends the home is more than just a set of four walls but the accumulation of a lifetimes worth of memories and possessions the level of personal mobility and support from friends and family enable the aging individual to remain in their home as long as possible at a more communitywide level the notion of the life territory includes features of the built environment such as accessibility amenities and public transport and more figure 1 conceptual framework illustrating the interactions between the notions of home place the built environment integration interactions with the community and the use of technology the working definition of ones life territory the arena in which older people see their life being played out is a multidimensional concept that covers both individuallevel and collective aspects on an individual level the concept clearly includes the actual dwelling place and the notion of home as well as the level of personal autonomy and interactions with a social network of family and friends the home is more than just a set of four walls but the accumulation of a lifetimes worth of memories and possessions the level of personal mobility and support from friends and family enable the aging individual to remain in their home as long as possible at a more communitywide level the notion of the life territory includes features of the built environment such as accessibility amenities and public transport and more generally public policy relating to older people including those living in nursing homes many participants expressed surprise at being asked to describe the arena in which their life is lived especially those living in nursing homes who felt that they had little control over it nursing home staff spontaneously described the life environment of their residents in terms of the nursing homes facilities and not as a part of a larger ecosystem within a community or region many people who are now reaching older age have seen great changes in society during their lifetime not least in their own locality their link with the local area is therefore the culmination of their lifes history years of experience and layer upon layer of personal memories it may also have a social dimension based on their profession and is contingent upon their level of mobility and autonomy there is also a strong cultural dimension to the relationship that older people have with their surrounding environment indeed they pursue preferred activities with likeminded people in their area generally groups who hold shared values in nursing homes that have close links with religious associations or groups the representatives or volunteers from these groups often have a leading role in the organisation of activities within the nursing home similarly religious services in the local church or within the nursing home are a strong point of contact with the community enabling residents to pursue their activities from before the move to the nursing home the importance of the surrounding built environment there was a consensus among all the interviewees in this study that towns and villages are not easy places for older people to navigate for both communitydwelling elders and nursing home residents the consensus was that getting about in the village or town can be akin to an obstacle course for people who have impaired mobility especially those in a wheelchair or people who use walking aids in terms of the built environment examples of problems cited include the pathways not being wide enough the presence of too many steps and stairs bollards that hamper the movement of wheelchairs no seats or benches for older people to take a rest no public toilets and a general lack of accessibility for public buildings participants also frequently cited a lack of public transport as an impediment to accessing services and amenities in the local area where transport exists it may not be accessible for people with reduced mobility nursing homes often depend on their own sources of transport to be able to transport the residents in some countries governmentled initiatives exist to provide transport for elders to have access to shops and cultural activities but those who might be eligible often are not aware that such services exist or fail to request access due to the administrative complexity certain amenities that are of particular importance to older people are often poorly accessible andor located outside of the town centre finally having easy access to shops and services is an essential determinant of the integration of older people in their local environment being able to do their own shopping and make their own choices of the products to buy is a seemingly banal activity that is nevertheless crucial for older people especially nursing home residents as a means to exercise autonomy and retain some degree of control over their life going shopping is not just an outing but it is also an opportunity for social interaction and a ritual for some older people who may make no other outings the proximity and accessibility of shops services and medical care is a source of concern for communitydwelling elders especially when they have to depend on someone else to take them there interactions between nursing homes and the outside community among the staff and residents of nursing homes who participated in this study there was a consensus that there is a compelling need to maintain interactions with the local community this point was felt to be essential in preserving the physical mental and cognitive health of the residents it was also felt to be an opportunity to debunk common myths about nursing homes being closed places that are isolated from the rest of society for the residents interactions with the community outside the nursing home represent an opportunity to break their routine and engage in new and fulfilling activities this interaction can take many forms the proximity of a town centre is helpful if there are cafés or shops that are easily accessible for the residents the presence of services within the nursing home give an impression of openness and accessibility conversely nursing homes that are located on the outskirts of urban areas or in rural areas regret the necessity to rely on transport to enable residents to access services and activities in the community nursing home staff all agreed that mobility is key to interactions with the community allowing residents to come and go as they please and having access to local shops and services is important in maintaining their sense of self their autonomy and their links to their previous lives especially for people who have lived in that community for many years conversely for residents with impaired mobility organising outings may be logistically more challenging due to lack of accessibility lack of staff to accompany outings or lack of funds outings such as picnics going to the seaside cinema or theatre or seasonal events such as christmas markets are important for residents as they make a change from the usual routine and help create and maintain social links some of the more autonomous residents even request the possibility to go on vacation nevertheless we observed a small minority of participants who were averse to outings feeling that it would be too tiring or too difficult some residents have no desire to go outside the nursing home either through lack of interest in the outing proposed or a lack of desire to participate in group activities there is clearly a delicate balance to be respected between accompanying and reassuring those who may have hesitations about the safety of an outing and respecting each individuals wish for a quiet life in view of the increasing numbers of nursing home residents with impaired mobility bringing the community into the nursing home may be a useful alternative when outings are not possible activities organised by outsiders who come into the nursing home are helpful and ideally should be open to the public from the local community and organised on a regular basis or on the occasion of local or religious festivals this provides an opportunity to create and maintain links with the outside community intergenerational activities were cited as an excellent initiative when the generations hit it off but were judged to be difficult to organise the feedback from the nursing home residents was not consensual about the success of having schoolchildren to visit for activities for example exchanges with other nursing homes seemed to be a more appreciated method of creating contacts as this allows residents to meet people who are in a similar situation to themselves finally the family is a major link to the local community both for communitydwellers and for nursing home residents many nursing home staff regretted that the residents families did not visit more often or that they were not more involved in the running of the nursing home a sense of integration the analysis of our interviews revealed that the level of integration within the community felt by older people is largely dependent on their network of social contacts and their seniority in the area we observed on the one hand people who are active in their communities and very well integrated either through associations or family connections this includes communitydwelling participants and nursing home residents who are in a nursing home in the same community where they previously lived and where they were thus able to pursue their social activities on the other hand we noted that communitydwelling elders are less well integrated if they are living in a dwelling place that was imposed on them similarly relocated nursing home residents have difficulty feeling integrated when they have no personal history or experience of the area or community especially if their family is not frequently present they have no memories and no connections in that place and may find themselves excluded from conversations that pertain to the locality the feeling of integration is also driven by feelings of utility and the sense of identity can be reinforced by the ability to do something useful for others this includes opportunities for older people to show others what they are capable of or to pursue activities that they engaged in prior to moving to a nursing home local elected officials praised the involvement of elders in driving cultural and associative activities in the community but their praise was exclusively for communitydwelling people nursing home residents were almost invisible in terms of integrating nursing homes into the local community it became clear from our interviews that there is wide disparity in the level of integration across the four participating countries in germany there is a particularly strong coordination between nursing homes and other public and private initiatives in the community whereas in the other countries coordination seemed to be largely dependent on individual initiatives integration also seemed to be facilitated when the nursing homes offered services for communitydwelling elders from the surrounding area in a minority of cases we observed a more compartmentalized vision of older people with activities exclusively targeted at communitydwellers and less concerned with nursing home residents there was also some evidence of rivalry between public and private nursing homes with an almost hostile climate in this context nursing homes in some areas may represent the blind spot of public policy regarding older people as if nursing home residents were no longer given the same level of consideration as their communitydwelling peers the use of new technologies many older people spontaneously cited digital technologies as a means of procuring a feeling of integration and involvement it makes it possible for them to maintain links with geographically distant family members via video calls such as skype many participants also mentioned that they used tablets and computers to buy things online especially when mobility is a problem and prevents them from going shopping many participants further stated that they used technological solutions to have access to culture such as music films television etc technology clearly provides an important opportunity for older people to maintain contacts with the community and a window into a wider world of culture consequently there was a consensus among all the participants that wifi access is important especially in nursing homes in this context training for nursing home residents who are less familiar with the use of computers and tablets was also felt to be lacking conversely attempts to introduce technology into some nursing homes were not universally successful with some participants reporting failed initiatives to train nursing home residents to use tablets for communitydwelling older people many processes inherent to living in the community now require a minimum level of proficiency in the use of the internet and this may be a disadvantage for those who are left behind in the digital divide discussion this study shows that five key features underpin the relationship between older people and the territory in which their life plays out first and foremost is the working definition of the life territory which is constructed at both individual and collective levels and tends to be delimited by the level of mobility the other features are the importance of the built environment interactions with the outside community a sense of integration and new technologies since lawton first proposed his ecological model of aging in the 1970s our knowledge of how aging people adapt to a changing environment and possible declines in functional capacity has been constantly evolving 6 the relationships between older people and their surroundings are infinitely complex and involve a range of factors related to aspects such as the person their history their family their socioeconomic and health status the environment and how it may have changed during their residence transitions in housing and relocations in older age are often unanticipated and may be precipitated by major life events such as an acute adverse health problem or the death of a spouse indeed stroke and hip fracture have been reported to be the two strongest predictors of housing relocation in later life 1314 for many people who have a stable background of many years of residence in the same place a move in later life may be a daunting experience and if moving to a more supportive environment may be an implicit admission of declining physical status 10 in this regard our findings are in line with the literature as we found that the participants have a definition of home and their life territory that goes beyond the physical space of the dwelling to encompass their family neighbours neighbourhood and wider community however our findings revealed that most people generally do not consciously think about the concept of their life territory although they implicitly recognize the extent of the geographical and social bubble in which their life plays out features of the built environment such as transport pathways access to shops and amenities were reported in our study to be important to older people as they largely determine the opportunities to avail of these services interactions with the environment are increasingly important for older people as they spend more and more time in their own home through retirement or for health reasons 15 agency or the capacity of older adults to make choices about important aspects of their lives is strongly impacted by the ability to access and avail of local services and maintain social connections indeed lack of access to public transport has been reported to contribute to social isolation among older people 16 in our study it became evident that relocated people may lose their sense of belonging and identity with their surrounding environment if they are unable to recreate memories and suffuse the new dwelling with the meaning and memories that contribute to the sense of home this appeared to be particularly difficult for people who were relocated against their will in line with the concept of stuckinplace where place can have negative connotations for those who feel trapped in an undesirable environment 9 as reported by some nursing home residents in our study relocated people may feel left out or devoid of a sense of belonging due to their lack of local knowledge history in the place attachment or connections this concept of integration was a major theme in the discourse of our study participants beyond integration at the personal level the participants in our study also emphasized the importance of integration at a collective level namely by maintaining links with the community this corroborates a previous report from a survey of longstay facilities in ireland in which murphy et al reported that connectedness to family and to the community was particularly important for the residents whereby strong links with the local community enhanced the residents feeling of connectedness 17 similarly wiles et al found in their study of the 121 older people aged 56 to 92 years in new zealand that attachment and connectedness operate at social and community levels and are not related solely to the place of residence 11 this means that older people can feel involved and connected regardless of whether they live in the community or in a nursing home in our study we found that there were differences across countries on this point with participants from some countries having a stronger tradition of religious or cultural feasts that provide opportunities to mingle with the community the interviewees in this study indicated that technologies such as tablets connected devices internet etc enhance autonomy agency communication and access to a range of services including cultural activities and online shopping in the current pandemic context where social contacts are limited for older people and may even be banned altogether for nursing home residents this means of communication with family and friends is essential in maintaining social links it also represents a means for older people to access services for those with reduced mobility or in areas where sanitary restrictions preclude inperson presence however our study participants did underline that not all elders are as enthusiastic or as competent in the use of new technologies congruent with the principle of the digital divide previously described in the literature 1819 perhaps the increasingly techsavvy generations now moving towards middleand older age will make greater use of technology as they age as a means to enhance their quality of life and autonomy study limitations this study has some limitations the representativeness may be suboptimal as only four european countries were included and a small number of participants in each country extrapolation of our data may not be possible to other countries or cultures where healthcare retirement systems and housing options for older people may be considerably different the diversity of participants included in the study was designed to enrich the discourse and provide insights from various viewpoints but we cannot exclude the possibility that important stakeholders may have been omitted furthermore there are additional limitations associated with the method and type of interviews however every effort was made to minimize this bias first several different researchers conducted the interviews second the researchers were trained in advance third we used a standardized interview guide with central analysis and interpretation and external triangulation of the analysis although the findings identify important themes the analytical method applied precludes interpretation and theorizing conclusions this qualitative study found that the life territory of older people from the four participating european countries is a multidimensional concept comprising five main themes namely a working definition of the arena in which life is played out the built environment interactions with the community integration and technology closer relations between nursing homes and local authorities are crucial to integrating the nursing home and its residents into the fibre of the community this is ultimately beneficial for those dwelling in the community as well as for the residents for older people who transition from the community to nursing homes preserving their social links and activities is important in maintaining their sense of place and wellbeing relocated people in the community or in nursing homes may be at risk of social isolation if they are unable to establish the social links necessary to create a sense of belonging in the new community all these aspects deserve to be taken into account by policy makers when shaping communities and developing housing and construction policies the following supporting information can be downloaded at breakdown of the constitution of the study sample from the four european countries interview guides and table s1 illustrative quotes for each of the five main themes to emerge from the analysis data availability statement all the data produced in this study is contained in the manuscript conflicts of interest sg and al are employees of the korian foundation the authors declare no other conflict of interest the funders had no role in the design of the study in the collection analyses or interpretation of data in the writing of the manuscript or in the decision to publish the results

the meaning of place and home for community dwellers and nursing home residents remains unclear we explored the relationship between older people and their life territory to propose a working definition of this concept which could be used to orient policy decisions individual semistructured interviews were performed with older people nursing home staff and representatives of local institutionselected officials in four european countries france belgium germany italy interviews were transcribed and analysed using thematic analysis in total 54 interviews were performed five main themes emerged i working definition of your life territory a multidimensional concept covering individual and collective aspects ii importance of the built environment eg public transport sidewalks benches access ramps iii interactions between nursing homes and the outside community specifically the need to maintain interactions with the local community iv a sense of integration dependent on social contacts seniority in the area perceived selfutility and v the use of new technologies to promote integration social contacts and access to culture this study found that the life territory of older people is a multidimensional concept centred around five main domains which together contribute to integrating older people into the fibre of their community

introduction w ith the increasing pandemic of obesity around the world developing countries also face this health burden in 2002 about 195 million chinese adults were estimated to be obese 1 the percentage of overweight in china has increased by 50 over the past decade 2 rapid socioeconomic demographic and nutritional transitions promoting unhealthy lifestyles and behavioral changes may drive the weight gain in this developing population 3 4 5 walking or cycling as a form of active transportation is inversely associated with obesity and may therefore have the potential to improve public health 6 10 in developed countries like the us canada sweden and australia motorized transportation has been established as a dominant sedentary travel pattern for many decades several studies have confırmed that driving a car is associated with obesity in developed countries 11 12 13 14 in china the rapid urbanization evokes equally rapid shifts toward a more sedentary lifestyle with transitions away from an agricultural economy and towards the acquisition of new technology 1516 for example active transportation covered up to 80 of daily travel in china until the 1990s but that situation declined dramatically thereafter 1718 the number of urban households possessing a private car increased about 19fold from 1996 to 2006 19 in 2022 chinas vehicle population might reach 419 million 20 such a rapid increase is likely to reduce the need for active transport and contribute to the development of greater prevalence of obesity in addition socioeconomic factors may play an important role in the development of obesity people who have high ses or live in urbanized areas may be the fırst to have access to energydense foods to have a decline in workrelated physical activity and to have access to motorized transportation in a developing country 1521 based on the fındings from the limited work done in china previously it is hypothesized that the use of motorized transportation is independently associated with changes in body weight and waist circumference this effect will be more pronounced in those with a high income or who live in urban regions and the use of motorized transportation is independently associated with the current obesity prevalence this was studied in chinese adults who participated in the longitudinal china health and nutrition survey methods data collection the data of the present study were prospectively collected in the survey years 1997 2000 2004 and 2006 in 1997 a total of 6418 participants of those aged 18 55 years without pregnancy or physical disability were included in total 5240 participants completed at least one questionnaire in 2000 2004 or 2006 of the 5240 participants available for followup 3853 completed every questionnaire during followup had no missing information on occupational physical activity ses or anthropometric measures and remained in the fınal analysis assessment of variables motorized transportation the possession of motorized vehicles was defıned as possessing motorcycles tractors or cars at the household level assessed by using questionnaires participants from the same household were assumed to have equal ownership of motorized vehicles participants were categorized as follows those who possessed motorized vehicles from 1997 until 2000 were defıned as having used motorized transportation for 3 years those with vehicles from 2000 to 2004 as having used motorized transportation for 4 years and those with vehicles from 2004 to 2006 as having used motorized transportation for 2 years based on these time frames and registration in each survey year the total duration of possessing motorized vehicles was calculated and categorized as nonmotorized motorized 15 years and motorized ͼ5 years physical activity occupational physical activity was categorized as light moderate or heavy the total weekly energy expenditure during work was calculated by multiplying time spent and met task scores as 20 40 and 60 mets per hour respectively for light moderate and heavy occupational physical activity 17 genderspecifıed tertiles of occupational physical activity were defıned only a limited percentage of participants attended leisuretime physical activity leisuretime physical activity was defıned as participating or not participating in such activities living region socioeconomic status and education urban or rural living region was used as a dichotomous variable to distinguish regional differences such as economic development infrastructure and social environment for ses individual net income included the sum of all sources of income and was divided into genderspecifıc quantiles income was categorized by the median education was categorized as primary education or less low middle school education upper middle technical school education and collegeuniversity education lifestyle smoking was defıned as have never smoked is an exsmoker smokes ͻ10 cigarettesday and smokes ն10 cigarettesday alcohol consumption was defıned as never drinking beerany other alcoholic beverage past year drinking less than two timesweek and more than three timesweek because of the low prevalence of smoking and drinking among women these two variables were not adjusted for statistical analysis in women dietary intake was collected by nutritionists using 24hour recalls over 3 consecutive days with the start day randomly allocated from monday to sunday and daily total energy and fat intake were calculated region was assessed at the time of inclusion in the study to obtain the best estimate of longterm habitual dietary intake occupational physical activity and income the cumulative average of the variable was taken for education smoking and alcohol drinking the most recent information was assessed adiposity obesity was defıned as bmi ն25 based on the suggested standard for the chinese population 23 according to the same guideline abdominal adiposity was defıned as waist circumference ն90 cm for men and wc ն80 cm for women changes in body weight and wc were calculated as the average difference of weight in kilograms measured at baseline and each available measure during followup statistical analyses men and women were presented separately because of the differences in lifestyle and socioeconomic factors multivariate linear regression was used to assess the linear associations between motorized transportation ses indicators and changes in weight and wc or current bmi and wc to assess whether interaction was present the likelihood ratio test was used to compare the signifıcant differences of the regression models with and without the interaction term multivariate logistical regression was used to assess the or for adiposity in association with motorized transportation of the 5240 participants in followup motorized transportation status ses andor anthropometric measures were not available for 265 of participants as an additional sensitivity test the analyses were repeated by using the complete data with multiple imputations for the data that were missing in these participants the missing data were predicted based on a regression model that included baseline and endpoint bmiwc baseline and endpoint motorization followup time education income occupational physical activity age and energy and fat intake missing values were imputed and 10 complete data sets were analyzed separately and the results were pooled into single estimated beta coeffıcients signifıcance of all analyses and adjusted or was based on twosided 95 ci an alpha level of 005 for all statistical tests was used statistics were performed using stata version 110 results table 1 shows the characteristics of 3853 participants about 46 participants were not in the nonmotorized transportation category during the ϳ78 years followup 27 possessed motorized vehicles for 15 years and 27 possessed vehicles for ͼ5 years those who possessed motorized vehicles for ͼ5 years had a higher wc at baseline and showed the highest prevalence of obesity at the end of followup men tended to have a twofold higher weight gain than the nonmotorized transportation group motorized transportation was also related to socioeconomic factors such as education income and rural residency motorized transportation for ͼ5 years was independently related to larger weight gain 2 heavy occupational physical activity was associated with a smaller increase in weight and wc in men compared with light activity high income and high education were associated with increased weight gain in men in women the associations were less pronounced although being motorized for a longer period showed a tendency toward more weight gain but not wc gain education and income were more strongly related to weight change in particular high education was protective against waist gain in women because the possession of motorized vehicles could be a proxy of ses or urbanicity the association between motorized transportation and obesity may vary with region and income motorized transportation had an impact on weight gain in men living in rural regions but not in urban regions however no effect modifıcation by living region was found between region and motorized transportation for weight and waist gain from the likelihood ratio test motorized transportation had an impact on weight and wc gain in men having high income but not low income no effect modifıcation by income was found between income and motorized transportation for weight or waist gain the association of motorized transportation with the current obesity status at 2006 is presented in table 3 the or of obesity was 130 and 193 for the motorized transportation ͼ5 years group in men and women the association of ses and region with the current obesity status was presented in appendix b income and education tended to modify the association between motorized transportation and current bmi in women with the impact of motorized transportation being stronger in women having low income or education as an additional sensitivity test to assess whether the results were influenced by the missing values 265 of 5240 participants with missing values were imputed and performed all analyses in the ten complete data sets separately and results were pooled into single estimated beta coeffıcients compared with the presented results the imputed results did not change appreciably and did not influence the conclusions wc waist circumference discussion a longer period of having motorized transportation was independently related to a larger gain in weight and wc in chinese men after 78 years followup when compared with those who never owned motorized vehicles the gain in weight and wc was slightly more pronounced in men with a higher income or from rural areas but the difference compared with low income or urban areas was not signifıcant in women using motorized transportation was only related to weight gain and not wc gain but the tendency was less pronounced than in men a longer period of having motorized transportation in the past was also independently associated with a higher or of current adiposity in men and women the present study can be compared with a previous study by bell et al 24 they suggested that the possession of motorized vehicles was associated with an increase in obesity and weight gain in chinese men based on chns data from 1989 to 1997 however few people acquired motorized vehicles between 1989 and 1993 and less than 13 of the participants had motorized vehicles before 1997 24 because of the possible time lag between the dependence on motorized vehicles and the onset of obesity the authors at that time might not have been able to fully conclude that motorized transportation independently contributed to an increased obesity rate the present analysis covers a rapidly changing period from 1997 until 2006 and the duration of using motorized transportation may give better prospective information than vehicle ownership defıned as a dichotomous variable another difference is that wc was additionally measured at the onset of the present study and it appears to be very important in assessing obesityrelated metabolic risks in the chinese population 25 it was found that chinese men had independently gained more weight and wc than those who never possessed vehicles during the followup and were more likely to be obese in 2006 such an association suggests that having used motorized transportation for a longer period contributes to obesity these associations were adjusted for income and education and motorized transportation as a proxy for socioeconomic wealth had only marginal effects on the strength of the association however the adjustments were not equal to controlling for wealth and some degree of residual confounding cannot be excluded with regard to women the association between motorized transportation and weight gain was less pronounced and it is diffıcult to draw a fırm conclusion a possible explanation is that men were more likely to be the predominant users of motorized vehicles in chinese households 24 the potential influence of regional differences was investigated assuming that urban residents may be the fırst to experience changes leading to modernized lifestyles the early access to motorized transportation and a high obesity rate in the present study rural residents tended note results are adjusted for baseline weight height age and wc followup time total energy and fat intake occupational physical activity education and living region for men additional adjustments were made for smoking and alcohol consumption wc waist circumference to gain somewhat more weight and wc than urban residents but the differences were not pronounced further living in rural regions had a slightly stronger impact on the association between motorized transportation and weight change although the fındings do not support the signifıcant modifıcation of this association by living region one of the possible explanations is that the regional variation was diminished by continuous development in some rural regions therefore rural residents also might have experienced increased income and use of motorized transportation and a larger increase in obesity than urban residents in the past decades 226 28 however misclassifıcation of the urbanrural dichotomous variable which might not reflect the full variation in health given the heterogeneity emerging in these areas because of the degree of urbanicity 27 cannot be completely ruled out social inequality in adiposity differs between men and women which may be explained by the current stage of development a high ses as proxied by high income and education was positively associated with adiposity in men however high education was inversely and strongly associated with adiposity in women which is in line with previous fındings in women from rapidly developing countries 28 32 income effects were absent in women this pattern was consistent with fındings from brazilian women especially with those from more economically developed parts 31 further use of motorized transportation tended to be associated more positively with only current bmi in women with low ses in the present study in the early stage of economic development as the level of urbanization increases the burden of obesity might shift from those with high ses toward those with low ses fırst among women from developing countries 263233 it is important to realize that social inequality in adiposity is in transition because of the levels of development and urbanization 2830 strengths and limitations the major strengths of the current study include the use of prospective chns data from 1997 until 2006 covering a time frame in china during which large changes occurred it has provided insight into the association between use of motorized transportation and ses with adiposity the present study also has potential limitations the period during which motorized transportation was used might have been misclassifıed because of the household possession of motorized vehicles and the true impact of motorized transportation use on adiposity was likely attenuated a wellinformed prospective study is needed to further investigate the extent to which reduced energy expenditure due to motorized transportation contributes to changes in body composition although the present results suggest a relationship between motorized transportation use and larger weightwaist circumference gain the results do not show causality for instance people may choose transportation patterns because of other unmeasured factors such as socioeconomic wealth or the accessibility to modern infrastructure third domestic physical activity was not assessed which was presumably important for daily energy expenditure in chinese women although a recent study performed in the same population did not fınd that reduced domestic physical activity resulted in higher body weight in women 16 finally it has been found that changes in dietary patterns were strongly associated with adiposity in the chinese population 2634 although dietary intake was adjusted for the present models residual confounding cannot be excluded conclusion motorized transportation was related to the increase in adiposity in this chinese population in an average 78year followup particularly for men it did not vary considerably with income or living region for women education was a more important determinant for weight gain than motorized transportation however the continuous socioeconomic transition may alter and differentiate the social inequality in adiposity of men and women and influence the types of physical activity participation in china 41735 assuming that the sustained development affects all chinese inhabitants a small increase in active transportation may have the potential to prevent obesity in this population 43637 an active lifestyle should be promoted for all combined by increased active transportation patterns and leisuretime physical activity to achieve the best health benefıts appendix supplementary data supplementary data associated with this article can be found in the online version at did you know you can listen to podcasts featuring kenny goldberg health reporter for npr radio in san diego as he interviews select ajpm authors go to collection to download the podcasts

background increased dependence on motorized transportation may contribute to obesity countries in rapid socioeconomic transitions such as china provide an opportunity to investigate such an association

introduction damaging events are classified according to natural and human causes however they have to reach certain human effects thresholds such as death injury and economic loss before they are identified as disasters the world has experienced dramatic environmental and socioeconomic changes in recent decades associated with these changes as noted by yodmani is an exponential increase in human and material losses from disaster events activated by such phenomena as population growth rapid urbanization processes increasing poverty environmental degradation and climate change affecting the social and economic development in many parts of the world the rise in disasters and its impact are functions of the vulnerability of people all over the world induced by humans determined path and justified quest for development it is important to note that increase in vulnerability is not uniform and always natural it is as a result of an entire range of constantly changing physical social economic political cultural and even psychological factors especially in urban settings that shape peoples lives and create the environments in which they live for this reason disaster can be seen as judgement on what humans have wrought the four elements that shape cities in the world are water air land and fire destructive as it may fire has been a fundamental force in determining the form of cities and the way buildings are arranged within the cities for instance todays modem city building codes and zoning ordinances contain regulations to prevent fire and control its spread however in lagos incidences of fire have hardly contributed to the citys improvement and or to adherence to building codes to prevent the outbreak or minimize fire disaster impact in nigeria institutional response to fire disaster dated back to 190 when the fire brigade was established its functions were beyond firefighting to include saving of lives property and provision of humanitarian services during emergencies the response to fire outbreak outside the daytoday public awareness on preventive measure through the mass media is usually the rationale for the establishment of fire service stations by law all the 774 local govemmentareas in nigeria are expected to establish at least a fire station over the years response to fire disaster in nigeria has been unanticipated unplanned and often poorly coordinated while response could be as calamitous as the disaster by compounding the impact of disaster on persons affected residential fire is a very common disaster that causes many casualties in the united states of america fire departments responded to 412500 home fires which claimed the lives of 25 80 people and injured another 12925 not including fire fighters also at least 80 per cent of all fire deaths occur in homes and result from human error such as leaving cooking stoves candles or fireplaces unattended smoking carelessly or not taking proper care of electrical appliances the second leading cause of residential fires and the major cause of fire in commercial properties is arson the third leading cause of home fires is a faulty heating system this paper is structured into six sections the introduction is followed by the fire development and disaster risk reduction section section three discusses the methodology follow by the presentation of findings part five of the paper is the discussion section while section six concludes the paper fire development and disaster risk reduction fire has been a source of comfort and catastrophe for human fire is a rapid selfsustaining oxidation process accompanied by the evolution of heat and light in varying intensities fire outbreak is triggered by three elements namely fuel heat and oxidizer the knowledge of the basic fire behaviour provides the foundation for understanding fire development in a compartment fire spread throughout a structure and in most cases fire development involves diffusion flames pyrolysis products released from heated solid fuel mix with air at the point of combustion sometimes this takes place at a considerable distance from the solid fuel when fuel and air mix prior to combustion ignition of the fuelair mixture can release a tremendous amount of energy one familiar way of representing the key components of combustion is using the fire triangle as shown in figure 1 fire outbreaks and residential neighbourhoods vulnerability in lagos nigeria combustion requires fuel and oxygen in the correct proportion as well as sufficient heat energy to start the reaction heat is the energy necessary to increase the temperature of the fuel to a point where sufficient vapours are given off for ignition to occur however most of the time this process is considerably more complex for instance in a typical building fire the wide variety offuels and limited ventilation produce a complex toxic and flammable mixture of solid gas and vapour through oxidation reaction the triangle illustrates the three elements a fire needs to ignite heat fuel and an oxidizing agent a fire naturally occurs when the elements are present and combined in the right mixture fire can be prevented or extinguished by removing anyone of the elements in the fire triangle for example covering a fire with a fire blanket removes the oxygen part of the triangle and can extinguish a fire although fire triangle consists of fuel heat and oxygen other materials can have a significant impact on how a fire develops noncombustible materials absorb heat energy and slow the process of ignition and combustion a simple demonstration of this concept is to take two sheets of newspaper and spray one with a fine mist of water and then try and ignite each sheet the moist sheet will be difficult if not impossible to bum due to the need for the match to heat up the water in the moist paper materials that absorb heat but do not participate actively in the combustion reaction are referred to as thermal ballast while this concept is important in understanding fire development it is also central to the effectiveness of fire control tactics used to prevent or reduce the probability of rapid fire progress 2010 air provides adequate oxygen to continue fire development during this initial phase of fire development radiant heat warms adjacent fuel and continues the process of pyrolysis a plume of hot gases and flame rises from the fire and mixes with the cooler air within the room this transfer of energy begins to increase the overall temperature as with adequate oxygen additional fuel will become involved and the heat release rate from the fire will increase a fire will enter the decay stage as the available fuel is consumed or due to limited oxygen hence remove anyone of the three elements and the fire will cease to bum weaken anyone and the fire will weaken increase anyone or more of the elements and the fire will increase in intensity armed with this knowledge the fire fighter can do more to manage a fire oxygen fire the dynamics of housing development has radically transformed the context content and concept of building industry and housing development developing countries are amongst the most vulnerable to the impacts of natural hazards there is significant impact of disasters on core development sectors such as housing energy health infrastructure education and environment where disasters strongly affect development patterns and processes through loss of lives damage to physical 260 ibadan journal of the social sciences natural and environmental assets losses in human and financial wealth erosion of social capital and governance systems nevertheless disaster risk reduction measures continue to be inadequately integrated into and poorly implemented within the framework of development policies and strategies atvarious levels the consequence is that every disaster occurrence results in enormous set back on economic growth poverty reduction progress towards achievement of the millennium development goals and overall sustainable development disaster risk reduction and management are essentially developmental issues because they consist of policies programmes and actions that must be taken either to mitigate or reduce the effects of disasters they also relate to existing legal and political institutions that are put in place for these tasks for instance disaster risk management must take into considerations issues such as exposure resilience capacity and ability to cope as well as vulnerability however measures of these variables vary with levels of development and the development process itself disaster risk reduction seeks to preempt a disaster and also to put in place following a disaster a rehabilitation process that rebuilds resilience to future disasters consequently disaster risk reduction focuses on policies and practices that minimize disaster losses by addressing interventions in three broad areas of hazard minimization reducing exposure and susceptibility and enhancing coping and adaptive capacity however as noted by ojo the capacity to anticipate cope with resist and recover from hazard impacts depends on social economic political psychological environmental and physical assets and the wider governance regimes and is closely related to adaptation methodology the study adopted the survey research design household questionnaire was administered to different groups of people who differ in the variable of interests but with common characteristics such as socioeconomic status educational background occupation and income status f or the purpose of this research nine local government areas namely mushin surulere lagos mainland shomolu oshodi iso10 alimosho ajeromiifelodun ikorodu and kosofe accounting for about 25 ofland cover in lagos state were selected based on population figures the lgas were structured into incomedensity neighbourhoods as follows low incomehigh density medium incomemedium density and high income low density neighbourhoods the number of existing housing stock in lagos disaggregated according to streets roads neighbourhoods and lgas was collected from the lagos state bureau of statistics the number of buildings in the selected lgas was 315305 the study adopted 05 from the existing housing stock as a representative sample of the target population for questionnaire administration presentation of findings the findings from the study are presented under three sub headings socioeconomic characteristics of the respondents the respondents perceptions on fire vulnerability and lagos state fire service recorded fire outbreaks from 2008 2015 socioeconomic characteristics the socio demographic profile of the respondents as represented in table 1 shows that density measured in terms of number of houses per square kilometre 545 of the respondents were living in high density area 357 resided in medium density area while 98 occupied low density area additionally 461 of the respondents have been living in the study areas for up 30 years and above long enough to provide reliable information relevant to the study important attributes of the socioeconomic characteristics of the respondents considered are age gender mari tal status educational qualification fire outbreaks and residential neighbourhoods vulnerability in lagos nigeria occupation and income classifications the age classifications show over forty one percent were within 41 50 years age bracket while 594 were males the marital status of the respondents indicated that 878 were married the inference of the age classifications and the marital status is that majority of those sampled were the heads of the family this further gave credence to the quality and reliability of the data obtained from the respondents sixty three per cent of the respondents had obtained postsecondary school education 221 had primary adult education 102 obtained secondary school certificates while 39 of those interviewed had no formal education employmentoccupation structure to a larger extent should be a function of education level attained however from the people interviewed 383 of the respondents were engaged in business trading 361 were professionals in different fields of human endeavours onetenth were publiccivil servants 41 were retirees 48 were farmers 34 were unemployed 08 were artisans the remaining were engaged in other activities ranging from informal activities to semiformal occupations in terms of income of the respondents majority of the respondents earned less than n80ooo per month while only 79 earned above n80ooomonthly in terms of frequency of fire outbreaks over about fifty per cent of the respondents had witnessed two occurrences per year 426 witnessed one occurrence per year while only 85 had witnessed more than two occurrences per year in the case of vulnerability attributes of the respondents to fire outbreak only 135 of the respondents agreed that their houses were vulnerable to fire outbreak while 865 of them did not agree the respondents perception that their homes were not vulnerability to fire outbreak may have influenced their decisions not to install fire extinguishers only 171 of the respondents had installed fire extinguishers in their homes in terms of proximity to fire service stations most of the respondents houses were located between 0 2km away from fire service stations however in terms of response time to fire incidence 938 affirmed that the response ratetime was slow while 20 of the respondents were indifferent to the response time according to them the response time was not an issue but what was done after the arrival of the fire service was more important than speed of arrival at the fire scene in terms of spatial distribution of fire outbreaks in the years under review high density neighbourhoods accounted for 531 of the incidence the medium density neighbourhoods accounted for 344 while the low density neighbourhood only recorded 125 of incidence of fire outbreak on the average in the past eight years 36 persons have died 12 persons injured 82 buildings and 33 vehicles were burnt from fire related incidences between 2008 and 2015 source derived from table 3 analysis of variation was adopted in analysing the variation of fire outbreaks across residential neighbourhoods using data presented in table 4 results of the investigations are presented in tables 6 and8 from the tables the calculated f for fire outbreak across residential neighbourhoods and from 2008 2015 were 4747 and 2090 respectively this indicates that there is significant variation in fire outbreaks between residential neighbourhoods significant at p d 005 however there is no significant variation in fire outbreaks over the years with f value not significant at p d 005 but there is difference in mean of fire outbreaks as shown in figure 2 discussion fire disaster has emerged as one of the most common disasters in lagos resulting in loss of lives and property the major cause of fire outbreak is due to human neglect this neglect can be traced to the clustering of human activities within the urban environment the costs of fires are difficult to quantify in monetary terms because they involve psychological emotional and environmental processes and services that are not traded in the marketplace vulnerability to fire disaster is a function of several factors which include socioeconomic indices housing characteristics and availability of infrastructural facilities and services the densification of urban low income residential neighbourhood especially by increasing population and cyclical poverty as noted by agbola further aggravated the existing vulnerability components ofthe low income high density urban settlements this is because the urban poor are affected by the double vulnerability fire outbreaks and residential neighbourhoods vulnerability in lagos nigeria namely disaster and poverty therefore they are disproportionately impacted in terms of exposure to risks and in terms of the limited resources at their disposal to respond to such risks the education profile of the respondents presupposed that the majority of them should be living in low density neighbourhoods as against the housing density observed also the income accruing to the respondents monthly could hardly meet the daily needs of the majority of the respondents bearing in mind the high cost of living in lagos this could have an adverse bearing on the disposable capital and overall standard ofliving of the respondents while capacity to cope with fire disasters would be compromised leading to increasing poverty and vulnerability to disasters especially in the low incomehigh density neighbourhoods this assertion was corroborated by available data on the number of fire outbreaks indicating the variation of fire outbreak across residential neighbourhoods the result oftheanova shows that f value of 4747 is significant for fire outbreak at p d 005 level due to human suffering and the associated impact on the environment as a result of fire disaster it is important for nations to learn lessons after every major fire incident in order to promulgate fire related laws and regulations strengthening decision making disaster response and management strategies however in nigeria despite the availability of laws and codes to ensure that human settlements are protected against fire outbreak little has been done in enforcing the codes it is also disheartening gleaning from the interviews with the officials of the lagos state fire service and the lagos state emergency management agency that the statutory agencies saddled with the responsibility to manage fire disasters have numerous challenges ranging from inadequate personnel poor capacity development and deficient equipment to lack of action plans to control and manage fire incidents effectively these challenges hampered the response rate and effectiveness of fire service in lagos state to respond to fire calls in nigeria according to the national emergency management agency the average response time to fire emergency ranges between 1 4 hours this is due to the chaotic nature of the nigerian roads and inaccessibility of most of the high densitylow income settlements where significant percentage of fire outbreak occurred however from the interview conducted with the lagos state fire services the agency claimed that most of the responses to fire outbreaks in the state were more of rescue call than actual call to putoff fire outbreak thus fire services are called when fire outbreak had overwhelmed the capacity of the local volunteers to control it by that time the impact of the fire would have escalated beyond the ability of fire services this outcome underscores the need for public enlightenment to educate the citizenry to engage the fire service when the smallest ember of fire is discovered the existing firefighters structures in lagos has clear desire to move forward and be proactive as stated by laws however the minimum requirements in terms of personnel and equipment to carry out their tasks are inadequate therefore they are not able to respond to fire emergencies the situation is compounded by the lack of adequate training of the fire fighters and the deficiencies in the training field there is currently no training programme for fire fighters in nigeria therefore the standard operational procedures and other instructional materials required to educate fire fighters in prevention and preparedness are insufficient beyond the training shortcomings the inventory of the existing equipment to fire fighters indicated that they do not have enough specialized equipment as breathing apparatus bunker gear and other rescue materials for example the highest aerial ladder in lagos and by extension nigeria can only be used to respond to fire not more than 3storey high buildings thus when there is fire outbreak in any of the high rise buildings in lagos they are at risk of total conflagration concluding remarks nigeria is known for their firebrigade approach to issues unfortunately the fire service has not bought into the approach as indicated by its poor response to fire disasters in lagos state for it to function the states fire services need general overhauling reengineering and repackaging to win the confidence of the public to which they are responsible however the strategies to manage disaster risk and vulnerability must begin by identifying the hazards and areas in the community that are particularly vulnerable uncoordinated planning in lagos brought about chaotic growth and the generation of irregular proliferation of informal settlement in recent decades urban communities have adopted more regulatory rather than structural approaches to disaster mitigation hence there is also need to review the 1992 and 1999 as amended urban and regional planning law to reflect the prevailing circumstances in nigeria innovative urban planning for rapidly expanding cities has shown the need for flexibility in applying planning regulations but also there is a greater need to apply planning guidance quickly as cities grow however as necessary as legislative reform is on its own term it is not a sufficient tool for increasing functionality equity and participation legislation can set standards and boundaries for action for example by defining development control building codes or training requirements and basic responsibilities for key actors in disaster management the strategies to be adopted should describe ways in which inclusive decisionmaking could be encouraged to integrate the knowledge and views of all stakeholders in development and disaster management the federal and state government should support the process another proactive disaster management strategy is insurance for instance in the developed world insurance is an important losssharing strategy to cushion the adverse effects of disaster a property or business insurance arises when a risk is perceived and the owner pays a fee usually on an annual basis to buy a contract that transfers the risk to a financial partner the insurer guarantees to meet specified costs in the event of damage through disaster to the property by this means the policy holder is able to spread the cost of a potentially unaffordable disaster over many years insurance mechanism is still weak in the developing country especially in nigeria where poverty and other socioeconomic disadvantage indices prevent the individual from taking insurance policy and the insurer is not predisposed to encourage individuals to insure their property due largely to premium default however globally property insurance against fire disaster has been adopted as one of the viable options in disaster management also most of the vehicles owners have fire extinguishers in their vehicles to fight fire outbreak the same cannot be said of individual house owners and or renters the vehicles are more valuable than the homes where the bulk of individuals investments were housed it is on this premise that the legal framework for the enforcement of at least one fire extinguisher per household should be promulgated and enforced in addition to this before new site and service schemes will be approved there should be provision for water main attached with water hydrants to make water available for fire service in addition to this before building plan are approved there should be provision for fire alarm water sprinkler and fire hydrant for proactive efficient and effective fire outbreak management strategy as part of global best practice in fire prevention and response the capacity of fire disaster management agencies should be developed and equipment required should be provided to enhance the effectiveness of the agencies in responding to fire outbreaks in lagos state

residential fire is a common disaster that impact human environment negatively it has been documented that response to fire disaster in lagos state and by extension nigeria has been unanticipated unplanned and often poorly coordinated most time response could be as calamitous as the disaster compounding the impact of fire outbreaks on affected persons irrespective of what causes fire disaster and where it occurs its consequences are often influenced by environmental political and socioeconomic disposition of human the paper adopts qualitative and quantitative approaches in eliciting required information while focusing on the recorded residential fire outbreaks in lagos from 2008 2015 this paper argues that vulnerability to fire disaster varies across residential neighbourhoods and from 2008 2015 in lagos in order to minimize the economic impact loss of lives property livelihoods and reversals in development gains associated with fire disasters the paper recommends the strengthening of the capacity of the disaster management agencies in lagos disaster education implementation of one building at least one fire extinguisher policy losssharing and mainstreaming of disaster risk reduction into developmental strategies and programmes

peoples trust is a key component for population compliance it directly impacts peoples risk perception social cohesion and behavioural changes and has been recognised as foundational in determining a countrys mortality and morbidity trajectory 5 6 7 countries which were the most successful in curbing covid19 infections were not those with the best health care systems or experts but rather those with high levels of national and community trust 8 trust can take several forms ranging from an individuals trust in national governments and officials to ones interpersonal trust in their surrounding community a 177country study investigating pandemic preparedness found significantly lower standardised infection rates with higher government and interpersonal trust 8 while associative rather than causative this finding suggests that increasing trust and compliance may reduce the global infection burden although some factors are largely immutable leaders and media influence levels of trust however it has been argued that the increasing politicization of public health is undermining trust in health care systems across the globe 9 this has led to persistent inequalities of access and outcomes 8 fuelled by a widespread infodemic 10 resulting in trust being asserted as a key determinant of health 9 political orientation and its relationship to trust have been found to significantly impact covid19 prevention behaviours 11 12 13 the ideologies underlying political identities may affect a persons belief in their national governments and institutions particularly if they disagree with the current party in office 11 a study conducted in italy found that the degree of compliance to social distancing orders was higher in provinces with greater political support for current legislation in provinces with high opposition support individuals mostly did not adhere to social distancing orders 11 understanding how factors such as political alignment may impact an individuals trust is vital in the development of policy aimed at enhancing compliance for recommended guidelines and health mandates the who identified the infodemic referring to the rapid spread of both accurate and inaccurate information in the age of the internet and social media as a key challenge in responding to covid19 and other disease outbreaks 14 misinformation and disinformation can provide simple yet erroneous explanations to help make frightening situations more comprehensible 15 there are many examples where misinformation and disinformation campaigns and conspiracy theories have minimised the threat of the virus itself and negatively impacted the overall health of a society and its social cohesion resulting in lives lost 1617 understanding and managing the infodemic is thus a matter of public health importance and investigating how trust is shaped is key to understanding information sources using an eightcountry crosssectional study design which recruited representative samples of adults we aimed to investigate peoples level of trust and how it was affected by their political orientation and information sources our primary goals were to epidemiologically describe levels of trust in health government and news media organisations and experts and measure the impact of participants political orientation and covid19 information sources on their levels of trust methods study design we conducted a stratified randomised online crosssectional study in seven countries england switzerland belgium philippines new zealand and one territory simultaneously between 6 and 18 november 2020 as hong kong is a special administrative region of china and enjoys governing and economic autonomy we referred to it as a country rather than a territory the timing of this study coincided with the beginning of the second covid19 wave 1 when the disease was still potentially severe restrictive measures were reimplemented no vaccines were available rising in pandemic fatigue was observed 18 and when the divisive presidential election were ongoing in the usa 1 in scientists doctors and health experts 2 in national health organisations 3 in global health organisations 4 in government 5 in politicians 6 in news organisations response options for each used a 10point scale ranging from 1 to 10 levels of trust primary explanatory measures we asked participants about their political orientation via the question when it comes to politics people talk about left and right where would you place yourself on a scale where 0 stands for far left and 6 for far right due to the political sensitivities in hong kong preceding instrument development 20 we did not question hong kong participants on their political orientation regarding information sources the participants were asked to what extent do you use the following sources to inform yourself about the coronavirus we devised 11 possible responses 1 the federal government each question had additional response options which ranged from 1 to 4 we collapsed questions into four domains health government news media and social media we calculated summed response scores for each domain and standardised them by dividing by the number of contributing variables we dichotomised these rescaled scores into higher and lower categories with this 25 threshold representing the midpoint on the fourpoint response option scale falling between often and sometimes sociodemographic and potentially confounding variables a detailed account of the sociodemographic variables is presented elsewhere 21 in brief participants could identify their gender as male female another gender identity and i dont knowi prefer not to answer due to the few genderdiverse respondents and those answering i dont knowi prefer not to answer we set these genders to missing to allow for meaningful statistical analysis we categorised age groups as 1824 2534 3544 4554 5564 6574 and ≥75 years of age we categorised usual household composition as living alone with spousepartner only with spousepartner and child other family and other nonfamily arrangements we asked participants if they were an essential worker with response options being yes no and i dont knowi prefer not to answer those who responded affirmatively were asked in which essential sector they usually worked participants who worked in health care and social services were further partitioned from the other essential workers the perceived threat that covid19 posed to self and country were separately assessed on a fivepoint scale with response options being very low low moderate high and very high we also queried the participants on financial losses linked to covid19 up to the time of the survey with response options being none insignificant significant very significant and i dont knowprefer not to answer finally we examined stress by asking the question thinking about the level of stress in your life would you say that most of your days are with response options being not stressful at all not very stressful a bit stressful rather stressful and extremely stressful procedure a detailed description of the procedure is available elsewhere 2122 country selection was governed by practical considerations including ensuring global continent and covid19 burden and response diversity within a constrained budget and timeframe together with having countryspecific lead investigators to provide linguistically and culturally appropriate insight and context the core team came together from preexisting professional connections including the who thematic platform for health emergency and disaster risk management research network due to time urgency and funding constraints this core team purposely approached and invited potential research leads in identified countries 2122 once finalised the international research team and partners then developed the survey instrument checking and confirming its language and content suitability for each participating country and making it available in english french german italian and chinese languages prior to the full eight country study the instrument was successfully piloted within canada 21 two polling firms in collaboration with international partners then undertook random participant recruitment and data collection using an online platform the sampling frame included online and offline sources encompassing where available publicly available records to ensure recruitment and representation of hardtoreach subpopulations quota sampling was employed and tailored for each country based on the latest available population census it comprised of age gender and region stratifications after contact eligibility confirmation and informed consent participants completed the survey which took approximately 20 minutes we set a minimum sample size of 1000 adults for each participating country except for canada which we set at 2000 this was to obtain a largely balanced sample sizes for each country thereby maximising statistical power for intercountry comparisons to gain reasonable intracountry power and to maximise country inclusion and diversity within a constrained budget and timeframe statistical analysis we used the strengthening the reporting of observational studies in epidemiology guidelines in reporting this study 23 we assigned survey sampling weights to participant data calibrated to match population census distributions correcting for any unequal representation due to quotas not being fully achieved we conducted all analyses using stata se version 170 accommodated survey sampling weights and employed robust variance estimators we considered a twotailed α 005 as denoting significance we initially described and compared participant numbers and sociodemographic characteristics by countries using pearson designbased ftest we assessed correlation between primary variables using weighted pearson pairwise correlation coefficients next we conducted crude and adjusted complete case regression analyses relating participants political orientation and information source level to their trust in health authorities governmentpoliticians rather than employing bivariable analyses to screen sociodemographic and potential confounding factors as suggested by sun et al 24 we included all variables in the adjusted model regardless of their significance we reported means and associated 95 confidence intervals and used walds type iii χ 2 statistic to determine the significance of variables within the regression models results participants and their characteristics we included 9027 adults with a mean age of 47 years 170 years with the oldest participant being 99 years 4667 were female 4318 male 28 neither female nor male and 14 preferred not to answer the question regarding household composition 2680 participants lived with their spousepartner and 2069 resided with their spousepartner and child the majority were nonessential workers although 800 participants reported being essential workers in health while we found no difference in sex between countries we observed a statistically significant difference in age usual household composition and essential worker distributions reflecting cultural differences participants from the philippines had a younger average age and were more likely to live with extended family and hong kong participants were more likely to be nonhealth essential workers 165 usa united states of america nz new zealand sd standard deviation †28 participants declared a gender identity that was neither female nor male and a further 14 participants preferred not to answer the question these 42 participants had their gender set to missing ‡includes those living with grandparent sibling child without partner and those living with family and nonfamily members §includes 61 participants who responded that they did not know or preferred not to answer 234 participants were unsure or declined to answer and their values were set to missing trust regarding the six individual questions we observed higher levels of trust towards all groups except for politicians however a proportion of participants reported very low levels of trust for each domain trust in health experts ranked highest overall and in each of the eight countries while trust in politicians ranked the lowest overall and in each country trust in national health organisations ranked second and trust in global health organisations ranked third we observed significant differences in the mean level of trust between countries for each of the six separate variables for instance although ranked lowest in both countries trust in politicians for new zealand participants was higher than in the usa except for between government and news organisations political orientation with hong kong participants excluded we obtained valid responses on political orientation from 8026 participants with 281 declaring as far left 553 as far right and 3427 as moderate information sources for the combined information sources domain scores complete nonmissing responses ranged from 920 for the derived social media variable to 960 for health overall participants sourced information to a higher degree from health government news media and social media sources participant correlations between these information sources was modest ranging from r 020 to r 039 crude analyses although trust was measured by six variables the correlation between some variables was strong trust in health authorities or experts had correlations ranging between 071081 similarly trust in governmentpoliticians had a correlation of 083 to reduce interdependence and test multiplicity we derived and adopted three primary measures trust in health authorities which combined responses to questions 13 trust in governmentpoliticians which combined responses to questions 45 and trust in news organisations which was given by question 6 for these regression analyses initially we considered conducting a principal component analysis to create the combined scores but the first components for each were almost linear combinations of the apposite variables so we opted to simply sum the response scores as the number of component variables were different for each derived primary trust variable we rescaled these summed scored to lie on the original 10point scale thereby enabling direct comparisons and facilitating interpretation in the six separate regression analyses of political orientation and information sources against the three composite trust variables moderate political orientation and higher information source levels were taken as reference categories participants oriented towards the left had a higher trust in health authorities and to a lesser extent in the news media than their right leaning counterparts while those oriented towards the right had a relatively higher trust in government and politicians additionally participants using higher levels of health information sources had the highest trust in health authorities while those using higher levels of government information sources and higher levels of new media information sources had the highest trust in governmentpoliticians and news media respectively however there cis derived from crude linear regression analyses and adjusted linear regression analyses relating participants political orientation and information source level to their trust in health authorities governmentpoliticians and the news media a positive mean difference indicates a higher level of trust compared to the reference group whereas a negative mean difference indicates a relatively lower level of trust ci confidence interval info information source was little difference in trust in health government or news media by those using higher or lower levels of social media information sources nonetheless all these reported associations were significant table 3 table 4 and tables s2 ands3 in the online supplementary document adjusted analyses while we observed some confounding in the adjusted regression analyses the patterns described for the crude analyses remain largely unaltered all the reported associations were significant apart from social media information source level related to trust in news media and social media information source level related to trust in health authorities discussion trust in health experts ranked highest across all eight participating countries while conversely trust in politicians ranked lowest unlike the ranking for health experts there was considerable heterogeneity in the mean scores for trust in politicians between countries at the extremes trust in politicians was the lowest in the usa and the highest in new zealands to10 at the beginning of the pandemic usa and new zealand had very different approaches to health messaging from their respective leaders with new zealands prime minister at that time globally heralded for her leadership in the nations covid19 response 25 messaging was swift informed and cohesive with the information provided by the nations ministry of health by comparison the usa president released conflicting information to his chief medical advisor creating confusion and distrust to medical advice and poor agenda management 25 notably as of 3 may 2023 usas total covid19 attributable death rate per 100 000 was estimated at 33959 approximately 60 times higher than new zealands rate of 5674 1 another known element in the trust of governments and politicians is peoples perceptions of corruption and nontransparency 26 the corruption perceptions index measures corruption within the public sectors globally for 2020 the time of this study usa and the philippines ranked the lowest among the eight participating countries while new zealand and switzerland ranked highest 26 the heterogeneity in the mean scores for trust in politicians between countries seen in this study may reflect these cpi differences hong kongs cpi was ranked third from the eight countries yet we observed a notable distrust in politicians this may reflect lingering illfeelings arising from the 2019 protests concerning the one countrytwo systems model under which hong kong and beijing currently operate and a growing unease of the pervasiveness of china as a second government in hong kong affairs 20 despite these political differences and events eroding political trust its impact on hong kong peoples trust in health experts appeared largely unaffected the mean values for trust in health experts and authorities for usa and hong kong participants was only slightly below the allcountry mean and was highest among philippines participants thus entrusting and empowering health authorities and experts to provide coordinated accurate health messaging information and recommendations is likely a fundamental strategy in ensuring the highest likelihood of population compliance 8925 coordination is also key as political trust is instrumental for compliance with health measures 5 2728 individuals political orientation and political alignment is also an important indicator for compliance with public health measures 1112 we found that leftoriented individuals tended to have higher trust in both health authorities and news media whereas those who were rightoriented had more trust in government and politicians differing political ideologies have been shown to affect the perceived impact of covid19 prevention behaviours 12 generally people with conservative ideologies emphasise on personal responsibility and selfautonomy by comparison those with liberal ideologies prioritise the collective and the interdependence between different groups political ideology has transformed the public response to health mandates something as simple as choosing to wear or not wear a mask could become a symbolic expression of political support 27 having such divisive and politicised public responses to health mandates can undermine the positive effect of timely collective action on slowing the rate of infection and protecting the most vulnerable members of the community importantly our findings must be contextualised as most of the eight countries studied here held rightwing offices at the time of the study partisan alignment and government approval are strongly linked an individuals alignment with party in office is a predictor of governmental approval 28 and may in turn allow for the implementation of impactful health policies to address domestic concerns for example vaccine mandates and lockdown procedures 5 future research should investigate the interaction between federal regional and individual political orientations and their alignment or misalignment and how this might affect an individuals trust confidence and sense of coherence the covid19 infodemic has highlighted the effect of misinformation disinformation andor conflicting information on causing confusion and risktaking behaviours that can harm health it also leads to mistrust in health authorities and undermines the public health response 17 our analyses demonstrated that in almost all instances the use of lower levels of information sources had a significant association with reduced trust discourse on disinformation and conspiracy theories preys on peoples fears and vulnerability during a period of uncertainty and provides simple yet often false explanations regarding complex and fraught situations 16 many of the emerging narratives regarding covid19 have health messaging that conflicts with that given by health experts such as alternative cures for covid19 and debunking the efficacy of vaccines and maskuse 29 as collective action is key to pandemic response misleading information campaigns threaten the health and wellbeing of society the relatively small effect size difference in trust between higher and lower social media user groups observed here likely points to a lack of nuance many users engaged in social media for many different purposes and may be unfamiliar with much of the malevolent content in retrospect a better question might have focused on the nature and source of the social media content rather than simply the frequency of use this study has several strengths such as its relatively large sample size and the timeliness and global spread of participant recruitment across eight countries in four continents however it also has important limitations first the survey was conducted during the covid19 pandemic and thus lacks baseline or prepandemic data which also may distort the presented associations and findings replication postpandemic would serve to understand the stability or otherwise of these relationships moreover unmeasurable nonsampling bias is also an important limitation while participant selection was stratified and randomised the sampling frame included online and offline sources which are less transparent than traditional methodologies and likely reduce the coverage for some subpopulations however we used targeted quota sampling and survey weights to mitigate these issues and ensure approximately representative samples another important limitation pertains to the primary variables themselves including the elicited level of trust while having good face validity and being informed by guidelines 19 and previous studies these variables have no published psychometric properties and may suffer from responder bias and they may have suboptimal test content validity and reliability further work investigating the variable psychometrics is vital additionally instrument translation and validation processes associated with the instruments were undertaken within the research team there were numerous pragmatic considerations and concessions made in designing attracting funding securing ethics and implementing this international study within a relatively short time frame 2122 one internal requirement was that at least one national lead for each included country was deemed necessary to ensure cultural and contextual guidance and appropriateness leads were also responsible for ensuring the instrument translations were linguistically sound however limited backtranslating and validation processes were undertaken so some countryspecific differences may have been the results of language subtleties another potential weakness is the crosssectional rather than longitudinal study design which negates any causal assertions here the directional and bidirectional nature of the trust relationships between the public experts and organisations cannot be distinguished the political responses and health policies to the pandemic evolve swiftly over a short period of time and peoples feelings regarding the pandemic similarly change therefore our findings are representative of populations in the relatively early stages of the pandemic and may differ if this study was repeated later finally unmeasured confounders are another source of potential error and may affect the presented comparative analyses between countries such confounders can lead to substantial bias in the estimated exposureoutcome estimates particularly if they are uncorrelated with the considered explanatory variables 31 study replication using different suites of variables is needed to understand their effect conclusions trust is a key determinant of health it is central to the successful implementation and uptake of public health measures although it shifts easily and significantly impacts society it has received relatively little public health research attention this study empirically highlights the universally high levels of public trust placed in health experts and authorities across eight countries we recommend that governments and policymaker coordinate their response with health experts and authorities thereby maximising the likely population health impact covid19 is not the first and certainly will not be the last global health crisis ethics statement the research ethics board of the centre intégré universataire de santé et de service sociaux de lestrie centre hospitalier universitaire de sherbooke approved the study electronic informed consent was obtained from all participants after reading the study information only those who actively agreed and consented to participate progressed to the online survey participants were able to withdraw at any time without penalty or need for explanation the research datasets contained no personally identifiable information the study complied with the ethical standards for human experimentation as established by the helsinki declaration and conformed to all the rebs relevant guidelines and regulations data availability the datasets used for statistical analysis are held by mg at the faculté de médecine et des sciences de la santé université de sherbrooke sherbrooke canada application to use these data must be made to mg through the corresponding author authorship contributions pjs is the guarantor mg el and pjs were involved in the research program conceptualisation design and implementation mg led the ethics application and obtained the funding aps and pjs conceived and led this study pjs analyzed the data aps and pjs led the drafting of the manuscript all authors contributed to manuscript revisions prior to submission and during revisions all authors have read and agreed to the published version of the manuscript disclosure of interest the authors completed the icmje disclosure of interest form and disclose no relevant interests additional material

in the covid19 pandemic who did we trust an eightcountry crosssectional studythe online version of this article contains supplementary material

introduction this paper is an exploration of the relevance of habermass social theory for understanding meaning making online it describes some of the key ideas within habermass work noting the central importance it gives to the idea of communicative action the paper then describes the importance habermas has had for educationalists and for those promoting a more discursive approach to joint meaning making in both formal and informal contexts finally the implications of a habermasian approach are explained highlighting value and difficulties the paper draws on a range of literature within both formal and informal learning contexts most of this literature concerns text based communication often but not always in asynchronous contexts background to habermas habermas is much celebrated as a social theorist though his interdisciplinary commitment and range of interests means that his work defies easy categorisation his intellectual roots lie in critical theory and as such habermas is concerned with contrasting social and political realities with missed opportunities for democratic emancipatory action as with critical theory in general habermas is a critic of positivism and a taken for granted scientism in which problems are addressed with purely technical solutions however his work is often contrasted to other critical theorists due to its underlying optimism about human development and in particular about the possibilities that language provides for communicative discourse habermass concern for discourse is closely tied to his early exploration of the concept of the public sphere for habermas this was a realm of our social life in which something approaching public opinion can be formed access is guaranteed to all citizens a portion of the public sphere comes into being in every conversation in which private individuals assemble to form a public body habermas saw the material basis for a public sphere in the emergence of a literate bourgeoisie in 18th century europe of particular significance was the rise of a free press and in spite of the restrictions and outright manipulation faced by the media he has continued to acknowledge and value the existence of a public sphere one which allows open debate including the expression of counter cultural voices distinct from public opinion habermas has contributed significantly to academic and public debate and his later work has covered a very broad range of topics including german history european integration and multiculturalism however of most concern to education theorists has been his concept of communicative action and his notion of an ideal speech community habermas shared with interpretivist social theory a rejection of the idea that what we know and validate as knowledge represents a correspondence to an objective reality rather he drew on the pragmatist tradition in particular the work of pierce to see knowledge as emerging through intersubjective agreements on social problems however he departed from neopragmatists such as rorty by raising the possibility that valid claims to knowledge could be reached it is a risky move to associate truth or validity with agreement and habermas was cautious however he held out the belief that at least in principle consensus could lead to truth or rather something we should recognise as true this was a position that habermas contrasted with post modernism for post modernism tended to throw doubt upon the possibility of reaching rationally derived consensus central to habermass work was communicative action this was not straightforward as a concept and was refined over time but at heart was the idea that i call interactions communicative when the participants coordinate their plans of action consensually with the agreement reached at any point being evaluated in terms of the intersubjective recognition of validity claims… those claims are claims to truth claims to rightness and claims to truthfulness depending on whether the speaker refers to something in the objective world to something in the shared social world or to something in his own subjective world here for habermas there was the possibility of establishing truth through rational consensus albeit establishing different kinds of truth would require the marshaling of different types of evidence habermas spent much time and intellectual effort in considering the different purposes for using language for example drawing a distinction between illocutionary and other acts and describing their consequences for communication but he also recognised that there were claims to truth or rightness which needed to go beyond textual analysis for example claims to truthfulness needed to be consistent with behavior a person can convince someone that he means what he says through his actions not by giving reasons habermas throughout his work wanted to identify communicative action as a special kind of discourse in which there was no other force than that of the better argument and no other motive other than the cooperative search for truth communicative action with its emancipatory potential could be contrasted with strategic action in which interaction was manipulated by the threat of sanctions or the prospect of gratification to gain an advantage over another individual or group this cooperative search for truth or what might be more easily described as a search for genuine consensus needed to take place in a kind of ideal speech situation in which those with competence were allowed to speak no one was constrained in speaking all were allowed to question the grounds for any assertion and new assertions could be put forward the ideal speech situation belonged in the weberian tradition of ideal types an abstraction to throw light on the key features of a case not all speech endlessly recreated the conditions for ideal speech indeed these conditions were improbable rather for communication to take place it was assumed that we could revisit ideal speech conditions and we could distinguish between a genuine and false consensus habermass view of communicative action was process oriented he had much less to say as to what we would reach consensus about and it could be assumed that we would find it difficult to reach consensus on many issues however striving for consensus remained central to habermas as it offered a way of marrying individual subjectivity and individual rights with a universalist moral ethic based on mutual recognition the search for consensus required an active attempt to see the world through the eyes of the other and to recognise ways in which ones own understanding of a situation may be distorted by ones own subjectivity and the social roles one was expected to play indeed habermas drawing in particular on kohlbergs work on child development associated maturity both in individuals and societies with the exercise of reflexivity a commitment to moral and individual freedom and recognition of the rights of others thus while continuing to recognise intellectual freedom as a legacy of the enlightenment his concern with mutual recognition led him to criticise classical liberalism for reducing ethical liberty to a possessiveindividualist reading of subjective rights misunderstood in instrumentalist terms the strength of habermass work lies in its attempt to address tensions inherent in complex democratic societies such as how can we be concerned both with consensus and with recognising countercultural voices how can we think about knowledge both as socially constructed and valid how can we have a social theory that is both sociological and raises questions of ethics and morality only his most uncritical supporters would say that he holds all the answers but he has consistently and imaginatively addressed the right questions using a range of sources from classical philosophy marxist theory and empirical sociology what has habermas got to do with education the implications of habermass work for education are not explicit indeed the implications for the conduct of social investigation in general are much more at the level of underlying assumptions about epistemology and ontology rather than frameworks for action however habermas has by virtue of the range and depth of writing stimulated thinking about educational practice both directly and indirectly he is best known to practitionerresearchers through carr and kemmiss attempt to define the concept of critical action research and to adult educators via mezirows concept of transformative learning habermass work is referenced too in the context of online learning indeed his theory of communicative action seems to fit very well with the idea of a discursive approach to learning for which communication technology offers valuable affordances add to the mix habermass focus on discourse and his appreciation of a democratic public sphere and it is not difficult to see why many online innovations particularly civic networks claim to be grounded on habermasian foundations however habermass influence is not confined to open forums and his work was an early point of reference in more formal settings for example boyd linked computermediated conferencing in higher education with habermass notion of practical discourse in which the only determinants of the outcome of the discussion are the solidity of facts and the logicality and comprehensiveness of the arguments boshier identified possibilities for a kind of ideal speech situation through electronic networks and rheingold took his enthusiasm for informal networking into the classroom and wanted new electronic networks to serve as a rehearsal for the open rational critical debate proposed by habermas and others cecezkecmanovic webb saw online collaborative learning as requiring a habermasian ideal speech situation offering equal access by all participants to the learning process equal opportunity and unrestricted contributions to collaborative learning at least from a technical point of view wegerif was rather more tentative and while he put forward the idea that cmc might be a suitable medium for establishing what habermas calls an ideal speech situation he was sceptical that this would happen in practice more optimistically mcconnell felt that aspects of online group work were aligned with habermass knowledgeconstitutive interests while it is not difficult to find enthusiasm for habermas amongst those proposing forms of online discussion habermas himself has not written in any depth on this topic and what he has written about the internet is at best lukewarm more specifically he recognised the opportunity which technology offered to circumvent controls in undemocratic regimes but expressed concerns over the fragmented nature of online networks he also attached importance to facetoface discussion when discussing modern mass media and indeed for habermas the public sphere was constituted by facetoface discussion of texts not the texts themselves limited as these contributions have been they imply some scepticism in regard to the emancipatory potential of online interaction based it would seem on a perception that technology might limit a genuinely public discussion hence the purpose of this paper is to ask what if anything can we really learn from habermas which might be important or relevant in understanding the educational potential of online interaction the value of a habermasian perspective on joint meaning making online in answering the above question our argument is that a habermasian perspective offers a way of thinking about joint meaning making online by providing a rationale for consensus a distinction between strategic and emancipatory purposes and a questioning of technoromantic thinking each is considered below habermas firstly provides an ontological rationale for consensus and an epistemology for assessing the validity of a claim to knowledge learners need to construct their own understandings as there are no guarantees concerning the validity or transferability of preexisting knowledge on the other hand something other than a purely subjective perspective is needed for there has to be a rigorous and ethical process for discriminating between different arguments courses of action and this requires the kind of rational critical discourse captured by communicative action as bamber and crowther put it this in the context of f2f professional learning it is through communicative discourse that learners construct ever more dependable in the sense of justifiable and tested normative structures on which action can be based habermas is placed between post modernism which he accused of performative contradiction by employing concepts that only modern reason can provide only to undermine these very concepts and an outdated positivism which claimed that there was an objective truth of course habermass position is far from unusual in regard to social theory or investigation of online spaces indeed it is often argued by those promoting online interaction that it is through the effort of explaining and defending positions that new knowledge can be generated furthermore central to many conceptions of online knowledge building is the idea of searching for consensus as seen for example in problem based learning virtual mathematics teams the generation of just in time knowledge and of joint artefacts models of community of inquiry the practice of peer assessment etc less ambitiously collaboration and sharing of perspectives are also seen as providing opportunities for individual learning in the context of community participation a habermasian perspective on consensus however brings a distinctive perspective on joint meaning making as it recalibrates how we think about knowledge building and the kind of evidence that we can provide to show that knowledge building has taken place for habermas communicative action was concerned with the coordination of activity and to the extent that it was reflexive and critical communication could be considered communicative and to serve emancipatory purposes searching for consensus was important but only if claims to knowledge were intensely interrogated for example in recognition of habermass interest in language suppose a proposal were put forward to make english a common second language to be taught in all schools either globally or more realistically within a particular geographical political region on the grounds that this would facilitate cross national communication following habermass discussion of communicative action this proposal might be considered in terms of its objectivity sincerity and rightness as the proposal is debated similar questions will be asked of other propositions and special focus given to the process by which any consensus was achieved for example did some participants defer to those with superior class or social positions was the evidence available to everyone were all able to contribute and so on in practice of course there are restrictions on all discussions subjective understandings will not disappear and indeed an important point to bear in mind is that insincerity in habermas encompassed more than a deliberate attempt to mislead it took in our own distorted understanding of our intentions nonetheless through a commitment to communicative action participants may move from subjectively held positions towards a reflexive understanding of their own position and in the process generate more reliable knowledge this argument for sustained debate is not of course ignored in the field of educational technology but the research can often seem to be dominated by instrumental concerns the fit of technologysupported collaboration with twenty first century skills and a search for technological affordances problematic too has been an over reliance on analysing meaning making through content analysis of messages as picked up for example in wee looi this interest in content analysis was triggered by henris as dunn lantolf argued this in the context of academic discourse when interpretations diverged the task was not to engage in strategic or teleological discourse to convince an interlocutor to see things ones own way or to gain an advantage for ones own interests but nothing less than active and intense dialogic engagement with these different discourses and world views key to a genuine consensus is an ideal speech situation habermass concept can be and has been criticised for being idealised but unlike major works of critical theory habermas is not easily dismissed as utopian antitechnology in intent or in spite of his grounding in historical materialism narrowly class based ideal speech was at least for habermas something that could be experienced by all in part and in principle was understood by all those who commit to communication however it was offered as a counterfactual and as such its purpose was to consider the gap between is with ought how can this critical perspective be applied to joint meaning making online perhaps the key insight it offers is that learning through online interaction is not and cannot be in itself learning by participation in a community of practice instead learning is rather a particular form of participation in which we give reasons and make explicit claims to validity in full knowledge that we may have got it wrong that our positions are distorting our understanding and that others will in good faith see things differently a critical approach is important as so many of the contexts in which online interaction is presented are benign for example the formal learning environments cited earlier but also informal communities for support groups interest groups and professional networks it is easy to be sanguine about the affective and motivational gains from participation in these contexts and to identify a process of knowledge building without asking difficult questions as to the status of that knowledge however there are plenty of less benign online contexts these are often associated with informal participation for example far right groups in belgium and race hate groups in usa eg mcnamee peterson peña 2010 but they also include formal learning contexts as in eve brabazons discussion of highly gendered and sexualised online discourse in the unexpected context of firstyear university students in a physical classroom these are all cases of participation through which members might too feel a sense of connection of empowerment and if participation is learning then learning is taking place a critical perspective is needed to underline these claims for these three cases were ones of distorted communication contexts in which strategic rather than communicative action was being promoted and in which sectional advantage not mutual recognition was sought in short members were concerned to gain at the expense of others it is now clear that a third contribution of a habermasian perspective is that it critiques a technoromantic view of technology here the earlier literature tended to see online settings and asynchronous interaction in particular as having advantages over f2f ones as a form of communication in particular learners could easily initiate manytomany discussions for themselves and they could respond as and when they saw fit many felt that power differentials were less obvious online online interaction seemed to create new patterns of turn taking and to overcome the dominance of particular individuals the archiving of messages was seen as allowing for more reflective argumentation and a rhythm which better supported deliberative consensus there were features of online environments for example a removed audience and an absence of immediate feedback which could lead to lessened inhibition but these could also support intimacy and group bonding as for example barak bonielnissim suler argue in the context of online support groups some of these often earlier claims about online affordances have become seen as overstated and it is recognised that participants in both formal and informal environments are differentiated in their behaviour for example as cecezkecmanovic webb identify learners will have different orientations to learning achieving an end and selfpresentation only some members of forums appear willing or able to engage in exploratory talk only some will lead discussion in open settings and significant numbers prefer to act the role of socalled lurker participants are differentiated in their attitudes selfconfidence selfesteem cultural background and linguistic ability as coco and short put it in the context of civic networks but of wider significance online communities are social constructions and reflect existing patterns of power and cultural constraints as well as habits and history thus technology really might allow new environments for and new forms of interaction but the attempt to draw conclusions from particular technological affordances is putting the cart before the horse a habermasian perspective in contrast would start by asking how can genuine consensus be reached before considering the media which could be employed to support the participants in reaching a consensus problems with a habermasian perspective a habermasian perspective it is argued enables a critical view of online interaction one that is focused on the process of deliberative discourse not on the affordances of the technology such a perspective would support members in their attempts to reach genuine consensus at least consensus concerning what should count as evidence when promoting and critiquing their respective positions a habermasian perspective provides too a rigorous and more defensible ontological and epistemological basis for knowledge building should we all then be habermasian there are problems with habermas and three have particular relevance in the context of online meaning making a perceived privileging of discourse over action a lack of practical detail and the infeasibility of consensus a general complaint made about habermas is that he was privileging a kind of white middle class discourse and idealising language in fact these criticisms alongside a greater concern for the sociological constraints on emancipatory action were to some extent at least addressed by habermas in his later work for example in discussing feminism and the politics of equality he argued that it was not enough to provide legal basis for equality without touching the fundamental levels of a societys cultural selfunderstanding perhaps the more telling criticism of habermass communicative action was that it privileged discourse over action and a very wordy abstract style of discourse at that to his critics habermas was envisaging an almost endless revisiting of the conditions for consensus that had little appeal in practical contexts it is therefore no surprise that say garrison anderson archer aligned their community of inquiry model with dewey rather than habermas for while dewey and habermas both held largely pragmatic positions on knowledge building and consensus and both drew on the earlier work of peirce dewey offered a more action oriented approach though note not one based on trial and error dewey however offered a less nuanced and less sociological description of intersubjective agreement and habermas rather than dewey might have greater relevance for the specifically discursive dimension of meaning making in the field of cscl habermass work is often seen as particularly abstract and not translatable into a framework of analysis in part this is because there is not one single version of habermas to work from though a communicative reason has been a common concern throughout his work and in part it is because habermas has carried out few empirical studies and of course relevant to our case none pertains to online worlds however he does provide some principles from which educators can work including key questions related to the design leadership and research of online interaction turning first to the design of online interaction habermas can help frame the right question rather than say which strategies should be adopted thus approaches such as pbl inquiry learning reciprocal teaching comentoring and so on may be valued as providing triggers for and motivations to sustain discussion but they need to be evaluated critically for example from a habermasian perspective designers will want to ask whether strategies lead participants to adopt surface or instrumental strategies as often seems to happen in practice and whether smallgroup working would lead to the generation of strategic groups interests at the expense of a wider more public discussion in respect to the leading of discussion habermas can help direct attention as to whether the performance of the role of a tutor in formal learning settings contributes to or constrains open debate on one hand having a tutor might introduce too high a degree of asymmetry within groups after all a tutor has a power and prestige denied to others on the other hand the tutor might help maintain a sense of reciprocity by for example identifying asymmetries and patterns of deference reminding participants that all points of view need to be considered and modelling a reflexivity which might be new for some and difficult to embrace in considering their interventions tutors are faced with two possible performative contradictions the first is that they act in the belief that it is only through their own efforts and direction that emancipatory learning can be delivered this is a contradiction as it views the learner as strategically compliant the second rather different contradiction is that tutors show a lack of sincerity by pretending they do not have specialised knowledge to offer or do not notice things which are noteworthy when in fact they do faced with these challenges tutors might need to accept that learning is invitational but that they have the responsibility to help support discussion while seeking to reduce asymmetry by showing communication was essential habermass work has further been helpful in analysing group work in the teaching and learning of mathematics not just to provide insight into how meaning is negotiated in a classroom but how communication and collaboration can break down into strategic positioning neither kent nor morselli and boero however drew on the ethnomethodological approach associated with cscl research into virtual math teams this leaves open the question as to whether there can be some overlap between garfinkels ethnomethodology and habermas and the work carried out in these respective traditions beemer amongst others thought there could be in that both garfinkel and habermas are concerned with finegrained analysis of language and exploring patterns and sequencing both are concerned too with how order is established in conversation and with what consequences however an important difference is that habermas explored intentionality and work carried out within the habermasian tradition has sought to directly address structural limits on agency in distinctive ways the third criticism and the one that goes right to the heart of habermas is that genuine consensus is not achievable or even desirable this is taken up in the context of online collaboration by hodgson reynolds though note that their paper is not an argument with habermas and there is much in its critique of a technological reductionist approach to learning which fits easily into habermass anti scientism hodgson reynolds however in contrast to habermas saw consensus as coercive to be a member of a community usually entails subjugation to its core values and norms of behaviour and to deviate from these in resisting assimilation is to run the risk of becoming marginalised in order that the integrity of the community is preserved thus striving for consensus may be felt oppressively particularly by those holding minority or counter cultural views and the authors argue instead for looser networks of online learners and recognition that our sense of identity shifts as we move in and out of groups and communities in short the authors saw value in pluralism and the acceptance of difference as both welcome and democratic in fact their perspective on online interaction ends up resembling a kind of networked individualism proposed by wellman boase chen more than a habermasian discourse community though they took the metaphor of city life to capture their proposal for a tolerant live and let live online cosmopolitanism there is much here that is attractive but there are objections to embracing online city life for example from a habermasian perspective consensus is an aspiration rather than a literal outcome of discussion in practice the best we can do is to strive towards consensus while recognising the unstable nature of that consensus and being transparent with our claims to validity discussion can finish with an agreement to disagree but in the process participants may gain a reflexive understanding as to why they disagree and a move towards intersubjective understanding and mutual recognition it is the attempt to reach consensus that is both a moral and genuinely educational one and if rational consensus were to be dismissed as a possibility then the scope of any discussion would be diminished along with its emancipatory potential furthermore while the evidence is mixed there is at least a realistic prospect that under the right conditions reaching greater intersubjective understanding is possible habermas himself cited several empirical studies to show this was the case or in his own words that the process of group deliberation resulted in a unidirectional change and not in a polarization of opinions there is further cautiously optimistic support in research on an internet enabled public sphere for example price found that in two citizen panels in the usa in which political discussion took place over an extended period some open exchanges of controversial ideas took place and a more nuanced understanding of issues reached in the online classroom collaboration has been seen as fostering understanding of other viewpoints and austin in work involving schools in ireland and northern ireland argued that structured pedagogic interventions across cultural divides could widen perspectives and provide knowledge about the outgroup of course conditions are important and not all evidence points the same way the internet particularly in anonymised unmoderated spaces can provide a stage for political extremism strategic intransience bullying and intimidation as austin also discussed forum members faced with points of view which threaten their status may end up holding on to their existing positions with greater certainty however while context is everything it is not difficult to imagine that participants committed to the cooperative search for truth might come closer to understanding each other and move towards agreement based on rationale grounds they may be able to see such movement as emancipatory as well as take advantage of more instrumental benefits almost as in lewins early work on groups irrespective of the decisions that are taken at least a case can be made that it is worthwhile to make the effort perhaps a more subtle response to hodgson and reynolds is to accept that consensus is in practice unlikely but to throw out striving for consensus as one aim of online interaction is perverse outhwaite teasingly suggested that for habermas to think about language primarily in terms of communicative rationality was to hold as fundamentalist position as catholic doctrine which considered sex solely in terms of procreation thus if looking only to celebrate in online or off line contexts the diversity of communication the creativity and playfulness of performance the opportunities for shuffling between various versions of self as well as the sheer utilitarian value of exchange of information we can give habermas a miss if we want to imagine how one purpose of online interaction might be to promote intersubjective reflexive understanding then it is to habermas we might turn conclusion habermas offered a perspective on language how we use language and with what consequences he did this from a critical theory tradition and presented a picture of communicative action that was optimistic but in its exploration of the different realms to communication was demanding we have suggested that a habermasian perspective on joint meaning making online is possible and such a perspective will be concerned with the striving for genuine consensus through unconstrained dialogue a process in which participants interrogate their own beliefs and actively engage with opposing points of view habermas offers a corrective to the overly literal accounts of knowledge building in the educational technology literature a habermasian perspective asks us to view participation critically and not to reduce learning to participation criticisms of our habermasian perspective include a lack of practical detail and a sense that it is not sufficiently action focused while critics would argue that genuine consensus is not achievable from habermas we can better understand the importance of striving for such consensus habermas reminds us that at heart it is though language that we understand the world and coordinate our action in the world uncertainty and exercising reflexivity this is a stance well modelled in the particular circumstance of mentoring in yukawa a wider responsibility for those leading discussion though one going beyond the scope of an individual tutor is to offer support to those lacking confidence and communicative competence to take part this is to recognise that open communication is not simply secured by giving everyone the de jure right to participate but that de facto there are those who feel less powerful either for personal reasons and or because of distorted classification roles reducing asymmetry is a challenge for those exploring the implications of habermass thinking in f2f settings and a general focus for those seeking to establish more democratic civic online networks experiences in both cases point to the size of the challenge and the resources needed to address it finally in relation to research habermass concern for validity claims and the moral purpose of communication can be adopted as a lens on activity rather than a particular method or methodology three cases illustrate this in the first hansen berente lyytinen used a habermasian perspective to understand collaborative activity to produce entries in the online encyclopaedia wikipedia in this study wikipedia could be regarded as an environment for rational discourse to the extent to which actors sincerely intend to engage in a cooperative search for truth through a formalized structure by excluding the use of force by meeting the rules of the ideal speech situation while engaging in a discourse that is open and continued for an extended period the authors were cautiously optimistic that wikipedia conformed to these requirements but this is not the key point rather the study showed that judgements about the quality of online interaction hinged on the process of communication and the ethical purposes which communication served in a second example schwarz de groot with a nod towards habermas sought to evaluate an innovation in the history classroom by showing that autonomy collaboration commitment to reasoning ethical communication and procedural mediation were important foci for evaluation of an online environment in a third example yukawas interest in intersubjective understanding led to a concern for truth sincerity and rightness as evidence of the coconstruction of knowledge this led to the marshalling of evidence within a narrative inquiry of two graduate students projects related to telementoring of school students these three studies took different approaches but all treated knowledge building as a process rather than a thing and drew on different sources of data including online texts student assignments journal entries and interviews the relationships between researcher and those being researched went beyond surface reading of online texts and evaluation of learning outcomes went beyond the instrumental however the three examples all concerned indeterminate contexts or at least ones in which there was an easily perceived normative dimension introducing such a dimension may be less intuitively obvious in more abstract fields of inquiry for example the learning of mathematics a frequently reported context in the field of cscl one way to show the relevance of a habermasian perspective here is to draw on accounts such as morselli boeros study of students understanding of mathematical proof albeit a study undertaken in a f2f context in this paper the authors accepted that there were objective grounds by which the rightness of an argument could be judged but they drew on habermas to show that mathematical knowledge could not be reduced to the realm of instrumental reasoning arguing instead that questions of mathematical proof necessarily involved intersubjective understanding for which

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y outh who are homeless and living on their own face multiple risks to their health including substance use among homeless youth in los angeles 68 engaged in drinking during a past30day period given the multiple negative health consequences of drinking for youth understanding factors associated with heavy drinking among homeless youth is important for prevention efforts the social networks of homeless youth may infl uence drinking and other drug use according to social learning theory individuals norms and behaviors may be infl uenced by people with whom they interact relatives and network members who engage in prosocial behaviors may be protective against substance use whereas interacting with network members who engage in substance use is associated with greater use affi liating with other homeless youth may be associated with risk of using substances because of the communication of norms generally accepting of an alternative lifestyle interventions that address social networks may have relevance in addressing substance use among homeless youth among homeless youth there has been no investigation of racebased differences in network characteristics and in the association of networks with substance use the present study investigates differences in network characteristics between black and white homeless youth and the association of network characteristics with drinking among these youth although rates of alcohol use are lower among black than white youth black youth experience more negative consequences including school problems and risky sex prevention science prioritizes culturally appropriate interventions including attention to racial differences in social networks the limited literature on racial differences in youths homelessness social ties and drinking suggests several hypotheses because white homeless youth tend to be more accepting of the label and experience of homelessness than black youth we hypothesize that black youth will have fewer homeless persons in their networks than white youth and that having homeless persons in the network will be associated with heavy drinking among white youth but not among black youth some research involving nonhomeless black youth suggests that both parental and peer consumption of alcohol or other drugs is associated with higher risk of substance use other research indicates that black youth tend to maintain closer relationships with family and do not value affi liations with their peers as much as do white youth therefore we hypothesize that compared with white youth black youth will report more relatives in their networks because black youth value their relationships with family members more than with their peers they might therefore be less infl uenced by peer norms and more infl uenced by family norms regarding drinking we therefore also hypothesize that relatives who drink will be more infl uential in black youths drinking than in white youths drinking because previous studies on social network infl uences on homeless youths drinking behavior suggests the importance of peer infl uences and because research also suggests that black youth value their affi liation with peers less than do white youth we hypothesized that drinking behavior of peers in the network would be less associated with heavy drinking among black youth than among white youth method study design we randomly sampled homeless youth ages 1324 years from 41 shelters dropin centers and street venues in los angeles county for a larger study investigating the social context of risky behaviors among homeless youth we used a multistage design in which we selected sites and venues frequented by homeless youth and randomly sampled youth within sites and venues shelters and dropin centers were eligible if the majority of clients were between ages 13 and 24 years and english speaking the research protocol was approved by the rand institutional review board a us department of health and human services certifi cate of confi dentiality was obtained measures outcome we assessed heavy drinking behavior that is episodic for ease of reference we refer to the outcome as heavy drinking throughout the article youth were asked on how many days in the past 30 days they had fi ve or more drinks of alcohol in a rowthat is within a couple of hours a dichotomous variable indicated whether youth had engaged in heavy drinking on at least 1 day in the past 30 days personal network characteristics of respondents we asked respondents to provide fi rst names of 20 individuals ages 13 or older that they knew who knew them and that they had contact with sometime during the past 3 months interviewers used standardized probes to assist participants in recalling 20 network members each participant nominated 20 social network members as requested and we concluded solicitation of names after the 20th person had been named egocentric networks are the focus in this study and encompass the ties surrounding a single focal individual for this study we included characteristics of network members in terms of types of persons and their drinking behavior types included individuals who are family students who attend school regularly employed persons and homeless persons we asked respondents about drinking behavior of their relatives and peers that is who do you think drank alcohol to the point of being drunk during the past 3 months we obtained the number of relatives and peers who drank to intoxication during the past 3 months and derived dichotomous variables for some of the measures given skewed distributions background characteristics of respondents we assessed age biological sex education level past30day income number of years homeless and number of different states in which they had lived analysis the analyses included weights to adjust for deviations from proportionatetosize stratified random sampling we used chisquare or oneway analysis of variance to test for differences between the samples of black youth and white youth in social network characteristics controlling for background characteristics we conducted logistic regression analyses to examine network correlates of past30day heavy drinking among black youth and white youth separately for every network characteristic in these models that was signifi cantly associated with heavy drinking in only one racial group we tested signifi cance of the observed difference using an interaction term in a regression model for the combined sample of black and white youth interaction terms were derived by multiplying race with the given network characteristic in these models we entered race the network characteristic and the interaction term controlling for background characteristics results youth differed signifi cantly by race with respect to social network characteristics black youth as opposed to white youth reported more relatives χ 2 1017 p 001 and more students attending school regularly χ 2 4937 p 001 white youth were more likely than black youth however to have homeless persons in their networks χ 2 3555 p 001 to have relatives in their networks who drink to intoxication χ 2 808 p 005 and to have more peers who drink to intoxication f 6086 p 001 a greater percentage of white than black youth drank heavily on at least 1 day during the past 30 days χ 2 2410 p 001 table 1 presents associations of the network characteristics with heavy drinking within each of the two racial groups controlling for background characteristics both black homeless youth and white homeless youth who had at least four persons in their networks who attend school regularly had lower odds of heavy drinking than their counterparts with fewer such persons white youth were more likely to drink heavily when they had more peers in their network who drank to the point of being drunk an observed difference between black youth and white youth that was signifi cant in analyses for the combined sample of youth the presence of homeless persons in the network was associated with drinking among the white youth but not among the black youth however the interaction term was not signifi cant in analyses for the combined sample of youth relatives in the network relatives who drank to intoxication and employed persons were not associated with heavy drinking in the separate models for either the black youth or the white youth discussion consistent with studies of nonhomeless youth black homeless youth were less likely to engage in heavy drinking than their white counterparts the greater consequences of drinking for black youth relative to white youth as shown in the study by hingson and zha however underscore the importance of understanding and addressing heavy drinking among black youth the fi nding that black youth have fewer homeless persons in their networks than white youth is consistent with previous research indicating that black youth tend to not identify with the label or experience of homelessness that black youth have more ties with relatives is consistent with research that black youth maintain stronger affi liations with family network members who attend school regularly may have been infl uential in protecting against heavy drinking for both black and white youth this characteristic has been associated with lower rates of drinking and other drug use as well as other risk behaviors among homeless youth in other studies the fi nding is consistent with social learning theory which posits that individuals values and behaviors are infl uenced through observation of and learning from other people as hypothesized drinking among peers was not associated with heavy drinking among black youth but was associated with heavy drinking among white youth studies have shown that black homeless youth value affi liation and closeness with their peers to a lesser degree than do white homeless youth thus peer norms regarding drinking may be less infl uential among black homeless youth white youth in our study appear to be enmeshed in a network within which drinking is a prevalent and normative behavior engaged in by infl uential peers additional research may shed light on the conditions under which prevailing social norms about drinking are most and least infl uential in determining the drinking behavior of homeless youth from different cultural backgrounds in contrast to our expectation drinking by black youth was not associated with relatives drinking perhaps due to our inability to distinguish parental behavior from that of other relatives in our data additionally having homeless persons in the network was not associated with heavy drinking among white or black youth a strength of this study is the probability sample of homeless youth in los angeles county although results may not generalize to youth in other regions the crosssectional design however is a limitation that prevents us from understanding whether networks differ for black youth and white youth over time longitudinal research has shown however that both social infl uence and social selection may operate concurrently among youth although white youth were at higher risk for heavy drinking this behavior requires attention in black youth as well alcohol misuse carries risks for multiple negative consequences including injury risky sexual activity and poor physical health minority youth are more likely than white youth to experience serious consequences of heavy drinking such as school problems risky sex and involvement in the criminal justice system to the extent that homeless youths drinking is infl uenced by their social networks enhancing or reducing certain network ties may be important points of leverage for intervention this study is the fi rst to our knowledge to investigate racial differences in understanding the association of social network characteristics with heavy drinking among homeless youth previous research has shown that homeless youth of different racial backgrounds defi ne their needs differently suggesting the importance of appropriately tailoring services our fi ndings support that for both black and white youth experiencing homelessness investments should be made in enhancing youths ties to students who are regularly attending school enhancing ties to students who regularly attend school might be achieved by reintegrating schoolage homeless youth into appropriate academic environments and affording higher educational opportunities to homeless youth the results indicate that white homeless youth are in particular need of interventions that reduce their ties with peers who drink because white homeless youth appear to be enmeshed in a drinking culture in that they are drinking more than black youth and spending time with peers who drink to intoxication programs to reduce heavy drinking among white youth may need to address this culture through networkbased interventions that go beyond academic integration racial differences in network characteristics deserve further attention in relation to health risk behaviors to ensure that networkbased interventions to reduce risky behaviors achieve maximum benefi t among all homeless youth

understanding factors associated with heavy drinking among homeless youth is important for prevention efforts social networks are associated with drinking among homeless youth and studies have called for attention to racial differences in networks that may affect drinking behavior this study investigates differences in network characteristics by the racial background of homeless youth and associations of network characteristics with heavy drinking heavy drinking was defi ned as having fi ve or more drinks of alcohol in a row within a couple of hours on at least one day within the past 30 days method a probability sample of 235 black and white homeless youths ages 1324 were interviewed in los angeles county we used chisquare or oneway analysis of variance tests to examine network differences by race and logistic regressions to identify network correlates of heavy drinking among black and white homeless youth results the networks of black youth included signifi cantly more relatives and students who attend school regularly whereas the networks of white youth were more likely to include homeless persons relatives who drink to intoxication and peers who drink to intoxication having peers who drink heavily was signifi cantly associated with heavy drinking only among white youth for all homeless youth having more students in the network who regularly attend school was associated with less risk of heavy drinking conclusions this study is the fi rst to our knowledge to investigate racial differences in network characteristics and associations of network characteristics with heavy drinking among homeless youth white homeless youth may benefi t from interventions that reduce their ties with peers who drink enhancing ties to schoolinvolved peers may be a promising intervention focus for both black and white homeless youth j stud

introduction international higher education provides a significant opportunity for individuals to pursue quality education abroad through such experience the individuals obtain a chance to develop new skills and knowledge obtain new friendships and networks and form novel civic values with increased capabilities newly formed through ihe the assumption is that the graduates will have a higher potential to contribute to their home countries and the wider society yet the contributions of ihe graduates to their home countries have not received adequate attention in the ihe literature the existing scholarly literature has traditionally positioned the discussions on contributions to home country in ihe within the frames of brain drain gain or circulationwhich are terms used to refer to the migration of highly skilled individuals the nomenclatures used to refer to this phenomenon in the literature vary and studies use different nomenclatures to convey different meanings these nomenclatures include brain drain brain mobility and brain circulation the studies that focus on this line of literature tend to argue that highly educated individuals emigrating from developing countries have been educated in governmentsubsidised educational institutions from early in their lives until their higher education therefore when these people emigrate all the investments on the development of individuals are seen as losses for sending countries because the returns on the investment are reaped by another country and future tax revenue is lost although remittances sent back by the migrant ihe graduates mitigate the monetary losses of the sending country according to marsh and oyelere these remittances are no match for the potentially lost future tax revenues and fiscal expenses made on subsidising their education in the brain draingaincirculation literature the question mostly revolves around whether individuals who went abroad to obtain a degree are a lost skilled workforce if they do not return and the subsequent consequences of this situation on their contributions to their home countries however this study does not situate the contributions of ihe graduates to society within the brain drain gain or circulation paradigms these popular models especially the idea of brain drain may have some problematic assumptions these assumptions include internationally mobile students being able to contribute to their home country by returning after completing their degrees abroad sending countries losing their skilled workforce when these students do not return and each persons identity belonging to only one nation and them showing loyalty to that nation rizvi contended that brain drain is a term that was coined in the 1960s by newly formed small states that worried about the loss of their skilled workforce to more developed countries and that it is becoming increasingly problematic in todays world brain drain essentially rests on the classical understanding of the relationship between social identities and the nationstate which some authors think may be weakening in the globalising world some criticism of the brain drain paradigm has emerged within the paradigm itself tung argued that people used to have a more clearcut understanding of who constituted expatriates are who constituted host country nationals are and how brain gain or brain drain are defined these notions have become much more blurred in the modern world in addition diaspora literature can also be relevant to the discussion of ihe graduate contributions to the home country diaspora groups and their contributions to the home country have been well examined in the literature however the studies that focus on the contributions of diaspora do not focus on ihe graduates specifically although the groups on which they focus may include migrant graduates as part of the larger diaspora group meanwhile those limited number of studies that do focus and differentiate ihe graduates within a diaspora group may not necessarily concentrate on the their specific contributions to the 1 3 home country diaspora in higher education studies is usually undertheorised and fragmented similarly ihe does not receive the attention it deserves from diaspora studies in contrast to the literature discussed above a recently emerging line of scholarly work in the ihe literature has started investigating ihe graduate contributions to the home country specifically and without building on the discussed binary brain drain logic of whether studying abroad is a lost skilled workforce upon not returning this recently emerging line of literature indicates that ihe contributes to the students home countries in several ways including having an impact on national policy improving bilateral diplomacy playing a positive role in the internationalisation of higher education and building capacity at organisations in the home country the following section discusses the main narratives in this emerging line of research main narratives in the literature for contributions to home country in ihe the existing scholarly empirical work has built on three distinct narratives when researching ihe graduate contributions to home country the first of these narratives which is also the most prevalent one frames ihe graduate contributions using human capital theory for example campbell who has been recurrently publishing on this topic has built on mcmahons expanded theory of human capital to argue that students who studied abroad obtain new embedded qualities which will help them contribute to their communities at home according to mcmahons extended human capital perspective human capital development is not just about increased private benefits such as income for graduates but also a potential contribution to society he argues that these highly educated international education graduates would have a social life outside their work environment to which they can contribute by establishing better relationships with their community in addition perna and colleagues works are also among the studies that have expanded the human capital narrative they have built on an earlier influential conceptualisation of human capital theory in building their narratives in the papers another narrative in contributions to home country literature is related to the human rights approach this narrative comprises studies that situate international education as part of ones right to obtain quality education according to this approach as quality education is ones right contributions to ones home country afterwards although desired cannot be made compulsory this narrative is especially valid for studying the expectations of scholarship providers some studies have looked into the contributions of internationally educated individuals with this perspective however this approach has not been as popular as the human capital approach especially in the designing of ihe scholarships for ensuring contributions to the home country after graduation a third narrative to frame international student contributions is that of the human capabilities approach this approach frames the goal of education as a process of increasing ones choices and freedom and highlights an individuals increased choices and agency after graduation while the capabilities approach has been influential in sociological and human development studies few studies have included this perspective in framing contributions of international students to their home countries in contrast sens emphasis on choices and individual agency can play an important role in illuminating the discussions on societal contributions of ihe graduates especially for situations in which graduates are reluctant or even against contributing to their home country the existing scholarly work supports this notion by pointing out that returning to the home country does not automatically equate to contributing to it and not returning does not automatically equate to not contributing to it the role of agency makes the difference here which has been understudied in contributions literature in this burgeoning line of research a few influential publications have drawn attention to the gap on the focus on individual agency in investigating ihe graduate contributions the current study contributes to this literature by filling out this gap building from new empirical insights from turkish students the following section will delineate on the framework of this study and the section afterwards will provide a background context for turkish international students theoretical framework an agential lens in her chapter campbell provided a discussion of the notion of agency in international scholarship graduate contributions she defines individual agency as the ownership for decisions and actions made by a scholarship grantee given the options available at the time it is how an individual exercises their choices and weighs their interests and desires against a given range of possibilities and specific life goals in this study i build on campbells agential approach to ihe graduate contributions and delineate agential perspective to contributions to home country in ihe utilising sens definition for individual agency ihe graduates have freedom to attain whatever they decide to contribute to their home country and beyond it as responsible agents this studys agential perspective incorporates the pushpull model in its theoretical framework building on campbells proposition that individual agency goes hand in hand with pushpull factors the larger sociological discussions always pair any discussion of agency of individuals with the external factors usually framed as the structure agency is crucial in human actions but it alone does not explain the whole picture and external factors needs to be incorporated pushpull factors are incorporated in the current work to discuss the external factors related to ihe graduate agency push and pull factors are widely used in migration and international student mobility studies however its use in framing ihe graduate agential contributions is relatively new in this model push factors are those that drive students away from their home demotivating them from contributing to it meanwhile pull factors are those that attract international students to specific destination countries the latter factors may result in decreased motivation to contribute to the home country as well but not necessarily as the graduates may still choose to contribute through different means such as creating diaspora connections or sending back remittances and investments as will be discussed in the findings section however push factors may be stronger in affecting ihe graduates agential rejection or shifting allegiance to contribute to their home countries although the participants of this study have studied in diverse destination countries they are all from turkey as such they all share similar push factors having moved from the same country for their international studies specifically in the turkish context push factors have emerged to be highly palpable and clear in the interviews thus influencing how ihe graduates negotiate their agential decisions for contributing to their home country the main topic of enquiry in this research turkish context and turkish international students international students are individuals who have relocated from one country to another to pursue an undergraduate or postgraduate degree education when defined this way close to 50000 turkish students were studying abroad in 2018 according to the most recent available data however turkish international students have been understudied in both turkish and the broader literature despite their large number turkish ihe graduates show similarities and differences from other international students they are similar in that they all go through the same dynamics of ihe they all cross country borders to obtain a degree education leave behind their existing networks and friends and form new ones and witness and experience novel communal values in a new setting in this respect the selected group may be viewed as instrumental in gaining a better understanding of the ihe graduates overall perceived contributions however turkish ihe graduates may differ from other ihe graduates in certain ways one difference is that they are from an uppermiddleincome country that is geographically near many highincome countries as a result they may have both the motivation and the means to cross borders this circumstance makes turkey susceptible to high levels of international student mobility and graduate migration a topic of great significance in the societal contributions literature turkey has also been undergoing a complicated and volatile political situation lately notably the recent coup attempt in 2016 this volatile atmosphere has been noted by several international watchdogs such as the economist intelligence unit and freedom house which argued that the freedoms in turkey are declining in addition to the political volatility the last seven years leading up to 2020 has been marked with significant decreases in economic purchasing power in current us terms such developments have created strong push factors which are especially marked with the largescale migration of highly educated whitecollar professionals to other countries as supported by europes immigration and asylum statistics these developments have created a rather pessimistic perspective for young adults studying abroad in this sense turkish ihe graduates have intrinsic value as stake puts it for studying ihe graduate contributions having said these this study does not consider turkish students as a homogeneous group the available datasets such as unesco or world bank for selecting international students are based on nationstate categorisations in this regard turkish students have been selected because the available datasets make it feasible to draw from such a categorisation methodological approach this study was conceived as a qualitative study that drew its data from semistructured interviews in this section i delineate the details of the methodological approach taken for this study participant selection the participants of this study were 50 turkish recent ihe graduates who studied in various host countries azerbaijan bulgaria germany and the uk were the four purposefully chosen host countries to go beyond one host country context and get an overall picture of agential contributions graduates who stayed in their host countries after graduation were interviewed in these countries and returnee graduates were interviewed in turkey these countries were selected among the top 10 most popular destinations for turkish students based on the unesco institute of statistics to ensure variety while preserving feasibility the countries were chosen on the basis of factors such as historicalcultural links political economy and the quality of higher education institutions the inclusion of multiple country contexts was not to compare the findings between each country context one by one but to provide a holistic picture of the agential aspect of contributions to the home country after ihe as the findings will indicate the agential aspect goes beyond one host country context in each country the participants were graduates of topranked universities to achieve this goal i used rankings such as times higher education qs world university rankings and unirank topranked universities were selected to account for the differences in quality and future opportunities offered by different types of higher education institutions the options accessible after graduation might impact ihe graduates perceived contributions table 1 below shows participant distribution for each country and the universities from which they received their degrees i screened the participants using a combination of snowballing and linkedins search tool the participants had a balanced distribution of return status migrant graduate 26 returnee graduate 24 migrant graduate means ihe graduates who were residing in their host countries during the time of the interview whereas returnee graduate means those who had returned to turkey at the time of the interview the participants also had a balanced gender distribution congruent with the total international student population moreover they graduated from a broad range of study areas ranging from social sciences to engineering and sciences the purpose of the study was to include degreelevel graduates to gauge the perspectives of those who stayed longer in their study abroad experience as compared to shortterm mobile individuals the participants of this study eventually constituted of undergraduate and masters graduates the participants were all young adults meaning their age ranged from 20 to 35 years old to obtain insights from recent international student mobility experiences and to ensure that the participant responses were comparable in addition the study did not include turkish government scholarship recipients turkish governmentfunded students have to work a certain amount of time in a prespecified organisation in turkey after graduation which can significantly influence graduate perceptions on their societal contributions moreover the majority of studies focusing on contributions to home country focus on scholarship recipients thus signalling an incentive to study nonscholarship recipients data collection and analysis i adhered to the british education research associations research code and received clearance from the university of oxfords research ethics committee i acquired participants informed consent and anonymised their data 3 all of the interviews took place between september and march 2020 i conducted the majority of the interviews in person the interview durations varied from 50 to 75 min only four of the 50 interviews were performed through skype the interviews were conducted in turkish because it is the participants and the authors native language the data from all of the interviews were transcribed the full coverage of interviews focused on the larger topics of selfformation and societal contributions in ihe as this study is part of a larger doctoral thesis selfformation is a relatively new framework that positions students as agential selfeducating individuals and focuses on their holistic formation this particular research focuses on the findings related to the contributions to home country after ihe i used thematic analysis to analyse the data as described by miles et al the analysis was carried out in turkish because the data were in that language however the selected portions were subsequently translated into english for publication this examination involved inductive coding in relation to the emergent patterns as indicated above the underlying study was not directly focused on the impact of push factors emanating from the home country but they emerged as a strong pattern for the participants of this study hence a fresh thematic analysis of existing qualitative data was conducted both frameworks emerged to be viable and coherent in framing contributions to the home country during the data analysis the more refined themes that emerged from the reanalysis are discussed in the following findings section findings this section reports the interview data under three emergent themes namely agential rejection to contribute better from abroad and shifting allegiances and transnationality these themes emerged without a specific prompt about unfavourable push factors emanating from turkey as indicated earlier thus a deeper exploration on these themes has become important agential rejection to contribute one of the main themes that emerged from the interviews was the agential decision of rejecting to contribute to the home country as discussed earlier in the theoretical framework part the excerpts below support an agential decision to reject contributing to home country turkey citing some of the perceived factors pushing them away from doing so the participants who explained they do not want to contribute to home country dwell on negotiations in their minds whether their home country turkey deserves their efforts in this matter simges quotation below exemplifies this perspective should i provide this support to turkey do i want turkey to develop … does turkey deserve it or did it give me something to deserve it in terms of education and social rights … i am not sure about that and i guess it doesnt deserve it simge bulgaria returnee graduate notice how she questioned whether her own country has given her anything at all when considering that primary secondary and tertiary education provided by state institutions in turkey are freely provided such an argument may not be entirely true however according to the reflections shared under this theme the situation is not that simple the participants often indicated their good intentions towards their home countries they explained that they are positively inclined towards contributing to their home country however the interviews also unearthed a negative tone and a despair that they do not see a reciprocity for their good intentions defne for example explains below the uneasy situation she faces when it comes to contributing to her home country i would be happy to contribute to turkey i mean our beautiful country but on the other hand i do not see reciprocity for this i have such positive feelings towards turkey but turkey does not seem to have such positive feelings towards me defne germany migrant graduate not seeing any reciprocity regarding such positive feelings is relatable to the push factors discussed in the theoretical framework of the study international education graduates are pushed further away from contributing to their home countries as they perceive that no one appreciates it the participant interviews included abundance of explanations such as defnes above some participants even went beyond and explained that contributing to home country can even be harmful to them kemals interview excerpt below illustrates this point the contribution i can give is mostly in the field of sustainable energy i want to do this but turkey does not want to get it and you wear out after a while you question what am i working for i mean it will not respect you it will denigrate you it will not care about you people dont accept your lifestyle i used to say i should contribute to my country but not that much anymore kemal uk returnee graduate 1 3 notice the strong wordings such as denigrate kemal feels that contributing to turkey his home country after graduation is not just pointless but also a tiring effort that makes him feel burnout hence he does not feel like contributing to his home country anymore political economic social and cultural factors pushing people from turkey need further attention in understanding ihe graduates agential rejection to contribute to their home country participants repeatedly mentioned governmental policies and practices as an important reason behind their agential rejection to illustrate salih provided specific reasons for why he has never thought of contributing to his home country before it will seem a little selfish but i have not thought of contributing to the country so why should i help this government there may be something like why i should help the country that voted for this government maybe this is why i didnt think about it salih uk migrant graduate as can be seen salih equated contributing to his home country to contributing to the incumbent government which seems to demotivate him to do so salihs explanation in this quotation seems to be connected with others in this theme in addition the participants also highlighted that they do not have any legal obligation to return and contribute to their home country either they were not government scholars onurs reflection below illustrates this situation well why dont you come back and contribute after studying abroad well its our own life our own choice maybe because of our resentment maybe we saw some negativities in turkey and not here and so we stay we didnt study here with a government scholarship we paid with the financial support given by our own family or the income we earned by working while studying onur bulgaria migrant graduate the role of agency is crucial in contributions to home country after studying abroad and it is even more highlighted when ihe graduates are not bound by any legal requirements the interview data shared in this section demonstrate how ihe graduates can agentially reject to contribute to their home countries regardless of their country of study and return status better from abroad this theme specifically highlights the perspectives of those participants who stayed in their host country after graduation but still dwelled on their intention to contribute to their home country this theme can be understood better with state and nation separation discussed by kim and bamberger ihe graduates still want to contribute but this intention is due to their allegiance to the nation separating it from the current governing state the participants argued that their contributions to their home country arewould be better from abroad they mostly cited two push factors that no adequate opportunities are available in turkey andor because their jobs are more difficult to do in turkey due to the restrictive atmosphere quotation marks used for the title of this theme denote that this term is an in vivo code below sample excerpts are shared to provide more details about this theme to start yasar is a finance graduate who currently resides in london uk during his interview he discussed extensively that his home country lacks big investment banks such as the one where he works in the excerpt below he explained how his contribution could be much better and on a bigger scale if he stayed in london instead of returning i think if i return i wont contribute as much as i do from here … my current company doesnt have any investment in turkey yet … even if investing in turkey becomes easier somebody needs to tell potential sponsors about it … 14 billion dollars a year enters to turkey in our area … our average investment at once is a 1 billion turnover if i do one project on such a scale in turkey that 14 billion will become 15 billion yasar uk migrant graduate for the explained reason yasar has taken the agential decision to stay in the host society where he obtained his international degree later in his interview yasar also discussed the increasingly notsoattractive restrictive atmosphere in his home country other participants were also conscious of the increasingly restrictive atmosphere in turkey this circumstance is also relevant for those who are interested in conducting academic studies that may include critical perspectives towards contemporary issues in turkey one example is presented in the excerpt below from zeynep she repeatedly mentioned the restrictive atmosphere for studying certain topics in turkey building on such claims she explained that she can conduct such studies in germany freely and hence contribute to her home country from abroad turkey italy and greecethese have vast numbers of unemployed women and some of them are not even considered unemployed … for example this is one of the topics i want to work on … i can work here on this population of women who are not even considered unemployed in turkey i do not have to return to turkey to do it zeynep germany migrant graduate as the sample excerpts indicate push factors such as restrictive atmosphere in the home country lead the participants not to return home nevertheless they still would like to contribute to it from abroad contributing better from abroad may come in different forms and not just limited to conducting critical academic studies ayten is another participant who is an international graduate of comparative politics in her interview she explained that she is advising one of the parliament members of the main opposition party in turkey a my doctorate is in politics and i look at the oppositions in venezuela and turkey … so that it is comparative im looking at the mistakes of the oppositions unfortunately the strategies the style they are similar researcher your counselling will help a lot then maybe you can show a way to the main opposition party in turkey a yes yes … and this would work better if they are more open to dialogue and selfcriticism ayten uk migrant graduate as the excerpt indicates ayten is putting her newly acquired information and skills into use to contribute to her home country but she does that from abroad moreover she explained later in her interview that she is even working in lowpaying jobs in the uk to not to return to her home country citing the earlier discussed push factors another form of contributing from abroad could be doing business with and importing products from turkey while staying in the host country these people mostly discussed their reluctance to return to their home country after their education and argued that their contribution would be much bigger if they stayed berkes example below illustrates this perspective i sell turkish brands lets say x million turkish liras a year so that you can understand the scale of it thanks to the exchange rate we contribute to turkey that much berke azerbaijan migrant graduate overall the participants of whom i shared their reflections in this section dwelled on their goodwill to contribute to the nation better from abroad the general thinking among them was that ihe graduates who have not returned to their home countries will continue to grow as the escape from turkey will continue in the future due to the political and economic situation in turkey which indicates that the theme of better from abroad will gain even more importance shifting allegiances and transnationality this theme gathers together the excerpts that indicate how the participants negotiated their transnational identity shifts similar to those discussed by rizvi and colleagues according to rizvi such transnational transformations could occur during any international study experience however the interview data of this study indicated that the push factors emanating from turkey are facilitating and even accelerating international students allegiance shifts to illustrate for zeliha below belonging is not to a specific country or bordered land anymore it is rather to the ideals she created for me there is no direct belonging to turkey but to the ideals i created this is not like any country or national unity border if it is a country compatible with my ideals i would gladly return live there and work even for little money zeliha uk migrant graduate zeliha above highlights her transnationality she does not feel she belongs to any country anymore her allegiance is now to her newly formed ideals and whichever country is compatible with them zeliha is not alone in this thinking the excerpt below from ranas interview also signifies this perspective i am from here but it is questionable whether i feel i belong here… because my heart is broken in general i saw that you could live more pleasantly so i want to create added value but will this be countrybased no it will be humancentred i think people are global and the world is a global place rana azerbaijan returnee graduate notice how she associates her overall disappointment with turkey to her feeling of belongingness she explains that she will make agential efforts to contribute to humanity instead rather than to her home country specifically even though she has already returned from studying abroad shifting allegiance and transnationality is very visible furthermore the acceleration of transnationality and shifting allegiances is visible even for those who already felt they were world citizens before their international higher education experience the excerpt below from aysel illustrates this notion as a person who sees herself a bit more like a world citizen i think that the issues of the world concern me therefore i choose my work accordingly … i was never like a person who thought that i should advance my country from one point to another but studying abroad further lowered my perceptions that i am attached to one nation aysel uk returnee graduate the interview data shared in this section indicate that ihe graduate contributions are impacted by the push factors in home country strongly these push factors impact ihe graduates perceptions in a way that they feel less attached to one nation as a result their allegiance shifts from their home country conclusions and discussion this study examined how international study graduates negotiate their agential decisions on contributing to their home country turkey at a time when push factors emanating from home country is highly palpable the findings section specified three emergent themes in relation to the earlier discussed framework of the paper agential rejection to contribute better from abroad and shifting allegiances and transnationality all three themes point out the importance of individual agency in ihe graduate contributions which has been mostly neglected in this line of research echoing tran and vu and campbell agency is an important concept mostly missing in the brain drain or gain literatures return status has been mostly seen as the defining factor for deciding whether an international graduate is a lost workforce the analysis in this study indicates that this notion is not necessarily true as some participants argued that they would do everything in their hands not to contribute to their home countries even though they had already returned their home country meanwhile others explained that their contributions would be better if they did not return to turkey thus supporting some of the studies that problematise return status in this line of research return status may still have an impact on the nature of the graduate contributions and their overall perceptions of contributions to their home country however individual agency is key here the findings indicated that agency has a larger role in ihe graduate contributions than the scholarly literature on this topic has acknowledged so far moreover as discussed earlier in the theoretical framework the larger sociological discussions of human agency always pair agency with external factors often termed as the structure human agency and external factors are always in interaction with each other hence i followed campbells suggestion in this study and included pushpull factors to incorporate the external factors in understanding the agential decisions of ihe graduates the findings revealed that combining individual agency with pushpull factors provides a more holistic explanation of contributions to the home country this study specifically focussed more on the push factors as they emerged to be highly prominent in the participants perceptions of their contributions to turkey as the analysis illustrated a significant number of participants demonstrated an agential stance to reject contributing to their home countries argued that they would contribute better from abroad due to their commitment to the nation but not necessarily to the current governing state echoing the distinction made by kim and bamberger and problematised their sense of allegiance to a bordered area called home country based on these findings the recent developments in turkey especially the alienating impact of governmental policy and practices have been pushing away its own citizens who have studied abroad from contributing to their home country many participants explicitly discussed this circumstance in their interviews as some of these discussions are included in the findings section participants had a shared thinking that turkey is increasingly becoming more restricted which is supported by several other sources and economically less attractive as measured by per capita purchasing power considering that ihe graduates are highly educated and selfformed young adults who have a long productive time ahead it is in turkeys best interest to win their hearts back the latter will be discussed more under the following policy implications section transnationality and problematising the sense of belonging to ones home country have also emerged as a strong theme from the analysis transnationality in international education is well researched and discussed however the analysis here indicated that push factors emanating from home have facilitated and even accelerated the participants shift in allegiance and transnational negotiations in their mind similar to rizvis counter arguments towards brain drain literature the contributions to home country discussions could also be considered to rest on the idea of the relationship between social identities and the nationstate even when they are framed differently than most brain drain studies however one main point here is that even though international education graduates who are motivated to contribute to overall humanity are desirable those graduates who specifically want to exclude their home country from this equation are a significant area of research policy implications in this section policy implications are discussed although these implications will be discussed with the specific example of turkey they are also relevant to other uppermiddleincome country contexts that are undergoing politically volatile situations as indicated earlier one in three participants repeatedly argued that they do not feel included in turkey and that their contribution is not wanted it is in turkeys best interests to win back the hearts of these highly educated young adults who have a long and productive future ahead of them the first and most important step to do so is to create a more inclusive policy atmosphere that sends out positive messages international education graduates would not want to contribute to an atmosphere in which they feel they are not accepted respected and even denigrated as kemal defne and others argued notably the participants of this study were not turkish government scholarship recipients as explained in the participant selection section turkish governmentfunded students have to work a certain amount of time in a prespecified organisation in turkey after graduation such mandatory measures do not apply to this studys participants as they are not officially obliged in such ways thus the focus should be on soft approaches in this regard turkey could focus on creating promising opportunities at home and providing a welcoming environment to maximise the contributions from internationally educated turkish individuals similar to what china the largest sending country has been doing in addition israel could be a good example as it used its diaspora to boost the internationalisation of its higher education israels case indicates that when treated well diasporas can help universities receive more international students which is a positive contribution to the development of universities in addition turkish embassies abroad could make positive gestures even small ones to help these young adults feel that they are not alone in their journey abroad and that their home country is there for them sending out small gifts such as calendars on important national days or reaching out during difficult times such as the current covid19 pandemic though small gestures can be instrumental in winning the hearts of these people back to illustrate the chinese embassy in the uk has been sending small gifts and cards to show support for its nationals in addition to turkish young adults who have studied abroad over 65 million turks are residing outside turkey this number is significant by any criteria although not all of these turks residing outside of turkey are as highly educated as ihe graduates they can still contribute to turkey in certain ways these groups need to be engaged as diaspora communities to ensure their contribution to turkey however this issue has not been studied adequately in the literature the recommendations provided above could help engage the overall diaspora of turks abroad but we need more studies that incorporate the specific dynamics of turkey and turkish people limitations the study utilised interviewing method which is a selfreported method and subject to selfdesirability issues that is the participants responses may have been influenced by what they thought was more socially desirable especially given that the questions were on contributions to home country this approach may have led to overemphasising socially acceptable and underemphasising socially bad behaviours several measures were taken to alleviate this potential issue one of them was to use a semistructured interview guide semistructured interview guides helped structure the questions and ensure more relevant responses moreover during the interviews probing questions were asked and examples were requested for claims made by participants lastly the participants were from turkey the agential lens discussed in this study is likely relevant to students from different backgrounds as well however the push and pull factors would be different as discussed in the context part while some findings bear instrumental value in understanding overall international students some bear intrinsic value specific to turkish students the conclusions and discussions should be interpreted with these considerations in mind

contributions to home country after international higher education ihe have long been considered within the traditional frameworks of brain drain or brain circulation however recent scholarship has hinted at more nuances into this issue than what has been predominantly discussed this study focuses on ihe graduate agency to investigate the contributions of studying abroad to a home country it builds from internationalcomparative fieldwork that included interviews with 50 recent turkish ihe graduates who studied in four purposefully selected countriesazerbaijan bulgaria germany and the ukand who either stayed or returned to their home country afterwards the findings highlight the role of agency in ihe graduates contributions to their home country returning to the home country does not equate to contributing to it as some participants expressed that they contribute better from abroad while others refuse to contribute even after returning the study also demonstrates that combining individual agency with pushpull factors emanating from the home country provides a more holistic explanation as the home country dynamics have been found to be influential on agential stances regarding contributions

older adults who experience chronic pain face many challenges from their illness which can affect their personal and healthcare relationships research indicates the importance of relationships on health and quality of life outcomes in older adults with cp however minimal research has explored their perspectives on the relationships they have with their healthcare providers healthcare system their cp and familyfriendscommunity objective to understand how older adults cp impacts their relationship with the healthcare system and how older adults cp impacts their personal relationships methods adults 50 years of age with pain were eligible to enroll in virtual focus groups andor interviews audio recordings were transcribed coded and analyzed via a mixed inductivedeductive framework approach using atlasti microsoft descriptive statistics were performed using stata 16 results sixteen participants participated in a focus group or an interview participants identified as white female and were between the ages of 5564 years old most participants held an associates degree or higher and reported private medical insurance coverage sessions lasted between 3090 minutes participants described complex relationships that could have positive or negative impacts on their ability to manage their cp and their overall quality of life relationships explored included the healthcare system clinician family other patients and cp discussion the relationships of older adults living with cp are multidimensional and can support or adversely affect pain management mental health and quality of life utilizing geographic information system techniques and a composite index this project delves into the intricate geographic patterns of property tax burdens in pennsylvania with a specific focus on older residents contemplating aging in place amidst limited financial resources the study scrutinizes various factors including property tax rates home values income demographics and other housingrelated variables to comprehensively grasp their effects on the financial feasibility of aging in place pennsylvania displays notable disparities in property taxes averaging approximately 15 of home value across counties due to distinct assessment systems and varying assessedtomarket ratios tax rates are also influenced and specified by smaller administrative and geographic entities including municipalities and school districts despite alternatives aging in place remains the preferred choice for most older americans this accentuates the significance of assessing property tax affordability that facilitates potential aging in place particularly for financially constrained but healthy seniors who may not qualify for tax rebates or local freezes moreover escalating housing prices and assessed values further emphasize the urgency cartographic and tabular findings from the study unveil challenging situations for seniors in specific county clusters of pennsylvania encompassing not only expensive urban but also typically affordable rural settings additionally areas with the highest tax rates are not always the most financially burdensome with all other factors taken into account this study offers practical insights that have the potential to inform adjustments in housing and tax policies aimed at benefiting older adults in pennsylvania florida united states

ageism continues to impact healthcare professionals attitudes toward older adults older adults are often assumed to be frail weak or a burden on society addressing ageist attitudes and myths about ageing which often lead to discrimination can impact policy decisions knowledge of opportunities available to older adults to increase healthy ageing is vital in any healthcare training program recognizing the growing needs to prepare health professionals to work with the increasing numbers of diverse older adults this research survey conducted for the college of health and human sciences chhs to examine the students attitudes and perceptions of ageing interest in ageing careers knowledge gaps in ageing and ageing topics of interest this survey resulted in 141 respondents who helped provide an informed baselines of chhs student misconceptions about ageing baseline of learning needs and topics and practice opportunities of interest this poster will share the unique results of this survey providing insight into students attitudes and perceptions on ageing additionally this poster will provide a brief picture of the colleges response to the survey including curriculum development and systemic changes

introduction the idea of stem was conceived by the national science foundation in the united states back in the late 1990s to meet the countrys challenge in becoming a leader in the field of science and technology initially identified with the acronym smet in the 1990s it was later changed to mets and eventually to stem in 2001 although over time stem has become increasingly important across nations the differences in policies and practices are broadly influenced by the economic regions the different approaches to stem are distinctly characterized by the four main geosocial separations english speaking countries western european countries asian countries and developing countries and thus variations in stem policies reflect the different economic cultural and social settings the focus of stem especially in the developing countries has been on improving stem education stem education merges the four disciplines science technology engineering and mathematics into a cohesive system with the objective to prepare students for the 21stcentury job market stem education provides skills that govern the way students think and behave including critical thinking problemsolving and the ability to adapt and work collaboratively the advancement of stem education in developing countries is in alignment with the goal for quality education as indicated by the sustainable development goals of the united nations vuong et al further contends that it is crucial to have more studies on stem education in developing countries as current scientific literature is mostly concerned with developed countries stem education consists of metadisciplines that combine the skills and knowledge from the fields of mathematics engineering science and technology in malaysia the acronym stem is used in three different contexts that are stem field stem education and stem stream related to science technology engineering and mathematics realizing the importance of stem education the ministry of education malaysia under the national education blueprint 20132025 transformed the existing curriculum to the standard secondary school curriculum by strengthening and introducing stem in the education system of malaysia as one of the pillars in the new curriculum this is to prepare the country to meet the challenges and demands of a stemdriven economy literature review stem education offers a wellrounded education encompassing a range of soft skills that renders the graduates more employable and prepared to meet the demands of the current employment according to emerging research priorities have focused on stem education compared to other priorities of stem a systematic review of research and trends in stem education between year 2000 and year 2018 by li et al revealed the categories of journal publications with the highest number of papers published in the category goals and policy curriculum evaluation and assessment while the least popular category is postsecondary teacher and teaching the other categories include k12 education culture social and gender issues postsecondary stem education and history philosophy epistemology and nature of stem education further a review of the number of publicly funded projects in stem education for different groups of participants from year 2003 to year 2019 by li et al revealed that most projects involved grade five to grade eight learners on the other hand found that the three popular topics among stem papers were innovation for stem learning professional development and gender gap and career in stem in addition researchers found that the top three countries in terms of publication of stem papers were the united states australia and canada suggesting the need for more publications from the developing countries as pointed out by vuong et al in the malaysian context in particular the review of stem education research conducted by jayarajah et al showed that the two highest research areas are teaching tool and teaching and learning the third place is shared by two categories that are learning strategies and gender the review which included articles from year 1999 to year 2013 intended to summarize the trend of literature across the stem disciplines in addition to the research areas jayarajah et al also revealed that most studies involved university graduates whereas studies at the school level were scarce taking a cue from these findings the trend in stem research shifted to more studies involving school children as opposed to studies involving postsecondary students from year 2010 to year 2020 according to freeman et al past studies have generally found considerable variability within countries and territories in terms of demographics specifically gender ethnicity socioeconomic status religion and distribution however certain areas have been given less importance and thus the need for future studies to consider these aspects of research in stem education for instance vuong et al urged for an examination of the impact of demographic factors on students performance in stem domains because they believe this will shed light on the intertwining relationship between ses and academic achievement ses is one of the most studied and consistent predictors of students academic achievement because ses explained most of the differences in students academic achievement numerous studies showed significant relationships and positive correlations between ses and students academic performance however there are lesser studies on the relationship between ses and stem education although initial studies focused on western countries and only after the late 1970s studies included developing countries these studies showed that ses had a greater impact on the academic achievement of students from developing countries than that of those in the developed countries moreover ses and its relationship with students academic achievement is one of the prevalent issues in educational research however there is lack of documented studies relating ses and stem particularly in malaysia study design study objective this study used the quantitative nonexperimental crosssectional explanatory design to investigate the association between ses and academic achievement in stem subjects among the malaysian undergraduate students from both the public and private education sectors kim et al argued that the construct of ses is multidimensional because it reflects the social system and so it is a challenge to accurately measure ses the commonly used definition of ses includes characteristics of family background while other definitions include assets and home resources in this study the definition of ses includes family income education level and employment of the adults in the families study questions this study focused on investigating the relationship between students academic achievement and the ses constructs related to their parents as such the three research questions are are there associations between parents education level and students academic achievement in stem subjects are there associations between parents occupations and students academic achievement in stem subjects are there associations between parents income and students academic achievement in stem subjects study variables as shown in figure 1 the independent variables for this study are parents education parents occupations and parents income and the dependent variable is students academic achievement in the stem subjects instrument and data collection the instrument used for this study is a survey questionnaire of ten items the reliability of the instrument was analyzed using cronbachs alpha as a measure of the internal consistency of the items the results show a cronbach alpha value for the ten items is 078 which is greater than the reliability standard threshold of 070 thus the questionnaire is reliable data was collected physically and virtually in physical data collection students provided responses on hardcopy of the questionnaire while virtual data collection used google forms in both formats of data collection students were first required to give their consent for their responses to be used by the researchers results and discussion table 2 shows the distribution of the students in the major school examinations that they sat for prior to their university entries most students sat for the malaysian certificate of education examination followed by malaysian higher school certificate examination and the unified examination certificate examination the malaysian certificate of education is a national examination taken by form five secondary school students in malaysia the malaysian higher school certificate is the last secondary school level public examination and is one of the options after completing year eleven and before pursuing a university degree meanwhile the unified examination certificate is a standardized examination under the malaysian independent chinese secondary schools system taken by students who have completed six years of primary education at a chinese primary school prior to their secondary level education parents education and students academic achievement table 3 displays the distribution of parents highest academic qualification whereby most of the parents highest academic qualification is only at the school level that is 463 for the fathers and 477 for the mothers a smaller percentage has attained postgraduate education that is 100 for the fathers and 77 for the mothers the school level category comprises primary and secondary schooling the tertiary education category comprises the diploma and degree levels and the postgraduate education category comprises masters degree and doctorate degree table 4 shows that there is no statistically significant association between students achievement in science and their fathers education level 3282 𝑝 0243 there is also no statistically significant association between students achievement in technologybased subjects and their fathers education level 3406 𝑝 0513 however there is a statistically significant association between students achievement in engineering and their fathers education level 5564 𝑝 0015 there is also a statistically significant association between students achievement in mathematics and their fathers education level 7974 𝑝 0000 this shows that students whose fathers have higher academic qualifications have higher grades in engineering table 7 shows that there is no statistically significant association between students achievement in technology and their mothers education level 3882 𝑝 0302 there is also no statistically significant association between students achievement in engineering and their mothers education 3934 𝑝 0282 however there are statistically significant associations between students achievement in science and their mothers education 4899 𝑝 0008 and between students achievement in mathematics and their mothers education 5989 𝑝 0036 table 8 shows the crosstabulation analysis between mothers academic qualification and students achievement in science for grades a b and c table 9 shows the crosstabulation analysis between mothers academic qualification and students achievement in mathematics for grades a b c and d table 8 shows that the percentages of students who obtained grade a in science increased when the academic qualification of their mothers increases for instance 250 of the students whose mothers are not educated obtained grade a while 609 of the students whose mothers have postgraduate qualifications obtained grade a in addition 08 of the students who got grade a have mothers who are not educated while 100 of the students who got grade c have mothers who are not educated further 114 of the students who got grade a have mothers who are postgraduates while 33 of the students who got grade c have mothers who are postgraduates this shows that students whose mothers have higher academic qualifications obtained better grades in science table 9 shows that the percentages of students who obtained grade a in mathematics increased when the academic qualification of the mothers increases for instance 250 of the students whose mothers are not educated and 657 of the students whose mothers highest qualification is school level have grade a in mathematics meanwhile 802 of the students whose mothers have tertiary education and 826 of the students whose mothers are postgraduates obtained grade a in addition 05 of the students who got grade a in mathematics have mothers who are not educated while 87 of the students who got grade a have mothers who are postgraduates this shows that students whose mothers have higher academic qualifications obtained higher grades in mathematics parents occupations and students academic achievement table 10 displays the distribution of parents occupations which has been classified according to the international standard classification of occupations of the united nations most parents of the students in this study are professionals that is 220 of the fathers and 283 of the mothers however many of the students were unsure in which category their parents occupations are these students either chose the wrong category or chose the option others hence the incorrect job categorization could have possibly affected the results of the analysis table 11 shows that there is a statistically significant association between students achievement in mathematics and their fathers occupations 10069 𝑝 0004 however there are no statistically significant associations between students achievement in science and their fathers occupations 5739 𝑝 0085 between students achievement in technologybased subjects and their fathers occupations 5771 𝑝 0375 and between students achievement in engineering and their fathers occupations 4897 𝑝 0703 for the service and sales workers group the percentages of students who got grade c is higher than percentages of students who got grade b but it is not substantially higher likewise with the elementary occupations and armed forces occupations categories for the three top job categories the percentages of students with grade a whose fathers are in these categories are higher than 10 while for the other categories the percentages of students with grade a whose fathers are in these categories are lower than 10 this shows that students whose fathers hold better jobs have higher grades in mathematics table 13 shows that there is a statistically significant association between students achievement in mathematics and their mothers occupations 13346 𝑝 0000 there are no statistically significant association between students achievement in science and their mothers occupations 5044 𝑝 0234 between students achievement in technologybased subjects and their mothers occupations 4599 𝑝 0801 and between students achievement in engineering subjects and their mothers occupations 4535 𝑝 0820 table 14 shows the crosstabulation analysis between mothers occupations and students achievement in mathematics for grades a b c and d within a job category of the mothers the percentages of students generally decreased from grade a to grade d for instance of the students whose mothers are professionals 847 got grade a 118 got grade b 24 got grade c and 12 got grade d however unlike the fathers occupations the percentages of students with grade a are lower than 10 except for the second category still this shows that students whose mothers have better jobs have higher grades in mathematics parents income and students academic achievement table 15 displays the distribution of parents income while table 16 shows the chisquare analysis between parents income and students academic achievement in the stem subjects the salary range shown in table 15 follows the household income classification in malaysia defined as the b40 group the m40 group and the t20 group whereby b40 represents the bottom 40 m40 represents the middle 40 and t20 represents the top 20 of the malaysian household income as seen in the table most of the parents of the students in this study have a combined salary in the lowest salary range that is most of them are in the b40 group table 16 shows that there is a statistically significant association between students achievement in science and their parents income 2344 𝑝 0003 there is also statistically significant association between students achievement in mathematics and their parents income 2709 𝑝 0008 however there are no statistically significant associations between students achievement in technology and their parents income 1074 𝑝 0378 and between students achievement in engineering and their parents income 895 𝑝 0536 table 17 shows the crosstabulation between parents income and students grades in science meanwhile table 18 shows the crosstabulation analyses between parents income and students grades in mathematics table 17 shows that 295 of students whose parents earn less than rm 4850 obtained grade a in science 477 of students whose parents earn between rm 4851 and rm 10970 obtained grade b and 574 of students whose parents earn and more than rm 10971 obtained grade c in addition of the students who got grade c 633 have parents in the lowest b40 group while 33 have parents in the highest t20 group this indicates that students obtained better grades in science when their parents income is higher similar with the science grades the crosstabulation analysis in table 18 reveals that the more the students parents earn the better their achievement in mathematics is that is from 662 when parents income is less than rm 4850 to 907 when parents income is more than rm 10971 for grade a in mathematics also of the students who got grade c in mathematics 545 have parents in the b40 group while 45 have parents in the t20 group again this indicates that students who obtained higher grades in mathematics have parents whose income is higher conclusion this study focused on the relationships between parents ses status in terms of their education occupations and combined income and the students academic achievement in stem as measured by their grades in the stem subjects these relationships are in the form of associations since parents ses status were categorical variables and students grades were categorical ordinal data results of the chisquare tests for association show that some of these socioeconomic variables related to parents ses were significantly associated with students academic achievement in stem subjects the study shows that there is a significant association between fathers education level and students grades in engineering and mathematics whereby students whose fathers have higher academic qualifications have higher grades in these subjects as to mothers education this study found significant associations between students grades in science and in mathematics whereby students whose mothers have higher academic qualifications have higher grades in these subjects also there is a significant association between parents occupations and students grades in mathematics whereby students whose parents hold better jobs have higher grades in mathematics as to parents income this study found significant associations with students grades in science and in mathematics whereby students whose parents earn more have higher grades in these subjects the results of this study are in conformity with previous studies that established a positive association between ses and academic achievement literature also reveals that ses is likely to play a more important role in students educational attainment in the developing countries more importantly research found that the strength of the association between ses and students academic achievement increases from lowincome countries to higher income countries with a widening achievement gap worldwide in addition the positive association between ses and students mathematics achievement found in this study agrees with previous studies while there may be many factors that relate to students academic achievement in stem subjects such as students intellectual ability and affective variables such as students dispositions and motivations in stem fields this study has focused on socioeconomic factors pertaining to parents education occupation and income one limitation on the data is that they are based on students selfreports and no triangulation was done with other sources or related variables also another limitation of the study is its generalizability since it is limited to the population of malaysian students implications of study although there are studies on students ses and their academic achievement in general please fillout this questionnaire with the needed information be assured that your information will be treated confidentially and data will be presented only in summary forms thank you very much for your time

although there is proliferating literature on stem science technology engineering and mathematics education studies on the impact of socioeconomic status ses on stem education are limited in developing countries studies on stem education in malaysia has largely involved the teaching and learning aspect while there are limited studies in other areas this study investigates the possible relationships between socioeconomic factors and malaysian students academic achievement in stem subjects data was collected from students in the higher learning institutions located in five different regions in malaysia using a survey questionnaire crosstabulations were made between the construct of ses and students academic achievement and analyses for chisquare tests for associations were carried out using the statistical package for social sciences spss results of this study show that there are statistically significant positive associations between students grades in engineering and their fathers education between students grades in science and their mothers education and between students grades in science and their parents combined income moreover there are statistically significant and positive associations between students grades in mathematics and parents education occupation and combined income future studies can identify the reasons for these associations and how malaysian students declining academic performance in international assessments can be improved by improving stem education

introduction the role of sustainability in higher education has been well recognized declarations on sustainability in higher education are pieces of international regulation over the past 30 years research at universities has produced substantial data to advise about deterioration of the environment resource scarcity and the need for sustainability this put a deeper pressure on the universities forcing them to reevaluate their role as a driver for sustainable development however it is well known that signing a declaration does not necessarily lead to implementation which is due to the lack of incentive structures presently universities and intergovernmental institutions have developed more than 31 she declarations and more than 1400 universities have signed a she declaration globally 1 the number of declarations is still increasing with a notable evolution of she definition 2 however implementation inside universities is very slow sustainability includes some degree of controversy and has a variety of meanings depending on the users their backgrounds interests and values and the context in which it is used in a postmodern world pathways towards sustainable universities are unlikely to be developed without resistance controversy and even conflict in fact we live in a pluralistic society characterized by multiple actors and diverging interests values perspectives and constructions of reality 3 as described sustainable development is a vague highly complex concept that is hard to understand to teach this concept current traditional structures and processes need to be broken different disciplines and subjects need to be integrated in university classes that need to be connected to realworld problems and actors the typical didactic triangle should no longer be designated by an active teacher who instructs passive students this is considered a fundamental break with the general idea that knowledge is determined and provided by teachers and class instruction is then absorbed and reproduced by the students as an alternative interaction between students and teachers needs to be reorganized in a way that directly generates a demand for learning in the sense of jointly searching for the meaning of the concept of sustainability both for the individual and for the systems in which they are also both embedded it should be noted that the new solutions will take place in complex systems and should cooperatively integrate the knowhow of various disciplines thus is interdisciplinary the unique and traditional disciplinary approach in university education applied to isolated systems represents an initial approach in the sense of having a treatable problem however it has the disadvantage of not allowing to apprehend and to understand the nature of the real problems which are naturally multidisciplinary it becomes necessary to understand that the essence of nature is inherently complex and interdependent education for sustainable development implies a paradigm shifting to a new approach that is able to contribute with new solutions to the new challenges in sustainable development 45 while the principle of interdisciplinarity incentives for cooperation across different subjects and disciplines transdisciplinarity concepts includes strong interaction between academics and practitioners in order to promote a mutual learning process between them for instance it is not possible to effectively research or teaching sustainable development of society without interacting with society in addition at this level we can perceive several levels of multidisciplinarity levels interdisciplinarity creates and promotes dialogue and exchanges between disciplines it is no longer a fragmented vision but an enrichment from different disciplines transdisciplinarity works on objects that do not belong to one discipline it aims to achieve a project through the use of different disciplinary activities pluridisciplinarity addresses an object of study according to the justaposition of multiple specialized looks the problem lies in the fragmentation of approaches although it is a way of approaching all aspects 6 the sustainable development • is intrinsically a multidimensional issue • is involved in a multitude of declarations and interpretations • should be taught through multidisciplinary strategies as seen sustainable development is a very complex task that calls for adequate strategies to be satisfactorily addressed works in this edition of track 7 this edition of teem18 track 7 has registered several works in many different domains as summarized below the theme of continuing engineering education and sustainability was developed and a declaration of commitment was presented as an outcome it should be noted that statements are compromises between systems with completely independent legal rules the persistence on new commitments are revealing and identifying the agents committed to the future when these commitments are developed in a higher education environment one must believe that we are sowing values that will impact the way future professionals act the remote experimentation approach was developed to seek to share resources relating primarily to the social and economic dimension interestingly there are recent approaches that use an environmental justification to this type of solution the classes in the simulation environment are particularly interesting to the student because it allows to practice several possibilities of what if problems but presents the disadvantage of not showing nature to act the laboratory classes fulfill this last object very well nevertheless presenting some disadvantages such as they require more time they are more expensive and they generate waste let us think about the amount of waste resulting from the chemistry classes of a school university state country etc if we do the same exercise for several areas of knowledge study we will easily find that the educational process generates a lot of waste remote laboratories are a possibility for a more sustainable educational process through sharing of experiments blended mobility as a way for the sustainable internationalization of higher education was developed above all in the social dimension however it also indirectly addresses the multiculturality 7 an important topic that is included in the conference designation the education of concepts for sustainability education oriented primary and secondary school are also presented in the form of mooc it is a development especially in the social dimension that curiously presents a profound change within the educational system itself that starts to imitate the social model in fact in school teachers belong to a group of older people who lend their experience to a group of younger students typically the education system operates in an open loop in the sense that in the education system students start in nursery school and end after higher education curiously some works shows closedloop working ie people from more advanced teaching groups are developing means of support to teach students of the earlier stages of education in a closedloop way this is an interesting example of a solution that aims to solve the complexity of education in sustainable development conclusion this theme of education associated with sustainable development has been developed consistently in teem only a few of the reasons that justify the high requirement of this theme were presented it is not surprising that only a few works by authors with special multidisciplinary abilities have been presented there is still a long way to go but sustainable development has an met history

sustainable development has been linked to the ecological economic and social dimensions and it appears from the outset that it is a complex task to include several very different aspects while planning and projecting this multidimensional feature migrates to education sustainable development that is as expected a complex task traditional education based on specialization of subjects and unidirectionality of strategies has often proved to be insufficient the present track intends to be a space of debate of the challenges posed to higher education professionals as strategic partners for the development of different mindsets able to tackle the real problems 1

background ingroup bias has been one of the most wellsupported psychological findings the groundbreaking research by tajfel et al demonstrated that ingroup bias can occur when group boundaries are completely meaningless such as when using random letters or inconsequential artistic preferences this phenomenon has been found to be so robust and stable that researchers even started investigating potential genetic components at the same time both different experimental manipulations and the nature of manipulated groups may increase or decrease the ingroup bias what has not been addressed previously is to what extent the larger macrosocietal context may also have an influence on ingroup bias it is noteworthy that those structural variables which have been extensively discussed within the classic social identity theory such as the nature of groups and their mutual relationships are likely to vary systematically across different societies these more distal cultural variables have remained largely unexplored in research on ingroup bias our question returns to the early writings by tajfel who explicitly stated that group processes need to be understood within the context in which they are occurring and can not be assumed to be universal in this study we focus on the effect of societal culture as one potential variable at a distal level affecting ingroup bias both under minimal group conditions and in realworld contexts examining this question will allow us to shed light on the boundary conditions of sit as well as outline some potential mechanisms that drive ingroup bias in both experimental and reallife situations sit is the dominant theory examining how individuals are linked to groups in intergroup contexts within societies a different paradigm focusing on individualgroup relationships has been individualismcollectivism focusing on the salience of individualgroup relations across societies a number of authors have noted cultural differences and discussed whether social identity processes are more applicable in collectivist compared to individualistic societies we address this issue directly regarding the second question the mechanisms underlying social identity theory have been challenged a desire to increase selfesteem has been long argued to underlie intergroup discrimination a plausible alternative mechanism is uncertainty reduction previous experimental research has focused on task uncertainty while recognizing that contextual uncertainty also may play a role here we examine macrocontextual variables linked to uncertainty at the societal level therefore crosscultural work can help to examine plausible theoretical mechanisms that drive minimal group effects in summary the aim of the study is to examine the strength of ingroup bias in both experimental and realword contexts and to link it to cultural differences in societal values therefore we explore how distal macrocontextual effects independent of specific structural intergroup variables within societies influence overall ingroup bias which will allow for a greater contextualization and positioning of social identity in a globalized world ingroup bias ingroup bias is the positive evaluation of the ingroup compared to the outgroup this evaluation can be accompanied by a preferential allocation of resources to ingroup members competition with outgroup members and collaboration with ingroup members or other perceptual affective or behavioural effects that positively discriminate the ingroup from the outgroup a condition that is often linked to ethnocentrism tajfel and his students demonstrated that such ingroup biases can be produced by a mere classification of individuals into random groups this socalled minimal group paradigm required that individuals have no facetoface contact group membership is completely anonymous there is no instrumental or rational link between the categorization and the experimental tasks to be completed by participants and the responses by participants have real implications for the groups but not the responding individual this experimental paradigm was an important element in the emergence of social identity theory individuals are thought to strive for positive social identities to maintain positive selfesteem this striving for selfenhancement is best achieved by intergroup social comparisons in which the ingroup is positively differentiated from an outgroup the exact nature and process of social comparison depends on the relations between the groups and their perceived relative status stability legitimacy and permeability this direct link of the ingroup bias to selfesteem motives has been debated and the current evidence is suggesting a more complex relationship hogg developed uncertaintyidentity theory as an extension of sit hogg focused on the motivational processes underlying group identification and argued that selfuncertainty is a primary motive for identification with groups to feel uncertain is an aversive psychological state and most people are motivated to reduce this sense of uncertainty put simply by identifying with a social group people derive a sense of meaning and belonging this subjective group membership in turn provides prescriptive norms and guidelines for appropriate behaviour that help individuals to navigate an uncertain world the uncertainty reduction mechanism has been supported in a number of experiments mainly focusing on task uncertainty despite debate around the relevant process mechanism leading to ingroup bias the relative effect of ingroup bias itself was found to be highly stable and robust a number of metaanalyses have summarized the empirical research to date and have demonstrated that the effect is replicable and consistent and it has been accepted as an important theoretical process in explaining intergroup relations uncertainty avoidance and ingroup bias as discussed above uncertainty has been suggested to play a major role in explaining intergroup discrimination hogg distinguished two types of sources of uncertainty uncertainty arising from the immediate task and uncertainty inherent in the larger social context larger context variation in uncertainty has not received much attention in the social identity literature but there is systematic variability in the management of uncertainty across modern societies hofstedes seminal study of culture defined uncertainty avoidance as the extent to which individuals within societies are socialized to avoid uncertain situations by establishing formal rules and structures higher uncertainty avoidance is a situational concern with reducing uncertainty which can be predicted to increase ingroup bias we therefore test to what extent this society level concern with avoiding uncertainty is related to ingroup bias greater uncertainty avoidance should be associated with greater ingroup bias individualismcollectivism and ingroup bias individualismcollectivism has emerged as a major dimension in cultural research that differentiates contexts in which individuals are thought to be selfreliant autonomous independent driven by their own attitudes beliefs and convictions and endorsing a rational attitude towards group membership with cultural contexts that socialize individuals to be interdependent to rely on ones duties norms and morals dictated by the group in deciding on actions and to form strong emotional and affective bonds with groups the former is more typical of western europe and north american societies where the latter is a typical socialization pattern in much of asia africa eastern and southern europe and south america associations between individualismcollectivism and ingroup bias in both directions have been observed potentially driven by different mechanisms first collectivism might be associated with higher ingroup bias hinkle and brown suggested that social identity processes are more likely to take place in collectivistic kind of groups because collectivistic groups or individuals are more likely to worry about ingroup identification a slightly different argument was provided by hogg as discussed above uncertainty reduction is one potential driver for intergroup discrimination therefore greater uncertainty avoidance should lead to stronger ingroup association which in turn leads to an empirical merging of uncertainty avoidant and collectivist behavioural pattern as a consequence empirically it will be difficult to separate ingroup attachment and uncertainty mechanisms because the two dimensions are intrinsically linked in line with these arguments uncertainty avoidance and collectivism are highly correlated in hofstedes data set or did not emerge as separate dimensions in other cultural frameworks such as schwartz these arguments are also consistent with the strategic equilibrium dilemma noted by yamagishi et al who predicted that in closedknit groups people practice ingroup favouritism because it gives them a competitive advantage and reduces uncertainty in contrast to these positive associations of ingroup bias with collectivism opposing relationships may also be plausible hogg observed that stable identities in a premodern society have been replaced by an atomistic individualoriented society which is accompanied by an erosion of traditional community links and stable collective identification targets this lose connection of the self to various possible groups then leads to a greater concern with group identities as well as a heightened need to establish and maintain links to ingroups in more collectivistic settings people do not need to worry about their identities or level of inclusion in the group since individualgroup links are stable and not negotiable people have typically little choice to stay or leave a group and fewer ingroups pervade more aspects of everyday life compared to more individualistic societies where multiple potential ingroups are available but temporally and geographically separated this socalled postmodern paradox therefore leads to individuals in highly individualistic societies to yearn for collective affiliations the evidence supporting either of the two mechanisms is mixed however these two hypotheses may not be conflicting with each other yamagishi et al suggested that collectivism is more strongly related to ingroup favouritism because it provides ingroups with a strategic advantage in contrast hogg speculated that the postmodern paradox increased the need of citizens in individualistic societies to identify with various possible ingroups the minimal group paradigm uses arbitrary group distinctions to the extent that people in individualistic societies crave identification we could expect a stronger bias towards these arbitrary groups in contrast in collectivist societies with more stable group membership there is less need for people to identify with novel groups but in contrast it is identification with real groups that is most important for collectivists individuals have been socialized to feel emotionally attached and strongly connected to their ingroups hence ingroup bias could be expected to be larger for real groups compared to randomly created groups in experimental settings that are likely to have little affective value for people in collectivist settings this integration suggests an interaction hypothesis ingroup bias is strongest in collectivistic contexts when focusing on realgroups and weakest in collectivistic settings when focusing on artificial groups ingroup might be intermediate in individualistic contexts with both real and artificial groups societal value dimensions we have identified two major dimensions along which societies differ that might be related to ingroup bias the societal variables of interest are related to individualgroup relations and the extent to which uncertainty is tolerated or not we examine the effect of variables derived from two different value frameworks these dimensions were derived from large scale studies in which individuals answered batteries of questions about their behaviours attitudes beliefs and values the corresponding scores therefore reflect modal tendencies of attitudes beliefs and behaviours of groups of individuals within a society individuals in all societies have options concerning their beliefs and behaviours and can engage in particular behaviours if the context allows it societal level dimensions of culture indicate that certain attitudes beliefs or behaviours are more frequent in some societies compared to other societies therefore reflecting overall behavioural tendencies of groups of individuals within a society in this study we ask to what extent such tendencies are related to ingroup bias the classic cultural framework was developed by hofstede he sampled employees in ibm and originally described four major dimensions the dimensions of interest for us are individualismcollectivism and uncertainty avoidance this framework has been extensively studied and is the most widely used dimensional framework of societal culture schwartz developed an alternative framework that shows some overlap but also deviates in important aspects based on ratings from teachers and students he distinguished autonomy from embeddedness this dimension is similar to individualismcollectivism but emphasises more being embedded in social groups and deriving meaning and identity from belonging to inclusive and strong ingroups compared to the opposing end where individuals are seen as autonomous in their thoughts and actions and are freer to act in line with their selfinterests schwartz argues that his autonomy versus embeddedness dimension is closer to the original ideal of individualismcollectivism having separate dimensions for the opposing ends of this assumed underlying dimension allows us to separate the differential effects of individualism versus collectivism schwartz did not identify a separate societal dimension of uncertainty avoidance however the notions of security values which are a central element of embeddedness values reflect a concern with avoiding insecurity and risks and maintaining stability and order in ones surroundings as noted above uncertainty and collectivism are potentially strongly intertwined and might be difficult to separate empirically in summary hofstede and schwartz provide alternative frameworks for measuring individualismcollectivism only hofstede provides separate scores for uncertainty avoidance for the sake of consistency we continue using the hofstede labels unless specifically referring to schwartz dimensions the current study in this study we explore societal effects on ingroup bias to derive a measure of ingroup bias we conducted a metaanalysis of experimental and correlational studies that reported an index of ingroup bias we were not interested in more subtle variations in the effect but were interested in whether the overall level of ingroup bias across conditions or group targets is influenced by more distal macrocontextual variables independent of the structural relations between the groups within a society given the nonspecific and broad nature of culturelevel dimensions by not paying attention to finer experimental distinctions or subtleties our approach provides a more conservative estimate of the influence of societal context on this psychological phenomenon this is also based on pragmatic reasons as it allows us to pool a larger set of studies by focusing on more inclusive criteria unfortunately to date there are not enough studies available across all the societies included in our study that would allow finer coding of structural variables within each society methods literature search and effect size coding we conducted a psycinfo and web of science electronic data base search in november 2009 using the key words minimal group and ingroupingroup bias we also consulted the reference lists of published metaanalyses on ingroup bias and minimal group studies a total of 498 articles with these key words were found in addition to these published articles a total of 20 unpublished articles or doctoral theses were directly obtained from authors via email the search strategy was focused on maximizing studies that were not conducted in the uk or usa the inclusion criteria for the studies were the following first the study needed to have been conducted using a version of the minimal group paradigm or have included some measure of ingroup bias second the national background of participants should have been stated explicitly we did not include migrant samples in our study but minorities that were resident in a country were included third sufficient information to compute an effect size for ingroup bias should have been available we coded additional parameters we are interested in overall ingroup bias yet status differences are the most consistent predictor of variability in ingroup bias if possible we coded one overall estimate of ingroup bias across all other conditions if not we coded status of the groups in line with mullen et al and buhl overall ingroup bias collapsed across status was coded as equal status if other conditions were included that were intended to experimentally decrease or eliminate ingroup bias we did not include those conditions in our coding if there were multiple dependent variables we averaged them per sample in essence our coding focused on overall estimates of ingroup bias averaging over variations in status group size and type of dependent variable if authors reported both ingroup bias and outgroup derogation only ingroup bias was coded there was not sufficient information across studies conducted in the various societies to consistently differentiate ingroup favouritism from outgroup derogation or any finer differentiation of sociostructural variables as discussed in sit research ingroup bias was coded in the direction that greater emphasis was given to an ingroup therefore a positive effect size shows a bias towards the ingroup in ratings allocations of points or money or recognition of group members a negative sign indicates a bias towards the outgroup all effect sizes were converted to correlation coefficients and then rtoz transformed the inverse variance weight was based on the sample size the final data set contained 269 samples from 121 articles based on a total n of 21266 participants from 18 societies see table 1 for the average ingroup bias by society together with standard errors confidence intervals and number of samples the list of studies and coded information is available from the first author country level indicators we used countrymeans for uncertainty avoidance and individualism reported by hofstede we used the averaged teacher and student scores for autonomy versus embeddedness from schwartz data for all 18 countries were available the validity of these indicators is extensively discussed in hofstede and schwartz metaanalytical strategy metaanalysis is a set of techniques that statistically combines the results of two or more independent studies to provide an overall answer to a question of interest in our analysis we are using a multilevel mixed effect model most metaanalyses use a fixed effects model effect sizes are seen as direct replications of each other and it is assumed that samples come from the same population although convenient this assumption is not justified in most cases a random model in contrast presupposes that studies are randomly drawn from a larger population of studies therefore both subjectlevel sampling error and variability between samples are considered random effects models provide more adequate representations of most metaanalytical data sets a significant advantage of mixed effects models is that findings can be generalized beyond the specific samples included in the metaanalysis the assumption is that studies are assumed to be random samples from a larger population of studies therefore the results can be generalized to other studies not yet conducted or to studies that were not included in the metaanalyses taking into account sampling of studies makes the results more conservative multilevel approach since we have studies nested in countries this nesting needs to be considered therefore we developed a 3level structure to account for dependencies with countries where effect sizes are level 1 study characteristics are level 2 and country is level 3 this setup also allows us to control for a number of potentially important confounding variables we first entered the publication year status of groups and whether groups were artificial or real we then controlled for any significant effect before entering the variables of interest at level 3 the effects of interest are the effects of society level variables at level 3 on the intercepts at level 1 and the effects of country level variables at level 3 on the effects of level 2 on the intercepts at level 1 given the relatively small number of samples we entered each predictor variable individually and then ran a final robustness test where all significant predictors were entered together results the overall ingroup bias using a random effects method in our sample was 0369 standard error 0021 with the 95 confidence intervals stretching from 0327 to 0410 this bias was highly significant z 1737 p 00001 there was significant variation in effect sizes q 222406 p 00001 societal differences accounted for 875 of the variability this is comparable to other cultural differences in psychological variables we first estimated the effects of sample characteristics at level 2 entering the publication year as a groupmean centred variable and both group status and group type as unstandardized predictors the effects for year and group type were not significant the effect for group status was significant higher status groups show higher ingroup bias removing year from the equation status remained significant and type became marginally significant real groups showed higher ingroup bias the two study variables together accounted for about 7139 of the variance in ingroup bias across societies the variance component for group type was marginally significant but there was no significant variability in the effect for status χ 2 5 128 p 050 hofstede supporting hypothesis 1 greater uncertainty avoidance was associated with more ingroup bias γ 0004 t robust 312 p 0007 the interaction with real vs artificial groups was not significant γ 0001 t robust 000 p 050 uncertainty avoidance explained 7902 of the remaining variance between societies after accounting for study effects at level 2 testing the effect of individualism the main effect was not significant γ 0001 t robust 138 p 019 hypothesis 2 was not supported because the interaction effect between individualism and group type was not significant γ 0004 t robust 099 p 034 schwartz values examining the effects of autonomy the main effect was not significant γ 0054 t robust 069 p 050 hypothesis 2 was supported because the interaction between group type and autonomy was significant γ 045 t robust 334 p 0004 figure 1 shows the relationship in line with hypothesis 2 ingroup bias is stronger for real groups in less autonomous contexts compared to more autonomous contexts autonomy explained 8795 of the variability in differential effect of group type on ingroup across societies examining the effect of embeddedness the main effect was not significant γ 0019 t robust 032 p 050 the interaction was not significant γ 0262 t robust 150 p 015 although hypothesis 2 was not supported the direction of the effect was in the expected direction and explained 4565 of the variability across societies robustness analysis to test the robustness of all the findings we entered all the significant effects in a single model uncertainty avoidance remained significant γ 0004 t robust 298 p 0009 autonomy was not significant as before γ 0053 t robust 0083 p 042 the interaction between type of group and autonomy remained significant γ 0515 t robust 405 p 0001 but the interaction with uncertainty was not significant γ 0001 t robust 032 p 050 discussion we examined ingroup bias across 18 societies the overall effect was significant and of similar moderate magnitude as in previous metaanalyses this suggests that ingroup bias is a relatively universal phenomenon at the same time the magnitude of the effect varied systematically across societies in more uncertainty avoidant contexts ingroup bias increased this finding supports uncertaintyavoidance theory identification with groups allows for reduction in uncertainty through allowing individuals to find a sense of who they are and what to expect of those in and outside of ones group our analysis was also able to shed some light on the previously encountered inconsistent results in relation to individualismcollectivism related dimensions individualismcollectivism is related to ingroup bias only under specific conditions it appears that individuals in less autonomous societies exhibit more ingroup bias if the targets are reallife groups in contexts where individuals are not strongly embedded in naturally occurring groups a longing for identification may lead to greater bias favouring novel groups however in contexts where individuals are strongly embedded in their groups ingroup bias may become stronger if the focus is on those groups with which individuals identify therefore the stronger identification with their ingroups will be expressed in ingroup bias for those groups they feel strongly identified with especially if the intergroup context is made salient and refers to relevant groups our results have a number of theoretical and practical implications first the findings suggest that intergroup conditions have a significant likelihood to deteriorate in high uncertainty salient contexts although plausible this issue has not received much attention to date theoretical and empirical work has emphasized the effects of threat the closely related affective state of uncertainty is likely to show similar effects on intergroup relations our results certainly demonstrate that a societal concern with uncertainty avoidance increase the likelihood to favour the ingroup over the outgroup these biases can have significant realworld implications if we convert it into money jobs access to basic resources or health education and social services the overall levels of uncertainty and the general social climate can potentially have a large impact on intergroup relations for example increases in unemployment as one potential antecedent of experienced uncertainty has been shown to be associated with increased prejudice against muslims in europe cohrs and stelzl found that when levels of unemployment increased dominance beliefs were more strongly related to antiimmigrant attitudes these findings suggest that additional to specific structural variables of the groups as typically studied in sit research there are larger macrocontextual processes that influence all groups and potentially acerbate intergroup processes we could not directly test such interaction effects but it is plausible that general societywide processes such as levels of uncertainty have an impact on the specific structural variables tested in sit research therefore the interactions between legitimacy permeability and group status may be weakened or strengthened depending on the larger societal context second we demonstrated one instance of how general psychological theories can be tested and extended through crosscultural analyses treating the world as a natural laboratory researchers can identify macrolevel variables with systematic variation around the world that are theoretically meaningful using these variables effects identified in rigorous laboratory experiments with high internal validity can be tested for their external validity such naturalistic quasiexperimental studies can also highlight areas for further research if some unexpected patterns emerge third the findings suggest that broad contextual variables influence responses of individuals in specific experimental settings one question that arises is whether individuals are higher in uncertainty avoidance themselves or whether the general social climate has an effect hogg speculated that individual differences may have some facilitating influence experimental work has focused on task uncertainty it would be interesting to tease apart the individual difference component from both task demands and the overall social climate one option would be to cross task demands and generalized uncertainty to examine the unique impact of either variable on identification processes limitations we reported a metaanalysis of ingroup bias one limitation is that the available information was scarce often researchers did not report sufficient information to allow calculation of overall ingroup effect sizes contacting authors to obtain information was not a very successful strategy since we only received 5 responses with only 2 of these being able to provide the information needed authors should be more conscientious about reporting experimental details and results because of this lack of information we averaged across experimental conditions and dependent variables this results in a rather crude and unspecific measure of ingroup bias our measure is similar in overall magnitude to previous metaanalyses so this is reassuring however we might have missed subtle effects as desirable as this may be the information from studies available from these studies did not allow finer coding without losing too much information specifically a separation of ingroup bias into ingroup favouritism and outgroup derogation would be informative however too few studies have used designs that allow the separation of these effects the inclusion of sit variables such as permeability stability and legitimacy are also desirable it can be speculated that societylevel processes interact with these structural grouplevel variables and differentially affect ingroup bias this is an important avenue for further research in short we had to make tradeoffs between maximizing samples from as many countries as possible while not coding all experimental characteristics or paying closer attention to experimental designs and discarding much information from less often studied contexts the fact that we found significant results in line with theoretical predictions is evidence of the robustness of the overall effects future metaanalysis with more primary studies could examine some of these interesting experimental variations conclusion we reported a metaanalysis on ingroup bias across 18 societies one of our overall strengths was using a 3level mixed effects metaanalysis procedure this allows us to generalize our findings to other studies not included in our data base we found a robust and consistent effect of uncertainty avoidance in line with uncertaintyidentity theory greater concern at the societal level with uncertainty was associated with greater ingroup bias this has significant implications for the understanding and intervention in intergroup conflicts conflicts are more likely to escalate in contexts where uncertainty is salient one potential intervention strategy could be to address general levels of uncertainty in a society author details 1 aarhus institute of advanced studies aarhus denmark 2 victoria university of wellington wellington new zealand 3 melbourne clinical and child psychology pty ltd albert road clinic melbourne australia competing interests the authors declare that they have no competing interests

we report a metaanalysis on the relationship between ingroup bias and culture our focus is on whether broad macrocontextual variables influence the extent to which individuals favour their ingroup data from 21266 participants from 18 societies included in experimental and survey studies were available using hofstedes 1980 and schwartz 2006 culturelevel predictors in a 3level mixedeffects metaanalysis we found strong support for the uncertaintyreduction hypothesis an interaction between autonomy and real vs artificial groups suggested that in low autonomy contexts individuals show greater ingroup bias for real groups implications for social identity theory and intergroup conflict are outlined

introduction family planning is an essential component of health care provided during the antenatal and postpartum periods that can prevent maternal and childcare complications and reduce premature mortality 1 but there are conditions in which family planning needs become unmet among these the postpartum period is a critical time of high unmet needs and has the potential to reduce the risks of closely spaced pregnancies 23 unmet need for postpartum family planning is defined as all sexually active and fecund women wishing to prevent unintended or closely spaced pregnancies during the first twelve months following delivery but not using any contraceptive method 45 to address these needs postpartum family planning which is the beginning of family planning services within the first 12 months after childbirth has a crucial role 6 globally 95 of women who are in the first 12 months of postpartum want to avoid pregnancy in the next 24 months but 70 of them are not using contraception 7 the most commonly used methods are relatively shortacting methods such as injections which have high discontinuation rates 89 also according to ethiopian demographic health surveillance 4 and 9 of pregnancies occur within less than six months and less than twelve months respectively after prior delivery the unmet need in the benishangul gumuz region is 211 and the met need is 285 10 which shows a great discrepancy in the utilization of family planning different studies conducted in developing countries indicated that sociodemographic characteristics antenatal care status resumption of sexual activities postnatal care the return of menses duration after delivery previous history of utilization of ppfp and place of delivery are predictors of ppfp uptake 9 11 12 13 in ethiopia the prevalence of contraceptive use among postpartum women varies from region to region most women do not start taking contraceptives at the recommended time 10 specifically in this study area the asosa zone utilization of family planning was low 1014 therefore this study is aimed at assessing associated factors in the uptake of ppfp in the asosa zone method study setting and study period a crosssectional quantitative study design was conducted in the benishangul gumuz asosa zone from september 1 to october 30 2021 asosa is the capital city of benishangul gumuz region ethiopia it is located in the asosa zone and is 670 km west of addis ababa this town has a latitude and longitude of 10°04′ n and 34°31′ e with an elevation of 1570 m the study was conducted in two hospitals and four health centers in the zone 49 of the population is female study design a crosssectional study design was conducted source population all postpartum women aged between 15 and 49 years who were living in the catchment population of the study facilities study population postpartum women who have given birth in the last 12 months and visiting the selected study hospitals and health centers for any maternal neonatal and child health services eligibility criteria inclusion criteria postpartum women who lived in the study area for at least six months and gave consent to participate in the study exclusion criteria postpartum mothers who were severely sick and unable to talk were excluded from the study abstinence and permanent forms of contraception were not included as a form of family planning sample size determination the sample size was determined using a single population proportion formula with the following assumptions according to a systematic review and metaanalysis the proportion of postpartum women who used postpartum family planning was 44 7 the marginal error of 5 the design effect of 1 and the 95 confidence level were taken after adding a 5 nonresponse rate the final sample size was 402 sampling techniques all hospitals and health centers in the asosa zone that are currently providing postpartum family planning services were considered in the study the total list of hospitals and health centers in the zone was obtained from the zonal health department then the study hospitals of reasons is also advisable unavailability of different forms of fp also made the participants not use the preferred option therefore we recommend the stakeholders in the study area to avail variety of fp methods keywords postpartum family planning asosa zone benishangul gumuz associated factors ppfp uptake and health centers were selected by simple random sampling the monthly average client load of the target age group in the mnch department of study health facilities in the past three months prior to the study was taken from registry books and the respective sample size for each selected health facility was allocated proportionally to their mnch department client flow finally an eligible postpartum woman who had been selected by systematic random sampling was interviewed at an entry point study variables dependent variable postpartum family planning uptake independent variables sociodemographic characteristics age educational status religion ethnicity marital status husband education and occupation obstetric factors family planningrelated factors breastfeeding facility readiness and place of delivery data collection procedures data were collected by six data collectors who know amharic and local languages the data were collected through intervieweradministered questionnaires which were adopted from reviewed literature on postpartum family planning 8913 15 16 17 18 19 20 21 22 23 to minimize potential bias the authors used precise tools and data collectors who were welltrained female nurses who were not working in the same health facility the overall process of data collection was supervised by one medical doctor data processing and analysis the data were checked entered and cleaned using epiinfo version 70 and then exported to statistical package for social sciences version 25 software for analysis using the odds ratio with a 95 limit of the confidence interval the association of dependent and independent variables was identified and their degree of association was computed potential confounding variables were controlled by using multiple logistic regressions descriptive statistics like frequencies and percentages were used to describe the study population concerning dependent and independent variables results were presented in text graphs charts and tables data quality control the training was given to the data collectors and supervisor on the objective of the study and how to conduct interviews the data collection process and completeness were regularly monitored data collection was done in the local languages since this study was conducted during the initial phase of the covid19 pandemic the field teams were provided the necessary personal protective equipment during the training pretest and actual data collection results sociodemographic characteristics of participants in this study 396 postpartum women participated making a response rate of 985 the mean age of participants was 277 more than half 222 of the participants were aged between 20 and 29 years two hundred thirteen people resided in the urban area regarding the participants religion more than half 218 were muslims followed by orthodox 108 regarding the ethnicity of the study participants amhara berta and oromo accounted for 119 113 and 106 respectively most of them were married one hundred thirty four of the participants had no formal education reproductive history and maternal health service utilization among study participants in this study 270 of the study participants were multiparous women three hundred seven of the participants attended antenatal care for the index pregnancy the majority 314 of the participants gave birth at a health facility the mean time that the study participants stayed at health facilities after giving birth was 132 h more than half 212 of the study participants did not attend postnatal care three hundred nine of the study participants were currently breastfeeding the result indicated that 45 of the participants had ever encountered an unintended pregnancy fertility intention among the study participants in this study nearly twothirds of the study participants had resumed sexual intercourse during the study period eightyonepoint6 and 18 of the study participants resumed sexual intercourse between 6 and 12 weeks and 12 weeks plus one day to 24 weeks respectively the mean time to return to sexual intercourse was 104 weeks three hundred twentyfive of the study participants have expressed their desire to have many more children more than half 175 of the study participants want to have more children within 3 to 4 years while 141 of them want it within two years the majority 309 of the study participants reported that the lifetime number of children they wanted to have was 3 to 5 the mean lifetime number of children desired by the study participants was 42 postpartum family planning uptake among study participants the result indicated that almost all 384 of the study participants had heard about at least one method of fp the most common form 336 was the injectable contraceptive method the participants got information about fp from health professionals in 298 of the study participants the majority 293 of the study participants used any type of fp method before the index pregnancy more than half of the study participants 212 had used ppfp in the last year the dominant method of fp used was the injectable method 116 followed by implanon 56 the least utilized method was the intrauterine device 11 more than threefourths or 184 of the study participants had used ppfp during previous deliveries among those who used the postpartum family planning method the majority 100 started using it at 6 weeks thirtytwo participants started using it between 6 weeks and 6 months only 11 participants started using it immediately after birth the main sources for ppfp methods were health centers 156 and hospitals 36 nearly threefourths or 154 of the ppfp users got their preferred methods the dominant reasons for preference of the method were convenience to use 61 and being comfortable for health 70 however more than onefourth did not use their preferred methods this is due to unavailability of the preferred option 30 and medical reasons28 associated factors to the uptake of postpartum family planning among study participants in the multivariate analysis some factors were significantly associated with the utilization of ppfp these are delivery at a health facility history of using fp before the index pregnancy and previous history of ppfp use on the other hand having a history of unintended pregnancy and currently living with a husband was not significantly associated with service utilization in the study area postpartum mothers who gave birth at the health facility were more than 3 times more likely to use the ppfp service compared to those who delivered at home mothers who had ever used ppfp before the index pregnancy were about 5 times more likely to uptake the service compared to those who had no history of using it ppfp utilization was more than 2 times higher among mothers who had used it after the preceding birth compared to their counterparts discussion use of fp before the index pregnancy having a history of ppfp utilization and health facility delivery were significantly associated with ppfp uptake among postpartum women in asosa zone benishangul gumuz regional state according to this study the prevalence of ppfp utilization was 5354 this finding is lower when compared to the findings from the study conducted in addis ababa 16 however the prevalence was found to be slightly higher when compared to the results from a systematic review conducted in ethiopia 17 a study conducted in arba minch 7 and debre berhan town 18 with a prevalence rate of 4544 44 and 416 respectively similar studies that were conducted in subsaharan africa 17 kenya 19 and pakistan 20 reported prevalence rates between 246 and 468 the difference might be due to the difference in study settings and period in addition to this more than half of the study participants in the current study were residents of urban areas which could be a factor in the increased prevalence rate due to the availability of health information and increased awareness compared to those living in rural areas almost all of the study participants had heard of at least one type of fp method this finding is comparable with the study findings conducted in debre berhan 18 and malawi 21 this similarity of findings could be due to the increased availability of information from different health facilities and social media worldwide in this study the dominant method of fp used by the study participants was found to be injectable at 5472 however the study conducted in arba minch indicates that the majority of the study participants had used implants as a fp method while only 132 had utilized injectable 7 a study conducted in pakistan showed that the most commonly used type of family planning method by postpartum women was condoms 20 this discrepancy in findings might be due to differences in the availability of family planning types study period and levels of awareness regarding different family planning options in this study more than onefourth did not use their preferred methods this is mainly due to lack of availability of the different forms of fp this might be because of the effects of corona virus disease as the study was conducted when the disease was a concern in the study area in the current study the majority of study participants resumed sexual intercourse between 6 and 12 weeks a similar study conducted in malawi showed that 61 resumed sexual activity during this time 22 however a study in west africa showed that the time to resume sexual activity is delayed beyond 1 year 23 the difference could be explained by cultural differences among different study settings in this study health facility delivery was significantly associated with the uptake of ppfp this finding is in line with the study conducted in uganda 9 this could be because women who gave birth in the health facility might get appropriate postnatal care advice and counseling regarding ppfp the return of fertility after birth and the importance of birth spacing the findings of this study had clearly indicated that the use of fp before the index pregnancy and history of ppfp utilization after previous deliveries positively affected its uptake this finding is consistent with a study conducted in addis ababa 16 this could be because women who had prior experience in using fp have a better understanding of the benefits and timing of ppfp uptake limitation this study is not without limitation one limitation is the relatively small sample size the other limitation is the husband health facility and provider perspectives were not addressed conclusion and recommendation postpartum family planning uptake in the study area was low uptake of ppfp was correlated with prior fp usage and delivery at a healthcare facility given these factors we recommend all study area stakeholders to promote fp use among women of reproductive age and to encourage deliveries at healthcare facilities designing a method to reach women who give birth at home for a variety of reasons is also advisable unavailability of different forms of fp also made the participants not use the preferred option therefore we recommend the stakeholders in the study area to avail variety of fp methods data availability the data sets are available from the corresponding author on a reasonable request abbreviations anc antenatal care edhs ethiopian demographic health surveillance fpfamily planning iud intrauterine device mnch maternal neonatal and child health ppfp postpartum family planning authors contributions rott ttb mg and as conceived the study participated in the design of the questionnaire in drafting and finalized the manuscript and assisted with the design of the study and data analysis all authors read and finally approved this manuscript for submission gt ld ag am and et conceived the study participated in the design of the questionnaire performed the statistical analysis drafted the manuscript and assisted in the design of the study and data analysis all authors prepared tables 1 2 3 4 and 5 figs 1 and2 all authors read and finally approved this manuscript for submission declarations ethical considerations ethical clearance was obtained from the research ethics review committee of wollega university approval numberid wuihs0432013 the letter was brought to the asosa zonal health office from the zonal health department a support letter was obtained and brought to the woreda health offices and hospitals following an explanation of the objectives of the study written informed consent was obtained from each study participant the participants were assured that all information was used only for the study confidentiality was assured by not recording the participants name on the questionnaire consent to publish not applicable competing interests the authors declare no competing interests

background the first twelve months after a woman has given birth is crucial for the use of contraceptives to prevent unintended pregnancy most women especially in developing countries do not realize that they are at risk for pregnancy during this period due to this contraceptive use by women is ignored at this time objective this study assessed the associated factors of postpartum family planning ppfp service uptake in the asosa zone methods a facilitybased crosssectional study was conducted among 396 postpartum women in the asosa zone an intervieweradministered structured and pretested questionnaire was used to collect data data entry and cleaning were done using epi info version 70 and analyzed using spss version 25 software multivariate logistic regression analysis was employed to identify factors associated with postpartum family planning uptakethe majority of the study participants 384 972 had heard about at least one method of family planning nearly twothirds of the study participants 641 had resumed sexual intercourse only 535 of the participants started using ppfp injectable forms 547 and implants 264 were the most commonly used methods more than onefourth 274 did not use their preferred methods family planning use before index pregnancy aor 48 95 ci 265 882 previous use of ppfp aor 24 95 ci 133 438 and health facility delivery aor 28 95 ci 146 549 were significantly associated with uptake of postpartum family planning conclusion and recommendation postpartum family planning uptake in the study area was low uptake of ppfp was correlated with prior family planning usage and delivery at a healthcare facility given these factors we recommend all study area stakeholders to promote family planning use among women of reproductive age and to encourage deliveries at healthcare facilities designing a method to reach women who give birth at home for a variety

introduction the one thing i keep going back to is the night of the stroke in the first hospital the nurses clearly didnt recognize the symptoms or they didnt recognize the symptoms in a younger female that to me is intensely problematic for very obvious reasons the whole experience was so bad that i was actually encouraged by one of my neurologists in that city to launch a complaint brain health gap from translational research to health policy and structural change disparities in understanding the prevalence detection and treatment of many forms of brainrelated illness that disproportionately impact women have received increased attention mechanisms for changing these disparities are increasingly called in importantly though women are not uniform demographic group various scholarly fieldsnotably within black feminist and critical race scholarship and more recently what has been termed crip of colour critiques from within disability studies 2 have highlighted the ways in which the intersections and interactions of racism patriarchy ableism and heteronormativity are crucial for understanding and addressing healthrelated inequity depending on how they are positioned by virtue of their social identities some individuals struggle with ableism and expectations of normative embodiment navigating medical care can often mean navigating medicalization and ableist assumptions that pathologize diversity in lived experience for others though just getting a foot in the dooraccessing care at allbecomes the issue when lived experiences are shaped by intersections of social power and minoritized group memberships health care may be withheld withdrawn or offered on terms that are low quality or compromise ones values and integrity understanding how these different dynamics contribute to gender inequity in brain healththe brain health gaprequires an approach oriented within intersectionality inequities in relation to access and quality of care within brain health exist not only along lines of gender we need to consider gender as imbricated with race ethnicity sexuality economic background ability age geography and religion as well as other sources of discrimination and subordination intersectionality is both a theoretical framework and a research praxis that understands inequity in relation to the dynamics of difference and sameness which impact people by virtue of their membership in social groups it is an approach explicitly oriented toward social justice an intersectional analysis offers a way of thinking about how social axes of power impact individuals vis a vis their multiple social identities within the healthcare system these overlapping systems of disadvantage andor privilege shape experiences of care in the context of stroke diagnosis and poststroke care these overlapping identities can result in clear markers of advantage for some while manifesting disparities in outcome due to bias and structural forms of disadvantage for others drawing on our own mixedmethods research exploring the care needs of young stroke survivors we turn to the narrative of ms g a woman in her early forties with a missed diagnosis of stroke ms gs symptoms were ignored or challenged by medical professionals because she did not fit the template of who a stroke patient was and because some aspects of her identity delimited the extent to which her testimony about her symptoms was taken as credible and yet ms gs social position was also marked at least in some ways by privilege her story provides a foundation for helping us to think about the complexities of the brain health gap in stroke more women than men suffer cerebrovascular accidents and womens outcomes are often worsethey are treated less aggressively for primary and secondary prevention they are more likely to have lower quality of life poststroke as well as higher prevalence of post stroke psychiatric comorbidities but as we argue we need to think intersectionally to understand the ways in which nuances contexts and multilevel factors come together to shape these broadbased inequity findings missed stroke isnt only an issue of genderif we are going to understand genderbased gaps in access and navigation through stroke care we have to understand how intersections of gender with age ethnoracial identity nationality language ability and other aspects of social identity come together to create affordances as well as biases that contribute to stroke outcomes the case when our team met her ms g was a single woman in her early forties a welleducated scientist working in a provincial public service position she had been away on a work trip when three days into the trip she experienced a sudden onset of gastrointestinal symptoms late one night as she described to us she realized something was very wrong when what seemed like typical nausea and vomiting was suddenly accompanied by a rapid and progressive loss of sensation and motor control in her right leg the day of the stroke i had felt off off in the sense that i felt like maybe i was getting sick that something was coming… i felt so rundown that i declined going out with my colleagues and i thought i would just have a quiet night i continued to not feel terribly well throughout the course of the night and i ended up going to bed a little bit early around 1000 then i woke up at 1100 with an intense need to vomit… then around 200 i started to realize that something was very very wrong because i had lost feeling in my right leg it started as a tingle and then it progressed into full paralysis of my right leg… i was starting to suspect i was having a stroke i ended up calling 911 i told the ambulance attendant that i couldnt move my right leg and we went to the hospital thats where the story gets really bad the the concept of crip makes reference to an orientation in critical disability studies that attends to insights from queer theory exploring how gendersexuality norms intersect with social pressures and norms relating to ability cripofcolour scholarship further layers intersections of critical race theory within this orientation nurses that i was assigned did not believe me when i told them that i had lost feeling in my right leg they thought that i was lying to them and were refusing care to me our team met ms g less than one year from her stroke and she was doing well all things considered she had access to rehabilitation she was supported with workplace accommodations she was managing mood and cognitive symptoms with multidisciplinary supports the ystroke needs study aims to understand the challenges facing young stroke survivors from the onset of symptoms through acute care and the rehabilitation process to longterm survivorship ms g participated in the qualitative arm of the project sharing with us her narrative of the experiences she had as she moved through the poststroke pathways within the canadian healthcare system even for as much as her outcomes were positive overall the experience of accessing stroke care had been marked by distress at one point in time i was so desperate for water and i knew that the water fountain was directly next to my bay i decided to try and walk there forgetting of course that my right leg was paralyzed as soon as i tried to stand up i hit the ground thats when one of the nurses told me outright that i was lying that she had seen me move my leg and since i had put myself onto the ground i could get myself back up so i tried to do that and i ended up falling backwards and dislocating my thumb which she then accused me of lying about she told me my thumb was just doublejointed and that it could move back i was in the er of the general hospital from 400 in the morning until noon at noon i was transferred out to the designated stroke hospital in that citys system despite symptoms typical of public education campaigns and infographics on stroke her symptoms were minimized unrecognized and mischaracterized putting ms g well beyond the optimal window for acute stroke identification and initial management the challenges and issues prompted by her experience are not simply related to a misdiagnosis through the inevitabilities of human error or the subtleties and evolution of clinical signs and symptoms ms g had articulated and displayed physical signs and symptoms of stroke these were interpreted by healthcare providers through a lens that could not make sense of these as stroke symptoms because of her intersecting social identities a younger single white woman her exam findings were read as anxiety at best and manipulation at worsta throwback to categorizations of hysteria that continue to impact the uptake of womens embodied experiences in the healthcare system the enduring legacy of hysteria as a label for womens health concerns highlights the persistent gender biases within the healthcare system relegating symptoms to historic stereotypes risks overlooking legitimate health issues perpetuating a cycle of disbelief that can impact the quality and timeliness of care acknowledging this historical context is crucial for dismantling stereotypes and ensuring a more equitable and compassionate approach to womens health rooted in evidencebased medicine and a genuine understanding of diverse experiences epidemiology of misdiagnosis in stroke a case for intersectionality i literally told the emt who picked me up and this is a quote its like my brain is sending signals that my foot isnt responding to and i dont know how that information didnt get to the nurses who were responsible for my care it seems to me that was pretty selfexplanatory what it meant but i think the one thing people really need to understand the signs of stroke in younger women my nurses i know i told you this but they not only didnt believe methey accused me of lying about my symptoms and that to me is unconscionable like ms g women who present with stroke are more likely to have their symptoms go unrecognized variations exist in the timeframe at which women receive standardized and evidencebased care and the type of care offered compared to men including being less likely to be seen by a stroke specialist or receive diagnostic testing the interplay between gender and adherence to guidelines is also rapidly evolving in 2018 twothirds of heart and stroke clinical research was reported to be based on symptoms in men 28 of women received ecg within 10min period in contrast to 38 of men clotdissolving therapy was offered to 32 of women in contrast to 59 of men more recently though we see significant geographic differences and a multiplicity of factors underlying in gender inequity in the detection of stroke as well as increasing sexbased parity within time trends in endovascular therapy gender biasbased knowledge gaps are variable in how they translate to clinical disparities in prevention diagnosis poststroke care and secondary outcome within the dynamic relationships between age gender ethnoracial identity language and nationality social ecological models of disparities relating to access to stroke care and functional outcomes from stroke are particularly demonstrative of the ways that gender ethnoracial minoritization and classsocioeconomic status are mutually constitutive of increased barriers and worsened outcomes epidemiological data relating to inequity and health disparities in stroke are welldocumented but understanding underlying causes has been more lacking often due to the complex and multilevel nature of the phenomena intraand interpersonal factors including implicit bias and stereotype threat institutional and organizational factors such as the number of care transitions that take place in stroke pathways multidirectional neighborhood and community factors that influence predisposing factors in addition to accessibility of care referral pathways and functional supports and larger policies and practices that can embed structural forms of racism amongst other discriminatory practices in health settings her younger age and a combination of typical as well as atypical symptoms decreased attention to stroke as a possibility young people have higher occurrence of less typical stroke symptoms and greater heterogeneity in stroke etiology this is especially true for women but rather than consider that age and gender might lead to the presence of less typical stroke symptoms in this case the intersection contributed to the characterization that ms g was not straightforward or was mistaken in her depiction of these symptoms this reflects how typical symptoms have been determined based on older bodied experiences which get set as the unmarked norm it also reflects what maya dusenbery has termed the trust gap that operates in healthcare settings the trust gap refers to a tendency to treat particular group members as less credible in their testimony or interpretation of their own experiences contributing to a dismissal or minimization of symptoms undertreatment and misdiagnosis the trust gap is lockstep with knowledge gaps and can be understood as contributing to what has been termed epistemic injusticea form of injustice in which particular group members are regarded as less credible or knowledgeable about their own situation due to their social position qua group member epistemic injustice exacerbates negative psychosocial impacts of medical experiences affecting a persons sense of self their ability to trust their own judgments and their recovery process while further contributing to asymmetries of knowledge power within medical contexts once i was transferred to the designated stroke hospital my care improved significantly… i was also in rehab for about a month… my stay in rehab was great everyone there was fantastic… at the point when i was discharged i was walking with a cane then about a week after i was discharged i was able to stop using the cane completely at this point in time my leg is completely recovered i still have a little bit of the frozen arm thing happening i can almost get my arm up but not quite yet but its improved quite a lot the only other major effect that im feeling is a bit of shortterm memory loss… id say there needs to be more understanding awareness and recognition of what stroke looks like in younger people they let me sit in the er department for five hours without doing any sort of neurological assessment had i had a clotbased stroke my outcome would be very different right now im extremely lucky that it was a hemorrhagic stroke importantly ms g also occupied social positions of privilegewhite fluent in the language higher socioeconomic group employedand so she was also able to advocate for herself once out of the emergency area her experience of being misdiagnosed and experiencing the trust gap about her symptoms was certainly distressing but was not repeated in numerous other health contexts she interfaced with it did not stop her from accessing further rehabilitation services care transitions are an identified area where stroke survivors from historically disadvantaged groups are likely to face challenges ms gs social identities contributed to misdiagnosis but they became assets as she transitioned out of the initial healthcare setting reflecting the dynamic nature of intersectionality what does intersectional brain health look like our discussion illuminates a number of different issues if the brain health gap relating to stroke is going to be addressed first a more nuanced understanding of challenges entering stroke pathways is needed including the ways that misdiagnosis in stroke among minoritized groups impacts downstream care the field needs to move beyond incidence rates for discrete demographic groups and understand differences within groups are being mediated by aspects of identity that are impacted by structural disadvantage the tendency to misdiagnose a stroke does not necessarily stem from a lack of technological advancements or incompetency among healthcare professionals rather it arises from a range of institutional and structural factors that may include implicit biases knowledge gaps surrounding who is impacted by less typical stroke symptoms and in what ways why certain symptoms are considered less typical and the systemic propensity to overlook or downplay symptoms in marginalized groups the ongoing disparities amongst minoritized groups in stroke reflect an urgent need for an awareness and understanding of how intersectionality impacts clinical acumen differential diagnosis and access to high quality care second understanding and addressing the broader impact of stroke on women younger adults and people racialized as minorities extend beyond the initial misdiagnosis challenge that intersectional frameworks can inform stroke survivors are confronted with a complex array of health outcomes impacting their physical wellbeing mental health and cognition which increase a persons interfacing with medical care and the need for care transitions barriers and facilitators of recovery need an intersectional framework for research and care delivery given that ethnoracial minoritization gender age language ability geography and nationality are all implicated as meaningful and context dependent to that end it is relevant that ms g was seen in the canadian healthcare contexta universal health system where acute care has substantive financial investment and where there is a degree of geopolitical stability understanding that the canadian context is but one location which will shift the valence of different social identities and their impact on stroke care is also crucial for ensuring that findings from one time and space are not erroneously generalized finally intersectionality calls us in to social change research that is merely descriptive will not shift us toward a more inclusive model of healthcare that can reduce the incidence of misdiagnosis improve treatment outcomes and improve quality of life from a biopsychosocial perspective biases that contribute to misdiagnosis lack of evidencebased intervention and worsened longerterm outcomes are often more impactful for stroke patients who are minoritized along multiple social axes of power given that agerelated biases are mutually constitutive with other forms of biases that influence stroke care we need to ensure that attention is not merely paid to interpersonal processes and knowledge gaps but rather that the larger underlying structural causes of these knowledge gaps are addressed when we fail to identify and name structural injustices as structural epistemic marginalization takes place that furthers worse outcomes and the systems that contribute to inequity 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 humans were approved by university health network research ethics board the studies were conducted in accordance with the local legislation and institutional requirements the participants provided their written informed consent to participate in this study 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

recent attention into sex and genderbased inequities surrounding outcomes for brain health disorders has generated momentum toward addressing what has been called the brain health gap importantly though women are not uniform demographic group in this perspective piece we discuss misdiagnosis in stroke as an aspect of access and quality of care within brain health drawing on narrative data from a mixed methods study of young stroke survivors we suggest that while missed stroke isnt only an issue of gender if we are going to understand genderbased gaps in access and navigation through stroke care we have to understand how intersections of gender with age ethnoracial identity nationality language dis ability and other aspects of social identity come together to create affordances as well as biases that contribute to stroke outcomes

introduction untreated dental caries has been shown to be the greatest disease burden in the world with untreated caries of deciduous teeth ranked as the 10th greatest global disease burden 1 as a consequence children suffer poor oral health and poor quality of life especially for those from socially disadvantaged backgrounds 2 the association between socioeconomic status and health outcomes has been well established and it further affected by such factors as ethnicity 34 for decades research on ethnic disparities in health has provided evidence that health inequalities may decrease or even disappear if ses inequalities were eliminated 5 however in recent years the focus on racialethnic health inequalities has shifted from race or class to the intersectionality between raceethnicity and class 6 for example findings from a longitudinal study of a birth cohort showed that health gains from improved family economic resources were smaller for black than for white young people 7 similarly the effects of parental education on families functioning to escape poverty was larger for white compared to black 8 based on the diminished return theory for minorities raceethnicity and ses are two different and interrelating factors of social position that may explain the role of racialethnic upon health inequities 69 during the migration process immigrant families face multiple disadvantages when adapting to the host society in terms of lifestyle and cultural norms these disadvantages include financial hardship for settlement language difficulty little knowledge of available social and healthcare resources and psychosocial stress caused by their unsettled immigration status with regard to oral health migrant children have been shown to have poorer oral health outcomes compared with children in the host country 10 it has been suggested that this may be due to the fact that migrant childhood is exposed to multiple disadvantages during the migration process which had adverse consequences for growth and health as possible consequences of these socioeconomic and cultural disadvantages children from newly arrived immigrant families are more likely to suffer the poorest oral health a recent australian study showed that length of time as a resident in the host country was an independent predictor for the preschool childrens obvious caries experience 11 an additional factor in a childs obvious decay experience is the association between maternal oral health related knowledge beliefs and practices and child oral health 12 13 14 15 furthermore mothers cariogenic bacteria can be transmitted to the child which has been shown in the association of maternal and childs levels of streptococcus mutans 16 other studies have reported an association between childrens caries experience and their mothers poor oral health status 1316 more significantly mothers who do not appreciate the importance of child oral health are less likely to brush their childrens teeth with fluoride toothpaste 16 it is therefore of importance to address these factors when designing a communitybased oral health promotion intervention to improve parents oral health related knowledge attitudes and behaviors regarding child oral health unfortunately little research investigating specifically chinese migrant parents oral health related knowledge beliefs and practices are available wong et al explored chinese parents perceptions regarding oral hygiene and access to dental care they found that parents had proper knowledge about the best feeding practice and had fatalistic attitudes toward child tooth decay 17 the lack of oral health related knowledge and positive attitudes created barriers for chinese parents when they sought preventive dental care for their young children wong et als findings further underscore the need of an oral health promotion intervention that is culturally appropriate for chinese migrant parents 17 communitybased interventions such as home visiting programs have been demonstrated to be effective in raising parental awareness of and assisting them to adopt healthy lifestyle behaviors that are beneficial to childrens health needs 18 19 20 using a onetoone health educational approach community health workers who are from similar ethnic and social backgrounds will be more likely to understand the psychosocial difficulties concerns and health needs of newly arrived immigrant families this as proposed will build up trusting relationships between parents and oral health professionals and will enable the delivery of oral health messages the aim of this study therefore was to examine the effect of a communitybased home visiting oral health education intervention delivered in a culturally appropriate approach for chinese newly arrived undocumented migrant mothers it focused on promoting mothers oral health related knowledge their intentions to brush their babies teeth with fluoride toothpaste and to control baby sugar snacking their oral health related behaviors as well as their own oral health in terms of obvious decayed experience materials and methods study design and setting the study design was a quasiexperimental study with no randomization of the participating chinese newly arrived undocumented migrant mothers undocumented migrants are people who are living without a valid residence permit authorizing them to permanently stay in the country in which they are currently residing 21 the study setting was in the south and west regions of belfast in the uk in northern ireland chinese migrant group constitutes the largest ethnic group with an approximately size of population of 8000 22 the majority of the chinese population originate from hong kong and have been residents in ni since the 1960s however in recent years chinese people from northern region of fu jian province of southern china one of the most deprived areas in china have migrated to ni most of the fu jian men work in catering services for long hours with low pay the fu jian undocumented migrant mothers are unable to speak much english and remain at home most of the time in terms of the dental health care system in northern ireland people have to pay for their dental treatments unless they are entitled to free national health service dental treatments 23 for example it is free for children under 18 and pregnant women as well as women with babies aged up to 12 months to receive dental examinations and treatments in nhs dental care services sample a sample size of 17 chinese migrant mothers in the intervention group and 17 in the control group was calculated to have 80 power to detect a difference in the caries incidence of 056 between the intervention and control group mothers d 3 mft assuming that the common standard deviation is 055 using a twogroup ttest with 005 twosided significance level on statistical advice the control group mothers were recruited six months before the recruitment of intervention group mothers this was to reduce the possibility of contamination from this oral health education intervention the intervention group mothers were selected to match the demographic profile of the control group mothers both intervention and control group mothers have been settled in the uk for no longer than three years all participants were undocumented migrants a snowball sampling technique was used in order to recruit this hard to reach group of newly arrived undocumented migrant mothers 24 this strategy relied on the initial participating mothers to provide access to other members of their group or community by word of mouth intervention program the intervention aimed to promote chinese newly arrived undocumented migrant mothers oral health related knowledge their intentions to brush babys teeth using fluoride toothpaste and to control baby sugar consumption and their oral health related behaviors in the first 12 months of the babys life therefore prior to the development of the program the chinese welfare association and community leaders were contacted the nature of the program was explained and advice requested using the information received from talking with chinese migrant mothers with toddlers born in belfast and understanding their health and social needs the program was formulated the communitybased oral health education intervention was delivered by a chinese community health worker in a culturally appropriate way through home visiting and telephone contact at five different time points over the intervention period during the home visits sy provided information about oral health focusing on promoting healthy feeding baby teething and benefit of twice daily toothbrushing using fluoride toothpaste as well as regular dental attendance for both mothers and babies she also demonstrated the correct toothbrushing techniques to the mothers in the intervention group and encouraged them to use the teething and oral hygiene resources as well as a trainer cup these were provided during the intervention in addition the trust between the chinese health worker and mothers was built throughout the intervention period and social support provided based on mothers needs such as referring them to the local social services and health andor oral health services table 1 the procedures of the intervention program 25 infants age intervention tasks support materials provided weeks the community health worker is to weaning information leaflet 3 • provide baby teething ring 4 mothers toothbrush and fluoride toothpaste months a telephone call was made to reinforce the information given at 8 weeks months the community health worker is to • emphasize the need to start to brush babys teeth with a smear of fluoride toothpaste as soon as first teeth erupt • demonstration of baby toothbrushing with emphasis on the smear size of fluoride toothpaste on baby • emphasize the benefits of introducing a feeding cup from 6 months onwards rather than a bottle • give advice on suitable foods and drinks for the benefits of babys teeth 1 baby trainer cup 2 oral health pack containing baby toothbrush and fluoride toothpaste 3 mothers toothbrush and fluoride toothpaste months a telephone call was made to reinforce the information given at 6 months months the community health worker thanked mothers for their participation baby feeding cup 2 toothbrushes and fluoride toothpaste for mothers and child data collection questionnaire the questionnaire was developed in several parts which included demographic information assessments of the mothers oral health related knowledge attitudes and behaviors mothers demographics included information such as their age marital status and postal codes of their residential areas the post code would enable an assessment of social deprivation to be made using the noble index of deprivation 22 the noble index of deprivation is a multiple deprivation measure that includes information from the seven domains of income employment health and disability education skills and training proximity to services living environment and crime and disorder the attitudinal items were assessed on a fivepoint likert scale ranging from strongly disagree through neither agree nor disagree to strongly agree these questions were derived from previous studies and had a good reliability and validity 26 the questionnaire contained one oral health related knowledge question with a single choice answer at the baseline assessment regarding the age of babies that mothers think they should start brushing babys teeth a section was included for the sixmonth and 12month questionnaire assessments to evaluate mothers knowledge and behaviors with regard to baby toothbrushing using fluoride toothpaste if the mother answered yes then she would be asked to complete this section about baby toothbrushing otherwise she would be advised to go to the next section of the questionnaire questions regarding mothers own oral health related behaviors such as toothbrushing behavior and dental attendance were included in the questionnaires using single choice answers such as how many times do you brush your teeth during the day and what is your usual reason for going to see a dentist assessment of mothers dental health status prior to the evaluation an independent and calibrated dental examiner who was blind with regard to the aim of the study was invited to examine all the participants teeth after training and calibration ass intraexaminer reliability was 094 mothers dental health status was assessed using obvious decay experience the protocol used recognizes decay which extends into the dentine on the basis of a clinical examination conducted without the use of probes 27 dental caries were diagnosed at the decay into dentine threshold using a visual method without radiography fiberoptic transillumination or compressed air the mothers teeth were inspected under standardized illumination the calibrated dental examiner used a flexilum light and mouth mirror all necessary steps were taken to prevent crossinfection for example disposable gloves and disposable mirrors were used and collected in medical waste bags and were disposed of in hospital outcome measures the primary outcome measures were mothers oral health related knowledge attitudes and behaviors with regard to baby toothbrushing sugar consumption and baby tooth decay as well as maternal dental health behaviors measured at eight weeks six months and 12 months the secondary outcome measure was mothers obvious decay experience examined at eight weeks six months and 12 months ethical considerations ethical approval was granted from the office for research ethics committees northern ireland all subjects gave their informed consent for inclusion before they participated in the study statistical analysis data from questionnaires were entered into spss 1201 frequencies were computed to describe the demographic profile of mothers of babies mothers attitudinal questions regarding their intentions to brush babys teeth using fluoride toothpaste and to control baby sugar consumption were summed according to the likert scales developed from factor analyses from the previous study 26 chisquared analysis and fishers exact test was used to compare mothers oral health related knowledge and selfreported behaviors between intervention and control groups at different time points throughout the intervention period ttest analyses were conducted to compare differences in maternal oral health related attitudes and mothers oral health outcomes at each assessment between intervention and control groups the differences with regard to changes over intervention time in the mean scores of maternal oral health related attitudes and their oral health outcomes between baseline and 12 months were compared between intervention and control groups using ttests the use of differences in the mean scores allowed the analyses of all the data while excluding the two missing mothers at 12 months results a convenience sample of 36 chinese newly arrived undocumented migrant mothers of new babies was recruited one mother from the intervention group and one mother from the control group were lost to the 12month followup as they moved from ni the baseline information indicated that mothers demographic characteristics were comparable between intervention and control group mothers oral health related knowledge at baseline sixteen mothers irrespective of their groups correctly answered the question that they should start brushing babys teeth as soon as the first teeth erupt no other statistically significant difference was shown between intervention and control group mothers at sixmonth assessment of the 18 mothers who stated they had started brushing babys teeth a higher proportion of intervention group mothers knew that they should start brushing babys teeth as soon as the first teeth erupted and the time they should start using fluoride toothpaste compared with control group mothers however there were no statistically significant differences between the two groups sixteen intervention group mothers knew the right amount of fluoride toothpaste when brushing their babys teeth as compared with control group mothers at 12month assessment of the 20 mothers who stated they had started brushing babys teeth a statistically significant higher proportion of intervention group mothers knew that they should start brushing their babys teeth and use fluoride toothpaste as soon as the first teeth erupted compared with control group mothers mothers oral health related attitudes no statistically significant differences were shown in mothers oral health related attitudes with regard to their intentions to brush babys teeth and to control baby sugar consumption between intervention and control group mothers at baseline at sixmonth follow up intervention group mothers had statistically significant higher mean attitudinal scores in importance and intention to brush babys teeth and importance and intention to control baby sugar snacking compared with control group mothers similar findings were shown in their 12month followup assessment when the changes of mothers attitudinal mean scores over intervention period were measured intervention group mothers had statistically significant changes in their perceived importance and intention to brush babys teeth and importance and intention to control baby sugar snacking compared with control group mothers these changes in mothers attitudinal mean scores between baseline six months and 12 months between intervention and control groups were also shown in line graphs when the changes of mothers attitudinal mean scores over intervention period were measured intervention group mothers had statistically significant changes in their perceived importance and intention to brush babys teeth and importance and intention to control baby sugar snacking compared with control group mothers these changes in mothers attitudinal mean scores between baseline six months and 12 months between intervention and control groups were also shown in line graphs mothers oral health related behaviors at baseline twentyeight mothers reported brushing their own teeth using fluoride toothpaste at least twice daily no statistically significant difference was shown regarding reported daily frequencies of toothbrushing between intervention and control group mothers twentythree mothers stated they were registered with a dentist eight mothers stated that they attended for regular dental examinations and the remainder reported that they went to see a dentist either for treatment or only if having problem with their teeth or gums nine mothers stated that they had never visited a dentist no statistically significant differences were shown with regard to mothers dental attendance at baseline at sixmonth assessment 18 mothers stated that they had started brushing their babys teeth at six months statistically significant higher proportions of intervention group mothers compared with control group mothers stated that they brushed their babys teeth statistically significant higher proportion of mothers from the intervention group compared with the control group stated that they brushed their own teeth at least twice a day twenty mothers reported that they brushed their babys teeth at 12 months statistically significantly higher proportions of intervention group mothers stated that they brushed their babys teeth compared with control group mothers no other statistical differences were found in mothers other oral health related behaviors such as regular prevention oriented dental attendance mothers obvious decay experience there were no statistical significant differences in mothers obvious decay experience between intervention and control group mothers at baseline six months and 12 months no statistical significant difference in mothers obvious decay experience over intervention period was found between intervention and control group mothers discussion the intervention has shown the promising effect in improving mothers oral health related knowledge perceived importance and intention to take care of babys teeth in terms of baby toothbrushing and sugar snacking and their improved selfreported baby toothbrushing behaviors mothers oral health related behaviors at baseline twentyeight mothers reported brushing their own teeth using fluoride toothpaste at least twice daily no statistically significant difference was shown regarding reported daily frequencies of toothbrushing between intervention and control group mothers twentythree mothers stated they were registered with a dentist eight mothers stated that they attended for regular dental examinations and the remainder reported that they went to see a dentist either for treatment or only if having problem with their teeth or gums nine mothers stated that they had never visited a dentist no statistically significant differences were shown with regard to mothers dental attendance at baseline at sixmonth assessment 18 mothers stated that they had started brushing their babys teeth at six months statistically significant higher proportions of intervention group mothers compared with control group mothers stated that they brushed their babys teeth statistically significant higher proportion of mothers from the intervention group compared with the control group stated that they brushed their own teeth at least twice a day twenty mothers reported that they brushed their babys teeth at 12 months statistically significantly higher proportions of intervention group mothers stated that they brushed their babys teeth compared with control group mothers no other statistical differences were found in mothers other oral health related behaviors such as regular prevention oriented dental attendance mothers obvious decay experience there were no statistical significant differences in mothers obvious decay experience between intervention and control group mothers at baseline six months and 12 months no statistical significant difference in mothers obvious decay experience over intervention period was found between intervention and control group mothers discussion the intervention has shown the promising effect in improving mothers oral health related knowledge perceived importance and intention to take care of babys teeth in terms of baby toothbrushing and sugar snacking and their improved selfreported baby toothbrushing behaviors these findings have further addressed the importance of tailoring the community based oral health intervention through including the local community in the development of the intervention more importantly this intervention supports the proposition that health intervention for newly arrived migrant groups should be provided in a culturally appropriate manner using community health workers who speak the same language and share the same cultural background the recruited chinese undocumented migrant mothers were characteristic of those with multiple social disadvantages being undocumented migrants had language difficulties experienced problems in adapting the mainstream society had lower levels of educational attainment and resided in disadvantaged areas 2829 the limited literature suggested children of migrant families had poorer oral health compared with children of indigenous families 30 a recent american study indicated a social pattern in childrens regular dental visits with children of nonpermanent residents having the lowest dental care utilization rate followed by children of permanent residents naturalized parents and usborn parents 31 to my knowledge no other studies have concentrated on the oral health of undocumented migrant families living in the uk therefore this is the first study to report findings of oral health changes in terms of parental oral health related knowledge attitudes and behaviors after a communitybased intervention delivered to this hard to reach population mothers in the intervention group of this study showed significant improvement in their oral health knowledge and selfreported behaviors in terms of controlling baby sugar consumption most of them knew that sugar was bad for teeth it seemed that the intervention group mothers were ready to receive and assimilate this message about baby sugar snacking into their daily dietary regimens of interest was the finding that mothers in the intervention group reported significant improvement in their perceived importance and intervention to control baby sugar snacking these are meaningful results as other studies have reported that prolonged bottlefeeding is found more often in migrant families 3032 similar findings were reported in other parental oral health intervention programs for newly arrived migrant parents in terms of the effectiveness in improving parental oral health related knowledge attitudes and practices to take good care of childrens teeth 3334 the other meaningful finding was the intervention group mothers had improved knowledge perceived importance and intention to brush babys teeth as well as their increased level of reported baby toothbrushing behaviors these effects might be due to several reasons first mothers received culturally sensitive information of baby tooth decay and the importance of toothbrushing with fluoride toothpaste to prevent child tooth decay secondly mothers were provided with a toothbrush and fluoride toothpaste for their infants and themselves this meant that the financial costs and length of time adopting this healthy behavior was reduced and thirdly the young mothers were more responsive it may be proposed that mothers were more ready to receive and act upon the oral health information about the welfare of their child this was reflected in mothers being more likely to practice toothbrushing skills including establishing and assisting with child oral hygiene routines in addition it may be postulated that the adoption of parental toothbrushing could be thought of in terms of the developed trusting relationship with sy and adopted more mainstream lifestyle habits 35 despite the intervention group mothers improved knowledge and attitudes towards baby toothbrushing many mothers expressed frustrations when brushing their babies teeth for instance some mothers complained that their babies would not sit quietly when having teeth brushed these frustrations may affect mothers confidence to develop and maintain routine oral hygiene practice in other words mothers who had low selfefficacy of baby toothbrushing might be less likely to adhere to this oral hygiene regimen as suggested by the health action process approach 36 similar findings were reported by marshman and her colleagues in terms of parents perceived barriers to brushing childrens teeth 37 these included parental selfefficacy of toothbrushing and their beliefs about the consequences it further indicated the importance of social support that may exhibit as an enabling factor to empower mothers to overcome such challenges for behavior change this is particularly significant for undocumented migrant mothers whose home based routines might be chaotic therefore it may be suggested that perhaps two home visits during the intervention period are not enough for chinese undocumented migrant mothers to develop all aspects of parenting including child oral health home care more intensive home visits would be recommended to encourage them to develop child rearing and parenting skills in a holistic approach that incorporates baby oral health related practice as a component while no statistically significant changes were found in mothers obvious decay experience between intervention and control group mothers this could be due to the relatively short period of the intervention to observe the changes in the clinical outcomes the reason of including mothers oral health status assessment in this intervention is according to the established strong association between mothers active caries status and childrens caries experience 16 future research should consider a longer followup period to record changes in parental oral health status as an indicator to evaluate the effect of parental oral health education interventions it may be suggested that this program has shown that giving oral health education to chinese migrant mothers in a cultural sensitive manner using a onetoone counselling strategy can assist in raising maternal awareness of child oral health during home visits the role of sy must be considered as a factor with regard to the effectiveness of the intervention sy a chinese mandarin speaker from mainland china conducted the program sy shares language culture and lifestyle habits in common with chinese migrant mothers living in belfast moreover sy was the same age as the mothers therefore sy understood the chinese migrant mothers psychosocial and health needs the mothers in turn trusted her and consequently remained in the program this partially explained the high retention rate in this study despite the small sample size more importantly this indicated the significance of the role of a community health worker sharing the same language and culture to understand and address the needs of this socially excluded group of mothers limitation of the study there are several limitations in this study the first is related to the sample the sample gathered was a nonprobability convenience sample this is inevitable given this group is not recorded in the uk databases that could be used as sampling frames 38 this is a most socially excluded group where the chinese migrant population amounts to just a few thousand throughout northern ireland therefore the limited sample we recruited was the entire population of accessible undocumented chinese migrant mothers with babies aged less than eight weeks during the recruitment period we acknowledge that the small size of the sample may increase the likelihood of type ii error despite this concern this work is innovative since there is little work done to promote oral health related knowledge attitudes and behaviors of this undocumented migrant group in northern ireland secondly as sy is the researcher and also the community health worker to implement the intervention the present study did not use any blinding measures to reduce bias which may affect the results of the study further sys high motivation may limit the reproductivity of similar findings for future interventions however this research work is regarded as meaningful for adding evidence into the limited literature to report effects of communitybased interventions delivered to the undocumented migrant parents moreover other studies have shown strong evidence in the effectiveness of having community health workers who share same language and culture to provide culturally appropriate health education 39 lastly the oral health related behaviors regarding baby toothbrushing mothers own toothbrushing and regular dental attendance were selfreported by mothers who might have provided socially favorable answers this may affect the reported effectiveness of this program furthermore the evaluation of the program may have been contaminated by sy mothers in the control group asked sy for information regarding dental health and how to access health and social services for ethical reasons it was impossible not to have answered their requests this concern of contamination allows a series of questions to be raised in relation to the effectiveness of the program it would seem reasonable to suggest the need to investigate the areas of contamination since this will assist in the development of future successful health promotion interventions for ethnic minority and migrant group parents conclusions to conclude despite the small sample size of the present study the community based parental oral health education program delivered in a culturally appropriate approach has shown promising effects to improve chinese undocumented migrant mothers knowledge attitudes and selfreported behaviors with a specific emphasis on baby toothbrushing and control of baby sugar consumption

background poor oral health remains a significant dental public health challenge for ethnic minority and immigrant groups living in the uk this study aimed to evaluate a culturally appropriate communitybased home visiting oral health education intervention for chinese undocumented migrant mothers to promote their infants oral health by focusing on their oral health related knowledge attitudes and behaviors methods a convenience sample of 36 chinese mothers with babies aged less than eight weeks were recruited in southeast region of belfast the local chinese community was consulted to assist with the development of the intervention the oral health education intervention was provided to 19 intervention group mothers through home visits and telephone calls during mothers first postpartum year they were also provided with unlimited social support during the intervention period mothers oral health related knowledge attitudes and behaviors regarding baby toothbrushing and sugar snacking were measured at eight weeks six months and 12 months results a higher proportion of chinese intervention group mothers had improved knowledge about baby toothbrushing at 12 months compared with control group mothers χ 2 1412 p 0004 significantly more intervention group mothers oral health related attitudes were enhanced regarding baby toothbrushing and sugar snacking compared with control group mothers conclusion this communitybased oral health education intervention has shown effects in mothers selfreported knowledge attitudes and behaviors in the intervention group when the community based and culturally appropriate homevisiting program improved the mothers oral health related knowledge attitudes and behaviors

introduction 1agenda 2030 and education the growing global concern about caring for the planet and ensuring prosperity for all meant that by 2015 the united nations established a series of global goals 1 these objectives are grouped into 17 sustainable development goals which in turn are divided into 169 specific targets that detail and specify each of the sdgs 2 this proposal of global sustainability is framed under the concept agenda 2030 and emphasizes that all levels of society both collective and individual must contribute to achieving the sdgs 3 in addition to focusing on ecology as a central axis these objectives include additional problems such as circular production waste generation poverty or health and welfare urban development or peace among others 1 in this way many spheres of intervention will be covered not only environmental but also economic ethical and sociological 4 with a clear purpose such as balancing current development with future progress however although the sdgs are a proposal to be achieved in 15 years some research has highlighted that the sdgs pace of achievement is not as 2 of 17 fast as expected 5 therefore all government and nongovernment institutions must collaborate to facilitate the acquisition of these goals 6 within these institutions education should be considered a key factor in consolidating sustainable habits in future generations 78 the united nations decade of education for sustainable development 9 already detailed this importance pointing to integrating sustainable development actions into all aspects of education to promote changes in knowledge and attitudes towards sustainability therefore at the institutional level education in all its amplitude is one of the main axes on which to structure sustainability 10 lauder et al 11 highlighted the importance of education in responding to the planets socioenvironmental problems this importance is recognized by sachs 6 which highlighted how education was a key factor in achieving the longstanding proposal of the millennium goals although education is addressed directly in sdg 4 quality education united nations educational scientific and cultural organization 12 established the concept of education for sustainable development aimed at empowering students to make responsible decisions in pursuit of a just society economic and environmental integrity in the present and future generations it has been pointed out that teachers play a decisive role in esd as those responsible for educating future generations 13 however the different institutions must clarify their goals indicators and concrete actions concerning the sdgs to develop results frameworks and collect data on the level of achievement 14 physical education physical activity and sport a key tool in obtaining the sdg the study of sport and physical activity pertaining to the sdgs has been mainly carried out by three institutions first the sixth international conference of ministers and senior officials responsible for physical education and sport 15 this conference identified three broad areas of intervention that aimed to develop an inclusive vision of access for all to the sport physical education and pa maximize sports contribution to sustainable development and peace and protect the integrity of the sport this paper reviews the various sdgs proposed to highlight those relevant to pa and sport however the pe role in agenda 2030 is not specifically set out parallel to mineps vi the commonwealth published a document where the contribution of sport to the sdgs was clarified 16 this document had the peculiarity of establishing a series of indicators and achievements that will measure the contribution of the different areas associated with sport more objectively when developing the sdgs at the same time it served as a reference along with the indications presented at mineps vi to publish a new report detailing what specific targets of each sdg could be worked on through sport 14 however the specifics regarding pe were not detailed finally in 2019 the iberoamerican sports council and the iberoamerican general secretariat jointly published a report establishing sport as a tool for working towards sustainable development 17 in this case they selected those targets of the sdgs that could be worked on through the pe sports practice or sport as an institution while establishing a thorough analysis of how this relationship would occur and proposed a series of strategies and partnerships for the promotion of sustainable development this reports main findings were that not all the specific goals for each objective have the same directionality and ramifications with sport highlighting instead a direct relationship with eight of the 17 sdgs and 19 of the 169 specific targets another example of sport and pas relationship with the sdgs is reflected in the narrative review of day and menhas 18 however again these authors cannot separate the relationship between pe and the specific goals proposed by unesco finally other institutions such as the who have confirmed these relationships and shown the health social and economic benefits of contributing to 13 of the 17 sdgs but do not specify concrete goals that could be worked on rather these institutional proposals emphasize the unified analysis of the concept of sport physical exercise and pa so much so that mineps vi 15 begins by considering this conceptual appreciation the term sport is used as a generic term that includes sport for all physical play leisure dance and organized improvised competitive traditional and indigenous sports and games in their different manifestations in contrast the commonwealth details the terminological differences between sport organized sport pa physical exercise pe and quality pe 14 however despite recognizing these differences the selection of targets from each sdg was perceived from a general perspective of sports in short it is of particular interest and necessity to establish meeting points to address the different challenges of the future from a multidisciplinary approach and that is where the main objective of the study resides when establishing the possible relationships between pe as a discipline that has among other curricular objectives pa in the natural environment as enjoyment and care of the environment and the sustainable development goals from the review analysis and relationship of the different specific goals it is specifically proposed to analyze the possible relationships of the new pedagogical models in pe as an engine of methodological change with the goals derived from the 2030 agenda to lay the foundations for future research related to the work that can be carried out from educational centers specifically pe for sustainable development becoming a priority objective of the new legislative frameworks in education for all these reasons this researchs main objective was to analyze and select the specific goals of the sdgs that can be implemented in the field of pe in addition having clarified which specific goals can be worked on in pe this study aims to relate these specific goals to the different models based on pe practices systematic review used for this study a critical review has been used as defined by grant and booth 19 with the main aim being the critical evaluation of all the existing literature aligned with the studys objectives beyond mere description including the degree analysis and conceptual innovation that it entails in addition to identifying the most important elements in the field of knowledge this approach to the study leads us to a future line of research or establishing a proposal or intervention model based on pedagogical models in our study as is typical of this type of work as indicated by the authors mentioned above similarly we could identify common elements with a narrative review such as the search or review of the complete literature or not and may or may not include a quality assessment which is in line with our work this type of review is truly useful in education since it allows us to detail in a justified and understandable way certain realities that may go unnoticed 20 narrative reviews help the reader understand the essence of the content displayed providing evidence and justification for the text 21 its use in research is necessary and fundamental since it allows justifying facts situations and evidence from an explanatory point of view and it is not new in the science and education of sport in our field 22 in this case the contribution is significant within pe giving rigor to such substantial elements as methodology and evaluation therefore it is not a traditional systematic review but rather an argumentative critical explanation about the justification of the close relationships and the contribution from the pe area and specifically from pedagogical models that can be made to sustainable development as a priority objective globally for this the united nations objectives under the concept of agenda 2030 and the specific goals derived from them are presented as the main elements reflecting all the possible actions that can be carried out from the scope of pe therefore it does not make sense to present the aspects related to the inclusion and exclusion criteria or the reliability of the data extraction rather it is more related to systematic reviews of an analytical and quantitative nature physical education and targets of the sustainable development goals a proposal selection this critical reviews first objective was to select those sdg targets that could be implemented in pe for this purpose an exhaustive analysis of the institutional contributions is presented in table 1 this table shows that of the 169 specific goals proposed by unesco the relationship between sport and sustainable development can be seen in 68 of them approximately 40 in the case of the iberoamerican sports council 17 however the sixth international conference of ministers and senior officials responsible for physical education and sport 15 selected a total of seven sdgs that relate to pa sport and pe the importance of this relational analysis between pe and sdgs could be justified by the very significance unesco accords to pe an example of this is to see how since the international charter of physical education and sport 23 in 1978 the role of sport and pe has been extolled as a fundamental right for everyone additionally agenda 2030 recognizes sport as an important facilitator of sustainable development and peace adding that it can increasingly contribute to making development and peace a reality by promoting tolerance and respect to support the empowerment of women and youth individuals and communities or to achieve goals in health education and social inclusion 24 despite this analyzing the united nations document for the esd pe activity or physical exercise is not mentioned 12 this lack of precision in the role of pe within sdgs may carry some risk going unnoticed by the relevant bodies despite institutional efforts to increase the number of pa practice hours among other issues the who recently showed that 80 of adolescents and young people still do not carry out the minimum recommended amount and something that is extremely worrying is the increase in sedentary lifestyles 25 this recent report has established new pa recommendations of approximately 60 min per day of moderate to vigorous aerobic activity for children and adolescents and at least 150 to 300 min per week for adults in addition during the covid19 pandemic period the importance of performing pa routines to enhance the immune system has been highlighted 26 the institutional analysis carried out through the proposals of the ibc the mineps and the commonwealth was made considering the concept of sport physical exercise and pa although a terminological differentiation is proposed in the commonwealth case it is not differentiated in the relationship with the sdgs however it is essential to note that these concepts are not synonymous and have specific limitations and possibilities independently for this reason to respond to the objective of this work we have taken as a reference the indications presented by the institutions and thus was able to carry out an analysis exclusively from the exclusive concept of pe since to the best of our knowledge no document defines the role of pe in the contribution of un sdgs therefore pe may not have as many possibilities of intervention in some of the targets of the sdgs or on the contrary it may be an essential piece in the achievement of some agenda 2030 goals thus it has been considered necessary to isolate the concept of pe and present a proposal where this matter can be related to the sdgs and their specific targets sdg 3 good health and wellbeing firstly the analyzed document coincides with sdg 1 no poverty and 2 zero hunger therefore the first relationship is established with sdg 3 table 1 showed four sdg 3 that could be related to pe however it should be considered that target 33 cannot be directly treated in this area on the other hand both targets 34 35 and 36 could be worked directly in pe the improvement of mental health and wellbeing expressed in goal 34 is one of the most evident relationships established through pe sessions there is enough evidence to confirm that pa practice increases students psychological quality 2728 with it understood that such practice involves the activity carried out continuously and systematically in relation to target 35 a direct relationship can be established with pe as this subject can keep young people away from substance use 2930 regarding sex education as set out in sdg 37 a direct link should be considered as pe helps with the knowledge of ones own body and strengthens sexuality 31 finally sdg 36 has been added since driver education is a topic that appears in some pe curriculum so it is feasible to consider a direct relationship between both it is interesting to note that taking the name of sdg 3 health and wellbeing as an exclusive reference it could be understood that it is one of the sdgs most related to pe however out of the 13 incorporated targets only four are considered for application through pe sdg 4 quality education the selection of goals made by the institutions studied makes sdg 4 one of the most relevant to pe firstly target 41 is considered to have a direct relationship with pe as the un has established pe as a fundamental right of all 23 and therefore it is a crucial component of equitable and quality education furthermore there is sufficient evidence at the neuroscientific level that establishes a positive relationship between the realization of pa and academic andor cognitive performance 32 33 34 for example improved concentration 35 better performance in general executive function 3336 or an increased sense of wellbeing or dream quality 3738 target 44 is oriented in the same direction by sport in general 1417 as it involves developing personal skills related to employment 39 target 45 points out the importance of reducing inequalities highlighting gender and vulnerable people in this case the relationship with pe would also be direct as it allows the integration of values such as teamwork companionship cooperation and an ideal opportunity to develop coeducation 40 a similar situation occurs with target 47 which emphasizes the importance of improving knowledge to promote sustainable development in this case pe is working on pa implementation in natural environments and presenting sustainable alternatives such as the use of bicycles 4142 the ibc 17 established a twoway relationship with this goal pe should be considered as an opportunity to generate selfconstructed materials or the design of alternative sports that reuse a sports space or facility for a purpose other than its original one 43 however pe in itself cannot directly offer the improvement of a sports facility so the relationship with this goal is indirect finally the possibility of administering target 4b to facilitate the increase of scholarships in developing countries has been discussed but this possibility seems more the responsibility of sports institutions than schools sdg 5 gender equality gender equality in sdgs has been presented as an essential foundation for building a peaceful prosperous and sustainable world 1 specifically in the case of pe it has been described as a reflection of society where gender norms are expressed in such a way that women are less likely than men to participate in pa outside of the educational field 15 and for this reason pe should be an opportunity to promote the empowerment and leadership of women thus avoiding discriminatory stereotypes 17 the analysis of institutions targets considered the direct relationship between pe and target 41 in eliminating discrimination against women for example the tone used in class to talk to students may be perceived as different amongst genders 40 factors such as these need to be monitored during pe classes to generate student awareness of gender inequalities likewise pe in preschool education or the first years of secondary education is an opportunity to show that there are no differences in physical performance between men and women 41 this justification being extrapolated to goals 52 and 55 furthermore as stated by mineps 15 the strong and active participation of women in decisionmaking processes has a major impact on social development so the empowerment of women can be achieved through the presentation of physicalsports initiatives in pe that are attractive to them but these initiatives must also have the support of institutions outside the education sector to offer an opportunity for practice outside the educational context finally the inclusion of target 53 is not considered for applicability to pe however the suggestion of an indirect relationship is proposed by the commonwealth and is justified by the empowerment that sport can generate in women 14 sdg 8 decent work and economic growth this sdg aims to ensure inclusive and sustained economic growth that can generate decent jobs for all 1 although the sport has been described as a source of economic growth and an opportunity for decent employment 17 the reality is that pe has minimal direct relationship with this sdg however the values worked on in pe are similar to skills that are supposed to be crucial to employability such as cooperation fair play or goal management 1439 however from a perspective focused exclusively on job creation pe does not have a clear relationship although it is true that a competitive use of the pe through for example the sports education model could allow students to learn sportrelated professions such as analyst trainer or journalist among others 44 it cannot be considered a direct relationship between employability and the pe this lack of a direct relationship with the pe has meant that the ibc 17 has not established a relationship with any of the goals among the institutional ones analyzed of the purposes that have been related 83 and 89 are considered to have the potential to be worked on in pe the first of these emphasizes the possibilities of sport in general as a way to entrepreneurship and innovation although this goal could also be related to the 44 as mentioned above among the pe pedagogical models the sports education model can be a method to promote employment alternatives directly related to sport as highlighted in mineps 15 the attractiveness of sport for young people makes it a valuable framework for employability initiatives in addition target 89 highlights the opportunity to generate sustainable tourism while promoting local culture pe has a direct relationship with this goal it works on content that supports alternative employment in the framework of natural environments and sustainability and the work of traditional sports and games or local food products is also related to the pe sdg 10 reduced inequalities sdg 10 aims to reduce inequalities to ensure the sustainable development goals 1 sport is undoubtedly an opportunity for social inclusion and diversity as equal opportunities can be promoted through sport 17 targets 102 and 103 include the importance of this equality which pe can work on directly as it has been shown that pe sessions promote cooperative attitudes and inclusion 45 46 47 regarding goal 107 the contribution of pe is not considered as both institutions 1415 selected this goal considering the benefits of professional sport to promote opportunities in underdeveloped countries this aspect does not apply to pe sdg 11 sustainable cities and communities the ibc 17 relates sdg 11 mainly through the bidirectionality of accessible sports facilities in cities and the opportunity for better social cohesion and equal opportunity therefore although the proposal of goals made by the three institutions analyzed is coincidental in both cases their relationship with pe is not contemplated a relationship with pe could be considered for example through activities framed within a servicelearning aimed at improving or developing the care of a park to carry out pa however this is a characteristic of the servicelearning model rather than pe itself sdg 12 responsible consumption and production this sdg relates to the responsible use of natural resources to avoid destructive effects on the planet 1 this approach is mainly related to institutionalized sportsrelated properties as the ibc 17 indicates sport can improve sustainable living awareness both for products and sports facilities or events from an educational perspective mineps 15 focuses on the importance of educational programs to raise awareness and thus influence attitudes to change consumer behavior and the real resources from the perspective of pe an indirect relationship with the goals that compose sdg 12 could be considered for example the realization of educational activities and projects that aim to explain the cost of natural resources entails the disposal of sports materials in addition describing the environmental impact that pa can cause in a natural environment could be a strategy to consider for responsible consumer awareness however these goals may not be regarded as the direct responsibility of pe rather the education systems responsibility in general sdg 13 climate action the environmental problems suffered by humanity today have not only been collected in an sdg but are also dealt with in sdg 14 and sdg 15 specifically the analyses performed have pointed exclusively to target 131 and its relationship with sport and pa 1415 the ibc does not relate to any of these sdg targets despite this this institution points out how sports culture usually promotes environmental care in any media since it is a useful tool for educating and raising awareness among young people 17 in addition mineps 15 emphasizes the value of sport in building resilience and the capacity to adapt to risks related to climate and natural disasters however none of the approaches directly highlights the value of pe in working on this sdg in the proposal presented the pe possibilities for environmental care are considered since it is one of the main contents for example the direct relationship with target 133 which specifies the importance of education and awareness to avoid environmental problems should be assessed some research has also shown pe students opinions when practicing sports such as plogging where they jog through different environments while collecting polluting waste 48 finally institutions should consider reviewing sdgs 14 and 15 to analyze a potential relationship between sports and pe sdg 16 peace justice and strong institutions conflict insecurity or injustice are a severe threat to sustainable development 1 the ibc 17 details that sport and pa can help reduce violence improve unity as well as promote dialogue and social cohesion therefore the institutional analysis carried out shows that six of the targets proposed in this sdg have been generally related to sport pe and pa despite this it can be seen that this sdg refers mainly to improving peace and justice in official organizations and institutions and therefore is far from the potential influence of pe assuming that most of the targets do not have a clear relationship with the subject of pe while it is true that the practice of pe within the framework of activities that require cooperation and collaboration such as sports would help improve interpersonal relations among students 39 an indirect relationship could be established with goal 167 in addition this goal could also be related to applying the personal and social responsibility model which has been considered a valid pedagogical model in pe for improving citizenship 4950 finally the practice of sports governed by rules can explain the importance of respecting operational standards in a community sdg 17 partnership for the goals finally sdg 17 considers the importance of global cooperation and partnerships to achieve all the targets set in agenda 2030 1 undoubtedly concerning the values that sport or pe represents it can help contribute to emotional connections and encourage cooperative habits 17 however as in sdg 16 the specific analysis of the targets shows that this cooperation is mainly aimed at global institutions generating synergies that help achieve the sdgs especially in developing countries therefore although pe is a great tool to promote cooperation among equals its influence would be far removed the targets proposed by sdg 17 as shown in section 3 a new proposal of specific targets is suggested for pe by way of synthesis from sdg 3 target 33 related to communicable disease transmission is proposed to be eliminated and target 36 is integrated because road safety is a content that can be addressed in pe the rest of the proposed targets are maintained sdg4 stays almost in its entirety except for target 4b related to the assignment of scholarships to developing countries a similar circumstance occurs with sdg5 since the proposed list of targets is accepted except for target 53 which aims to avoid harmful practices such as child marriage however sdg8 has been limited since only two targets consider a relationship with the pe in sdg10 the decision was made to eliminate target 107 which is dedicated to facilitating migration and mobility for sdg 12 five of the six targets proposed remain for sdg 13 the proposed goal is accepted and it is suggested that 133 be added which seeks to improve education for climate change concerning sdg 16 despite offering six proposed targets 167 is the one that has been suggested with the potential to be worked on in pe finally sdg 11 and 17 have been eliminated because their goals have not been found to have transferable aspects to pe practicebased models contents and sdgs working in physical education now that the first objective has been achieved this critical reviews second objective was to relate the specific goals of the sdgs to different practicebased models achieving this objective is key because pe is characterized as a subject that offers a great methodological variety due to its content nature this diversity of methodology leads to the appearance of different teaching models that have demonstrated their validity in pe these models can be classified as cooperative learning sports education model or the model of personal and social responsibility additionally in recent years other emerging options have appeared such as adventure education attitudinal style health education or selfconstruction of materials cooperative learning the approach to cooperative learning techniques from pe will allow personal skills that improve positive interdependence social and group responsibilities individual responsibilities and promote interaction 455152 although cl techniques are not exclusively characteristic of pe the nature of pe implies greater contact and interaction which means that the benefits of cooperation are strengthened 5153 cooperative performance in pe could help contribute to the achievement of different goals a clear relationship can be observed with target 167 which aims to guarantee inclusive participatory and representative decisions which are characteristics that are intrinsic and specific to cl 5253 another example occurs with target 44 which deals with developing entrepreneurial competencies to facilitate employment access with cl leading to developing important innovative and cooperative attitudes in students for job demands 5455 in addition target 45 which focuses on promoting equality for vulnerable people can be worked on from a cl perspective thanks to the fact that all participants in a cooperative group must value their colleagues work to achieve a common goal 5657 target 83 could be added to these suggestions since it also considers entrepreneurship creativity and innovation in the business context where the social and individual skills of pe acquire special significance 5859 model of personal and social responsibility the personal and social responsibility model has been shown to be a valid pedagogical model in pe to develop students competencies related to individual and group responsibility 5060 therefore this model encourages respect equality and social values 4761 to be connected to those sdg goals with similar objectives for example social responsibility has been documented as a model that allows social awareness development regardless of gender 62 therefore targets 51 52 55 and 5c together seek to eliminate inequalities between men and women and at the same time promote and favor the empowerment of women and equal opportunities additionally as was the case with cl psr contributes in a direct way to develop peoples personal and social awareness 63 so it could also be related to the achievement of target 167 to guarantee inclusive decisions and participation in addition to the goals proposed in sdg 10 such as 102 based on the social economic and political inclusion of all people and 103 that aims to guarantee equal opportunities and reduce inequalities 6061 sports education model since this models main objective is to create a context that generates sports experiences as authentically as possible 44 it could be interesting to link it with those sdgs related more to employability it must be borne in mind that sports directly and indirectly produce a significant amount of money and employment for example according to ine sports in spain account for 33 of gdp and more than 400000 jobs representing 21 of total employment 64 in europe according to european union data it represents 212 of gdp and 272 of jobs and at a global level 600000 million a year or 152 of gdp worldwide 65 one of the excellent characteristics of this model is the variety of roles it offers to students beyond the role of an athlete for example the role of coach physical trainer journalist marketing or different management positions mediators risk control etc can be implemented 44 in addition to this multitude of functions it is of course necessary to take into account the social and personal skills that this model entails such as teamwork the transfer of responsibilities empathy and the promotion of autonomy 66 due to all these factors the sdgs goals could be related to this pedagogical model for example two goals of sdg8 ie 83 on fostering entrepreneurship creativity and innovation and 82 focused on achieving higher levels of economic productivity through diversification technological modernization and innovation in addition target 44 aimed at improving skills to access employment decent work and entrepreneurship finally it should be noted that all those goals related to the development of socialization or respect could also be worked on through this model for example target 167 seeks to guarantee inclusive participatory and representative decisions that respond to needs adventure education model this model was created to generate a learning context where interaction with the natural environment involves a series of elements of natural or fictitious risks 67 this model has been related to green pedagogies which involve a work philosophy that consists of the concept of a human being with an innate capacity to develop its full potential in interaction with the natural environment in addition gehris et al 68 pointed out that this model helps promote activities in natural environments in students free time in addition the who points to the practice of pa as an opportunity to stimulate care for the environment 25 therefore it seems to indicate that the realization of pa in natural surroundings promotes environmental care thus a relationship could be established between some of the adventure education and different sdg goals although caring for the environment is included in three sdgs none of the reference institutions chose to relate to sdg 14 and 15 therefore from the proposed goals presented in this work the relationship of ae with goals 131 to strengthen the capacity to adapt to risks related to climate and natural disasters in all countries and 133 to improve education awareness and human and institutional capacity regarding the mitigation of climate change should be considered additionally the proposed goal 121 should be considered since it aims to manage natural resources sustainably and efficiently finally goal 83 emphasizes the development of sustainable tourism that helps promote local culture so it has been presented as ae could contribute to this goal thanks to the promotion of pa in the natural environment with all that it entails selfconstruction of materials the selfconstruction of materials has been a common way of working in pe for years having among other objectives to develop an ecological conscience both in pe students and in the educational community 43 in addition the selfconstruction process of material has been documented as an ideal tool to develop the cooperation capacity and creativity of students 43 aspects highlighted in different goals of the sdgs for this reason this emerging model could be related to the goals of sdg 13 that generally defend the importance of respect for the environment or the reduction of the consequences of global warming additionally the relationship of the materials selfconstruction model with sdg 12 and its targets 121 regarding sustainable consumption and production 122 on the efficient use of natural resources 125 about the reduction of waste generation and 128 to guarantee quality information is direct finally the cooperative environment that is generated during the creation of a selfconstructed material as well as the creativity that this act entails will enable the development of skills related to entrepreneurship health education haerens et al 2011 69 pointed out the importance of conceiving pe not only as the development of a set of skills but that health should be at the center of the approach to the subject although this objective can be understood as basic or general to pe this model focuses on the effectiveness of achieving this and not just the motor aspects themselves in this way it will be possible to obtain greater regulation of pa outside the educational context that is why haerenes et al 69 highlighted the importance of conceiving this model with the idea of health education being a lifelong learning therefore he must be related to the goals that appear in sdg3health and wellbeing specifically target 34 on the reduction of premature mortality and promotion of mental health and wellbeing and target 35 on the reduction of addictive substance abuse the positive effects of pe and pa on young people are well known because of all the strategies aimed at promoting healthy habits as it is understood that as a habit or routine that is repeated regularly an active occupation of free time will generate more vital happier citizens with a higher quality of life beyond the models the contents of pe in addition to the relationship between the proposed models the nature of pe and the contents that are usually covered in its curriculum allows the development of different goals that have been selected in this proposal for example road safety education represented in target 36 has been included in some physical education curricula this promotes the use of bicycles among students to contribute to sustainable and healthy mobility on the other hand although it is not included in any goal it does speak in a general way in sdg4 of quality education in this sense it could be interesting to relate the neurocognitive and academic benefits of performing pa in a chronic 6970 or acute way for example using active breaks as an educational tool 7172 in summary for these models it should be considered that not all of them will be able to contribute to obtaining the sdgs however the selection of goals that has been carried out has been regarded as the content that the pe can work on allowing a more significant contribution to the goals in the selected sdgs for all these reasons table 2 presented below shows a synthesis of the 24 goals that can be worked on from the pe perspective and the relationship with the different modelsbased practice basic pedagogy and the contents of the subjects therefore the practical applications of the different contents worked on in pe and the modelsbased practice could be contributed to the specific goals of the 2030 agenda directly and indirectly for example the development of environmental awareness and the sustainable use of resources through an adventure education model or the selfconstruction of materials the development of virtues of cooperation teamwork or respect thanks to the cooperative learning models and that of personal and social responsibility work performance and entrepreneurship in an indirect way through the sports education model or simply improving adherence to performing pa thanks to the health education model this critical review will allow for action strategies to develop the sdgs in an educational context it may also contribute to transferring these actions beyond the educational community and initial and permanent training developed as an engine of change these aspects and those that go through defining realistic objectives and establishing verifiable results indicators and sources of data as well as ensuring that the objectives are in accordance with the available resources and develop a culture of institutional capacity to achieve said goals will achieve greater outcomes having a reliable how where and why to invest resources to maximize contributions to the development goals in a more practical sense conclusions pe is a transcendental subject that could contribute to achieving the goals and objectives set out in the 2030 agenda beyond the healthy virtues of pa and exercise pe creates a context very favorable that allows the development of cooperation respect coeducation and entrepreneurship all aspects related to the development of the sdgs however regarding the first objective proposed in this research it can be concluded that not all the sdgs goals can be implemented in pe after our analysis of the 169 goals proposed by unesco only 24 can be developed in pe classes in relation to these 24 goals and in responding to the second objective of the research it has been shown that most of them can be worked through in the context of pe in addition some practicebased models such as cooperative learning the model of personal and social responsibility or the selfconstruction of materials will allow the development of more sustainable behaviors in young students however we believe that future research projects should be developed to facilitate the application of the sdgs in the educational context for example improving the ability to measure and evaluate the contribution of sport pe and pa to the sdgs will be key to ensuring that they occur in relation to this idea the commonwealth through unesco published a practical guide and indicators to measure the contribution of sport pe and pa in achieving the sdgs a similar analysis focused exclusively on pe will allow teachers to establish more stable criteria to develop the goals of the 2030 agenda in a more specific way in the educational arena simultaneously it will make it possible to evaluate the degree of achievement of said goals so it could be interesting to establish curricular links between the 17 sdgs and the different academic subjects this data will allow more reliable conclusions to be reached on how where and why to invest to maximize the contribution to development goals in a more practical sense

the sustainable development goals sdgs is a global strategy that aims to obtain a more equitable and just world these objectives are organized into 17 sdgs detailing 169 targets different international institutions have emphasized the relevance of education to developing citizens who contribute to achieving the sdgs for 2030 however a review focused on physical education pe has yet to be performed therefore the objective of this work is twofold first to analyze and select the specific sdgs that can be implemented in the area of physical education second to relate these specific goals to the different models based on physical education practices this review showed how three institutional documents have previously related sport physical exercise and physical education to specific sdgs based on the search done this review article selects those goals that could be integrated into the educational context through physical education the bibliographic and critical analysis in this research shows that of the 169 specific goals proposed in the sdgs only 24 could be worked on in physical education upon completion of the analysis a proposal for the relationship between the practicebased models and these 24 goals is presented the contributions made in this paper will allow teachers to establish links between pe sessions and sdgs while raising awareness to develop students who contribute to a more sustainable world

3 conclusion ethnic differences in cognitive development diminish throughout childhood for the majority of groups cumulative exposure to the uk environment may be associated with higher cognitive development scores what is already known on this subject  ethnic differences in cognitive development exist during critical periods of early child development what this study adds  ethnic differences in cognitive development narrow between the ages and 3 and 7 for indian bangladeshi pakistani and black african children living in the uk however ethnic differences are persistent for black caribbean children throughout early childhood  children with uk born mothers score higher on cognitive tests than their counterparts with foreign born mothers but this generational difference diminishes with age  generational differences in cognitive development are partially explained by differences in parental socioeconomic circumstances behaviours and modifications to the home environment background ethnic differences in early life development have been described across a range of minority groups within a variety of national contexts 1 2 evidence from the uk suggests that indian black caribbean and black african children are less likely to be delayed on developmental milestones at nine months of age whereas pakistani and bangladeshi infants are more likely 2 at age three indian pakistani bangladeshi black african and black caribbean children are disadvantaged in terms of cognitive development compared to the white uk population 3 wellestablished influences on cognitive development include social and economic disadvantage experienced in early childhood 4 the influence of parental class 5 education 6 income 7 health behaviours as well as child care 9 parenting styles 10 and household structures 11 all explain to varying degrees the differences observed between individuals however the patterning of exposures shaping cognitive development is not the same across ethnic minority groups for example ethnic minority groups in the uk tend to be more socioeconomically disadvantaged than the majority population but the extent of deprivation varies considerably between groups and across socioeconomic indicators 12 once such factors are accounted for then there is considerable evidence that ethnic variations in early development are attenuated 2 13 conversely some ethnic minority groups may be more advantaged than the general population in terms of health behaviours affecting child development indian pakistani bangladeshi and black caribbean and black african mothers in the uk are more likely to breastfeed 14 and have lower prevalence of smoking in pregnancy 15 than the general population and have also been observed as being more advantaged on measures of parenting such monitoring educational involvement and having higher aspirations for their child 16 further investigation into the effects of beneficial exposures such as health promoting behaviours may have important implications for policies targeting the behaviours of the majority population most investigations attempting to explain ethnic differences in health have focussed on first generation migrants or exclude migration status completely it is important to consider that such social or behavioural factors which may underlie differences in cognitive development are not fixed over time or generation for instance some ethnic groups in the uk have been shown to improve upon their occupational social class obtain higher levels of educational qualifications and experience higher household incomes in the generations following migration 17 given that social class is associated with cognition 18 it is possible that the parents upward intergenerational social mobility may be accompanied by higher levels of child cognitive development 4 5 6 7 health and social behaviours might also exert their impact on childrens development via biological pathways or psychosocial pathways or a combination of pathways yet the behaviours underpinning these pathways to development are liable to change as a consequence of acculturation and approximation towards the social norms of the majority population 20 21 it is therefore likely that significant generational differences in development exist in ethnic minority children but these patterns and the underlying casual pathways have been neglected in the research to date the overall aim of this study is to describe generational differences in ethnic inequalities in cognitive development over the first seven years of life and identify factors determining these differences the first objective is to examine the extent to which sociodemographic characteristics differ between generations the second objective identifies generational differences in the home learning environment and parent styles further investigation will examine whether there are ethnic differences in child cognitive development at ages three five and seven the final objective estimates the magnitude of generational differences in development and assesses the influence of purported sociodemographic and environmental causal factors the investigation hypothesises that crossgenerational differences in development are accounted for by differences in socioeconomic disadvantage as well as variations in parenting styles and the home learning environment methods the millennium cohort study is a nationally representative longitudinal study of 19244 families with children born in the united kingdom between 2000 and 2002 22 this investigation uses family interviews and child assessments conducted for all participants at ages three five and seven years the family interview was completed by the main carer of the cohort member at each time point ethnicity childs ethnicity was defined by a parent using categories from the 2011 england and wales census 23 the five largest nonmixed ethnic minority groups living in the uk were eligible for analysis indian pakistani bangladeshi black caribbean and black african the mixed group was excluded due to considerable heterogeneity in terms of family origins as well as socioeconomic characteristics generation child generational status was defined according mothers nativity when assessing child outcomes the uk born category refers to a child with a uk born mother whereas foreign born implies the mother was born overseas comparing generations living in the same time period mitigates against unknown contextual effects which may confound comparisons between generations living consecutively cognitive development all cognitive tests were intervieweradministered in the home at age three children completed the bracken school readiness assessment which measures the comprehension of 88 concepts relating to colours letters numbers sizes comparisons and shapes to predict readiness for more formal education 24 in addition the naming vocabulary component from the british abilities scales 25 asked children to name items from a booklet of coloured objects at age five the bas naming vocabulary test was repeated the naming vocabulary test was repeated in addition to the pattern construction battery this tested spatial awareness dexterity and coordination whereby the child constructs a design from patterned squares and cubes a third picture similarity component assessed problem solving by asking the child to place pictures alongside matching pairs at age seven the bas word reading assessment was administered to measure childrens reading ability number skills were assessed using the standard progress in maths test 26 and the bas pattern construction test was readministered each cognitive test score was agenormed against its respective reference population 27 and was transformed to a zscore to allow subscale comparisons principal components analysis has been previously used on this data to derive a weighted index score which quantifies a unifying general characteristic 28 29 the combined index score captured the maximum possible variation between the scores and was normalised to mean zero and unit variance the index captured 70 58 and 57 of the variation between ability scores at ages three five and seven respectively all items within each index were positively correlated with one another and made roughly equal contributions to the combined index explanatory factors demographic factors included the mothers age at birth and household language at each time point socioeconomic factors were assigned at age three and included the parents highest current or previous occupational social class using the national statistics socioeconomic classification this schema was collapsed into a three tier hierarchical scale 30 with an additional category for parents who had never held a job the parents highest qualification was summarised on a four tier hierarchical scale with an additional category for overseas qualifications maternal health behaviours included whether the mother smoked in pregnancy and whether the child was ever breastfed the childs home learning environment was assessed using agespecific measures 31 age three assessed how often the child was read to and how frequently they were helped with the alphabet taught songs or rhymes painted at home and taught to count by the parent age five assessed how frequently the child was read to attended a library taught songs or stories painted at home and played with toys with a parent age seven assessed how frequently the child was helped with reading writing and maths home learning responses for each age were collapsed to a summary score and split into quintiles lastly parenting style was assessed at each age according to whether the family has rules whether they are enforced does the child have regular mealtimes and bedtimes and how many hours per day the child watches television statistical analysis this complete case analysis of 8601 singleton births uses a repeat cross section of the same individuals at all three time points analyses were conducted using stata se version 131 and used survey weights to account for the clustered sampling design foreign born white uk mothers were excluded in order to describe the extent of ethnic inequalities relative to the majority of the population who are uk born descriptive analyses show the generational differences in the distribution of demographic socioeconomic and health behavioural factors as well as indicators of the home learning environment and parenting styles at age three a repeat cross sectional analysis was performed to examine whether the size of the relative differences in development varied by age linear regression estimated the difference in the age and gender standardised mean cognitive development zscore between ethnic minority groups and the white uk born reference group at ages three five and seven respectively lastly multivariable linear regression estimated differences in the mean zscore between children with foreign born mothers and those with uk born mothers for each ethnic group by age models were adjusted stepwise for sociodemographic factors maternal health behaviours the home learning environment and parenting styles missing data missing data was highest for test scores at age 3 due to a lack of parental consent missing data averaged 36 across all other variables a sensitivity analysis was performed using multiply imputed data derived using a burn in of 20000 iterations to stabilise the markov chains a further 25000 iterations were run creating 50 imputed datasets at every 500th iteration there was little variation in mean z scores between the complete case and imputed data longitudinal weights were also applied to account for nonresponse and minimise bias due to loss to followup results table 1 shows a greater proportion of households with foreign born mothers were disadvantaged than their uk born counterparts in terms of social class and to a lesser extent for education overall the prevalence of smoking in pregnancy was considerably higher in the uk born mothers than the foreign born for all ethnic minority groups lastly there were inconsistent generational differences in the initiation of breastfeeding the proportion of indian and black caribbean mothers who never breastfed was higher for those who were uk born whereas the proportion was higher for foreign born pakistani bangladeshi and black african mothers stepwise adjustment for household language socioeconomic factors maternal health behaviours and home learning environments and parenting styles accounted for an incremental reduction in the generational gap in most ethnic minority groups however after full adjustment bangladeshi children with uk born mothers were significantly more likely to have higher scores than those with foreign born mothers though this is interpreted cautiously based on the low uk born sample size at age five black african and pakistani children with uk born mothers again scored significantly higher than children with foreign born mothers but this was not significant after full adjustment by age seven these there were no significant generational differences in any models with exception to the small bangladeshi sample children by age five and two years after school entry ethnic differences were considerably diminished for all but the black caribbean children the extent of these developmental differences varied according to the generational status of the mother children with uk born mothers scored higher for cognitive development than those with foreign born mothers though this was not significant in many cases due to limited power this advantage diminished after differences in the distribution of the parental sociodemographic economic and home learning environments maternal health behaviours and parenting styles were controlled for therefore generational inequalities in early life cognitive development do exist within ethnic minority children yet these inequalities appear amenable to change these findings highlight the importance of changing social experiences of individual ethnic groups across time and the extent to which they may explain developmental outcomes which are known to predict later life health 32 this study indirectly showed that generational differences in development narrow over time as there were no observable differences apparent by age seven a cumulative exposure to the uk following migration has been shown to result in acculturative changes which may influence behaviours and ultimately health 15 21 it is possible that the developmental scores of children with foreign born mothers may have increased to a greater degree throughout childhood than in those with uk born mothers due to the greater scope for acculturative change indeed data presented describe a limited degree of approximation across generations in home learning behaviours and parenting styles towards to those practised by the white uk reference group crossgenerational uptake of these behaviours might also explain why ethnic minority children with uk born mothers scored more highly overall than those with foreign born mothers as well as behavioural explanations there was an implied association between socioeconomic advantage in all uk born groups and higher cognitive test scores in the majority of groups the generational differences in test scores were attenuated slightly after controlling for this advantage at all ages these findings are supported by previous work with the mcs using alternative markers of social circumstances 2 3 as well as investigations from elsewhere 1 10 these findings continue to suggest that reducing socioeconomic disadvantage in early life is likely to have a positive impact in reducing health inequalities in early years as well as over the remainder of the life course throughout early childhood the significant and persistent inequality observed in black caribbean children contrasted significantly to the other ethnic minority groups despite the black caribbean group being relatively more advantaged in terms of parental social class and qualifications lower educational achievement by black caribbean males in particular has been a matter of contested debate in the uk for over forty years 33 racismled explanations such as teachers having low expectations based on stereotypes 34 or cultural explanations whereby educational success is not viewed by the child as desirous 35 have been presented as likely mechanisms influencing development there is further evidence that mothers experienced racism is linked to markers of early child development 36 with garcia coll and colleagues suggesting that racism leads to segregated contexts which may influence developmental process in children 37 alternatively our findings may be a consequence of the recognised cultural limitations of the bas 25 38 and groups with lower levels of english proficiency may be disadvantaged in completing verbal tests to account for this household language was taken into account in our models yet the black caribbean group had the greatest proportion of homes speaking english suggesting that language issues are an unlikely source of significant bias in this scenario nevertheless despite accounting for differences in parenting values and beliefs and language biases this study could not confirm why the test scores of only the black caribbean children did not converge to those of the white uk majority population strengths and limitations these findings from a large nationally representative longitudinal study are consistent with other studies which were limited by shorter followup periods 1 3 the findings from the black caribbean group are similar to american studies describing persistently lower test scores for black children into later childhood 39 although modelling produced broadly consistent trends across most groups many values did not reach statistical significance this was due to restricted sample sizes particularly so for the bangladeshi group for which results should be interpreted cautiously despite many of the observed trends being broadly similar to those of other minority groups relatedly larger models controlling for ethnic differences in physical activity dietary habits and body composition and child care which may be associated with cognitive development were not possible due to the limited power within the highly stratified sample developmental differences between children attending state or private schools were controlled for but were not significant in final models and are not shown finally foreign born mothers indicators of socioeconomic position may not be an accurate reflection of lifetime social position due to downward social mobility following migration 40 conclusion for the majority of ethnic minority groups inequalities in cognitive development appear to consistently narrow throughout early childhood however children of all groups with uk born mothers score higher in cognitive tests suggesting that intergenerational exposure to the uk social environment may have a positive influence on development abbreviations

background differences in cognitive development have been observed across a variety of ethnic minority groups but relatively little is known about the persistence of these developmental inequalities over time or generations a repeat cross sectional analysis assessed cognitive ability scores of children aged three five and seven years from the longitudinal uk millennium cohort study white uk born n7630 indian n248 pakistani n328 bangladeshi n87 black caribbean n172 and black african n136 linear regression estimated ethnic differences in age normed scores at each time point multivariable logistic regression estimated withingroup generational differences in test scores at each age adjusting stepwise for sociodemographic factors maternal health behaviours indicators of the home learning environment and parenting styles results the majority of ethnic minority groups scored lower than the white uk born reference group at age three with these differences narrowing incrementally at ages five and seven however the black caribbean group scored significantly lower than the white uk born reference group throughout early childhood at age three pakistani black caribbean and black african children with uk born mothers had significantly higher test scores than those with foreign born mothers after baseline adjustment for maternal age and child gender controlling for social behavioural and parenting factors attenuated this generational advantage by age seven there were no significant generational differences in baseline models

introduction compelling evidence shows consistent condom use to be associated with lower hiv infection rates among female sex workers worldwide in indonesia which is the worlds most populous muslim country commercial sex is technically illegal but generally tolerated regulations vary widely with some cities implementing but seldom enforcing radical laws to prosecute those who engage in or manage the business of prostitution government attempts to promote safer sex and increase female sex workers level of condom use during commercial sex have had limited success despite extensive prevention efforts with such failures also occurring globally awareness has grown of the need to shift efforts from focusing solely on individuals to approaches that attempt to understand and subsequently create social environments that encourage positive behavioural change indeed a growing literature confirms that the environment within which a population at risk engages in sexual activity influences their hiv risk likewise the social settings where sex transactions occur appear especially promising as venues for both understanding risky behaviour and for promoting safer sex this study examines the structural influence of sex work environments on condom use among female sex workers recruited from three types of sex work venues discotheques bars brothels and entertainment places in senggigi on lombok island in the eastern indonesian province of west nusa tenggara senggigi is an excellent location to study the influence of sex work venues as the city hosts a wellestablished sex industry that constantly attracts foreign and domestic tourists as with much of southeast asia sex in senggigi is sold through contact initiated on the street through bars within brothels and as a sideline to other occupations sex work venues as risk environments numerous studies indicate that hiv risk behaviour varies by sex work venue client demographic characteristics and their place of origin also appear to influence sex workers condom use within commercial sex environments at the individual level none of these studies however investigate possible patterns of condom use by sex worker and client characteristics both across and within venue type moreover most studies of female sex workers treat sex work venue characteristics as merely one among many independent variables few studies have examined the contextual influence of venues on other potentially important variables or compared differences in female sex workers behaviour across different types of venues one study in the philippines for example utilised multilevel analysis to examine the situational context for hiv risk behaviour practices of sex workers this research however focused on the contextual influence of sex work venues in general and did not directly address variations in hiv risk behaviour across venue types or at multilevels of influence a multilevel approach that allows simultaneous examination of multiple determinants of fsws condom use including variables measured at the individual the client and the contextual levels may be more effective in helping target prevention efforts we hypothesise that the type of sex work venue where sex workers meet their clients predicts their use of condoms specifically at the venue level we expect that management style as well as policies and services that support safer sex will be associated with greater condom use at the individual level we further posit that condom use varies according to the womens personal characteristics including their knowledge about hiv at the client level we anticipate that condom use varies by the type of client with whom the women engage in paid sex consistent with findings reported in the literature we expect sex workers to be more likely to use condoms with new rather than regular patrons methods study design and proceduresa crosssectional multilevel design employing ethnographic observation and indepth interviewing was used to identify and recruit female sex workers in senggigi on lombok island in the eastern indonesian province of west nusa tenggara ethics approval for the study was obtained from the institutional review board office for the protection of research subjects university of illinois at chicago and also the regional development planning agency office of research west nusa tenggara outreach workers from two local nongovernmental agencies helped the senior author gain access to and ethnographically map the range of sex establishments and venues in the senggigi commercial sex area contextual information about the venues was further obtained though ethnographic observations of the sites and informal interviews with women selling sex within them twentysix sex work venues initially were identified and subsequently categorised into one of three venue types brothels freelance and entertainment places where women were employed for other purposes but sold sex on the side with the exception of six freelance locations where approval for study recruitment was unnecessary a managers or owners permission was needed to approach and recruit potential participants for the study all five brothels eight out of ten massage parlours and three out of five karaoke bars granted permission for a total sample of 22 venues including the six freelance locations to participate in the study the women had to be 18 years of age or older solicit clients at one of the participating brothels freelance locations or entertainment places in the senggigi area and be willing to provide informed consent to participate in the study no woman was sampled twice or worked at more than one type of sex work venue in sampling for the study a woman was considered to engage in sex work if she reported having exchanged sex for money at least once in the last three months this definition recognises that sex work in indonesia is practiced both regularly as a main source of income or intermittently within the context of other forms of employment such as spa attendant or nightclub entertainer of 151 women from the 22 venues who agreed to eligibility screening for the study 115 reported exchanging sex for money in the last 3 months with at least one paying client after gaining informed consent the senior author administered a structured questionnaire that asked the women to describe the characteristics of the venue where they engaged in commercial sex including their perceptions of its managerial policies and support for hiv risk reduction if any the women also were asked about their demographic background knowledge about hiv and a series of questions about the demographic characteristics of their three most recent clients and their sexual and substance use behaviours with them to protect confidentiality code numbers were used instead of names or other personal identifiers and all completed interviews and other data were kept in a secure location to which only the senior author had access measuresthe dependent variable for this analysis was a dichotomous measure of fsw condom use it was obtained by asking the women about each of the last three clients with whom they reported having vaginal sex in the last three months did you use a condom when you had vaginal intercourse with this client independent variables were measured at three levels sex work venue personal and client venuelevel variables included supportive versus nonsupportive management style as reported by the fsws and defined by whether or not a venues owner or manager appeared to emphasise profit over ensuring their health and welfare including protection against aids perceived managerial support has been found to be a significant predictor of condom use during commercial sex a second venuelevel variable assessed each establishments hiv riskreduction policies and services if any as measured by the sex workers reports of whether or not the venue provided free condoms offered one or more hiv educational sessions for the women andor gave permission for them to attend hiv education sessions conducted by local nongovernmental organisation the 16 sex work venues were coded for statistical analysis according to whether or not the women perceived being subjected to a negative management style that maximised profits over concern for their wellbeing and also whether or not the venue where they worked offered hivaidsrelated policies and services or not personallevel variables included each sex workers demographic characteristics and knowledge about hiv transmission demographic variables for the women were coded as marital status educational achievement place of origin and age knowledge about hiv transmission was measured using a summation index based on the total number of correct responses to a series of 14 questions adopted from a previous study of female sex workers in indonesia clientlevel variables were collected and coded as 1 client type 2 origin of the client and 3 client age analysisa grounded theory approach was used in analysing the studys ethnographic data to inductively identify patterns across and within venues of how the women met their clients their work hours and any venuebased rules or regulations to which they had to adhere when engaging in commercial sex interview data reporting venuerelated variables the personal characteristics of sex workers and those of their clients by type of venue also were examined using bivariate statistics including oneway analysis of variance chisquare and fishers exact test when cell sizes were small a random intercept threelevel hierarchical generalized linear model examined the relationship between sex work venue and sex workers condom use multilevel analysis is appropriate for use with nested data where individuals within a particular group are posited to be more similar to each other in terms of the outcome variable than they are to individuals in a different group in this studys design clients are nested within female sex workers and female sex workers are nested within sex work venue thus sex work venue characteristics at the highest level as well as sex worker and client level variables are predicted to influence condom use among female sex workers figure 1 illustrates the set of predictors at each level that potentially influence womens condom use results of the 151 women recruited from 16 sex work venues who were initially screened for possible enrollment in the research 115 reported exchanging sex for money with at least one paying client in the last three months of these 115 women 39 engaged in brothelbased sex work 47 sought clients through freelance solicitation at discotheques and bars and 29 worked at entertainment places where commercial sex was offered as a possible sideline to the womens other work responsibilities most of the 115 sex workers reported having had at least three recent clients during the previous three month period with the remaining 9 sex workers reporting one to two recent clients in total 330 client encounters were available for analysis due to four missing values at the client level the final sample represented 326 clients nested within 115 sex workers and 16 sex work venues characteristics pertaining to each of these levels are described below sex work venue characteristics analysis of the studys ethnographic data provides a rich contextual overview at the venue level of how the women typically met their clients their work hours and compensation and the typical venuebased rules or regulations to which they were subject when engaging in commercial sex brothelsas is typical throughout indonesia the 5 brothels sampled in this study consisted of single dwellings managed by the buildings owners these somewhat homelike structures included a main residence for the brothel owner and hisher family and also one or two additional rooms designated for commercial sex that were accessible through a separate entrance the buildings also featured additional communal space where sex workers wait for customers or drink alcoholic beverages with them prior to sex women who sell sex in such brothel arrangements usually live in the surrounding area in small rented rooms managed by a different landlord they typically arrive for business around 7pm and stay until 23am some come earlier to socialise with one another while waiting for clients should clients seek their services during the day brothel owners contact sex workers who live nearby the women usually are paid relatively small amounts of money per sexual act brothel owners typically receive brothel room rental fees from the women no other form of commission is charged although owners may make additional money from the sale of liquor that is consumed on the brothel premises as nonemployees renting commercial sex space the women report not being subject to explicit rules set by the brothel owners once a woman contracts with a particular brothel however she cannot easily relocate elsewhere because brothel owners typically collude to discourage this out of mutual selfinterest thus brothel owners appear to exercise a kind of informal monopoly or exclusivity over the women who work out of their establishments freelance locations discothequesbars in senggigi are in the business of selling evening leisure activities that include drinking music and dancing open typically from 8 pm to around 23am their busiest nights are thursday friday and saturday anyone including women with the intention of contracting commercial sex can enter as customers upon paying a small covercharge sex workers who solicit clients through these establishments are not employed by or have any direct association with the establishment and the latter receive no commission from sex work transactions commercial sex contracted through these venues is freelance at the discretion of the sex worker and the actual sexual exchange occurs elsewhere such as at a nearby hotel sex work for freelancers begins in the early evening with the women approaching prospective customers from the many small kiosks that sell cheap snacks cigarettes and alcohol that line the streets alongside the bars and discotheques as the night progresses sex workers shift their approach to waiting for potential clients directly at the discothequesbars entrance or by paying the cover fee to enter the women report preferring to contract foreign tourists as clients but domestic men who look wealthy are also desirable targets the women usually charge modest amounts per sexual act and their clients are expected to pay for a hotel room nearby clients wishing to spend the night are charged more guiders to be accompanied during singing and drinking by a song guider a client must pay a small hourly fee a vip room also is available for rent the women receive a fixed monthly salary from the karaoke owners they also earn an additional fee if selected by a client to accompany him to the vip room song guides also receive a commission for each alcoholic drink that their clients order entertainment places women employed as song guiders typically work between the hours of 8pm to 3am sexual acts are contracted at the discretion of the song guider and usually enacted at a nearby hotel while they also may occur in a private vip room managers vary in permitting this practice song guiders who disclosed selling sex were reluctant to discuss their fees with the interviewer possibly due to fears of managerial disapproval at earning outside income the contractual agreements between the women and the bars that employed them varied one karaoke bar implemented a threemonth contract with a renewal possibility while the others allowed women to work indefinitely as long as they maintained a good performance a good performance was defined as having certain numbers of regular customers compliance with regular working hours and adherence to other rules implemented by the managersowners all three bars employed a female mami to supervise female bar staff and housed the women in dormitories owned by the establishment massage parlours by local ordinance are officially called spas to avoid using a term synonymous with prostitution most consist of several small rooms or booths where services take place in addition to massage therapy these establishments also provide beauty care and a range of sexual services prices for services vary by the luxuriousness of the spa sexual acts performed at massage parlours typically involve a modest cost some owners collaborate with nearby hotels for outside bookings managerial style by type of venuequantitative analysis of venue variables contained in the interview data provides further insight as to the possible influence of a venues managerial properties in supporting the womens wellbeing and in offering access to hiv services out of 16 participating sex work venues nine were supervised by managersowners out of those nine only three offered hivaidsrelated policies and services by contrast of the seven venues not supervised by managersowners more than half offered or supported access to hivaidsrelated services sex worker characteristics at the individual level the characteristics of the 115 sex workers differed by sex work venue in terms of their place of origin age education marital status place started sex work and residence the average age for freelance brothel and entertainmentbased sex workers were respectively 24 27 and 31 years freelancebased sex workers were more educated and more likely to be single compared to their brothel and entertainment counterparts women working in brothels were most likely to have been born on lombok as compared to 62 of freelancers soliciting clients at barsdiscothéques and only 7 of entertainmentbased fsws while most sex worker masseuses were born on lombok most karaoke employees were originally from java with a number also coming from the islands of bali sumatra and sulawesi differences in place of origin reflect the preference of karaoke bars to hire nonlocal women so as to attract wealthier customers by projecting an image of a highclass business most women working freelance or in brothels but not those working in entertainment venues reported senggigi as their first sex work site no differences were found in the mean number of years employed in the sex work industry andor the mean number of years worked in the current venue knowledge of hiv transmission differed by venue type freelancebased sex workers scored slightly higher in knowledge about hiv transmission and prevention when compared to their brotheland entertainmentbased counterparts clients characteristics table 2 provides characteristics of clients by sex work venue results show that overall reported condom use was 39 for commercial sex freelancers soliciting clients at discotheques and bars were more likely than their brothel and entertainment counterparts to use condoms to have younger clients and to have foreign as opposed to domesticindonesian clients no differences in client type were found across the three venues predictors of condom use across and within levels 13 table 3 presents results from a threelevel random intercept hglm model that uses variables from all three levels to predict sex workers condom use fitting of a random effects null model confirmed that condom use varied by sex work venues at the venue level we hypothesised that differences in perceived managerial style and hivrelated policies and services that supported or encouraged risk reduction would help to explain variation in condom use as shown in table 3 and contrary to expectation sex workers perception of support from venue managers or owners in ensuring their health over maximising establishment profits was not associated with increased condom use neither was having hivrelated policies that provided support for accessing services or146 at the personal level variability of condom use by individual sex workers across sex work venues was statistically significant marital status was associated with higher condom use the likelihood of condom use for women who had ever been married was two times greater than for those who had never been married unexpectedly sex workers knowledge of hiv transmission was not related to increased condom use at the client level the likelihood of sex workers condom use did not differ by whether or not the client was new or regular only a clients demographic origin proved significant having a domesticlocal indonesian client as opposed to a foreign client was associated with less condom use discussion despite initial expectations type of venue was not related to sex workers condom use when examined using multilevel modeling this finding runs contrary to previous research from other countries and studies showing a relationship between condom use and venue type perhaps such differences disappear statistically when multilevel analysis is used to control for nested effects a possibility that calls for the increased use of hierarchical models to confirm or rule out this explanation also with so few women reporting that they used condoms plus a small sample size differences in condom use by venue type may have been too small to detect at the individual level only sex worker marital status was related to condom use women who reported having ever been married were more likely to use condoms than their single counterparts other research also has shown similar findings possibly marriage leads to greater familiarity or acceptance of condom use due to experience with reproductive family planning or possibly it confers greater incentive for actively protecting against hiv and sexually transmitted infections for family reasons at the client level and contrary to our expectations sexual exchanges with new as opposed to regular clients did not predict condom use this finding runs contrary to other studies that have found a greater tendency to use condoms with new clients as noted earlier however we did find an association between condom use and the geographic origin of clients women were less likely to use a condom with their domesticlocal indonesian clients than with foreigners a finding supported by results from other indonesian sex worker studies from a prevention standpoint such consistent findings suggest that hiv messages directed at sex workers should emphasise that hiv can be contracted through unprotected sex with clients of all backgrounds and types also since men typically control decisions about condom use during commercial sex interventions that promote requests for condom use by clients appear warranted conclusions numerous hiv risk reduction programmes ranging from individual community to structural interventions have been implemented in several geographic areas in indonesia since the early epidemic in the late 1990s nonetheless recent integrated biological and behavioural surveillance among fsws in indonesia found no evidence of increased condom use and indonesia is now experiencing one of the worlds fastest growing epidemics in this regard we failed to find that managerial support for hiv education and encouragement for riskreduction through the provision of free condoms predicted greater condom use such limited efforts appear insufficient in generating positive action education alone for example seldom evokes sustained behavioural change and merely making condoms available does not assure their use the delivery of comprehensive specially tailored and scientifically proven risk reduction programming and access to innovative nonjudgemental health care could show different results the thai 100 condom program offers an example of a multilevel prevention programme uniting fsws establishment managers and local authorities to jointly promote condom use during commercial sex comprehensive programming sponsored by or delivered through venues could have an indirect payoff for the environments where sex work takes place brothel owners make money from the rooms that the women rent and possibly also receive a cut of the proceeds companionship between se workers and clients prior to transactional sex contributes to alcohol sales at brothels karaoke bars and discothéques also an unknown number of men likely patronise massage parlours and other leisure settings with the expectation of contracting commercial sex through the experience consequently a strong argument could be made that it is in the best interest of these venues to adopt comprehensive policies to help protect the health and wellbeing of the women and the establishments customers easy access to condoms through restroom dispensers and other means might encourage their use massage parlours and karaoke bars could sponsor hiv education sessions after hours or encourage employees to attend those offered locally by nongovernment aids organisations furthermore condom use can be encouraged through hiv education and social support delivered by the mamis that are employed to supervise female employees on the job and in companyprovided dormitories venue managers frequent communication to both sex workers and clients concerning the venues condom use policies and the importance of their use would help to ameliorate some of the genderbased power disparities that hamper womens request to male patrons for safer sex from a policy perspective possibly only social and structural changes in indonesia that result in better life chances for economically vulnerable women including education and employment can help to curb entry into sex work and ameliorate the economic conditions that promote unsafe sex also local regulations regarding prostitution need to be changed to support establishment owners efforts at encouraging hiv risk reduction and to help them avoid jeopardising their business by agreeing to promote condom use with support from an employer and acceptance by clients a sex worker is likely to be more comfortable using condoms to lower her probability of contracting hiv special hiv prevention efforts also must be made to target freelance workers who see clients outside of an employer relationship successful strategies to do so include identifying and training key sex worker indigenous leaders whose beliefs practices and behaviours are seen and imitated by others domesticindonesian clients can also be reached for further hiv prevention messages at their work places this study has moved toward a more comprehensive approach via inclusion of the effects of sex work venue on fsws condom use the finding has shown that condom use among sex workers is a multilevel phenomenon that is unevenly practiced in senggigi across fsws venues and clients by using hierarchical linear modeling the investigator was able to examine a diverse multilevel set of predictors that might be associated with sex workers condom use although these data highlight the importance of addressing condom use as a multilevel phenomenon there are several limitations that must be acknowledged first this work relies on selfreported quantitative and qualitative data regarding sensitive behaviours and may be subject to recall and selfpresentation bias attempts to decrease these biases were made by building rapport with respondents and assuring them of privacy and confidentiality second the number of units nested at each level was relatively small which may lead to less precise quantitative findings this is generally not considered problematic however when employing hierarchical modeling because of the robust nature of these estimation methods third our venue and client data were all based on proxy reporting by the fsws and our ability to verify the sex workers reports of managerial style or to collect indepth information regarding additional clientlevel variables of possible importance was limited we also do not know who initiated condom use during each sexual encounter such information might be useful in explaining why the women were more likely to use condoms with foreign versus domestic clients finally our analysis did not include the full range of behavioural and psychological constructs at the individual level that have been found to affect condomuse these variables include commitment to safe sex selfefficacy selfesteem perceived personal future personal sense of hiv vulnerability and peer behaviours and influences future research may benefit from using hierarchical linear modeling to examine to what extent if any these factors differ in their effect by venue type given that rates of hiv are rising among indonesias female sex workers further research is needed to extend the findings from this study to more effectively guide prevention efforts several recommendations for future research seem salient first larger sample sizes per venue are needed to more precisely identify the multilevel determinants of sex workers condom use second studies are needed to identify and explain a broader array of venuelevel risk factors third issues of power gender and violence that characterise the sex industry across indonesia likely pose strong barriers to hiv riskreduction in some settings and great opportunities for prevention in others these factors warrant exploration in future venuedriven studies finally our study focused on condom use among clients but condom use among a wider range of partners also merits further investigation multilevel model of the influence of sex work venue fsw and clientlevel variables on fsws condom use

this paper examines the structural influence of sex work venues on condom use among female sex workers in the senggigi area of lombok indonesia a crosssectional design employing ethnographic observation structured interviews and hierarchical linear modeling was used to examine condom use among female sex workers who solicited clients at three types of sex work venues freelance brothels and entertainment places karaoke bars and massage parlours the sample consisted of 115 women nested within 16 sex work venues drawn from the three venue types rate 39 of condom use varied across sex work venues perceived management style hivaidsrelated policies and riskreduction services differed by venue but this variation did not explain differences in condom use at the individual level higher condom use was associated with female sex workers having ever been married at the client level condoms were more likely to be used with foreign rather than domesticlocal indonesian clients low rates of condom use among indonesian female sex workers during commercial sex suggests the need for increased hiv prevention efforts that acknowledge sex worker characteristics and relationships with clients that place them at risk future research into the effects of social context on hiv risk should also be considered

introduction understanding how generation z enters the workforce is crucial as they start to graduate and enter the job market generation z is defined by oxford english 1 as individuals born between the 1990s and 2010s they are the generation of people who have changed their online behavior due to how they use technology the main difference between millennials and generation z according to 2 is how they use technology when they were young in addition to being constantly connected to their digital environments 3 stated that generation z also spend a lot of timeconsuming videos and interacting with their social networks moreover 4 declared that they try to show off their reliable identities on social media according to a study conducted by chen et al 5 generation zs social media usage has become a tool for shaping their personal brand and influencing job market performance the genuineness of a generation z individuals online image can affect their jobseeking behavior this is why social media has become a vital component of recruitment process 6 employer may use branding techniques to build a distinctive image that sets it apart from its rivals 7 it is clear that employer reputation and image affect the organizations ability to attract candidates 8 the concept of employer branding was first explored by barrow and ambler 9 it is a process that aims to improve the image of an organization to attract and retain the best talent in 2014 sharma and chhabra noted that it is a trend that is becoming more prevalent due to the increasing number of companies struggling to find qualified candidates when job seekers are considering various organizations for their next job they usually rely on number of attractiveness factors such as corporate reputation diversity work life balance and work environment to get a deeper understanding of the working conditions of the company social media enables marketers to create distinctive interactions between their brands customers and employees 10 due to the rise of social media customers employees and others have become more empowered and engaged in their relationships with businesses 11 organizations must exercise caution while managing and auditing their social media branding operations as viewers have grown more active 10 while businesses are aware of the potential and advantages of social media marketing many are still unclear about how to use it and gauge its efficacy which makes it difficult to manage and implement social media campaigns 12 with focus on the fact that generation z have grown up with social media and are now digital natives they will likely start working for companies in the future though the exact traits and working habits of this group are still unclear according to 13 the expectations of gen z workers are different from those of previous generations without a comprehensive understanding of this group businesses will not be able to find the ideal candidates this will also affect their retention and recruitment efforts to accommodate the needs of generation z workers businesses should conceptualize and construct workplaces that are conducive to their talents moreover cennamo and gardner 14 15 twenge 16 asserted that the difference between generations in how they prioritize an employers attractiveness varies according to a study conducted by 17 terjesen et al 18 there is still a gap in the knowledge about the preferences of various generations when it comes to the attributes of an employers attractiveness also there is a lack of reliable research on the preferences of professionals coming into organizations from gen z this research aims to identify the dimensions of employer attractiveness among generation z and investigate whether there is a statistically significant difference in the perceived importance level of each attractiveness dimension based on gender education and study program taking into considerations the mediating role of the social media platforms in shaping gen z preferences to apply for a job also the research was conducted in egypt among students of private universities with various disciplines explores the expectations of gen z workers and the characteristics of employers that they consider when it comes to choosing a job the structure of this research is as follows to accomplish the purpose of this research to build the groundwork for the empirical research on employer fig 1 research conceptual model attractiveness thorough literature review is carried out and the various traits of the generation z are reviewed the social media platforms and gen z preferences to apply for a job the methodological processes are then displayed the empirical portion then begins with a description of the research sample and dimensions of employer attractiveness are found using structure equation modeling analysis this research extends the existing literature and contributes to the theory by testing the research model in a different context applying it to current students in the private universities in egypt literature review and research hypotheses employer branding and employer attractiveness due to the various demographic factors and trends that affect the labor market companies are now revising their positions it is clear that not every candidate is interested in the same job position at the same company instead there are multiple positions that are available for the same candidate in the market this has caused the hr department to rethink its role and how it sells the jobs franca and pahor 19 emphasized that its beneficial to seek help from areas that used to fall under the category of pure marketing disciplines after examining the image and reputations of companies the concept of employer brand emerged according to 20 they declared that companies are looking for new ways to retain and attract skilled and experienced workers due to the global shortage of qualified and experienced individuals according to urbancov et al 21 employer branding programs can help organizations attract and retain skilled workers and improve public awareness moreover employer branding refers to a corporations reputation and value proposition it also includes a set of principles and tools that can help companies improve their image furthermore the management of a companys employer brand involves planning developing and communicating its value proposition this stage involves coming up with a set of goals and values that are tied to the organizations culture and goals the second stage involves developing a strategy that will help attract and retain workers finally the third stage involves aligning the internal and external brands to ensure that the organizations image is easily recognized employer attractiveness is defined as the perceived benefits a potential employee anticipates receiving by working for an organization 22 hence it affects recruiting and employee retention 23 an attitude or expressed overall good affect toward an organization toward considering the corporation as a desirable entity with whom to establish some interaction is another definition of employer attraction 24 p 221 organizations should advertise their employer brand to recruit talent attractiveness and accuracy are the two key metrics for determining an employer brands success understanding what appeals to job searchers is crucial for firms in a severe talent shortage since it affects both employee retention and recruiting 25 in contrast company independent information sources like wordofmouth employee recommendations and online reviews are thought to be more reliable because they are less likely to be manipulated by organizations 26 previous studies have demonstrated a significant correlation between employer attractiveness and employer brand 2227 employer branding is the idea of creating a clear view of what makes a firm different and appealing as an employer both internally and externally 28 p 51 in order to create a positive employer brand image distinctiveness must be carefully crafted this influences the brands appeal and attractiveness in the long run organizations must focus on employer attractiveness to draw in job candidates and differentiate their brand 8 being attractive is a quality of the employer brand 29 according to 30 the attractiveness of an employer is operationalized based on the attributes that candidates consider when making their job selection these attributes can then be categorized into different groups according to the preferences of potential employees which makes it easier for them to choose an employer although 31 defined the concept of employer attractiveness as a combination of factors that include the location salary and culture differentiated the concept from symbolic elements this concept is commonly used in empirical studies according to 30 the attributes that candidates consider when choosing an employer are usually can be used by prospective employees to determine which organizations they should choose based on their preferences literature has various suggestions on how to categorize employer attractiveness the scale was suggested by 30 it features five different values which is represents a scale that can be used to determine an organizations level of attractiveness according to the perception of the employees and job seekers the five values defined as follows the interest value is an individuals interest value is determined by the extent to which they are attracted to a company that provides a stimulating work environment and innovative work practices the concept of social value is defined as the extent to which individuals are attracted to organizations that provide enjoyable work environments good relationships and a cooperative atmosphere the economic value of an individual is determined by how much they are attracted to an organization that provides them with highquality employment and compensation the concept of application value is used in our research to measure the level of attraction that individuals have to an organization that values them and provides opportunities for them to develop their skills and knowledge a persons development value is linked to the confidence and recognition that they receive from an employer as well as their careerboosting experiences in this research we also add a management and worklife balance value to the employer attractiveness measurement which indicates the extent to which people are attracted to an employer that provides them with opportunities to balance their private and professional lives moreover we also add reputation to the employer attractiveness measurement the characteristics of generation z based on the work of mannheim in 1952 and presented in management research the term generation denotes individuals who were born at the same time as the historical or social events that occurred during that period the proximity of such individuals to similar environments can influence their perception and behavior moreover benson and brown 33 17 lyons et al 34 twenge et al 16 declared that the concept of generation has gained widespread recognition among management practitioners and academics it stems from the belief that various generations have their own work attitudes and values which dictate the kinds of work environments and management practices that they prefer the most racially and technologically diverse generation is generation z according to the institute for emerging problems social networking is a crucial aspect of generation zs existence and they have a casual direct and distinctive communication style they are a generation that values according to a study by dan schawbel 35 generation z is less driven by money than generation y and is more entrepreneurial trustworthy tolerant and openminded based on the findings of singh and dangmei 13 generation z is the most demanding acquisitive materialistic and entitled generation to date it also tends to be impatient lacking the ambitions of previous generations suffering from attention deficit disorder with a high dependence on technology and a low attention span moreover mihelich 36 declared that the generation z has a strong feeling of responsibility for the environment and is particularly worried about environmental issues furthermore generation z want to be heard and although they are tech aware and have made technology a part of their identity they lack problemsolving abilities and have not shown that they can look at an issue put it in context analyze it and come to a decision consequently the following general hypothesis is formulated h1 employer attractiveness significantly impacts generation z intentions to apply for a job the effect of social media platforms on generation z the rise of social media and online job portals has drastically changed the way recruitment is conducted todays younger generations are looking for jobs on the internet besides job portals applications and other social media platforms also play a crucial role in the recruitment process nowadays the recruitment strategy is more individualized and focused 37 moreover social media has made it much easier for companies to find candidates who are not actively searching for work in the past it was very challenging to reach out to these individuals since people can easily access information about companies and individuals due to the widespread use of the internet employers should monitor how they market their businesses online moreover it is important for job seekers to monitor their social media profiles to make sure that they are not only presenting themselves as a credible candidate but that they are also contributing to the companys success also declared that over 70 of recruiters check an applicants social media page before making a decision the most popular and extensively used social media include the social networking site facebook the microblogging site twitter the videosharing website youtube the photosharing website instagram and niche social media sites like linkedin and golden line 86 of employees have coworkers among their friends on social media according to research by oconnor schmidt and drouin while 77 of people use social media at work the fact that 44 of people share information about their jobs on social media is significant from the perspective of the topic of this essay 3839 the distinction between personal and professional social media platforms is one of the various methods to classify social media platforms 4041 user behaviors are essentially unrestricted in personal social media platforms exposing a wide range of details about different aspects of their lives 42 almost 289 billion people use facebook the largest personal social media platform 43 twitter instagram and tiktok are some additional significant personal sm platforms linkedin the largest professional social media platform has nearly 800 million users in these platforms more constraints are imposed upon the user sharing a larger depth of professional information but less information from other facets of life accordingly we hypothesis the following hypothesis h2 there is significant relationship between employer attractiveness and the use of social media platforms job pursuit intention positive social media posts are typically shared by staff who have great opinions of their employers and produce real information about their work and abilities 44 based on the research by 45 they declared that due to the increasing number of people using social media both employees and employers are trying to promote their brands both parties should take the necessary steps to protect their online reputations moreover 4647 revealed that the rise of social media has shown that it is no longer just a place for informal communication and entertainment it has also become a vital part of peoples lives as it allows them to connect with their networks most of companies nowadays are sharing content related to their business and also about their employees on different social media platforms such as facebook linkedin and twitter furthermore 47 and malaska and nadeem stated that linkedin has become the social media platform that businesses professionals and employees most frequently utilize as the largest professional network in the world linkedin has inevitably become a crucial social media tool for businesses 48 professionals from all over the world use linkedin to access the most recent business material connect with current and former coworkers seek professional advice and look for potential job vacancies 4950 students use linkedin to showcase their capabilities accomplishments learned skills and prospective work interests in order to develop a distinctive brand in the cutthroat job market 51 by adding their work experience recommendations from former coworkers professional credentials and other information to their linkedin profiles professionals maintain and improve their personal brands 5253 linkedin is a platform used by staff members to discuss their jobs career experiences and accomplishments 54 the promise of an employers brand is enhanced through social media this process involves leveraging existing employees to endorse the organizations message and provide a voice for the brand social media affordances also help the employer brand reach its target audience and increase its visibility therefore the following hypothesis is formulated h3 the use of social media platforms has a mediating effect on the relationship between employer attractiveness and gen z intentions to apply for a job methodology this research aimed to find out what generation z thought about the various aspects of an employers attractiveness and whether social media platforms influenced their perception of an employers attractiveness and whether they would be more inclined to apply for a job also this research was conducted on fresh graduates and final year undergraduate students from private universities in egypt the participants are from different majors which is a group of individuals that are expected to be highly skilled and sought after by employers data collection and sample design this research utilized a quantitative method to analyze how generation z views the workplaces attractiveness in egypt and how this influences their choices when it comes to apply for a job social media platforms also played a role in this relationship it was carried out through a judgmental sampling method among fresh graduates and finalyear students of number of private universities in egypt the researchers were able to enroll them through various means such as social media groups mailing lists and personal contacts and the participants were chosen from private universities in egypt the researchers conducted the survey online among the students who are expected to graduate within the next couple of months and join the workforce and also the fresh graduates all the participants had been chosen from different majors three hundred questionnaires were distributed and 200 complete and valid questionnaires were received as shown here in table 1 it could be concluded that the sample groups proportions with females comprising 492 and males 508 the sample groups age breakdown indicates that the majority of the respondents 52 are aged between 21 and 22 while 327 are below 20 years old the remaining 2 are aged 2324 or above moreover the majority of the respondents have a bachelors degree with 20 stating that they have a masters degree and another 17 having a doctorate furthermore according to the specialization a high proportion of them claimed to have studied various fields of business such as finance human resource management and marketing among the most popular study subjects among the respondents were international business and entrepreneurship generally the data collected by the research questionnaire revealed valuable information about the educational backgrounds of the respondents which can be used to inform future research and improve the recruitment and marketing strategies of companies measurement development the independent variable employer attractiveness scale was adapted from berthon et al 30 taking into account some modifications to fit the respondents culture this was set to make it easier for the respondents to understand this scale was modified by dabirian et al 55 added two dimensions to the scale worklife balance and management in addition this scale was modified by schlager et al 56 by adding reputation to the scale a fivepoint likert scale was used to assess the importance of each item the dependent variable job pursuit intention scale was adapted from highhouse et al 57 the scale of the mediator variable social media was adapted from collins and stevens 58 this scale was developed originally to be used in general marketing consequently it was modified to match the objectives of this research to know the mediating role of social media platforms in the relationship between employer attractiveness and generation z intentions to apply for a job data analysis the researchers used partial least squares in the analysis of structural equation modeling to test the hypothesis of this study the study also analyzed the structural model and the measurement models validation the advantages of using partial least squares over the traditional methods were numerous it helps minimize inaccuracies in the calculation of variables results reliability and validity of the measurement it could be concluded from table 2 that the validity and reliability measures of the different constructs are presented in table 2 the first one which is employer attractiveness exhibited an average variance of 0878 and an average composite reliability of 0980 the constructs cronbachs alpha of 0977 also indicated that the items within it are related to each other while social media platforms composite reliability and internal consistency score of 0202 and 0719 indicates that it may be less reliable and consistent than the other constructs however they still have acceptable factor loadings ranging from 0320 to 0699 but its individual components show that they still follow the same underlying concept moreover the job pursuit intentions composite reliability and internal consistency score of 0814 and 0956 indicates that it is highly reliable its cronbach alpha of 0943 also supports its reliability furthermore the different constructs of employer attractiveness dimensions that are related to the concept of work life balance development and interest social value and management and work environment exhibited high internal consistency they also have high alpha values ranging from 08 to 0957 this is concluding that the different constructs used in the research are reliable and valid indicators of the concepts they are related to they support the use of such constructs in future studies as shown in table 3 the results of the larcker and fornell criterion for assessing the validity of various constructs the value of the diagonal is the average variance of each construct while the off diagonal is the correlation between them according to the results the average variance of each construct is higher when compared to the correlations between them and other constructs although the link between working environment and social media platforms is relatively high this suggests that there might be overlap between these two constructs further research on their operationalization and conceptualization is required table 4 illustrates the results of the htmt analysis which is a type of test for discriminant validity that involves calculating the ratio between two constructs if the ratio falls below 09 then the discriminant validity can be upheld the table shows that the htmt ratios for all the constructs were below 09 which indicates that the discriminant validity of each pair of constructs can be upheld this means that the measures used in the analysis exhibited good discriminant validity as shown in table 5 it represents the models testing quality with regard to the two main variables namely job pursuit intention and social media platforms the r square represents the variance in the dependent factors value while the r square adjusted considers the models predictors the table indicates that the r square for job pursuit intention is 0583 which implies that about 583 of the variance can be explained by the models independent variables on the other hand the adjusted value indicates that this figure drops to 563 after taking into account the predictors the r square for social media platforms is 0315 which indicates that about 315 of the variance can be attributed to the models independent factors on the other hand the adjusted value shows a slight decrease when the model takes into account the predictors generally from the above discussion it could be concluded that the values indicate that the model can provide good explanatory power when it comes to job pursuit intention and moderate power when it comes to social media platforms nevertheless it is crucial to keep in mind that these values may be affected by the models specific measures and variables and these may not be generalized to other situations testing research hypotheses the following table 6 summarizes the results of a mediation study that analyzed the link between various factors that affect job pursuit intention these include social media platforms and employer attractiveness from table 6 it could be concluded that in h1 the notion that an employers attractiveness can influence job seekers minds is supported by the hypothesiss path coefficient 23129 and pvalue 0015 and this is showing a significant relationship between the two these hypothetical ideas try to determine how an employers attractiveness affects job seekers intentions in addition to economic and social status other factors like reputation and worklife balance can also have an effect generation z intention to apply for a job as shown from the abovementioned table the hypothesis h2 indicates the relationship between the social media platforms and an employers attractiveness the path coefficient for its relationship is 0562 while the pvalue is 0001 this is reflecting the significant relationship between social media platforms and employers attractiveness while in hypothesis h3 the effect of social networking sites on the connection between job seekers intentions and companies attractiveness is analyzed the path coefficient and pvalue of 0240 and 0001 respectively suggest that these sites mediate the link between the two it could be concluded that the result of the study indicates that the employers attractiveness has a positive discussion and implications the aim of this research was to identify the various attributes that employers consider when it comes to hiring and retaining gen z talents in a sample of 200 students in egypt the research was conducted to determine the differences between the various attributes of employers although the dimensions of employer attractiveness were highly rated the significant differences can be determined based on the requirements of gen z workers for instance they really consider the development and personal growth and how the employer will invest in their skills to maximize their competencies in addition they highly rate the attractive pay and benefits as one of the important dimensions they consider when they decide which job to apply for moreover want a fun work environment that is conducive to their personal development and a positive relationship with their superiors other factors such as workplace diversity as well as the employer reputation and work life balance which may be provided in flexible working hours and remote working are also taken into account to attract talent this is support what was believed about generation z attitudes according to chillakuri and mahanandia 59 and schroth 60 moreover the results of this study revealed that the low rankings of the application value and interest dimensions contradict the expectations of this generations leaders regarding their goals and ethical practices this was contradicted with 61 this suggests that the development of a comprehensive understanding of this generations expectations should be conducted through a systematic approach moreover the results of this research can act as a launching point for the development of a more accurate understanding of workers expectations from generation z towards the attributes of the employer attractiveness furthermore the results of this research can be used to compare the expectations of gen z talents with those of their counterparts in other studies also in research conducted by liu et al 50 the generation z prioritize the development value as the first value they consider when they decide to apply for a job moreover in research by wallace and colleagues asserted that the interest value was ranked as the most important value when it comes to choose their future employer furthermore the study conducted by 62 revealed that economic value was at the center of students perspectives on cultural disciplinary and generational factors they were not able to identify the underlying factors that influenced these differences nevertheless our research serves as a starting point for further research that explores the multiple disciplinary cultural or generational elements of knowledge that shape generation z perceptions of the different attributes of the employer attractiveness that may affect their choices to apply for a job the findings of this research contribute to the literature by providing insight into the factors that influence the attractiveness attributes of employers it also shows how the use of different social media platforms such as can affect generation z decisions to apply for a job and choose a specific employer in addition that this research can help employers develop effective branding strategies moreover the findings of this research show that the various dimensions of employer attractiveness were relevant to the participants the mean scores indicate that the importance of the dimensions of an employers attractiveness is acknowledged by the applicants this is in line with studies conducted by 63 and 64 furthermore in this research the classification process used to determine the expectations of each group was carried out based on the education gender and study program the way an employee sees the organization can become a resonance of their perceptions which is why it is important that an organization takes into account the needs of its external and internal markets when developing its messages the study revealed that various factors such as development interest economic value social value besides the working environment the company reputation and to what extent the organization provides the employees with the worklifebalance all of those attributes can affect the intentions of generation z to apply for a job consequently this finding is quite vital from a professional and academic perspective the attributes of employer attractiveness can help them create effective marketing and hr strategies that are aligned with the needs of its employees and job candidates furthermore the research revealed that a positive image of an organization is very important in attracting candidates in addition to being able to manage the various aspects of its brand social media activities can also help improve the companys image even if individuals have different images of the organization and its logo the latter still exerts an influence on the preferences of potential employees conclusion the results of our research indicate that social media can help improve a companys corporate image which in turn increases the likelihood of attracting and retaining more candidates in addition to its content the platforms communication channels also play a vital role in its success this is by utilizing symbolic brand attributes in social media companies can stand out from the crowd and develop a distinct personality one of the most important factors that employers consider when it comes to building their social media presence is having a distinct personality and this is can be achieved in their social media platforms and specifically most our sample stated that linkedin is considered the most trustful platform when it comes to look for a job this can help them identify their ideal candidate and reach a wider audience however its also important to avoid providing too much information about the company doing so might cause people to think that the company is not interested in them or that they are not capable of handling the situation it was concluded that in order to become more competitive employers need to become more agile in their approach to improve the attractiveness of their brands to young job seekers this can be done through the development of new technologies and strategies that can help them attract and retain the right talent the findings of this research have practical implications for hr professionals it further reinforced the academic literature on the topic of employer attractiveness and how it affects the decision of generation z in applying for a job also the role of the use of social media platforms by the employer to reach and influence generation z decisions to apply for a job also this is research provided the perceptions of egypts generation z towards the attributes of employer attractiveness limitations and future area of research in egypt certain restrictions on education culture or discipline may prevent the generalization of findings about generation z these can identify the effects of varying cultural and educational factors on the population our research focused on the mediating role of social media platforms in the relationship between employer attractiveness and generation z intention to apply for a job we may take into account the different elements such as social identity consciousness employer prestige career awareness and career selfefficiency when assessing its role for generation z into their decisions to apply for a job we recommend that future studies apply longitudinal analysis since our study was conducted as a crosssectional analysis we are not able to determine the extent to which the attributes of employers attractiveness that respondents value influence their employment decisions this research focuses on generation z perceptions of the attributes of employer attractiveness to apply for a job for many job seekers their expectations and observations about the attributes of employers vary significantly from one another this study is not applicable to the older generation such as the baby boomers and millennials future research should focus on choosing students from a wider range of academic background and colleges different generational cohorts like millennials etc human resource managers middleand upperlevel managers and executives and generation cohorts from different geographies to understand how gen z is now more interconnected with the gen z population of other geographies and the world through internet culture suppose there are any similarities or differences in the employer in that case preferences can be attributed to them which will lead the organization to improve further and adapt their talent acquisition strategies due to the similaritydissimilarity of the found results furthermore we would suggest that future studies explore the various elements of brand appeal that generation z consider when it comes to choosing an organization for their future employment such as organizations sustainable development strategy gender diversity and remote work environment understanding these factors can help businesses attract and retain skilled workers finally the generalizability of the research findings is questioned due to two major factors first it only analyzed a single generation the workplace which is generation z and the second is that it used a small sample size for quantitative study future research on this topic is suggested to use qualitative approach with both job candidate and hr managers to close the gap between the hr professionals and the job candidates abbreviations competing interests the authors declare that they have no competing interests

the way jobseekers apply for jobs has drastically changed due to the rise of digital technology with the rise of social media jobseekers nowadays typically utilize social networking sites or other online platforms to look for work and it has made it a vital part of the labor market especially among the young generation the aim of this research was to determine the mediating effect of social media platforms on the relationship between employer attractiveness and generation z intentions to apply for a job the researchers use a judgmental sampling method among fresh graduates and finalyear students of number of private universities in egypt structure equation modeling were then used to analyze the data the finding of this research revealed that social media platforms has a mediating effect on the relationship between employer attractiveness and gen z intentions to apply for a job moreover when it comes to choosing an employer the younger generations prioritize economic value social value reputation and developmentinterest factors over the applicationdiversity working environment aspects and management and work life balance furthermore this research revealed that the significance of certain aspects of a job change depending on the participants educational level and the studys program the contribution of this research provides valuable insight into how employers are perceived by young job seekers they can also be used to develop effective recruitment strategies and improve the communication between hr professionals and candidates

background the considerable rise in the prevalence of overweight in india where over a billion people reside 1 2 3 4 presents a serious public health concern given the association of overweight with increased noncommunicable disease risk 5 in the early stages of economic development and urbanisation overweight and obesity prevalence tends to be higher among individuals of a higher socioeconomic position arguably due to an increased financial capability to meet and exceed nutritional requirement 6 7 8 9 as societies develop economically the prevalence of overweight increases among the poor and rural population 6 7 8 9 10 11 12 13 14 since indias economic liberalisation in the early 1990 15 economic growth has not been uniformly distributed across the country in addition to considerable heterogeneity in culture customs and diet the current levels of economic development between indias states varies substantially for example the gross domestic product of delhi is eight times greater than that of the state of bihar 16 consequently the prevalence of overweight and the extent of the increase in its prevalence in recent decades varies considerably subnationally 1 2 3 for instance in bihar the prevalence of overweight among women increased from 37 to 117 between 1998 and 2016 whereas in delhi the prevalence increased from 12 to 335 over the same period 1 however little is known about variation in the subnational socioeconomic patterning of overweight in this paper we aimed to understand how recent trends in the association between overweight and sep differ between indias most and least economically developed states between 1998 and 2016 a period in which indias gross domestic product per capita quadrupled from us 432 to us 1750 17 the main rationale for this study was to unmask subnational heterogeneity in trends in the association of overweight and sep in india not observed when analysing national trends demonstrating this would imply that nationallevel trends may not be generalisable at a subnational level 18 a study of this nature is of importance as health policy is dictated at the state level therefore estimating the prevalence by state development and urban and rural areas may highlight different immediate health policy priorities between less and more developed states we conducted secondary analysis using repeated crosssections from staterepresentative data from 1998 to 2016 to estimate the prevalence of overweight in india by sep in the five most and least economically developed states in india in more economically developed societies there is usually higher prevalence of overweight among poorer individuals where for instance there is a higher exposure to relatively cheaper fatty foods 6919 this is more likely to be the case in urban areas where risk factors for overweight are usually much greater we therefore hypothesise that in indias most developed states we will observe a considerable increase in the prevalence of overweight among lower sep individuals and relatively smaller increases among higher sep individuals on the other hand in indias least developed states we expected to find larger increases among higher sep individuals compared to lower sep individuals this is supported by the fact that poorer individuals in societies with lower levels of economic development are more likely to be unable to afford to meet nutritional requirements whereas the relatively rich may be more exposed to overweight due to a greater access to excess food 69 data we used the national family health survey surveys 2 3 and 4 all three surveys collected health and demographic data on women aged 1549 whereas surveys 3 and 4 collected data on men aged 1554 the sampling method was designed to include a nationallyrepresentative sample of individuals within a nationallyrepresentative sample of households additionally in india the nfhs surveys are also representative at the level of the state the nfhs surveys select rural and urban samples separately specifically in rural areas in all three waves analysed rural samples were selected using twostage sampling whereby the first stage involved selecting primary sampling units or villages with a probability proportional to size and the second stage involved selecting random households from each village in urban areas nfhs 2 and 3 used a slightly different sampling procedure to the one in nfhs 4 in nfhs 2 and 3 threestage sampling was adopted whereby in the first stage wards were selected with a pps in the second random census enumeration blocks were chosen in each ward and in the third random households were chosen from each ceb 2 3 on the other hand nfhs 4 adopted a twostage approach in urban areas whereby cebs served as the psu selected using a pps and households from each psu randomly selected were a psu to contain fewer than 40 households the psu was joined to the nearest psu the 2011 census helped determine the sampling frame in nfhs 4 1 in all three surveys interviews used a uniform questionnaire and were conducted by survey teams a womans eligibility for the survey was determined by whether they were between ages 1549 and for the nfhs 3 and 4 whether they spent the previous night in the selected households men aged 1554 in the households were eligible for the mens survey in nfhs 3 of the selected households in nfhs 4 a random sample of households were selected to determine eligibility for the mens survey 1 in india there are currently 36 statesunion territories we restricted our analysis to states that have been in existence since the collection of the nfhs 2 survey states created between the surveys were not considered in the analysis we selected five states to indicate the most and least developed states as the study aimed to demonstrate a divergence in the trends in their socioeconomic patterning our primary objective was to highlight variation in trends in the socioeconomic patterning of overweight within india we therefore chose not to include all the states in india as this would lead to the inclusion of states that are closer to the average level of per capita net state domestic product for india as a result we would risk placing states at similar levels of economic development in the most and least developed states categories consequently underestimating the extent of the variation in trends our classification of states was based on the per capita net state domestic product in 201415 using the base year 201112 the most economically developed states were goa maharashtra sikkim haryana and kerala with a pcnsdp ranging from ₹112444 to ₹241081 compared to an all india average of ₹72805 the least economically developed states included bihar assam uttar pradesh manipur and madhya pradesh with nsdppc ranging from ₹23223 to ₹44809 20 we limited our sample to nonpregnant women whose inclusion could bias the associations we sought to identify this left a total of 96365 women and 18729 men in the most developed states category and 289200 women and 54669 men respectively in the least developed states category as nfhs2 only sampled evermarried women we restricted our samples in 200506 and 201516 to this population to allow the comparability of the study population across surveys additionally respondents with missing height and weight data were also omitted from the sample leaving 76050 women in the least economically developed states as multistage sampling approaches were adopted in the collection of the nfhs we included the sampling weights included in the data set to account for unequal selection probabilities outcome we used the body mass index variable included in the surveys to separate individuals into two groups overweight and not overweight this categorisation is based on the whos recommended cutoffs for bmi classification 5 rather than split the continuous bmi measure into multiple subcategories of overweight we used this classification as the main aim of the paper was to analyse trends in excess adiposity and research has found an elevated risk of ncds and mortality beyond a bmi of 2499 kgm 2 2122 we did not use a continuous measure of nutritional status as observed populationlevel increases in bmi we would expect to observe over the study period could be driven by a both individuals moving into overweight categories and individuals moving from underweight to normal weight the latter of which does not capture increases in excess adiposity height and weight information on women aged 1549 in nfhs2 3 and 4 and men aged 1554 in nfhs3 and 4 were collected by specially trained investigators a solarpowered seca digital scale was used to measure the weight of respondents with the nfhs2 report claiming an accuracy of ±100 g the height of respondents in nfhs2 and 3 was measured using a measuring board designed for use in survey data collection in nfhs4 the seca 213 stadiometer was used to collect respondents height information 13 independent variables exposure of interest we used a measure of educational attainment as our primary indicator of sep this was based on the answer to a question regarding the number of completed years of schooling and respondents were assigned to one of the following education categories no education primary education secondary education and higher education higher levels of education can increase earning capability along with the accumulation of employable skills both of which make it a suitable proxy for sep for sensitivity analysis we verified our results using a standard of living assetbased index as an alternative measure of sep in surveys measures of sep are seldom examined in isolation as one measure cannot adequately describe all socioeconomic differences in a health outcome 23 as education and sol capture different aspects of sep the pathways through which it is associated with overweight may also differ for example those with high education may work in more sedentary jobs 6 7 8 9 increasing their risk of overweight whereas sol may be positively associated with overweight through determining the ability to afford excess food 6 7 8 9 some suggest that in lowmiddle income settings where there is a substantial informal employment sector and earnings not in the form of monetary enumeration household income may not be an appropriate measure of sep rather the stock of assets may be more reliable 24 data on household income to proxy sep is likely to be very sensitive to seasonal fluctuations in repeated crosssections and may not capture the true level of wealth of the household additionally in transitioning societies it may be more common to receive income inkind rather than monetary enumeration 25 and households may draw money from multiple sources 24 limiting the ability for respondents to adequately recall all income in a questionnaire we created our own sol index using principal components analysis after pooling the household surveys over time the inputs we used into the pca included information on the households stock of assets their access to services and other household characteristics we completed this process for urban and rural areas separately due to differences in the importance of different assets between urban and rural residents the percentage of respondent households in urban and rural areas by characteristics used to build the sol index in each survey is presented in additional file 1 table s1 we then ranked households based on this new index and assigned the first second and last third of the weighted sample a sol classification of higher medium or lower standard of living we examined the validity of the sol index we created by comparing the ranking of households using the index from the pooled data within one survey and the surveyspecific wealth index already included in the data the correlation coefficient in each of the three surveys used was greater than 095 suggesting a very strong agreement with our measure and the household rankings determined the surveyspecific index covariates our final models were adjusted for the respondents age and marital status marital status was categorised as either currently married or not currently married and was included as married individuals have been found to be at higher risk of being overweight 26 we would have also preferred to control for the respondents occupation higher prevalence of overweight may be expected to be observed among individuals in more sedentary jobs 6 7 8 9 and sedentary labour may be expected to be more prevalent among higher sep individuals however it was not possible to control for occupation in our research due to the fact that it was collected on a very limited subsample of the respondents in nfhs 4 methods in our preliminary analysis we calculated the weighted prevalence of overweight in each strata of the education sep variable separately for indias most and least developed states by sex and urbanrural residence we then calculated the ratio of the prevalence in the highest educational category to the lowest in each survey in order to account for the hierarchical nature of the data in our main analysis we fitted multilevel logistic regressions with psulevel random intercepts for each sex and urbanrural residence separately failure to account for this deliberate clustering at the sampling stage of the data collection process would have caused us to underestimate the standard errors of our results we used surveyspecific interaction terms to estimate the log odds ratio of overweight in each category of our sep exposure variables relative to the lowest category of each sep variable in each survey we monitored changes in standard errors of the main sep exposure variable in order to determine whether there was multicollinearity of the main exposure with added covariates coefficients from the adjusted models were subsequently converted to a predicted prevalence with 95 confidence intervals to make the results easier to interpret results the characteristics of respondents in the surveys used are presented in table 1 in both the most and least developed states the percentage of women with secondary education and in the higher sol category is higher in later surveys compared to earlier ones on the other hand the percentage of women with no education and in the lower sol category decreases over the surveys for example in the most developed states the percentage of women in the higher sol category increases from 16 to 65 between nfhs 2 and 4 whereas the percentage in the lower sol category decreases from 44 to 9 the percentage of respondents classified as overweight increases in each successive survey the largest increase was observed among women in the least developed states where the percentage of overweight respondents increased from 6 to 19 between nfhs 2 and 4 similar trends are found even when we do not limit our sample to nonpregnant and evermarried women in our preliminary analysis we found a consistent trend of increasing prevalence of overweight in both indias most and least developed states this trend was found amongst both men and women in urban and rural areas as expected the most developed states generally had a higher overall level of overweight prevalence compared to the least developed states and especially in urban areas and among women we found a higher relative increase in overweight prevalence in indias least developed states whereas the prevalence among urban women doubled from 17 to 34 in the least developed states between 1998 and 2016 the prevalence increased from 24 to 39 among urban women in the most developed states similarly in among rural women overweight increased nearly fivefold from 3 to 14 in the least developed states compared to an increase from 10 to 23 in the most developed states although the prevalence of overweight increased among individuals of all educational attainments the extent of the increase in prevalence over the study period was consistently highest among those with lower levels of education this was reflected in a declining the ratio of prevalence among those with higher education compared to those with no education for example in urban areas of indias most developed states the prevalence of overweight was 514 times higher among highly educated women than women with no education in 199899 compared to 179 times higher in 201516 notably the smallest ratio was reported among women in 201516 in urban areas of the most developed states whereas the highest ratio among women was found in rural areas of the least developed states among men the lowest ratio was found among rural residents in the most developed states whereas the highest was found in rural areas of indias least developed states in our adjusted analysis we found that the difference in prevalence between the highest and lowest sep category generally declined among women between 1998 and 99 and 200506 the largest decline in this difference was among women in the most developed states where we observed substantial increases among women with low educational attainment between 1998 and 2016 and no notable increase among women with higher education in the least developed states we observed increases in overweight prevalence among women of all educational attainments however the increases were to a greater extent among women with little or no education although the overall prevalence of overweight is consistently higher among urban women than rural women we found no notable differences between them in their socioeconomic patterning trends we sensitivity analysis results of our sensitivity analysis are presented in table 3 and in figs 4 and5 using the sol index as the main exposure shows a similar trend of a notable convergence of overweight prevalence across sep among women particularly in urban areas of indias most developed states additionally it supports the considerably more mixed trend of overweight patterning among men we identified when using education as the exposure of interest discussion statement of findings this study has found that the trends in the socioeconomic patterning of overweight in india varied between indias most and least developed states between 1998 and 2016 when examining the difference between overweight prevalence in the highest and lowest sep groups we found a converging trend of overweight prevalence across sep among women between 1998 and 2016 as expected this trend amongst women was more pronounced in indias most developed states particularly in urban areas however similar trends were observed in the least developed states and in rural areas the converging trend amongst women appears to be driven by relatively smaller increases and in some cases a decline in the prevalence of overweight in higher sep groups compared to lower sep groups this convergence appears to be limited to women as amongst men we did not identify any notable convergence in the socioeconomic patterning of overweight between 2005 and 2016 using sol as the main exposure of interest we found similar albeit a more attenuated convergence in the socioeconomic patterning of overweight few studies have examined subnational variation in the association of sep and overweight in countries that have undergone rapid economic development the only similar study we identified in india used a standard of living index as the primary exposure and reported a similar converging trend in the prevalence of overweight across sep in states with a high overall prevalence of on the other hand they identified a diverging trend in standard of living in states with a high prevalence of underweight amongst women between 1998 and 2006 27 our more uptodate examination of subnational trends in additional subpopulations suggests a more nuanced picture of the socioeconomic patterning notably we find no evidence of a diverging trend of overweight across sep in any of the subpopulations and that there are notable differences in the trends between the sexes and urban and rural areas although there still remains a positive association between sep and overweight across all the subpopulations we analysed in india studies in other countries have identified a negative association between sep and excess weight in more economically areas of countries that have undergone rapid economic development one study in brazil found a positive association between obesity and per capita household income in both more and less economically developed regions of brazil in 197475 by 199697 the association was negative in the more economically developed regions whereas the positive association in the less developed regions persisted 28 this suggests that brazils more developed regions in 199697 may have been at a more advanced stage of the epidemiological transition than indias most developed states currently other studies using measures of household income and educational attainment as the primary exposures and focusing on women in chinas most economically prosperous regions have also found a negative association between sep and prevalence of overweight 2930 we also identified a particularly notable convergence in the prevalence of overweight by sep among women when compared to men other studies have identified similar differences by sex one study in china found highincome men and women with low education to be at highest risk of obesity in an economically prosperous province 29 another study in china found that higher education was associated with lower odds of overweight among women and higher odds of overweight among men 30 in south korea a country that experienced a remarkable pace of economic growth in previous decades 31 one study still found a positive association of income with obesity among men whereas they found a negative association among women 32 the increased capacity of higher sep individuals to afford to consume excess food 6 7 8 9 is a commonly suggested reason as to why the association between overweight and sep is positive in lowor lowmiddleincome countries like india however the smaller difference in overweight prevalence between lower and higher sep women in indias most developed states particularly in the most recent period may be due to an increased ability to afford expensive healthy foods and an increased level of health consciousness among higher sep individuals 63334 on the other hand particularly in indias most developed states lower sep individuals may be increasingly able to afford cheap high calorie fatty foods 635 our study has some limitations firstly we would have ideally liked to have used additional indicators of excess adiposity to complement our findings bmi may be limited in that it cannot distinguish between lean mass and body fat nor does it have information on the distribution of body fat potentially making it an inaccurate measure of central adiposity 36 however other studies have shown a strong correlation of bmi with measures of central adiposity among indians such as waist circumference 37 consequently we would not expect the trends we report to vary considerably between adiposity measures another possible limitation associated with our use of the bmi variable to inform our main outcome of interest is the potential difference in the body fat percentage at any given bmi between higher and lower sep groups research amongst children from higher income countries have shown that lower sep groups may have a higher percentage of body fat at any given bmi compared to higher sep groups 1438 although this may be limited to high income societies we are unable to verify the association of body fat and bmi in our data as the nfhs does not collect body fat information were a similar phenomenon observed in india this would imply a more rapid convergence in the socioeconomic patterning of overweight in india than we have reported we limited our study population of women in 200506 and 201516 to evermarried women as this was the sampled population in 199899 however a slightly higher proportion of the sample was nevermarried in 201516 than in 200506 additionally the prevalence of overweight is lower among nevermarried than in currently married women this may have led us to potentially overestimate the prevalence we reported for 201516 and therefore underestimate the extent of convergence overweight prevalence across sep there are some slight differences in the rankings of states by pcnsdp in 200506 and 199899 compared to in 201415 for example in 200506 the state of odisha had a slightly lower pcnsdp than manipur additionally gujarats economy is 19 larger than sikkims in 200506 however sikkims economy almost tripled within a decade 20 these discrepancies are however unlikely to change the overall message of the study and instead inclusion of these states is expected make results more relatively conservative another limitation of our study involves our use of the standard of living index based in part on the ownership of assets common criticisms of an assetbased index like the one we used includes the fact that it makes little accommodation for the quality of assets 2439 potentially leading to misclassification of households for instance televisions in poorer households may only receive terrestrial transmission whereas in higher sep households may receive digital transmission despite this the simple collection of asset ownership information is not expected to affect the variable substantially 39 additionally as we used three broad sol categories across a large data set any misclassification is not expected to be substantial another criticism of asset indices is that certain assets are likely to have different importance between broad geographical areas although we attempted to remedy this to an extent by calculating separate sol indices in urban and rural areas the importance of some assets may still differ between other geographical levels of aggregation 18 despite these issues assetbased indices offer an affordable and stable longterm measure of household wealth for large surveys in lowincome settings 24 furthermore our use of two different measures of sep in this study ensures that we have captured a large portion of the avenues through which sep and overweight are associated finally the crosssectional nature of the data we used did not enable us to draw conclusions about the causal relationship between overweight and sep although this was not an explicit study aim such information may have enriched our understanding of the reasons as to why overweight is more prevalent among particular socioeconomic groups in india despite these limitations we use the most recent state representative data making our findings both generalisable and the most current estimates of these trends some have suggested that overweight is a disease of affluence in low and lowmiddle income countries 4041 we find evidence of a much more nuanced picture of the socioeconomic patterning of overweight when we examine subnational trends whereas it may be an appropriate description of the positive associations between sep and overweight we identified were the identified trends to continue especially among women in indias more economically developed states there may be a negative association in the coming years we find no evidence that were past trends to continue there would be any change to the socioeconomic pattering among men the markedly higher increase in overweight among lower sep indians will be an important consideration in the near future as state governments are already tasked with tackling the burden of infectious diseases within this demographic a statespecific approach will be needed to face the challenge of raising general access to staple foods whilst simultaneously trying to lower demand for unhealthy foods 27 42 43 44 additionally attempts to close the difference in the association of overweight with sep between men and women may wish to focus on improving healthrelated behaviors among men conclusion although the association between sep and overweight is still positive a continuation of past trends suggests that urban areas of the most developed states in india may be the first to show a negative association commonly seen in highincome countries the success of policies to slow the increasing prevalence of overweight may depend on understanding how trends in socioeconomic patterning of overweight have developed and may continue to develop in the future additional file additional file 1 table s1 percentage of households with the following assetscharacteristics by survey and urbanrural residencepresents the ownership of assets and household characteristics by urban and rural residence across india in the three nfhs surveys used table s2 percentage of the full womens sample in each strata of the sep exposures and the outcomepresents the distribution of the data across the sep variables and main outcome in the full sample of women table s3 predicted prevalence of overweight from the regression model in indias least developed states demonstrates potential underestimation of the convergence in socioeconomic patterning of overweight in least developed states when including nevermarried women and pregnant women abbreviations bmi body mass index ncd noncommunicable disease pcnsdp per capita net state domestic product sep socioeconomic position sol standard of living competing interests the authors declare that they have no competing interests

background indias economic development and urbanisation in recent decades has varied considerably between states attempts to assess how overweight including obesity varies by socioeconomic position at the national level may mask considerable subnational heterogeneity we examined the socioeconomic patterning of overweight among adults in indias most and least economically developed states between 1998 and 2016 methods we used state representative data from the national family health surveys from 1998 to 99 200506 and 201516 we estimated the prevalence of overweight by socioeconomic position in men 1554 years and women 1549 years from indias most and least economically developed states using multilevel logistic regressionswe observed an increasing trend of overweight prevalence among low socioeconomic position women amongst high socioeconomic position women overweight prevalence either increased to a smaller extent remained the same or even declined between 1998 and 2016 this was particularly the case in urban areas of the most developed states where in the main analysis the prevalence of overweight increased from 19 to 33 among women from the lowest socioeconomic group between 1998 and 2016 compared to no change among women from the highest socioeconomic group between 2005 and 2016 the prevalence of overweight increased to similar extents among high and low socioeconomic status men irrespective of residencethe converging prevalence of overweight by socioeconomic position in indias most developed states particularly amongst urban women implies that this subpopulation may be the first to exhibit a negative association between socioeconomic position and overweight in india programs aiming to reduce the increasing overweight trends may wish to focus on poorer women in indias most developed states amongst whom the increasing trend in prevalence has been considerable

introduction sexual and reproductive health and rights are crucial entitlements relating to women and girls sexual and reproductive health 1 these rights address the prevention of sexually transmitted diseases including hiv genderbased violence maternal mortality and provision of essential health services 2 3 4 since the international conference on population and development and the beijing platform for action national srhr policies have been demonstrated to support societies and contribute to a countrys wealth 2356 the importance of srhr is further underscored by section 56 of sustainable development goal 5 dedicated to achieving srhr for all 7 human rightsbased approaches by emphasizing rights over needs have become the focus of sustainable strategies for change 589 the basic principles of hrba include empowerment of rightsholders and dutybearers nondiscrimination open participation accountability and defined and established linkages between rightsholders and dutybearers 58 for sexual and reproductive health hrba empower women to claim their rights and dutybearers to fulfil their obligations 810 by focusing on nondiscrimination hrba also specifically consider those who are vulnerable marginalized and discriminated against 810 giving agency to the less powerful in society achieving these principles requires coordinated multisectorial approaches based on an analytical understanding of the needs of groups available resources and challenges 1112 adolescents and emerging adults aged 1524 comprise around a fifth of the population in low and middleincome countries 13 yet their needs are often overlooked and particularly regarding sexual and reproductive health underfunded 2614 in uganda teenage pregnancy rates are high with one in four women aged 1519 giving birth 15 adolescent girls and young women experience higher risks of genderbased violence a disproportionate likelihood of sexually transmitted diseases and frequently lack access to sexual and reproductive health services 2616 for agyw living in urban slums their visibility is reduced further by the double vulnerability of age and poverty 17 previous studies considering srhr of women in lmics have focused predominantly on sex workers or maternity settings 18 a recent scoping review identified no qualitative evidence regarding sexual and reproductive health challenges among young people living in slums in uganda and limited qualitative evidence in the rest of subsaharan africa 17 a crosssectional study undertaken among 1324 year olds in makindye and nakawa divisions of kampala uganda identified sexual abuse a significant issue among participants but the underlying facilitators and barriers were not explored 19 there remains a need for studies focusing on agyw regardless of parity or engagement in sex work this plain language summary every woman is entitled to good sexual and reproductive health this involves being free from sexually transmitted infections genderbased violence and maternal mortality and able to access essential health services in low and middleincome countries adolescents comprise a fifth of the population yet their sexual and reproductive health needs are often overlooked adolescent girls and young women are more likely to experience genderbased violence sexually transmitted infections and poor access to sexual and reproductive health services those living in slums have even worse outcomes but little evidence exists regarding the opportunities and barriers to improving sexual and reproductive health among adolescent girls and young women in a slum setting in this study we conducted focus groups and interviews with 21 adolescent girls and young women living in two ugandan slums 10 individuals with an essential role for example at state level as well as 30 other stakeholders including healthcare workers teachers parents district leaders and community support officers working with adolescent girls and young women results indicate that adolescent girls and young women lack information regarding their sexual health what services are available and who and where to go if they experience violations such as sexual assault in instances of sexual assault fear and stigma prevented adolescent girls and young women from going to the police and instead disputes were handled informally between families participants in our focus groups and interviews felt that education and training were needed and that health services need to improve interventions are necessary to improve adolescent girls and young womens sexual and reproductive health in this setting keywords sexual health reproductive rights hiv jurisprudence patient advocacy reproductive health study aimed to explore the underlying factors impacting on the realisation of srhr of agyw living in slums in wakiso district uganda methods indepth interviews and focus groups were conducted in wakiso district uganda between februaryaugust 2019 qualitative data were collected regarding knowledge attitudes and experiences of srhr of agyw living within slums kibwa and kileku slums were selected as both are unplanned settlements representing established and emerging slums whose semipermanent population is known locally to face overcrowding unhygienic conditions and high levels of violence and sexual crimes two focus groups were held with agyw aged 1423 years resident in either slum recruited through established community connections there were no exclusion criteria as a wide range of lifeexperiences were sought invitations to participate were by phone or verbal invitation focus groups were limited to an hour during daytime in private and accessible locations ten 11 indepth interviews were held with key informants including state and nonstate actors purposive sampling with assistance from the wakiso district community development officer was used to select participants based on their essential role in realising agyws srhr participants were invited to participate by telephone three focus groups were held with stakeholders selected for their obligations to srhr for agyw purposive sampling with assistance from the district officer for health and snowball sampling were used invitations were by telephone email and letters groups were held in private spaces separate to working environments participants gave written informed consent participants under 18 years who were unmarried required a caregivers consent unless pregnant individuals who participated in focus groups were each given a number to identify themselves with so individuals names were not used in recordings no prior relationship existed between research team members and participants ethics committees in the uk and uganda approved the study design data collection interview and focus group topic guides were developed by members of center for health human rights and development uganda and university of warwick uk trained researchers from cehurd with qualitative research experience facilitated each focus group two additional cehurd members wrote reflective notes focus groups were held in luganda with english as required data were recorded transcribed translated and checked for accuracy by members of cehurd triangulation with reflective notes was undertaken to reduce researcher bias data analysis data were coded by members of cehurd and university of warwick using nvivo with coding decisions discussed with a third university of warwick team member transcripts were thematically analysed using simultaneous inductive and deductive approaches with emerging themes compared within and across transcripts disputes were handled through team discussions and consensus findings were reported following the standards for reporting qualitative research 20 patient and public involvement patients andor public were not involved in the design recruitment conduct or reporting of this study results of 61 people invited to take part in the study none declined table 1 describes the participant characteristics agyw included in the study were aged 1423 years six participants were aged 1417 years eleven were aged 1820 years and four were aged 2123 years table 2 outlines the identified themes and subthemes additional file 4 includes examples of illustrative quotes for each subtheme understanding of sexual health and rights agyw had a reasonable understanding of hiv identifying how it is spread lifelong implications of diagnosis and the importance of medication adherence several key informants identified misconceptions about sexual health held by agyw but they are fed the information like if you use a condom it will get stuck inside you you understand community support officer 1 key informants stated that lack of education on srhr was a reason for misconceptions many key informants believed that agyw underutilized healthcare services because they were unaware of them or what they offered …they dont keep informing the community of the availability of these services and the fact that wakiso is a periurban district people settle and people go away people settle and people go away so the people who come in tend to miss the services thinking they are not available district leader 1 key informants were able to name some srhr agyw articulated their right to consent to sexual intimacy access health services and accept healthcare key informants and stakeholders felt agyw lacked information on how to redress their rights if violated which was borne out by testimony from agyw suggesting they were unsure where to go if their rights were violated they can get justice but they havent got guidance they even say am pregnant and am 13 years but if they are going to imprison my partner i should also be imprisoned they dont understand that we are helping them in their lives to save them and also from diseases number 2 focus group 4 sources of information a wide range of sources provided information about srhr for stakeholders and key informants for example training workshops and visiting lawyers however government restrictions on reproductive health education were seen as a significant barrier for agyw they have the right but our government and leaders like the religious leaders currently dont accept or allow these young girls to know about some health issues for example reproductive health community support officer 2 official means of disseminating information were through radio programs and fliersposters in english some stakeholders noted that printing information in english was not helpful to those who could not read or speak english agyw identified their peers and communitybased organisations as predominant informal information sources parents were often seen as barriers to understanding withholding reproductive health information stakeholders described parents as unsupportive of family planning and lacking openness with their children about sexual health there are parents that dont believe in family planning they come and say my child has started taking medication its also a problem especially because the parents also dont know about the importance of family planning number 4 focus group 4 but most parents keep things secret from their children and we dont tell them what is going on in the world number 5 focus group 3 experience of and barriers to healthcare nearly all participants stated that local healthcare services lacked resources and medications agyw were therefore asked to pay for healthcare from feeforservice clinics to essential medications for many the financial burden was too high combined with fear and stigma some participants stated that agyw often resort to using unregulated and traditional medicine …when i reach the pharmacy where am to buy the drugs from the drugs are 30000ugx and i only have 10000ugx in my bag so i find that medication too expensive in that case i will just go and pluck some omululuza and kamunye and i drink because it is the cheaper option that will help me number 10 focus group 5 they fear if they get a problem may be they want to abort they can use these herbs and someone calls you and says this one is here dying they say she has taken herbs community support officer 3 stories of poor healthcare and stigma associated with sexual health issues were common reasons for agyw not to utilize services many agyw felt they were treated differently because they were young and poor and those in dutybearer positions did not listen to their needs for agyw accessing healthcare perceived lack of respect caused them to shy away from further healthcare some agyw recalled positive healthcare experiences i was given a lot of care where i gave birth from even when i hadnt paid money but that was in the name omitted government hospital number 10 focus group 2 some agyw were denied healthcare access when visiting without a husband present a key informant stated husbands often prevented their wives from accessing family planning services agyw and key informants stated that despite the periurban environment travel distance and costs were significant barriers to healthcare …the distance is long and it is not like everyone can walk there or has the money… number 10 focus group 1 violations of rights most participants specified that money and poverty played a significant role in the violation of agyws rights participants recalled stories of desperate family members for whom money was a driver for them facilitating their daughters to engage in underage sex and child marriage however parents actions were not always described as seeking monetary gain a local leader noted that parents forced their children to marry because it mirrored their own experience …our problem is with the parents who force their children to get married fast mainly because the parents too got married early number 5 focus group 4 agyw also described experiences where perpetrators with money were treated differently and a perpetrators word was considered more credible than the word of assaulted agyw other agwy described experiences of attempted corruption of their rights for money my uncle came home and he was kind of forcing me to accept money from him which was 500000shs and placed it on the table asking me to get the money and testify in court saying i wanted what happened to me number 4 focus group 2 many agyw described guardians and dutybearers violating their rights this was echoed by stakeholders and included confidentiality breaches from teachers to health workers what has brought the biggest issue is health worker they dont keep confidentiality so people will not go to see them if they dont keep confidentiality number 7 focus group 4 key informants noted that sexual assault violations were normalized over a certain age some participants stated that agyw are taken advantage of when trying to better their education or obtain jobs high alcohol and drug use amongst men were named as underlying causes of domestic violence towards women sexual domestic violence is high in areas like this for us men the rate of drinking alcohol and drug abuseyou know what these result into when they go back home they harass women because of poverty and other things so our sisters have got problems because domestic violence is high and rape unknown number focus group 3 barriers to justice and redress of rights violations many stakeholders noted that while official channels existed for women to redress their rights cases were often informally handled between families these community courts left little support for women involved the other challenge that we have is that parents also always negotiate with the people that rape their children and we find ourselves in situations where cases are settled between families without consideration of the challenges that the survivor is going through or even worse still the diseases she may contract from such experiences number 5 focus group 4 even when attempting to use formal channels of justice several agyw experienced the prioritizing of others reputation over their right to justice guardians in the home education and healthcare environment suppressed their rights due to appearances and to save perpetrators from jail but when i tried to tell the owner of the school he told me to leave that alone and kept silent he said the good thing you are soon finishing senior 4 and you leave the school leave that alone because if you report you are going to tarnish the schools reputation number 4 focus group 1 but when she told the person she stays with that is her grandmother the mother of her uncle she asked one thing do you want my son to be arrested so after they had raped her she was in pain but because her grandmother doesnt want her son to be arrested she didnt get her number 10 focus group 1 agyw sometimes choose to live without justice because they fear they will be left without support so someone may not get justice because the man used her and that if the man is arrested she may not get supports and there will be no one to support her so it ends that it is like they have not got justice because she wants to find a way of ensuring the man looks after her number 9 focus group 3 key informants identified stigma towards agyw who experienced violations and agyw felt stigmatised when pregnant men stigmatizing us throwing comments such as look at her she gave birth at a young age look at her legs those are the comments they throw at us number 4 focus group 2 stigma was related to experiencing violations and the act of redressing it some participants stated that where violations were reported the victim endured further discrimination and shame the potential for additional stigma associated with reporting violations presented a significant barrier then the shame that is attached to the person who had been violated oh dear society will be like so she thought that reporting will help everywhere she will pass she will be despised the more community support officer 4 an individuals status in terms of money age and education greatly influenced whether a reported violation was believed or taken seriously cost and corruption were a common theme in preventing justice particularly regarding police involvement many participants stated they felt the police were not effective and were open to corruption our side at the police our mother had 100000 ugx but she told them she had 50000ugx then they agrees to come and arrest the person but we waited for them and they didnt show when we went back they told us we must add more money because what we had given them was lesslittle so we abandoned the case number 6 focus group 1 health professionals were seen as reluctant to testify or support victims coming forward suggestions for change many participants suggested that further education would empower agyw to speak up against violations also mentioned was the need to educate other stakeholders members of the community and government officials as misconceptions were evident at all levels one participant suggested that srhr education should extend to boys and men given the importance of their role in ensuring women achieve their srhr so i think the other challenge is sexual and reproductive health rights being looked at as exclusively for girls so the boys will always do whatever they want thinking that this is only for girls which to me is something the society needs to come out strongly to educate the male youths community support officer 4 one service provider however felt that education may be wasted on agyw they felt a divide between adults and the younger generation and suggested that the younger generation resisted advice from elders most dont want to be sensitized in that even though you organize a training they do not attend and yet they would have been of use to them in learning and understanding if there is any chance of an issue like this happening in the future and it is in these trainings where they would get knowledge on what to do in case the need arises number 6 focus group 5 according to key informants and stakeholders there may be little difference until the laws are changed to align with agyws needs even with increased education they young women may want to acquire post abortion or abortion services but its against the law so they dont maybe some of these cases end up into death community support officer 5 for example in schools the information we give them according to the ministry of education and sports it is less to what they need they tell us not to talk about abortion but this is what the girls are facing and they need this information and service provision somehow but they cant access they need the knowledge but you still cant give because its against the law community support officer 5 another key informant suggested that more resources and funding specifically for adolescent health would improve service delivery more funding should be directed towards adolescent health because we really dont have a vote for adolescent health as a standalone we are running… integrating it with other services and we run on other service now like hiv and ride on them district leader 2 many stakeholders suggested that fighting corruption would make a difference to overall srhr service delivery one participant felt sentences for perpetrators were too light and did not act as significant disincentives to repeat offence can i also add that the police is not doing us enough justice because ideally whoever violates should be handled by a strong law people dont understand that once you violate a girls or boys sexual rights you are ruining this person for good someone found guilty takes a very light sentence and goes and violates another one they bring them back and its the same light sentence community support officer 4 discussion themes arising in the data describe srhr gaps and violations as they relate to agyw living in urban slums in uganda and suggest areas amenable to intervention based on hrba principles analysis revealed that poverty remains a common driver of srhr violations reducing healthcare access rendering treatments unaffordable exposing vulnerabilities in the lives of agyw and their families and preventing justice by tolerating environments where corruption particularly by police is pervasive despite these challenges there appeared ample opportunity for promoting empowerment through education as recommended by the world health organisation 21 with knowledge gaps identified raising awareness amongst agyw stakeholders and the wider community could address misconceptions encourage participation and set the stage for stronger accountability mechanisms our study is the first to outline the challenges faced by agyw in achieving srhr in a slum setting in uganda indeed a recent scoping review identified no qualitative evidence regarding sexual and reproductive health challenges among young people living in slums in uganda and limited qualitative evidence in the rest of subsaharan africa 17 a crosssectional study undertaken among 1324 year olds in makindye and nakawa divisions of kampala identified sexual assault as a common issue in keeping with our findings 19 initiatives like specifically criminalizing genderbased violence as enacted in uganda in 2010 22 can be important in the journey towards supporting agyw to achieve srhr however as data from this study show legislation alone cannot solve the problem other qualitative and implementation studies have utilized bottomup hrba to affect change methods focusing on legal empowerment for health promotion have been applied to hiv 23 while communitybased awareness campaigns have demonstrated attitude shifts towards young mothers through empowerment and income generation 24 these interventions highlight the strength in strategically incorporating the wider community when addressing srhr issues this study encouraged open discussions of experiences and opinions amongst peers critical to the process of developing hrbas 11 this information provides a current assessment and analysis of rights upon which interventions can be tailored to address the specific causes of nonrealisation of rights for these agyw thus avoiding carbon copying of methods elsewhere and strengthening the likelihood of sustainability 25 the unfpa suggests that empowerment comes from not only knowing your rights but also knowing that those in power are aware dutybound and actively supporting these rights 8 an additional strength of this study is in establishing partnerships and networking stakeholders and dutybearers in their awareness and commitment to protection of agyws srhr the interviews with key informants brought additional depth painting a wider picture of the structural causes effecting the realisation of agyws srhr this study was conducted in just two slums in a single country and not all findings will be generalisable to other contexts other limitations include the selfselecting nature of participants particularly agyw who were under 18 requiring parents consent may have limited participation to those whose parents were open and might not represent experiences of agyw whose parents held different attitudes however this was likely overcome with the inclusion of agyw over 18 in fact parental beliefs and behaviour as rights violations and barriers to justice were identified the participant threshold was predetermined based on available time and resources and on participants roles and affiliations within the slums further studies in urban areas allowing for more participants would help achieve data saturation conclusions this study has identified important barriers and facilitators for agyw to achieve their srhr in an urban slum context barriers identified included stigma towards pregnant teenagers cost preventing healthcare access and family police and school sometimes acting as barriers to the redress of rights facilitators identified included education to address misconceptions and improved accountability mechanisms the knowledge obtained from this study and the connections established will be used to develop an intervention based on legal empowerment and social accountability approaches grounded in human rights norms the resulting intervention could increase awareness empower and promote agency in agyw living in slums 25 the need for such an intervention was evident in discussions with key informants many of whom actively sought advice regarding rightsbased implementation from the research team while this study was conducted in uganda worldwide reports suggest that many countries are struggling with similar misinformation resource constraints and communitydriven stigmas 2 suggesting that a resulting intervention may be relevant to other contexts too through awareness and continued engagement targeted interventions for the realisation of agyws srhr can address underlying causes and positively shift attitudes for the promotion of health additional file 4 is a competing interests none declared

background sexual and reproductive health and rights are critical entitlements best supported through human rightsbased approaches empowering rightsholders to claim their rights and duty bearers to fulfil their obligations implementing these requires information on the current needs and challenges faced by those seeking to claim their sexual and reproductive health and rights we aimed to identify the underlying factors influencing the realisation of sexual and reproductive health and rights for adolescent girls and young women living ugandan slums by 1 exploring the role of relevant service providers and stakeholders and 2 uncovering knowledge and gaps in protecting adolescent girls and young womens sexual and reproductive health and rights methods qualitative data were collected through focus groups and interviews focused on current knowledge behaviours and attitudes towards sexual and reproductive health and rights among adolescent girls and young women service providers and stakeholders data were analysed thematically using nvivo software ten indepth interviews were conducted with key informants two focus groups were held with adolescent girls and young women living in two slums in uganda 21 participants in total and three focus groups were held with community leaders service providers teachers and parents 30 participants in total adolescent girls and young women lacked information regarding their sexual health services available and redress mechanisms for rights violations formal sources of information were frequently inaccessible family members were sometimes the source of rights violations and informal methods of redressing rights were often sought stigma and fear were common features both in healthcare and in the pursuit of formal justice with dutybearers habitually breaking confidentiality education and training were the predominant suggestions offered for change conclusions adolescent girls and young women continue to face obstacles in achieving their full sexual and reproductive health and rights targeted interventions for the realisation of adolescent girls and young womens sexual and reproductive health and rights can address underlying causes and positively shift attitudes to promote health

introduction crosssector coproduction involving volunteers in the production and delivery of public services has come to the forefront of many advanced welfare states across europe and elsewhere increasing pressure on public welfare economies has led to a new agenda of increased nonprofit and voluntary involvement in welfare policy fields such as elderly care childcare labour market activation and integration of refugees and immigrants in response these policy fields have become more open to crosssector collaboration and sectorial boundaries have become more fluid however there is a lack of systematic knowledge on how differences between welfare policy fields enable constrain and shape coproduction into different forms and practices this study seeks to contribute both empirical knowledge and a conceptual framework for analysing these fieldspecific differences within individual policy fields the coproduction agenda involves strong mutual awareness among public nonprofit and forprofit actors of involvement in a common enterprise simultaneously this expands the legitimate terrain for volunteer and nonprofit involvement in service production and delivery this blurring of the boundaries of legitimate participation creates opportunities for new crosssectorial forms of collaboration and practices policy makers see coproduction between public actors and voluntary nonprofit actors as a key element in the future welfare architecture across a range of social issues however coproduction activities are set within different fields with varying degrees of structuration different power constellations dissimilar degrees of contestation and various distributional logics and conflicts over resources and recognition existing research shows that different field structures can enable or constrain the development of new organisational forms and can impact the space available to negotiate and enact new and innovative practices how different field characteristics enable constrain and shape coproduction between public sector and voluntary sector actors are of growing concern a major review of some 120 cocreation and coproduction studies concludes that we know too little about to what extent the policy field in which cocreation is implemented is influential with respect to the type and effects of these processes suggesting that the challenges opportunities and practices of coproduction depend on the specificities of the service in question one key comparative study suggests that both regime and social policy domains may have a critical impact on the shape of organisational hybridity similarly comparative studies of the geographical and institutional contexts of coproduction indicate that field effects may be very real and tangible a recent comparative study across norwegian municipalities likewise demonstrates the correlation between the institutional context of different fields and variation in coproduction patterns how coproduction of service delivery at the front line in everyday practices is shaped by field properties however remains less researched to address this gap we investigate how different fieldlevel conditions enable constrain and shape coproduction practices in crosssector collaborations within a comparative case study of two different welfare policy fields at the local municipal level the fields investigated in this study are elderly care and welfare services for refugees the two case fields are similar in terms of the increased involvement of nonpublic actors who work alongside or with public welfare providers to meet new and increasing demands for services the fields differ however in the broader political and public attitudes towards the two groups of welfare recipients which manifests as differential access to and distribution of human resources and organisational resources these differences may have a significant impact on the conditions and opportunities for crosssector collaboration based on extensive qualitative data from one large danish municipality we compare how particular ways of organising and practicing crosssector coproduction were shaped enabled and constrained by the structures of the two policy fields we find that differences in field properties resulted in two different forms of coproduction practices which we term embedded and exterior in the field of elderly services coproduction practices take the form of embedded coproduction in this field crosssector coproduction typically received more support from the top management of the municipality more human resources were invested in coproduction projects and more investments in spatiomaterial infrastructure were made to facilitate coproduction moreover there was relatively open access to locales for crosssector collaboration and volunteers were welcomed within public sector facilities in the field of refugee services coproduction practices take the form of exterior coproduction in this field coproduction received less or no support from municipal top management and primarily remained outside of the physical and symbolic spaces of the public sector and instead took place in fragmented shortterm collaborations our research demonstrates that different field conditions for coproduction resulted in different opportunities for and openness to crosssector collaboration moreover each form of coproduction casts public and voluntary actors in different positions leading to different tension fields conflicts and boundary struggles over public and voluntary responsibility and terrain within the elderly field voluntary actors were frequently forced into defensive positions in an effort to guard their autonomy whereas voluntary actors often pushed for a more ambitious coproduction agenda within the field of refugee services against a cautious public sector in both cases considerable tensions and ambiguities resulted from these fieldspecific positions and oppositions in what follows we first review relevant field theory and develop an analytical approach to fields helpful in understanding the unfolding of coproduction practices within policy fields second we present the data and methodology of our study and we briefly outline the arguments for our selection of policy fields as cases third we describe and analyse the different distributions of support and resources across the two fields at the municipal level and demonstrate how these shape constrain and enable different forms of coproduction practices across fields lastly we discuss the implications of the embeddedness of local coproduction practices within different policy fields policy fields and coproduction our study concerns how different fieldlevel conditions shape enable and constrain crosssector coproduction of social services as specific organisational practices for this purpose we consider a field as an institutional environment of symbolic legal regulatory and spatiomaterial affordances and relationships that can shape actors opportunities and constrain action a field is characterised by a certain constellation of identifiable elements such as national rules and regulation political priorities different public and private service providers and different professional norms consequently different policy fields provide differential access to key resources for different actors which shape service production and practices moreover given the different allocation of resources positions and relationships between actors from different sectors also depend on field specific characteristics within the extensive literature on fields one dominant approach primarily focuses on shared norms and practices emphasising the structuring and constraining power of fields the institutional logics approach for example perceives fields as arenas containing logics or organising principles that govern which actors are considered legitimate participants and which kinds of technologies organisational goals and managerial practices are authorised other approaches such as the theory of strategic action fields instead conceive of fields as arenas of conflict and strategic action aiming to create and contest field rules this approach focuses on the differentials of power emanating from the unequal distribution of resources and positions and social skills among actors for our purpose we follow monika krause´s argument that whether specific fields are characterised by shared norms and consensus rather than conflict and struggle is an empirical question a field approach allows us to observe how fieldrelated differences in specific actors access to various kinds of resources and support help shape fieldspecific crosssector coproduction practices moreover the focus on the practices at the concrete frontline of service delivery enables an appreciation of the implications of the various forms of support for coproduction outcomes and the positions available to coproducing actors based on a review of research on fields and crosssector collaboration we propose a framework sensitive to the impact of field context on how coproduction practices unfold across the public and voluntary sectors field context involves both immaterial elements such as ideology or political visions organisational resources and the spatiomaterial resources such as buildings and locales made available to coproduction we identify three key dimensions of the field context 1 overall ideological legitimacy of coproduction as a collaborative practice 2 distribution of formal support and access to human and organisational resources 3 distribution of spatiomaterial resources below we elaborate how these field dimensions all play a critical role in shaping enabling or constraining crosssector organisational practices into fieldspecific forms the first dimension ideological legitimacy is important because coproduction is not only a model for organising collaborative initiatives across the public and voluntary sectors but alsoand perhaps primarilya normative ideal for the pursuit of shared public and private responsibility institutional research on crosssector collaboration shows that participating partners depend on ideological backing to legitimise investment in resources and infrastructure and to support general guidelines for collaborative experiments typically this kind of general ideological legitimacy manifests in favourable discourse production such as government strategies or governance models which promote particular understandings and models for the best practice of coproduction specific role interpretations are also promoted and may guide negotiations and practices between public and voluntary sector actors these models for best practice and collaborative roles may permeate local field discourse and perceptions among coproduction participants helping to stabilise mutually accepted practices and social rules as common ground among partners navigating new terrain our second analytical dimension formal support concerns the access to and mobilisation of human and organisational resources and support for coproduction as pivotal field conditions individual actors and organisations operating in different welfare policy fields depend on local top leaders and managers support for coproduction initiatives and projects for two main reasons first it connects coproducing actors to political and administrative authority which strengthens the positions of actors seeking to advance new collaborative initiatives and coalitions second formal support also eases access to organisational and human resources such as professional competencies and funds which may help actors establish and sustain collaboration and become attractive coproduction partners the third dimension spatiomaterial resources concerns access to physical or virtual spaces and infrastructures for coproduction by including a focus on spatial resources we follow rodner et al who posited that spatial aspects of institutions help enact or constrain said social interactions as with any other organisational practice crosssector coproduction depends on a mixture of digital and physical meeting places for coordination planning and everyday practice conversely the absence of stable physical and virtual meeting places or an excessively frequent change in locations may constrain crosssector interaction and trustbuilding even though the literature on fields and institutional transformation rarely pays much attention to space and materiality in general a growing body of research in organisation studies emphasises the importance of space in shaping and contesting fields according to this work spatial resources may cover the access toor ownership ofbuildings premises or websites sustaining the organising or practicing of coproduction or they may manifest as geographic nearness to key field institutions or as the density of organisations in our analysis we focus on how these three mutually dependent dimensions of policy fields provide a complex web of ideological political formal and spatiomaterial conditions for public and voluntary actors that underpin the local manifestations of fieldspecific practices of crosssector coproduction and we demonstrate how these different coproduction practices affect the openness and support for coproduction as a legitimate collaborative effort across the public and the voluntary sector study design methodology and data we selected the two welfare policy fields of elderly care and welfare services for refugees for comparison because they both enjoy a high level of ideological legitimacy of coproduction state actors local municipalities and voluntary organisations within both fields all work to address important public concerns and recognise that crosssector collaborations are essential in this endeavour elderly care is of interest because of the growing elderly population and demands for rehabilitation measures and refugee services because of increasing global migration the purpose of this selection is to limit our investigation to policy fields where coproduction should be expected to occur in practice and consequently to provide access to data on coproduction where it is actually taking place next the two policy fields were selected because they represent different political attitudes towards the deservingness of the recipients which on a local level may spill over into different distributions of resources on the two remaining dimensions formal support and spatiomaterial support whereas elderly people enjoy a high degree of deservingness the opposite is the case within the field of refugee services this research design suggests that if policy fields play a role in forming coproduction practices and structuring actor positions such differences should emerge in this study we analysed coproduction practices within the two fields on a local scale within the aalborg municipality one of denmarks largest with approximately 200000 inhabitants in mainly urban and suburban residential areas the aalborg municipality explicitly supports coproduction in the two fields making it similar to most danish municipalities we collected data on all activities and projects involving voluntary organisations or volunteer initiatives targeting vulnerable elderly people and refugees that were defined by the local public or voluntary actors as coproduction the empirical material focused on the type of coproduction concerning social service production such as community development social support activities and leisure activities for vulnerable groups the major part of the activities in our material further could be characterised as community coproduction in which voluntary organisations and volunteer initiatives make supplementary contributions to the provision of social services the case study combines several qualitative methods two years of participant observation of meetings and everyday organisational life thirtyfive interviews with volunteers public managers public employees and users five focus group interviews with elderly people the next of kin of the elderly people and refugees and document analysis of project descriptions municipal policy documents and organisational publications such as newsletters and strategy papers the analysis in this paper is based on material from the entire empirical archive all data were managed according to ethical standards we illustrate main findings with quotes from interviews and with examples of coproduction initiatives and projects from our observations and field work in the analysis we have a particular focus on differences across the two policy fields on the three analytical dimensions our analytical strategy starts by looking into how the ideological legitimacy of coproduction as a practice for local actors materialised in widespread positive attitudes towards local partners and projects engaging in solving complex tasks and services across the municipal and the voluntary sector however despite strong ideological support across both the elderly field and the field of refugee services the resources available to coproducing partners differed significantly across the two fields in two consecutive sections we demonstrate how the elderly field was characterised by strong formal support and substantial access to spatiomaterial resources whereas the opposite was the case for the field of refugee services the next analytical step offers a conceptual characterisation of each of the two organisational forms of practicing coproduction labelled embedded and exterior which resulted from the differential distribution of key resources within each of our fields lastly we analyse how these two fieldspecific forms of practicing coproduction each impact the space and positions available to public and voluntary actors and we analyse the ambivalent fieldspecific tensions and conflicts that arise as a consequence there are limitations to a single municipality study such as ours there may be variations in local municipality and civil society regimes we do not capture there may also be differences related to the size of fields or the traditions of collaboration that would demand a more encompassing comparative design the aim of the field comparative case design however is not to generalise in a statistical sense but to arrive at analytical generalisations that can advance our conceptual understanding of different patterns of coproduction local ideological legitimacy of coproduction in our case municipality a high degree of openness towards crosssector collaborations existed within both the elderly field and the field of refugee services key municipal and voluntary sector actors were keen to work in different partnership constellations describing coproduction as an activity in which citizens voluntary organisations and municipal organisations engaged in identifying and addressing unmet social needs through collaboration thus we found a positive attitude and a shared understanding of coproduction among representatives from public and voluntary organisations across both fields and interviewees illustrated ideal coproduction practices by referring to concrete model projects one example of such a model project which was mentioned by several interviewees included one of the local churches that arranged relocations of refugees from temporary housing to permanent residence the problem for the municipality in this case was a lack of legal authority to support and finance relocation in many cases the refugees were left without means and networks to help them and in this case church volunteers offered practical assistance and even provided used furniture for the refugees another example from the elderly field involved a request from the municipality which could no longer find resources to accompany elderly people to the dentist with fewer elderly people having artificial teeth this was a growing problem since a lack of attention to oral hygiene could develop into more serious health problems in this case volunteers stepped in to accompany the elderly to the dentist as a token of the open attitude and as concrete support for the idea of crosssector collaboration the municipality employed volunteercoordinators within both elderly services and refugee services in both fields the intended role of the volunteer coordinators as boundary spanners was to cultivate and sustain fruitful crosssector partnerships across municipal and voluntary actors thus at the local level we found a high degree of ideological legitimacy of coproduction and a high degree of openness towards crosssector collaborations within both the elderly field and the field of refugee services furthermore within both fields local actors highlight particular projects as models for successful coproduction practices however there were also considerable differences between the two fields and successful coproduction typically depended on the municipality formally initiating or endorsing coproduction projects and supporting them through the allocation of staff and access to municipal institutions physical spaces andor digital platforms in the following two sections we describe the different distribution of formal support from municipal management and the different distribution of spatiomaterial resources within the two fields formal and spatiomaterial support in the elderly field within the elderly field the formal support from municipal management and policy makers stood out distinctly as an example the top management of the elderly administration were present at the launch of a large crosssector coproduction project to counter loneliness among socially atrisk elderly people an experience we did not observe within the field of refugee services furthermore formal support involved staff allocated to the project entrenching the project as an important collaborative effort the high level of formal support also meant that volunteer involvement was perceived as noncontroversial while voluntary associations recruited some of the volunteers involved in coproduction in the elderly field others were recruited directly through local public institutions through word of mouth or via a website designed to support the recruiting of standalone volunteers on the municipalitys website local citizens could post their interest in volunteering after which municipal staff typically the municipal volunteer coordinator would match individual volunteers with municipal activities for the elderly in this field the volunteer coordinator employed by the municipality had a mandate to promote and facilitate coproduction initiatives and enjoyed wide degrees of freedom from top management to initiate new crosssectoral collaborations or employ standalone volunteers as she saw fit during an interview the volunteer coordinator put it like this well we have a freedom charter in the elderly administration so we should dare break boundaries and limits and we do that definitely furthermore the formal support at the local level was supplemented with plenty of stable spatiomaterial resources that were allocated to coproduction in the elderly field volunteers were welcomed in the local elderly homes and activity centres as active providers of supplementary activities such as tandem cycling singalong cafés or personal visitors for the elderly in other words crosssector coproduction and volunteers in general were welcomed and actively invited into municipal spaces through buildings and virtual infrastructures volunteers either organised or standalone were treated as trustworthy complementary and highly desired resources consequently coproduction in the field of elderly services was often practiced within municipal institutions and spaces one illustrative example of the high formal support and spatiomaterial integration of coproduction within the elderly field was the project called active young patients with dementia the coproduction project targeted citizens recently diagnosed with dementia and was initiated and organised as a crosssector collaboration in which the municipality and the involved voluntary organisations collectively defined the needs of the elderly in focus and agreed on how to organise activities responding to these needs the project manager was a former municipal employee and the project was physically located in a municipal administration building reflecting the important formal municipal support forand influence onthe project the municipality provided formal support and spatial resources for the aypd project and the project manager emphasised on several occasions how the aypd from the beginning was endorsed by key actors within the municipal elderly department during an interview she said i have been employed by the municipality before and there for many years people had been saying we would like such a service for citizens suffering from dementia where you could walk in from the street we could have some employees to sit there providing advice and guidance and the voluntary association said we would also like such an option could we do this together so we the municipality had meetings with the voluntary association about how we could join forces in this project thus in terms of both formal support and spatiomaterial resources the field of elderly services provided an institutional environment with resources and opportunities that could support actors from the municipality and the voluntary sector in coproduction efforts formal and spatiomaterial support within the field of refugee services the ideological legitimacy of coproduction in the refugee services field matched that of the elderly field however in terms of putting ideals into practice we found significant differences compared to the elderly field and it was apparent that the field of refugee services constituted a significantly different institutional environment with less formal support and spatiomaterial resources at disposal in terms of formal support the municipality similarly allocated resources to a volunteer coordinator in charge of cultivating and sustaining crosssector collaborations however whereas the coordinator in the field of elderly services was expected to actively encourage initiate and support collaboration with volunteers within municipal spaces the volunteer coordinator in the field of refugee services performed the role of boundary spanner in a more reluctant manner in fact we observed several instances in which voluntary organisations tried to initiate new coproduction projects to address specific refugee needs but were met with resistance from the volunteer coordinator and other municipal staff one example was an initiative from a large nonprofit organisation to launch a coproduction project escorting refugee children to voluntary leisure activities which was dismissed by the municipal administration the municipal employees justified the rejection by arguing that the project would cater to a certain group of children contrary to the goal of integration within existing services moreover as the municipal volunteer coordinator added during a conversation even though the project was framed as an initiative to strengthen the inclusion and integration of refugee children and their families into local communities the projects could inadvertently contribute to pacifying and thus marginalising this group the general reluctance towards certain forms of volunteer iniated coproduction projects was explained by a team manager from the refugee services field in the municipality during an interview we also have a strategy in the aalborg municipality concerning the reception of newly arrived refugees we want refugees to be integrated into the existing social systems that are already present in the municipality consequently the municipal actors worked to make immigrants selfreliant as soon as possible after their arrival this policy made it illegitimate to provide services that seemed to help refugees with problems that they in principle should address by themselves the lower level of formal support was grounded in a local policy mirroring broader national political discourses for justifying the treatment of immigrants as ordinary citizens and consequently not gaining access to extraordinary public or voluntary coproduced services consequently fewer coproduction initiatives and projects were met with support from the top management of the municipality and fewer resources in the form of staff were allocated to this field in terms of spatiomaterial support we also found that the field of refugee services provided significantly different conditions for coproduction compared to the elderly field in contrast to the elderly services field there were no spaces or public premises where potential coproduction could take place consequently crosssector projects typically took place off public premises or in temporarily available locales with no permanent spaces available for joint coproduction activities the crosssector collaboration was typically organised in a form in which actors from each sector worked in separate locales spread over the town one example of this distant form of practicing coproduction was a project called the job club after a series of crosssector meetings where the volunteers had argued for closer functional and spatial integration between municipal and volunteer support activities for refugees looking for jobs the project ended up in a format in which the municipal staff would define tasks that volunteers could assist in solving the volunteers would then attempt to provide assistance for the refugees as defined by the municipality in their own temporarily rented venues thus in terms of both formal support from municipal management and access to public premises the field of refugee services provided voluntary and municipal actors with fewer resources and opportunities for coproducing services fieldspecific forms of coproduction practices we have demonstrated that municipal formal support and access to spatiomaterial resources differed widely between the elderly field and the field of refugee services in this section we argue that the predominant forms of practicing coproduction within the two fields were shaped by field properties and structures that enabled and constrained coproducing actors differently within each field based on two criteria 1 the availability of municipal access points and 2 the degree of integration of coproduced services into municipal institutions we theorise that the practice of coproduction takes two distinct forms that emanate from the different structuring of the two policy fields within the elderly field we found several municipal access points most notably in the form of elderly centres and local activity centres where volunteers and voluntary organisations could engage in services for the elderly and promote ideas for coproduction furthermore a digital infrastructure provided citizens with plenty of opportunities for volunteering and the volunteer coordinator enjoyed a status in which new avenues for coproduction could be legitimately promoted the high number of municipal access points further paved the way for the volunteers and the voluntary organisations to operate in close proximity to elderly citizens and municipal staff on the inside of municipal welfare institutions thus several coproduction projects took place within public premises which blended public and voluntary resources by contrast within the field of refugee services there were few municipal access points for coproduction and in many instances such as in the case of the job centres volunteers and voluntary organisations were denied access instead coproduction projects and initiatives had to be practiced outside and away from the municipal realm and without the same supply of formal and material resources that characterised the elderly field thus coproduction typically unfolded in temporary locales made available to volunteers by the municipality with volunteers as visitors and the municipality as the distant host due to their temporary and distant nature services initiated in the field of refugee services typically lacked the stability and continuity needed for solving complex problems such as integration of refugees living under temporary and uncertain conditions to capture the combination of a high degree of municipal access points and a high degree of integration of coproduced services within municipal institutions we suggest the term embedded coproduction the opposite combination of a low degree of municipal access points and a low degree of integration of coproduced services into municipal institutions can be captured by the term exterior coproduction in the next section we scrutinise the consequences of these two distinct forms of coproduction practices for the tensions and ambivalence of local actors operating within the two policy fields local tension fields and ambivalence the two different forms of practicing coproduction within the two policy fields did not simply enable coproduction within the elderly field or constrain coproduction within the field of refugee services rather the two forms of practicing coproduction produced complex and ambivalent tension fields resulting in different forms of conflicts and contestations that cast municipal and voluntary actors in opposing boundary struggles within the elderly field the practice of embedded coproduction sustained a high level of experimentation in the service provision for the elderly and an openness towards coproduction the different kinds of formal and spatial support that we documented and which underpinned the fieldspecific ways of practicing coproduction provided key actors such as the municipal volunteer coordinator and leaders from voluntary organisations with formal support and spatial resources and opportunities for advancing and influencing coproduction in the service provision towards closer and extended collaborations however the embeddedness also entailed among municipal staff a sense of fertile ground for pushing a coproduction agenda that implicated a potential instrumentalisation of volunteers as an illustration the volunteer coordinator from the elderly field said we have plenty of volunteers and a couple of times i have had to how should i put it sack volunteers because they should support our core tasks the municipal volunteer coordinator as a key agent in promoting crosssector coproduction in this field felt that she acted on a solid mandate for expanding the use of volunteers as long as it aligned with the municipalitys core tasks in the case of embedded coproduction it would thus seem that institutional disruption was primarily pursued by public sector employees who tried to expand the legitimate set of tasks provided by volunteers in response volunteers and their organisations took on the role of institutional defenders who attempted to protect the boundaries of the voluntary sector in interviews with volunteers and voluntary leaders in the field a recurring point of concern was how to prevent volunteers from taking over municipal core tasks volunteers as one volunteer leader put it should be the icing on the cake and not cheap labour a leading volunteer from one of the larger organisations serving elderly people put the concern for boundary transgression as follows in my opinion it is like this if the municipality thinks that the volunteers need education resembling that of professionals front line staff then we are on the wrong track from a public sector point of view the embedded form of coproduction seemed attractive for several reasons first the embedded form helped sustain the institutionalisation of an instrumentalised and individualised conception of volunteering this was attractive because it opened up municipal elderly institutions and activities for additional voluntary resources that could be accessed and put to use in a flexible manner second the open attitude secured a permanent willingness to invest in new experiments and ways of practicing coproduction which expanded the terrain of possible and legitimate collaborative partnerships in the field of refugee services the exterior form of coproduction was prone to ambivalence as well on the one hand the ad hoc temporary and exterior form of practicing crosssector coproduction meant that many crosssector activities faced opposition from the municipality and dried up unlike the field of elderly services municipal staff within the refugee service field such as the volunteer coordinator took a defensive approach maintaining that the municipality should only respond to universal problems or address particular problems through existing services against this backdrop the voluntary organisations took the ambitious position and tried to expand the municipal responsibility to include more of the specialised needs of the heterogeneous refugee population in the face of such attempts to redefine the boundaries between private and public problems and expand local governments services and responsibilities municipal leaders would act as institutional defenders resisting volunteer initiatives often with reference to legal matters or municipal policy for example one municipality leader within the refugee field said some volunteers are prone to think you know if you put a little more pressure on the municipality then things will go their way but it will not and it is mega frustrating from a local public sector perspective the exterior form of coproduction had the advantage of legitimising and sustaining a distance between the volunteers and the public frontline service providers the contested boundaries over which tasks belong to which sector made the exterior form of coproduction a welcome formatfrom a public sector point of viewfor keeping critical volunteers at arms length the absence of shared spaces further constrained volunteers from performing frontline advocacy and challenging public practices and sectorial boundaries in the field of refugee services public sector agents became institutional defenders working to maintain sectorial boundaries and avoid expansion of the economic and legal public territory conversely the volunteers particularly those from the larger ngos on the one hand attempted to expand the responsibility of the municipality to encompass more problems relevant to different groups of refugees however the lack of general political consensus and legitimacy and the lack of formal support and spatiomaterial resources placed volunteers in an outsider position which made it difficult for these actors to access and persuade public partners to engage in coproduced activities instead the defensive municipal attitude seemed to retain and emphasise the distant advocacy role of voluntary organisations on the other hand while impeding crosssector coproduction from materialising in any durable forms of practice the exterior form of coproduction prevented volunteers in this field from being instrumentalised and exploited as cheap labour to the same extent we observed in the field of elderly service conclusion recent reviews of crosssector coproduction research reveal a lack of knowledge on how different policy fields shape enable and constrain the practice of coproduction to address these shortcomings this study used a comparative case design and compared the practice of coproduction across the fields of elderly services and refugee services the two fields were chosen as cases because they both faced complex social problems combined with a high degree of openness towards supplementary voluntary services however the two fields differed with respect to formal support from municipal management and the availability of spatiomaterial resources within a local municipal setting which in general was supportive of the idea of coproduction we first asked how different fieldlevel conditions enable different organisational practices of coproduction second we explored how these fieldspecific ways of practicing coproduction further influenced the spaces of coproduction and the tension fields and oppositions between coproducing actors from the local public sector and the voluntary sector this paper contributes to the study of coproduction and broader crosssector collaboration research in two main ways first we show the importance of the embeddedness of crosssector coproduction between voluntary and public actors within different policy field structures by focusing on how coproduction unfolded within a local context we outlined how the unequal distribution of formal support and disparate access to spatiomaterial resources led not only to different practices but also to diverging outcomes and perspectives for coproduction whereas the embedded practice of coproduction within the elderly field in general sustained an integrated and close form of collaboration between public and voluntary actors on the inside of public institutions the exterior practice within the refugee service field in many cases blocked opportunities for coproduction or relegated coproducing initiatives into detached and segmented services our results point to the importance of studying how coproduction as an organisational practice is rooted in different policy fields the practice of coproduction on the ground by volunteers voluntary organisations public managers and frontline staff does not necessarily lead to the political visions of pooled resources and shared responsibilities instead coproduction should be perceived as a practice that is created shaped and made concrete in interdependence with locallevel conditions that are heavily entrenched in specific policy fields in particular we found that formal and spatial support mattered to how coproduction materialised in a local context and further that such local support structures are manifestations of wider national conditions second we show how each of the two ways of practicing coproduction entail ambiguous outcomes and antagonistic positions for voluntary and public actors depending on the policy field importantly we argue that neither of these practices is unequivocally beneficial or detrimental to the coproduction of welfare services within the elderly field we found that the supportive spaces as well as instrumental and individualised perceptions of volunteers as coproducers entailed a tension in which public actors pushed for expanding the legitimate tasks and territories of volunteers and their organisations in reaction leaders and members of voluntary organisations raised concern that public ambitions compromised organisational autonomy and pressed for mandated voluntary services in this case coproduction in practice did not result in a shared sense of responsibility but instead increased attention to the risks of boundary transgression within the field of refugee services we found that public caution and reluctance towards initiatives to work more closely across the public and the voluntary sector on the grounds of compromising universal welfare state values confined voluntary organisations to their classic roles of community building and advocacy in this case a tension arose in which coproduction in practice did not promote new and innovative services but instead reinforced the classic opposition between public authority and voluntary advocacy table 1 summarises our findings our research also has implications for policymakers we believe that two lessons are particularly relevant first instead of being attracted to coproduction as a model which can be governed by way of abstract governance principles public and nonprofit managers should direct attention to concrete practices second rather than thinking in terms of general recommendations for coproduction independently of policy fields policy advisers should be sensitive to how different conditions for practicing coproduction are embedded within broader field structures our study bears the limitations of a local field study a design which is not well suited for generalising beyond the one municipality in any statistical sense however guided by a strong comparative design we believe that our results contribute a conceptual understanding of how policy fields impact coproduction practices and how the oppositions between public and voluntary actors vary systematically with field properties with the growing popularity and need for cross sector collaboration to tackle complex social problems more research is warranted to understand how field properties enable or constrain the potentials of coproduction competing interests the authors including henriksen grubb and frederiksen declare

crosssector coproduction involving voluntary organisations in the production and delivery of social services has been adopted across many welfare states economic and demographic changes have led to increased involvement of volunteer initiatives in different welfare policy fields how different field properties enable constrain and shape coproduction practices remains however under researched in this article we address this shortcoming in a comparative case design exploring the practices of coproduction within the two fields of elderly services and refugee services we develop a conceptual framework and demonstrate that differential distribution of resources leads to diverging outcomes and perspectives for coproduction based on a twoyear indepth study of one large danish municipality we find two forms of coproduction practices which reflect different field conditions in the field of elderly services coproduction takes the form of embedded practices and in the field of refugee services coproduction takes the form of exterior practices we demonstrate that each of these coproduction forms entail ambiguous outcomes and antagonistic positions for voluntary and public sector actors depending on the policy field

introduction the protective effects of socioeconomic status on health 1 2 3 4 5 6 7 8 are not equal across racial groups 910 while high family ses such as family income and parental education are protective overall 1112 and low ses financial strain and poverty may partially explain why racial minorities suffer from worse childhood health 13 the smaller health gain from ses among minorities may be another mechanism by which racial disparities in health exist 910 according to minorities diminished return theory 9 unequal health gain from ses is a neglected mechanism behind racial health disparities 10 supporting this theory 910 considerable research has shown that ses has stronger effects on drinking patterns 14 depressive symptoms 15 suicidality 16 chronic disease 15 and mortality 17 18 19 20 for whites than blacks either due to the extra costs of upward social mobility for blacks compared to whites 2122 or high levels of discrimination among blacks 23 ses generates less health for blacks than whites in some extreme examples high ses not only does not improve health but also becomes a risk factor for poor health of blacks for instance income was positively associated with major depressive disorder among black boys 24 and black men 2526 and high education attainment is associated with a higher risk of suicide in black women 16 and an increase in future depressive symptoms in black men 15 while high ses promotes health of the general population 27 28 29 this effect is not universal across racial groups 910 30 31 32 33 racial groups vary widely in their capacity to navigate the system and translate their ses resources to tangible health outcomes 233435 although high ses reduces exposure to risks 27 28 29 these effects are unequal across various social groups 212236 that is the very same ses indicator such as income generates a smaller change in purchasing power for the economically and socially disadvantaged group compared to the privileged group 37 38 39 40 in other words high ses better enhances the majorities access to goods and services and the health 27 28 29 41 of whites compared to blacks 42 as society treats groups by their race and skin color the same increase in ses generates smaller leverage in material resources human capital and psychological assets for blacks than whites 4344 one explanation for this pattern is the extra psychological and physiological costs of upward social mobility 21 22 23 for blacks 2441 which minimize the health gain from high ses 4245 in this population blacks may also have a higher risk of using high cost effortful coping for upward social mobility 4647 these mechanisms collectively suggest that ses may have a smaller effect on the health of blacks compared to whites 3448 as the minorities diminished return hypothesis has suggested 910 childhood asthma is the leading chronic disease for children under 18 in the united states 1 approximately seven million children suffer from asthma in the us significant disparities in ca exist across race and socioeconomic status groups 1 low ses and black families are at higher risk for ca prevalence of ca is 82 99 and 122 among families with income above 200 between 100 and 200 and less than 100 of the federal poverty line respectively the risk of hospitalization having an emergency department visit or death from ca are all two to four times higher in black families compared to white families 1 case et al in 2002 showed that chronic diseases such as asthma follow the social gradient in income 49 to better understand whether minorities diminished return theory also explains some of the racial disparities in ca we compared black and white families for the negative association between living above the poverty line and ca although research has established the effects of race 50 and ses 5152 on ca very few studies have ever studied multiplicative effects of race and ses on ca 53 so it is still unknown whether it is race and ses or race or ses that cause ca disparities 54 to generate generalizable results on the multiplicative effects of race and ses on ca we used data from the national survey of childrens health a study with a nationally representative sample of children 18 years old or younger in line with the minorities diminished return theory 9 we hypothesized that ses would have a larger protective effect on ca for white compared to black families materials and methods design and setting this study used a crosssectional design the current study used data from the nsch a nationally representative study sponsored by the national center for health statistics nsch was a landmark survey that generated national and statelevel representative prevalence estimates for a variety of childrens health indicators 55 56 57 ethics the nsch study protocol was approved by the cdcs institutional review board adolescents parentslegal guardians provided informed consent adolescents provided assent more information on ethical aspects of the study is available 58 sampling similar to other national studies such as the national immunization study 55 56 57 the nsch sampling frame was based on the state and local area integrated telephone survey 55 56 57 to briefly describe the study sampling procedure trained interviewers called telephone numbers at random to identify households with at least one child under the age of 18 from eligible households one child was randomly selected for the interview the study also included an interview with the adult in the household who knew the most about the childs health and wellbeing after excluding participants based on raceethnicity criteria our analytic sample consisted of 86537 children who were 17 years old or younger and 10134 black data collection the study conducted an overall number of 102353 interviews all the interviewers were completed between january 2003 and july 2004 and were performed either in english or spanish trained interviewers asked parentsguardians a series of questions regarding their childs physical emotional and behavioral health as well as access to health care 55 56 57 variables the current study included the following variables child race child demographic factors family socioeconomic status and child health status race for confidentiality purposes the nsch collected child race as white only african americanblack only other races and multiple races the current study only included blacks and whites 55 56 57 family poverty status interviewers asked parentsguardians about household income 55 56 57 income to household size was based on the department of health and human services federal poverty guidelines 55 56 57 living above the poverty line was defined as a dichotomous variable 5859 overweight overweight status was a dichotomous variable calculated based on bmi which was derived from the parents or guardians reports on the height and weight of the child parents and guardians were asked the following two questions how tall is your child now and how much does your child weigh now bmi based on parentreported height and weight strongly correlates with bmi based on direct measurements of height and weight 6061 bmi was calculated as weight divided by height squared to define overweight status the centers for disease control and prevention genderand agespecific growth charts were used 62 bmi ≥ 95th percentile was considered as overweight 62 63 64 we operationalized the variable as a twolevel categorical variable childhood asthma a single item was used to measure the history of ca parents were asked has a doctor or health professional ever told you that your child has asthma responses included no yes do not know and refused this selfreported measure of physician diagnosis has been used in the panel study of income dynamics as well as the behavioral risk factor surveillance system statebased telephone survey selfreported physician diagnoses are valid and reliable selfreported measures of lifetime asthma in both children and adults 6566 data analysis weights to generate nationally representative results the nsch sampling weights were applied these weights are calculated based on a base sampling weight and adjustment for multiple telephone lines per household as well as for nonresponse the weights were poststratified so that the sum of weights for each state equals the total number of children in that state as estimated for the july 2003 us census data 55 56 57 to account for the nsch complex survey design we used stata 130 to analyze the data taylor series approximation was used for the estimation of complex designbased standard errors and variance all percentages means ses confidence intervals and p values reflect the sampling weights and are thus generalizable to nationally representative estimates to describe our sample we reported frequency tables and means with 95 cis for bivariate analysis a spearman correlation test was used we ran multiple logistic regression models first in the pooled sample and then in whites and blacks in the pooled sample the first model only included the main effects of living above the poverty line race and covariates the second model also included the race × living above the poverty line interaction term in all models family ses was the independent variable ca was the dependent variable and age gender and overweight status were covariates race was the focal moderator adjusted odds ratio 95 ci and associated p values were reported p values less than 005 were considered significant results descriptives this analysis included 86537 black or white children this sample was composed of 76403 white and 10134 black table 1 summarizes the descriptive statistics for the pooled sample as well as white and black children as this table shows black children were from families with a lower education and lower income and who were at a higher risk of being overweight bivariate correaltions table 2 summarizes the bivariate associations in the pooled sample as this table shows parent education was negatively associated with ca among children pooled sample logistic regressions table 3 shows the results of two logistic regressions one without interactions and one with race by ses interactions model 1 showed that in the pooled sample living above the poverty line was negatively associated with odds of ca model 2 showed an interaction between the effects of race and poverty status on odds of ca suggesting that the negative association between living above the poverty line on odds of ca was smaller for black compared to white families race stratified logistic regressions table 4 shows the results of two logistic regressions specific to race model 3 and model 4 showed a negative association between living above the poverty line and ca for white and black children however the magnitude of the negative association was larger for white than black families discussion the current study showed two findings first there was an association between ses and ca in the pooled sample second blacks and whites differed in the negative association between family ses and ca prevalence of ca was lower for high ses blacks and whites however this association was stronger for white than black families the first finding on the protective effect of poverty status against ca was in line with the epidemiology 67 and economics 49 literature that has shown a social and economic gradient in childrens health this literature was reviewed and explained by case et al in 2002 49 the second finding that the very same ses indicator shows a stronger negative association with ca for white than black families is similar to the results of studies on the association between family ses and selfrated health obesity and impulse control 68 69 70 this is partly because black families with high educational attainment have a higher risk of staying in poverty compared to white families 7172 it was only recently that minorities diminished return was found to be valid in children 6869 as most of the supporting literature has recruited adults 1516 or older adults 3442 although the exact mechanism for a smaller health gain of ses among blacks is still unclear these findings support the growing evidence that differential gains start early in life and are partially responsible for racial health disparities in childhood 69 that is smaller health effects of family ses on the health of black children is one reason for worse health outcomes in black children compared to white children 6871 further the socially privileged majority group and the socially and economically disadvantaged minority group do not equally gain from the same ses resources in another related study using data following 1781 youth from birth to age 15 from the fragile families and child wellbeing study 69 blackwhite differences were found in the protective effect of family structure and family ses at birth on subsequent bmi at age 15 the study revealed race by family ses and race by family structure interactions on bmi indicating smaller effects for blacks compared to whites race by gender stratified regressions showed the most consistent patterns of associations between family ses and future bmi for male and female whites family ses and structure at birth did not protect black males or black females against obesity 15 years later the study was one of the first to show that the minorities diminished return theory also holds for youth 69 the results of this study should be interpreted with caution our results do not suggest that blacks are unable to efficiently use their available ses resources or turn their ses resources into tangible health outcomes this argument has been used to blame marginalize and stigmatize blacks for a low chance of upward social mobility despite having historically been victims of slavery racism and discrimination 73 their socioeconomic status and poverty has been wrongly attributed to their culture 74 instead it is the social structure segregation and structural racism that are responsible for minorities diminished return 910 black families face disproportionately higher rates of societal and structural barriers in their lives that may hinder their ability to gain health from any ses resource that becomes available to them the current us social system fails blacks by charging them extra psychological and physiological costs to climb the social ladder in a raceaware society the process of upward social mobility is associated with more social psychological and physiological costs for blacks than whites 2122 the current us system is designed to maximize the gain of the privileged group even if it may cause only minimum gains for other social groups 910 this offers rationale for why the us is experiencing a stubbornly high blackwhite economic gap the easytoidentify trait of black race in the us has facilitated activities that systematically force blacks into worse environments than whites of their same ses these forces outside the black community in real estate private and public facilities and professional services can act with virtual impunity despite efforts to control them 54 75 76 77 sometimes they are unconscious behaviors of people and institutions exercising some power or professional gatekeeping which exacerbates segregation and discrimination 78 79 80 in others they are conscious and are defended as protection against reverse racism 81 82 83 ses may not similarly enhance the environment for whites and blacks thus high ses black families may be at a higher risk of environmental exposures to allergens tobacco smoke and indoor and outdoor air pollution other mechanisms such as smoking that may be more cultural than structural may be involved research has shown that education has smaller protective effects against smoking 33 which may increase the risk of ca 84 these mechanisms should be explored in future research one reason why ses may fail to show strong effects for blacks is that high ses blacks face high levels of interpersonal and instructional aspirations black families who seek new opportunities are forced to fight societal barriers that increase the costs of moving up the social ladder one example of this is the effect of discrimination on reduced health gains that commonly follow high ses 15 we argue that in the presence of racism and discrimination and in a raceandcoloraware society high aspirations may not be protective but detrimental to blacks health this is in line with the recent research suggesting that high ses may be a vulnerability factor for black families 2324 a finding which is replicated for adults 23 and adolescents 24 of course we are not suggesting that blacks should not have high aspirations instead we argue that upward social mobility should not be associated with extra costs for minority groups and assert that all groups should benefit equally from climbing the social ladder 2122 the finding on the overall protective effect of family ses against odds ca is in line previous studies on the protective effects of high ses against a wide range of health outcomes 69 85 86 87 88 89 low ses is a root cause of illness and ca is not an exception to this general rule 1 several stateoftheart studies have shown the wellestablished link between ses and health 2 3 4 5 6 7 90 however this ses gain is smaller for blacks a pattern that is not limited to childhood 910 a study showed that education better changes the drinking habits of whites than blacks in older adults 42 in the health and retirement study high income was associated with low bmi for white women and black women but not for white men and black men high educational attainment was also associated with higher physical activity and sleep quality for white men white women and black women but not black men 34 among adults education 18 employment 91 neighborhood quality 92 and social contacts 93 generate a smaller gain in life expectancy for blacks than for whites all these findings are in concert and support the minorities diminished return theory of the systematically smaller health gain of ses for blacks than whites 16183494 limitations our study had a few methodological limitations as the study used a crosssectional design causal conclusions are not plausible despite the temporal ambiguity of exposure and outcome it is more plausible to conceptualize poor ses as a cause and ca as an outcome although ca may contribute to or be followed by greater family poverty ca is often preceded by abysmal innercity conditions 41 95 96 97 this study measured ca using selfreported data although selfreported data are valid to measure ca 6566 the diagnosis of ca not being confirmed to meet nhlbi or other society guidelines is a major limitation the study is at risk of omitted confounders we however controlled for the effects of obesity which is linked to ses as well as ca medications particularly preventive inhaled corticosteroids 98 this study is prone to bias due to nonclassical measurement error the poverty line is endogenous as families have some control over what their income is overall the poverty line is not the best ses measure as it does not adjust for cost of living and families with the same poverty status may face different levels of financial hardship depending on the part of the country given that many federal and state antipoverty programs are tied to income there may be asymmetric bunching to address this problem future research may use a donut specification as explained by barreca et al in 2011 99 this approach drops families within 10 or 20 of the poverty line to reduce measurement bias 99 in the current study we did not have income values but levels so we could not use donut specification in addition the study did not collect data on parents race the results may differ for black and white children with white and nonwhite parents this study was limited to blacks and whites only future research should test if other minority groups such as hispanics indian americans immigrants sexual minorities and other minority groups also gain less from their positive ses indicators as shown in table 4 the ors for blacks were not statistically significant this may be partially due to the imbalanced sample sizes between blacks and whites although the nsch data set contained variables for hispanic ethnicity the sample size of hispanic blacks was very small so we could not model the differences between hispanic whites and hispanic blacks as a result we limited our sample to nonhispanic white and nonhispanic blacks more research is also needed on the role of other ethnic groups regions and neighborhoods on these relationships future research should replicate the findings reported here among other marginalized groups such as immigrants third all the study measures were those at an individual level there is a need for future research on contextual factors that surround black and white families across ses levels we also do not know if these findings hold for other ses indicators such as family structure household size employment and wealth the data were old the results should be replicated using other similar data sets such as psid nhanes nhis or brfss research may also try to replicate these findings for educational attainment and other ses measures despite these limitations this is one of the first studies to explore blackwhite variation in the link between ses and ca conclusions in the united states the negative association between living above the poverty line and ca is smaller for black families compared to their white counterparts future research should use longitudinal data to establish causation between ses and asthma by race the role of structural racism interpersonal discrimination and societal barriers in these patterns should be explored public and economic policy solutions should go beyond equalizing ses and eliminate minorities diminished return from ses which is a neglected contributor to racial health disparities in the us policy solutions to health disparities require jointly addressing race and ses as race and ses do not operate independently author contributions sa designed and performed the current analysis mml drafted the paper and contributed to the interpretation of the findings both authors contributed to the revisions and confirmed the final version of the paper funding this current research received no external funding

background living above the poverty line reduces the risk of physical illnesses including childhood asthma ca minorities diminished return theory however suggests that the protective effects of socioeconomic status ses on health are weaker for racial minorities than white families it is unknown whether the association between ses and ca differs for white and black families aims using a national sample the current study compared black and white families for the association between living above the poverty line and ca methods data came from the national survey of childrens health nsch 20032004 a national telephone survey a total of 86537 black or white families with children 17 years old or younger were included in the study this sample was composed of 76403 white 8829 and 10134 black 1171 families family ses living above the poverty line was the independent variable the outcome was ca reported by the parent age gender and childhood obesity were the covariates race was conceptualized as the moderator a number of multivariable logistic regressions were used in the pooled sample and specific to each race for data analysis results in the pooled sample living above the poverty line was associated with lower odds of ca an interaction was found between race and living above the poverty line on odds of ca indicating a smaller association for black compared to white families although racestratified logistic regressions showed negative associations between living above the poverty line and ca in both white and black families the magnitude of this negative association was larger for white than black families conclusions the health gain from living above the poverty line may be smaller for black than white families due to the existing minorities diminished return policies that merely reduce the racial gap in ses may not be sufficient in eliminating racial health disparities in the united states public policies must go beyond reducing poverty to address structural and environmental risk factors that disproportionately impact blacks health policies should help black families gain health as they gain upward social mobility as they are more likely to face societal and structural barriers multilevel interventions are needed for the health promotion of blacks

introduction although many technical breakthroughs have occurred in healthcare recently human behavior is still the largest source of variance in healthrelated outcomes 1 key healthy behaviors include quitting smoking a balanced diet regular exercise and a low alcohol intake 2 which are the most important for keeping healthy unhealthy behaviors cause much of the illness suffering and early deaths related to chronic diseases and conditions 3 which comprise approximately half of deaths in the united states at the same time healthcare costs 171 of the gdp in the united states and 56 of the gdp in china as health behavior plays a key role in wellbeing morbidity and mortality as well as healthcare costs 1 improving health behavior is the greatest hope for improving the quality of personal life and reducing the burden of preventable diseases and death around the world 4 thanks to efforts in public health education and peoples personal interest in learning about healthrelated issues most people are aware of the risks of unhealthy behaviors however many people continue to engage in unhealthy behaviors for various reasons it is even more difficult for individuals living with chronic disease who must maintain a strict level of healthy behavior throughout their lifetime changing and adhering to a healthy behavior are primarily personal selfmanagement issues for individuals many intervention approaches could be used for individuals to promote their healthy behaviors the social ecological model 5 could be used to summarize such factors that affect health behavior on four levels individual level social environment physical environment and societal factors the individual level factors directly affect the health behavior including the demographic characteristic and the psychological factors the social environment factors comprise social influence brought by various social relationships like organizational characteristics formal rules and regulations in social institutions formal and informal social networks and social support systems physical environment factors include the natural environment and the manmade environment the societal factors are mainly policies on issues such as active transport education health or the environment since the demographic characteristic physical environment and the societal factors are difficult for individuals to manage the psychological factors and social environment factors turn out to be critical for people to adopt and maintain healthy behaviors 6 getting support from the social environment to improve ones attitude motivation selfefficacy and promoting healthy behavior is a great way of changing and adhering to a healthy behavior the development of web 20 technology resulted in the dramatic growth of the electronic social environment and blurred the boundaries between the real and the virtual world 7 increasingly social contacts and entertainment happen in the online environment and online social relationships become one of the most important parts of our life the virtual online social environment has an increasing influence on human beings behavior and attracts more and more attention following the patientdriven health care model many health 20 applications combine health information with experience through the use of information and communication technologies allowing the user to be active and responsible in improving their own health 8 health applications are becoming recognized as an effective selfcare information sharing and disease selfmanagement tool today 9 which also provides us with a great opportunity to explore the effect of the online social environment on health behavior the online health community is a popular health application that provides functions of social support q a with physicians quantified selftracking and clinical trials access 10 it provides users with selfentertainment selfassociation selfdesign selfdiscipline and selfhealing tools 11 it is a convenient way to find peers who have experienced similar situations to share information and experiences or to get personal stories and practical advice 12 users can join the ohc to make use of the power of social influence in the ohc to pursue a healthier condition communication in the online social environment is characterized by physical separation anonymity temporal flexibility and the absence of nonverbal communication 13 the online social environment allows users to extend their social network and communicate with others at any time ignoring social class affluence level education level and many other features of the offline social environment ohcs also lower the cost of forming relationships to help users improve their health the ohc provides users with various social relationship functions such as developing friendships or joining groups to support each other or compete with each other in the offline environment it is nearly impossible to find so many peers with whom to form relationships and engage in healthy behaviors many studies have explored how the social influence exerted by social relationships affected health behavior from a number of perspectives however most existing research studies are mainly based on the offline environment which focused on strong social ties like family members and friends who meet face to face 14 15 16 17 18 19 20 researchers also reported that online social relationship bring significant improvements in some aspects of health behavior change 21 through encouragement accessing answers to specific healthrelated questions and sharing success stories online social networks motivate individuals to achieve similar goals 22 exploring collegeaged womens facebook use and eating disorders walker et al found that facebook intensity online physical appearance comparison and online fat talk is positively associated with eating behaviors 23 mhasawade et al studied the role of the built and online social environments in the expression of dining on instagram 24 merchant et al delivered weight loss intervention content through facebook to college students with the help of a health coach but whether the health behavior changed is unknown 25 wang et al examined physical activity intervention programs via facebook and found that the social network sites yielded some positive psychological effects but the maximization of benefits needed to be studied 26 studies on health behavior have mainly focused on the common social network sites like facebook and twitter but online health communities which focus on health have received little attention furthermore few works have explored the effects of the mechanisms promoting healthy behavior in online health communities in this paper we attempted to investigate how the social influence of online social relationships affected health behavior we focused on three subquestions how does the scale of the social relationship affect health behavior although users of ohcs benefit from social relationships establishing and managing the relationship take time and effort therefore we may care that there is a proper scale of the social relationship for users how does observing others behavior affect the ones health behavior observational learning is a form of social learning that occurs since childhood does it still exist in ohcs based on the characteristics of ohcs here we considered the participation in the following social relationships friendship mutual group and competing group we explored the scale effect and the observational learning effect from the three types of social relationships how could the interaction with peers affect ones health behavior users talk to each other to get and provide information or emotional support in the ohc considering the detailed content of the social support interactions which was recognized as informational support emotional support and companionship support 27 we explored the effects of the different types of social support on health behavior the rest of the paper is organized as follows we introduce the theoretical background the related works and hypotheses in section 2 we introduce our study setting and describe our data in section 3 section 4 presents the research model section 5 reports the results and our analysis finally in section 6 we conclude our work with a discussion of study implications limitations and future research directions theoretical foundations theoretical background observational learning the social learning theory encompasses a mechanism through which individuals learn from each other with direct communications and a mechanism of observational learning where the behavior of individuals is influenced by their observation of other peoples choice observational learning does not need reinforcement to occur but instead requires a social model such as a parent sibling friend or teacher the ohcs provide a large number of peers for individuals who could become the model selfdetermination theory this is a macro theory of human motivation and personality that focuses on the socialcontextual conditions that facilitate versus forestall the natural processes of selfmotivation the sdt proposes that competence autonomy and psychological relatedness are the basic psychological needs of humans 28 it specifies that psychological needs are essential needs that individuals must satisfy to thrive just as people cannot thrive without water and food 29 satisfying basic psychological needs could also motivate people to initiate healthy behaviors 29 online communication with peers provides an opportunity to satisfy individual psychological needs which helps to improve healthy behavior social support theory social support is defined as an exchange of resources between at least two individuals and it is perceived by the provider or the recipient to be intended to enhance the wellbeing of the recipient 30 referring to the web of social ties that surround individuals one important function of a social network is providing social support 4 the connectedness in the network indicates a persons social embeddedness and how they derive support from the environment 31 bambina points out that social support in the ohc includes informational support emotional support and companionship 27 hypotheses development the ohc provides a platform for users to selfmonitor and interact with peers the selfmonitor provides users with an opportunity to record all the users health behavior and the interaction allows users to observe each others behavior and support each other we focused on the effects of the observational learning from others behavior and social support from the interaction on health behavior social integration is the involvement level in social relationships and its measures primarily focus on the social networks of individuals including the network structure and the characteristics of ties 32 low levels of social integration are most deleterious with higher levels being less advantageous once a threshold level has been reached having at least one strong intimate relationship is an important predictor of good health 33 although little social integration is not good for health behavior there are also severe limits on the quantity of social ties 34 robin dunbar proposed a theoretical cognitive limit to the number of people with whom one can maintain social relationships 35 as friends and other social ties increase less attention may be paid to health behavior h1 social integration has a curvilinear relationship with health behavior introduced in theory of planned behavior descriptive norms are a type of social norm that describe what others actually do 36 and they have a significant effect on intentions which summarize a persons motivation to act in a particular way and represent how much time and effort they would devote to performing a behavior 37 people will follow others behavior as described by the herd effect 38 furthermore people will feel guilty about not performing a positive behavior in accordance with their surroundings social learning theory puts forward that people learn from others through observing their behavior in the social context such learned information allows people to adjust their own behaviors appropriately as one observes others behaviors the user could increase their selfefficacy and be encouraged in ohcs users participate in healthy behavior together and share their progress they can get descriptive norms from different social ties h2 descriptive norms in ohcs are positively related to health behavior according to the sdt people feel that support and intrinsic motivation are what drives them to perform a behavior for the sake of enjoyment 28 berkman et al found that social support could enhance selfefficacy 40 cobb found that sustained social support and social influence were required to promote smoking cessation and smoking abstinence in online social networks 41 low support from family and friends are barriers to followup care behavior for breast cancer patients 42 bambina illustrated the difference between ohc social support and traditional social support noting that the social support in the ohc includes informational support emotional support and companionship 27 informational support includes advice referrals teaching information broadcastingseeking and personal experience 27 through providing healthrelevant advice and recommendations the ohc gives users more choices to make their own informed decision about how to behave satisfying the need for autonomy identified by the sdt 28 the experiential information from other patients provides users with a window on others second opinions information that is difficult to ask directly yet could help people to better understand a health condition and determine their own behaviors 31 learning that others have overcome similar conditions could help satisfy the basic psychological need of competence to perform behaviors 28 according to the sdt knowledge about health risks and benefits is one of the core determinants for changing individual behaviors and habits 43 h3a informational support from online social ties positively affects health behavior the emotional support provided by the ohc includes understandingempathy encouragement affirmationvalidation sympathy and caringconcern 27 such emotional support affects users relatedness need and could help them feel competent to perform behaviors 28 lack of emotional support or isolation from other patients can become a barrier to health behavior adherence 44 ohcs can providebe a source of support from a large number of persons without time and space limits h3b emotional support from online social ties positively affects health behavior companionship in ohcs includes chatting humorteasing and groupies 27 which can satisfy the relatedness need by making individuals feel that there are others who enjoy their presence and that they are a valuable part of something bigger than themselves 45 such support can be found in the discussion forum of the ohc and make individuals feel they are not isolated from the world the human body physiological and psychological needs knowledge level and psychological maturity all change over time people become increasingly rational and analytical as they mature 46 ohc participants will get more information and experience about health behavior through information provided by the website and sharing experiences users will take advantage of the information to make more rational decisions people will tend to guide themselves based on information instead of following others behavior which is the descriptive norm as they become more analytical they will value the information more which may increase the effect of informational support on health behavior and decrease the effect of emotional support as growth continues the behaviors will become internalized and less affected by external factors therefore we get the following hypotheses h4a the effect of descriptive norms on health behavior will decrease with longer membership duration h4b the effect of informational support on health behavior will increase with longer membership duration h4c the effect of emotional support on health behavior will decrease with longer membership duration the conceptual framework is showed in figure 1 materials and methods study context many treatments have been used to address obesity including surgery 47 behavior therapy and various dietary approaches 48 the last two approaches depend on personal behavior changes for successful materials and methods study context many treatments have been used to address obesity including surgery 47 behavior therapy and various dietary approaches 48 the last two approaches depend on personal behavior changes for successful weight loss the energy imbalance between the consumed and expended calories is the fundamental cause of obesity 49 thus dietary and exercise behavior are the most important ways to lose weight our dataset is from a free online weight loss community that provides apps online tools and community support to help members maintain healthy behavior available functions include finding an available diet recording their food exercise and weight diary establishing online social relationships and exchanging support with others we crawled members information including personal profile food diary exercise diary weight diary forum communication and group participation the detailed data we obtained included the time the users joined the platform the starting weight and the target weight the users weight diet and exercise records as well as each record time list of users friends social support groups and competing groups the group participants in social support groups and competing groups their diet and exercise records and recording time the communication data between users and others on the platform to clean the data we deleted some members information members who did not share information members who did not recordshare weight information members who wanted to lose less than 3kg or whose initialstarting weight was less than 50 kg we obtained members information from 201112 to 20111231 spanning 52 weeks finally we obtained 6225 members for our analysis for the security of the data we used random numbers to index the users and stored the data on an external disk without connecting with the internet dependent variables selfmonitoring is the centerpiece of behavioral weight loss intervention programs 50 which involves recording the details of health behaviors so that individuals are aware of their current behaviors selfmonitoring could increase participants selfawareness of their targeted behaviors through reminding the participants when the behavior is diminishing and implementing strategies to counteract compliance problems 51 according to selfregulation theory selfmonitoring precedes a selfevaluation of the progress made towards ones goal and selfreinforcement for the progress made 52 consistently selfmonitoring exercise was significantly associated with fewer difficulties with exercise more exercise and weight loss 51 studies that focused on dietary selfmonitoring have also found significant associations between selfmonitoring and weight loss 50 participants with an increased frequency of selfweighing got significantly better weight loss outcomes than those who maintained or decreased their frequency of selfweighing 53 people who want to lose weight need to focus on healthy diet and exercise behaviors the main selfmonitoring behavior is recording dietary intake and physical activity 54 we adopted the diet and exercise selfmonitoring behaviors as the dependent variables everyone had their own definition of healthy behavior even those with similar conditions which led to several sets of behaviors it was difficult to identify whose behavior was healthier since the behavior information in ohcs is selfrecorded by users it is frequently incomplete andor false leading to incorrect statistical results on calorie consumption thus recorded calorie intake is not a valid measure for health behavior however overweight or obese members take care of themselves and try to behave appropriately for their health the selfmonitoring functionality provided by ohcs consists of easytouse data entry screens for conditions symptoms treatments and other biological information which will be seen in a graphical display 10 the more one monitors their health behavior the healthier their behavior becomes therefore the recorded frequency of diet and exercise in a week is a proper proxy of health behavior we adopted a users recorded days in a week as the measurement of health behavior participation if a user recorded their health behavior one day of the week the users recorded frequency in the week will be one if a user recorded their health behavior all days of the week the recorded frequency will be seven if the user did not record health behavior in a week then the recorded frequency will be zero users recorded their diet behavior more frequently than their exercise behavior but the distribution of the frequency was similar between the diet and exercise behavior table 1 presents the statistical information of the users recorded frequency in the 52 weeks zero has the highest number and seven is the second highest independent variables as discussed in the previous section we focused on the social relationships in an online social environment including social integration social support and descriptive norms which influenced individuals directly social integration we used the number of social ties to measure social integration 34 a social network consists of a series of social ties which aim to assemble similar members to improve their health together in ohcs members connect with each other through friendship and group participation two individuals follow each other directly in friendship whereas a person follows a set of individuals in the group relationship therefore friendship is recognized as a strong tie and the group relationship is identified as a weak tie in this paper in ohcs there are two kinds of groups the mutual support group in which people share the same goals or interests to support each other the competing group in which people pursue a goal in a given period at the same time competing with each other and challenging themselves despite the difference in the two kinds of groups they could both have advantages for users the mutual support groups provide a warm and accepting interpersonal climate in which the client is accepted whether or not their goals are achieved 39 the competing groups show additional rankings for weight loss results providing a competitive environment we employed the number of social ties to measure the social integration of social relationships including the friend number and the support group number the establishment of effective social relationships is a dynamic interactive process it is hard to put a date on when a relationship will start the interaction is an essential part of establishing a social relationship we applied the first actual interaction time of two friends as the time of the friendship formation the interaction included commenting and voting on journals replying to posts and reviewing recipes the members participation time in the mutual support group was set as the first post or reply to a post in the groups as some friendships did not have interactions and some members in mutual support groups did not post we also introduced the order of every users friendship formation the order of the group members participation time in the group and the users participation time in the ohc to refresh the relationship establishment time as well as the challenge group number as friendship and membership in the support group will last forever we also included the number of friendships with a duration of less than three months and the number of groups a user participated in for three months or less we chose three months because the duration of the competing group was a maximum of three months descriptive norm the descriptive norm was the behavior of others which was recognized as an important variable that affected behavior in the ohc the surroundings included friends and other group members therefore we used the recorded frequency summation of a users friends the recorded frequency summation of a users mutual support group members and the recorded frequency summation of a users competing group members to represent the descriptive norms social support in the ohc users made friends and participated in groups to communicate with others and pursued the goal of becoming healthier in this paper we identified social support as informational support emotional support and companionship and coded the messages according to bambinas research 43 members in the ohc communicated with each other in the forum and exchanged social support with others through posting messages we recognized the detailed support content contained in the messages by making use of the sentiment analysis in lingpipe 55 we computed the quantity of social support members received according to the characteristics of the communication in the online forums member variables the members special information significantly affected their behavior we introduced the following variables the members initial weight which was the initial condition of individuals we could infer that the member with a higher initial weight may have had a higher level of motivation to participate in healthy behavior the members expected weight loss ratio which was the initial goal for healthy behavior the duration of the members participation in the ohc the number of diet changes which reflected the members weight loss activity level the variable descriptions and data statistics are listed in table 2 research method selfmonitoring behaviors the dependent variables were the recorded frequency of a member in a week which was an ordinal variable ranging from zero to seven more records represented healthier behavior we introduced the ordered logistic model 56 to relate the latent health behavior level to the users monitor frequency we expressed this model in terms of a latent linear response where observed ordinal responses record it were generated from the latent continuous responses the record it was the latent monitor level for user i at time t for the observed recorded frequency record it we modeled the true recorded frequency as equation t is the social integration variables n is the descriptive norm variables s is the social support variables and m is the member specific variables k is a set of cut points k1k6 the observed recorded frequency responses were generated by applying thresholds ks as in equation we modeled that the probability that user i recorded their health behavior frequency smaller than or equal to s at time t is showed in equation record it β 13 s it1 γ 13 t it1 δ 13 n it1 α 15 m it η 1 p it ε it record it                  0 i f record it ≤ k 1 1 i f k 1 ≤ record it ≤ k 2 7 i f k 6 ≤ record it p p record it ≤ k s 1 exp exp to control the individual factors we could not observe we introduced the randomeffects ordered logistic model to evaluate the effect of social relationships on health behavior 57 results main result table 3 shows the estimated results the variance information factor was less than 5 in our models which showed that multicollinearity did not appear to be an issue the random effects model could control all timeinvariant latent variables that may have influenced the dependent variable 58 the start weight of the users tended to have a positive relationship with health behavior as the coefficient of explossratio was negative users who aimed to lose a higher proportion of weight were concerned with their diet and exercised less this could be explained by realizing that a big goal may lower the selfefficacy which will lead the member to be inactive the ohc participating time of a user had a negative relationship with their health behavior which was consistent with previous work individuals who tried more times to lose weight were more likely to fail the more times a user changed their diet the more involved the user was in healthy behavior changing diet was a signal of individuals degree of eagerness to meet their weight loss goals social integration the effect of social integration on health behavior varied with the type of social ties but was consistent for both diet and exercise behavior fnum first had a negative effect on health behavior and the effect became a ushaped curvilinear as the fnum increased spnum had a negative relationship with health behavior these were inconsistent with h1 however chalnum had a positive effect on health behavior and the relationship was shown as an inverted ushaped curvilinear one which was consistent with h1 the most obvious difference between the challenge relationships friendships and the mutual support was the duration of the relationship we tested whether the duration of the relationship caused the different effect of social integration on health behavior in the next part descriptive norms the coefficients of descriptive norms for friendships and competing groups were positive the behaviors affected by ones social ties were significantly positively related with their health behavior hypothesis h2a was supported however the effects of descriptive norms from mutual support groups were very small even insignificant compared to the effects of friendships and competing groups we also explored whether the duration of the relationship led to the different effects of descriptive norms from competing groups and mutual support groups social support infosp had a significantly positive relationship with health behaviors with a higher level of informational support users performed a higher level of dietary and exercise behaviors hypothesis 3a was supported emotsp was significantly positively related with the health behaviors users who received more emotional support performed a higher level of dietary and exercise behaviors hypothesis 3b was supported online social relationships effect on health behavior over time we also considered the effect of online social relationships on health behavior over time based on the duration of ohc participation competing groups lasted no more than three months but mutual support group membership and friendships would last forever which may have led to the different effects among the social relationships on health behavior to explore whether different relationship duration affected health behavior differently we evaluated the effect of social integration and descriptive norms for the first three months after a friendship was formed and mutual support group participation began replacing the fnum spnum fdietnum and spdietnum in model 1 with fnum3m spnum3m fdietnum3m and spdietnum3m respectively we obtained model 2 to explore whether the effect of social relationships on health behavior changed while participating in the ohc based on model 2 we added the interaction items of membership duration and social relationship variables in model 3 the estimation results were shown in table 4 the effect of online social relationship duration in model 2 the social integration of friendship in the first three months of the relationship had a significantly positive effect on health behavior and the scale of the effect changed as the curvilinear relationship this was consistent with h1 the social integration of a mutual support group in the first three months had a significantly positive effect on health behavior and the scale of the effect changed with the curvilinear relationship this was also consistent with h1 comparing the importance of online social relationships to contrast the relative importance between social ties we multiplied the coefficient of social ties by its mean and compared the results the social integration of friendship had a larger effect on health behavior than the mutual group and the competing group the mutual group and the competing group had nearly the same importance when comparing γ 2 × spnum and γ 3 × chalnum comparing the descriptive norms from different social ties the results were similar to social integration descriptive norms from friendship had the strongest effect on health behavior among the three social ties and the descriptive norms from the two groups caused a similar effect on health behavior multiplying the coefficient by its mean we found that emotional support was more related to health behavior than informational support the effect of ohc membership duration by including the interaction items of membership duration and social relationship variables we tested how the effect of social relationships on health behavior changed with membership duration in model 3 social integration had a greater positive effect on healthy dietary behavior with longer membership duration however this was not true for exercise behavior however the effect of descriptive norms became smaller with longer membership duration h4a was supported social support had a different effect on health behavior as membership continued the effect of informational support on diet and exercise behaviors became stronger with a longer membership duration h4c was supported however emotional support had a weaker effect as time passed h4b was supported discussion interpretation of findings the social integration of friendship and mutual support group relationship positively affected health behavior in the early stages of the established relationship but the effect becomes less positive even negative based on the whole data as the relationship continues h1 is conditionally supported whats more the positive effect of the descriptive norms of friendship and mutual support group on health behavior become larger especially the effect of mutual support groups this may be because some relationships still showed up in the data but there was less contact or attention the effect of social integration for competing groups remains the same descriptive norms from social relationship had positive effect on health behavior friendships have the strongest effect on health behavior among the three social ties and the descriptive norms from the two groups caused a similar effect on health behavior this may be because friendship is a strong social tie compared to groups and strong social ties cause a larger effect on behavior than weak ties 59 the effect of descriptive norms becomes smaller with longer membership duration the behavior motivated by descriptive norms is herding behavior which is irrationally motivated by emotion as they become more involved in the ohc users understand more about the ohc environment and become rational which may lead to the decreasing effect of descriptive norms the emotional support and the informational support were positive related with health behavior emotional support was more related to health behavior than informational support which is consistent with yans work 31 social support had a different effect on health behavior as membership continued the effect of informational support on diet and exercise behaviors becomes stronger with longer membership duration however emotional support has a weaker effect as time passes users will become more rational so they will be less affected by social norms and emotional support and more affected by informational support in addition users will learn more from information which will reduce irrational behavior contribution and implications most of the previous research on health behavior was based on survey data and the social relationship variables were static as the data was collected at one time we extended the research on health behavior to online social relationships and explored how health behavior was affected by online social relationships with experimental verification using a set of longitudinal data by seeking to understand the motivation mechanisms that stimulate healthy behavior our research has the following implications we found that more social integration descriptive norms and social support improve individual health behaviors for health application designers more informational support and emotional support should be provided to users with more informational support for older users and more emotional support for newer users in addition they should recommend more active friends for the user and provide more opportunities to access others behavior information when designing the health application limitations this paper has limitations that need further work firstly we only identified the content of social support the support source was not identified social support may be identified from different sources such as friends or group members secondly we only considered social integration from the number of social ties other aspects of social integration that could be considered in the future include communication times and content as for data limitations we only considered shortterm competing relationships the effect of longer competing relationships should be examined in the future conclusions this study revealed that online social relationships play an important role in promoting healthy behavior empirical data was collected from an online weight loss community and the randomeffects ordered logistic model was employed to test the proposed hypotheses the results indicate that social integration descriptive norms and social support from online social relationship have a positive relationship with users health behavior we explored three types of online social relationships friendship mutual support group and competing group social integration in an online friendship has a stronger effect than other online social relationships and in mutual support groups and competing groups social integration has similar effects on health behavior similarly descriptive norms in online friendships have a stronger effect than the other two online social relationships and in online mutual support groups and online competing groups descriptive norms have similar effects on health behavior the effects of social integration and descriptive norms in online social relationships are stronger at the beginning we also explored the effect of membership duration and social relationships on health behavior changes the effect of social integration on health behavior will become larger as membership continues however the effect of descriptive norms on diet behavior will become smaller with longer membership the effect on health behavior will increase for informational support but decrease for emotional support author contributions conceptualization methodology software validation formal analysis investigation resources data curation writingoriginal draft preparation and visualization were mainly done by yl conceptualization writingreview and editing supervision project administration and funding acquisition were mainly done by xy all authors have read and agreed to the published version of the manuscript appendix a every post was analyzed from two dimensions the social support type of content seeking social support or providing social support the results are listed in the table a1 is the probability of containing informational support in the post a2 is the probability of containing emotional support in the post b1 is the probability of seeking social support in the post b2 is the probability of providing social support in the post the social support type of a post was assumed to be independent with seeking or providing in the post a1b1 is the probability of seeking informational support in the post for user i joins the discussion on the topic started by others and writes post p the user gets support from posts before post p if for if break infosp infosp × else for if break infosp infosp × user i starts the topic and writes post p the user gets support from posts after post p for if break infosp infosp × box a2 emotsp is computed as below for user i joins the discussion on the topic started by others and writes post p the user gets support from posts before post p if for if break emotsp emotsp × else for if break emotsp emotsp × user i starts the topic and writes post p the user gets support from posts after post p for if break emotsp emotsp × compsp is computed as the sum a3 in the forums for user i at week t

human behavior is the largest source of variance in healthrelated outcomes and the increasingly popular online health communities ohc can be used to promote healthy behavior and outcomes we explored how the social influence social integration descriptive norms and social support exerted by online social relationships does affect the health behavior of users based on an ohc we considered the effect of three types of social relationships friendship mutual support group and competing group in the ohc we found that social integration descriptive norms and social support information and emotional support from the ohc had a positive effect on dietary and exercise behavior comparing the effects of different social relationships we found that the stronger social relationshipfriendshiphad a stronger effect on health behavior than the mutual support group and competing group emotional support had a stronger effect on health behavior than informational support we also found that the effects of social integration and informational support became stronger as membership duration increased but the effects of the descriptive norms and emotional support became smaller this study extended the research on health behavior to the online social environment and explored how the social influence exerted by various social relationships in an ohc affected health behavior the results could be used for guiding users to make use of online social relationships for changing and maintaining healthy behavior and helping healthcare websites improve their services

introduction with 1891 billion people or more than onefourth of the worlds population living there south asia occupies about 52 million km 2 or 1171 of the asian continent and 35 of the planets land area it is also the most populous and densely populated region in the world in south asia females made up 4838 of the population overall in 2021 according to reports however women are 36 less likely to use the internet than men are throughout south asian nations comparing the rate of female mobile phone ownership to that of males might help comprehend the gender gap in south asia 124 million fewer women than men benefit from mobile phone ownership despite the inadequate internet usage by women in south asia social media platforms have a big impact on the expansion of womens educational opportunities it gives women the option of receiving a topnotch education while learning online any educational institution no matter where it is located can provide a degree through distance learning additionally using a search engine instead of visiting a library makes it easier for women to rapidly obtain reliable information from internet sources by blogging a student can strengthen their writing skills free blog writing enables students to write regularly without fear that their thoughts will be critically analyzed and social media platforms may be effectively used for collaborative work it is also more convenient because women do not have to physically go out to meet through the internet they complete the assignment as a group however social media has both a positive and negative impact on women women are more active than men in content sharing social media using instagram tiktok facebook and pinterest more than men the first issue with the negative effect is the type of distraction it causes the class students the breakdown of the educational system is caused by a large number of bloggers and writers who broadcast inaccurate information or inappropriate material on social media furthermore social media reduces students ability to interact with one another in person another issue is that women share their personal information on social media without adequate comprehension and some illintentioned individuals use that information for malicious purposes this has a negative impact on the woman and her family and it has been observed in south asian countries that womens education has been permanently discontinued as a result concurrently the essential figures in a judicial frameworkjustice judge attorney and public prosecutorare also on social media and the influence of social media can be apparent on their judicial work in both positive and negative ways the common law system of delivering justice is fundamentally based on the idea of open justice which holds that justice should not only be done but should manifestly and unquestionably be seen to be done a set of substantive open justice standards is established by the open justice concept and is typically followed by courts there are three such rules first that evidence is disclosed publicly to those in attendance in court second that decisions are rendered in open court and third that nothing should be done to prevent the creation of fair and accurate reports of judicial proceedings including by the media at the beginning people nowadays are learning about a far greater number of court decisions than they did in the past having the chance to learn about new or revised legislation as well as being aware of constitutional and human rights and this is only feasible in a comparatively simpler way thanks to social media due to social media alone the administration of south asias densely populated nations where the use of the law is limited in comparison to developed countries has been obliged to prosecute several criminals even in developed countries like america social media had the greatest impact on the breakthrough movement that took place under the title black lives matter in the trial of the police officer who killed george floyd a black man however here comes the dilemma when in any jurisdiction predilection can be influenced by social media according to nevett he has been detained more than 70 times since he began documenting the citys police department the new york city police department nypd in the late 1990s his use of film to expose police brutality paved the way for the expanding police accountability movement that is now seen throughout the us and expresses the revelation of racism in the police as a result numerous changes have been made as a result of the videos release including the defunding of the police and civil rights demonstrations additionally the black lives matter movement would not have taken off without the video documenting george floyds murder furthermore people are continuously exposed to proof of several organized crimes being committed including war fraud interstate conspiracies and other classified information yet some of the material is propaganda in order to affect the overall course of events propaganda is continually disseminated and the ordinary citizen has little ability to distinguish between fact and fiction from a sea of data individuals are making judgments prior to the conclusion of any legal proceedings as a result of their freedom of speech and thought which has an impact on the actual occurrence a judge who utilizes social media is likely to be affected as one study found that 445 of us judges use social media the conflict between judicial impartiality and freedom of speech is manifested through judges social activity and has deep historical origins in the early greek societies of homer and hesiod impartiality is mentioned as a crucial component of a fair trial and a crucial quality of those who administer justice however the goal of this review article is to determine how the literature already in existence learns about those global issues in south asian nations what recommendations or remedies they offer and where the research gap is explained by the nature of social media activities on education and justice which are examined by reviewing existing literature sultana and akter analyzed primary data which was collected by interview survey authors used the principal component analysis with sample size 100 in bangladesh respect to the variables were age gender marital status qualification personal income family income designation children working hours work experience and social media findings showed that people demand more security and safety when engaging in online commerce in addition to other variables like access to the internet and other infrastructure and recommended creating guidelines for managing a digital platform and keeping users secure webbased businesses should prioritize cyber security in order to foster trust in the online environment and assure womens access to digital technology and a good ambiance to do this the entire community must cooperate in bangladesh mahmud mohsin irfan muyeed and islam carried out research using firsthand information the variables were gender age marital status education income work religion social media and region the methodology was crosssectional approach exploratory analysis and multivariable logistic regression the main results showed that social media users who were male young single highly educated and living in cities were more likely to have adequate knowledge of positive attitudes toward and appropriate actions toward tuberculosis based on the findings the authors suggested that programs and interventions be set up to improve knowledge attitudes and behaviors regarding tuberculosis in bangladesh with a focus on females young and elderly people people who live in rural areas illiterate or less educated people and people in order to conduct research in india saha paul yaya and bankethomas used secondary data and pearsons chisquare multivariable binary logistic regression authors state that social media usage is significantly associated positively with awareness of sexual activity pregnancy contraception and human immunodeficiency virus marital status did not correlate with social media use and married adolescent females were much more knowledgeable about sexual activity pregnancy and contraceptive options they also recommended that without significant investments in education and the renovation of relevant social and structural integrity effective social media usage would not be possible adolescent females should be empowered both socially and economically through education which may be provided through greater access to digital technologies and their dissemination literature review in addition to spreading thoughts on the legal system and the government new bulletins can help raise peoples levels of awareness social media has the power to completely transform the nations justice system social media which is beneficial for swift justice is used to critique mistakes carelessness and delays in the legal system during court hearings the supreme judicial council should exercise its authority to enact laws that promote quick justice once the case trial begins the deadline for each cases conclusion should be stated the bar and bench should cooperate to inform the system of the value of swift justice in addition to the principle that justice delayed is justice denied it is important to keep in mind that justice hurried is justice buried while creating rules to ensure prompt justice the sample size was 318 when using primary data and the grounded theory approach nova saha shafi and guha stated that the majority of participants in cyberbullying are women who experience sexual harassment people who declare that the harasser is someone they know and people who seek social assistance are frequently victimized humiliated and mistreated the author also recommended that you consider the policies establishing connections between social media sites the government law enforcement and social assistance organizations establish social support networks to track down connect with and assist victims of online abuse establish basic efforts to promote cultural and religious values and teach them to individuals in training implement technical measures like a location monitoring network and a reliable algorithm to identify offensive or obscene language and prevent people from connecting jahan and ahmed has been used mann whitney and kruskalwallis tests sample size 209 there are some variables used such as the faculty or institution year of study places of origin computer skills internet connection used period of favorite social networking sites use frequency of use preferred time to access snss friend connections group connections reasons for using snss to communicate and use of sns for academic purposes the findings are that students mostly utilize social networking sites for communication with friends and classmates but they are also enthusiastic about utilizing snss for academicrelated activities these features and capabilities benefit students in their education the authors are recommended and students should investigate how they may use them for academic work teachers should encourage learners to communicate with them through these platforms academic institutions ought to encourage the adoption of cuttingedge technology in the administration of their services amit barua and kafy have taken positive measures including mobile applications whereas negative measures include artificial intellectual technology extremism is motivated by political and religious convictions extremism and divisiveness among bangladeshs educational institutionsbanglamedium englishmedium and madrasahare fueled by peoples lack of indepth understanding of their own religions the youth of the nation have easy access to the internet which might make them more susceptible to the risks of violence and radicalization the hello ct app the digital security act of 2018 as well as other securitydriven internet surveillance and counter narrative activities by counter terrorism and transnational crime cttc are not well publicized and do not match the level of demand tanvir matiur and hossain state that young people are constitutes a key demographic for radicalization and recruitment by violent terrorist organizations in bangladesh the extreme groups makeup is distinctive and at odds with mainstream secular political ideologies national and worldwide extremist organizations use social media platforms to spread misinformation misunderstand divine instructions and deliver hate speeches to the general public in an effort to deceive and fulfill their own goals table 1 presents a summary of relevant literature the research gap indentified that this is the first time initiative in the study region such as south asian countries have been never been examined in that particular research issues this review makes better opportunity in social media access effectiveness ensuring justice better and quality education and modernization gender age education occupation the most popular social media platforms were facebook and whatsapp people accessed social media platforms more than 5 times on average in compared to women men use smartphones the internet and social media substantially more often although social media is fast expanding as a educational background regional variation and gender 1 in both public and private institutions english is the most prominent and often used language among facebook users with private university students favoring the language much more 2 when writing comments online students from public institutions used less formal language than those from private universities 3 male comments outnumber female comments additionally women tend to utilize emotive terminology and they tend to comment on nostalgia fashion women making progress diet and party logistics nawaz abbas javed mughal and nabeel primary data pakistan gender age educational background experience institution type daily use 1 members of public and private organizations utilize social media equally for decisionmaking information sharing criticism and creation 2 the participants inventiveness knowledge sharing and criticism on social media have a big impact on decisionmaking kausar and ghafoor primary data pakistan interaction with peers interaction with teacher and engagement the majority of students believed that using social media would hurt their grades only a tiny minority of respondents report benefits from using social media while the majority report negative effects such as invasion of privacy substance abuse missing meals preventing students from concentrating on their academic work and consuming the majority of their productive time khan demographic identities motivations media target audience positive and negative experiences initiated by their peers participants began using anonymous social networking sites such as askfm yik yak secret and sarahah because they wanted to get funny messages from individuals in their known social circles because many of our participantsparticularly womenreceived unsettling messages and sexual assault through these anonymous social media the platform lost its appeal to them additionally anonymous social media platforms enabled them to speak out against influential social groups including political parties academic institutions and religious organizations raza both primary and secondary data pakistan 1st of march 2020 to the 31st of march 2021 integration and biasness remarks condolence marketing religious violence gender the facebook group is assisting the pakistani community in norwegian society by giving them a platform to stay in touch express their opinions about norwegian society change their beliefs and norms as well as acquire help get information about various events in terms of charity for condolences and help regarding the residents and financial matters pakistanis use this social media site like any other group to openly converse on topics that are too delicate to discuss elsewhere and to share kumar and thapa primary data india 2013 social media media spread quotient information interpretation social media and thinking 1 users access material on social media with some care demonstrating their intellectual prowess since they are not always motivated by the information they find there instead they check the information before accepting it 2 users say that they might have changed after engaging in debates on social media and they acknowledge that it has an impact on their opinions and way of thinking about social issues gurman nichols and greenberg primary data india 3 september 2013 and 1 october 2013 gender rape joke personal or vicarious experience urbanization modernization capital punishment police issues politician issues blames females excuses males twitter may be a particularly useful platform for india to voice opposition to and viewpoints on gender based violence gbv especially extensively reported highprofile gbv cases more often than men women spoke out against the stereotype that blames women for genderbased violence and they also tended to choose oneway communication over twoway communication name of author type of data country duration variables resultsfindings sachdeva and kumaraguru primary data india gender age education for policing tasks including traffic control rumor detection public opinion analysis and investigations to gather evidence both civilians and police favored facebook and whatsapp while residents believed that privacy concerns were a key barrier to using open street map to connect with police officers were concerned that citizens may publish important information on the platform jeopardizing their own security dutta primary data india 2020 impact of the lockdown provision of online classes pedagogy adopted in the teaching learning process benefit and limitations of online classes 1 for communicating with students popular apps include whatsapp youtube and video conferencing programs like zoom skype jitsi meet cisco webex starleaf whereby and hangouts 2 the monotony of the classroom has been interrupted by video conferencing equipment and online social media 3 in a nation like india the spirit of online learning is hampered by technological issues primary data bhutan thailand gender country students in universities in bhutan are aware of the growing power of social media their amount of selfcriticism on social media however is just mild ghalley primary data bhutan 2018 gender education types of social cites every college student was using a social networking website of some kind the justification for utilizing social media is to socialize digest information and interact with family and friends another common reason people used social networking sites was for entertainment and boredom students mostly used smart phones to access social media and the most popular search engines are google and youtube methodology when reviewing articles and all pertinent data bias can be minimized by using explicit and methodical techniques which produce reliable findings from which decisions can be made a systematic review can offer a variety of advantages and contributions for example we can discover whether an effect is consistent across trials and what additional research would be needed to confirm the result methods can also be used to determine whether studies carried out in a particular cultural setting significantly differ from those carried out in other cultural contexts in terms of certain characteristics of the sample or study level that have an impact on the phenomenon being studied interrelation of social media on education and justice we can strengthen our belief in the importance of social media for womens education and justice as a result of the abovementioned article there are different types of social media like social networking media sharing networks and discussion forums at the beginning when looking at south asian nations it is clear that compared to social networking sites discussion sites like reddit and quora have a far lower user base quora or reddit are useful in a lot of aspects educationally students can find expert opinions on the respective topics and topics are so diverse that they include almost all fields that come under education this allows students to get clear concepts in the best possible manner and this keeps the students interested all the time furthermore students can get personal experience from the expert and get expert advice about their career and skills including how to develop them as a result it is evident that the citizens of south asia are not benefiting substantially from online forums like reddit quora etc on the other hand facebook is used more frequently followed by youtube than either linkedin or twitter among social networking sites youtube is initially more wellknown in south asian nations than educational websites like khan © 2023 conscientia beam all rights reserved academy coursera linkedin learning and master class students may study at their own pace on youtube because of the convenience of pausing fastforwarding rewinding starting again and rewatching as necessary its content quality including visuals audio relevancy frequency and consistency is also handy for them educational videos have a higher impact than other information materials such as texts it is accessible on almost any screen a student would come across and it can be used on mobile devices like smart phones and tablets as well as smart televisions furthermore english subtitles can be produced consequently and free of charge once the substance makers empower the implicit translation and transcription highlight youtube offers the choice of empowering making and altering captions showed as shut subtitles basic interpretations in the video portrayal segment or even interpretations into various dialects hence students who do not know the contentgenerated language will find this tool useful additionally youtube has localized versions in more than 100 countries and may be accessed in 80 different languages and it offers remote access moreover computermediated communication in the classroom has the potential to improve the rapport between students and teachers which might result in better student results online interactions between students and professors that use immediacy in their emails are more likely to occur students also reported high levels of motivation and practical learning showing good views about the course and the teacher when they watched an instructors website with high degrees of mediated immediacy including forms of selfdisclosure secondly the fact that the internet operates instantly and is a virtual place while the law is bound by jurisdiction presents a huge difficulty in connecting social media and the law social media is fluid and dynamic it could be anything from a passage from a diary to a portion of an image making it difficult for the law to handle the law is an artifactthe product of the collective minds of a community or a civilization the outcome of a thinking processand the courts only deal with antiques within a legal framework social media has no bounds but the law has some formal or legal constraints different social media platforms have evolved into safe spaces for people to express their experiences and demand justice in the contemporary global environment when many nations experience egregious human rights violations and political and social upheaval not only do social workers and campaigners utilize it but on several occasions normal citizens have used twitter and facebook to express their experiences in order to establish a place where groups activists and individuals may call for justice people are utilizing social media to form ties raise awareness and assist people from all over the world in their quest for justice social media played a significant role in movements like the arab spring uprisings in the early 2010s the human rights campaigns online initiatives focused on legalizing samesex marriage in the us the occupy wall street movement and black lives matter disseminating the message through social media made it possible to create online spaces where people could come together and find support additionally minorities difficulties such as ethnic violence sexual harassment and other types of oppression are frequently underreported social media represents this by highlighting the very first testimonies of victims and it also helps to advance social justice also focusing on recording events through social media we may analyze the hong kong demonstrations in 2019 when protestors utilized social media to publish images and videos of events to tell the public and the globe about the prodemocracy movement so it is clear that social media is actively contributing to the advancement of womens education and justice it has made education more accessible and convenient and it has brought people from all over the world together to support the oppressed in the pursuit of justice conclusion currently social media has significance in solving social problems and promoting education and justice the third industrial revolution came to an end and social media exploded in popularity this medium is wellliked not only by young people but also by people of all ages people can instantly see events happening anywhere in the world thanks to social media it is currently exerting more influence than any other medium for exchanging information people use this medium to converse with one another exchange knowledge and turn monologues into conversations young people make up the majority of social media users overall as soon as the details of any world event are made public word spreads additionally users can view it and comment on it social media can be the ultimate tool for collaborating on social problems this is possible through social media this approach may occur to some extent in teaching and learning collaboration communication and critical thinking skills are not as useful in formal education unless taught directly by the teacher because the function of social media is to spread any information to everyone immediately it requires critical thinking if the information is from a trustworthy source and the teacher can get it to all of the students social media can play a significant role in other words a teacher can use social media to give students accurate information social media makes it possible for teachers to get large groups of male or female students or many students to collaborate on a project given that the teacher will receive a prompt response by discussing a subject here which is not possible elsewhere due to the potential of the internet medium the level of social communication has multiplied over time social networking websites are thought of as depending most on the effectiveness of human communication through the use of social media individuals are entirely eliminating geographic distance in human communication and ensuring that law and justice are easily accessible to reduce crime social media plays a significant role in developing countries like bangladesh and india the contribution of this study is to identify the importance and positive views of social media in education and justice further research should look into quantitative approaches that will be more effective for stakeholders authors contributions all authors contributed equally to the conception and design of the study

the initial purpose of this study was to review the impact of social media on womens education as well as education and justice in south asian countries social media is actively contributing to the advancement of womens education and justice it has made education more accessible and convenient and it has brought people from all over the world together to support the oppressed in the pursuit of justice this is the first time an investigation using secondary sources of information in the research area such as south asian nations has ever been looked at in relation to that specific research issue better access to social media efficiency ensuring justice better and higherquality education and modernization are all improved by this review this study also makes a contribution by highlighting the value and favorable perceptions of social media in justice and education as well as social awareness limitations exist and future research should focus on quantitative strategies that benefit stakeholdersthe purpose of this study was to review the impact of social media on womens education as well as education and justice in south asian countries which has never been examined by other researchers this research contributes to society by creating awareness about the importance of justice and womens empowerment

introduction in recent years the study of issues related to happiness has been a highly productive area of work and a topic of growing interest internationally however little research has focused on groups in situations of social difficulty especially in countries with low levels of development this is despite the fact that as diener points out the influence of external factors such as the lack of sufficient resources to meet basic needs may be more relevant for personal happiness that an individuals various dispositional factors various studies highlight the existence of a positive relationship between happiness and level of income and note that the individuals personal financial situation may play an important role in accounting for happiness poverty has often been considered a situation in which the degree of wellbeing is very low and extreme poverty is thought to have a very negative effect on happiness the normal perception is therefore that a very poor person can hardly ever be happy and in cases where this occurs their happiness is attributed to the very low level of their future expectations or their ability to adapt to their apparently unfortunate situation however as rojas points out individuals are more than mere consumers and there are other things in their lives besides money indeed the relationship between income levels and satisfaction in other relevant areas of life is practically nonexistent and as such the income level alone predicts practically nothing about satisfaction in several areas that are important to individuals it is therefore common to find happy people with very low incomes which could explain why these individuals obtain a great deal of satisfaction in other areas of their lives social relationships and stable ties with family friends partners and community are to a large extent predictors of subjective wellbeing and overall happiness but brannan et al noted that despite the growing number of crosscultural studies focusing on wellbeing little is known about social support outside the western civilization individuals mention feelings of happiness when they meet others furthermore people who say they are very happy have stronger relationships with family friends and couples the consistency of the data leads to the conclusion that social relationships are necessary for happiness caunt franklin brodaty and brodaty note that social relationships are a very important factor in peoples wellbeing and especially in relationships with family and friends but also relationships in general in this regard a lack of social relations or social relations of poor quality has a significant negative impact on happiness the different circumstances surrounding people in terms of secure and stable elements in their life also appear to have a significant effect on their subjective wellbeing and overall happiness possibly because of adaptation some of the circumstances that most consistently predict high levels of overall happiness are being married and being sufficiently wealthy to meet basic needs caunt et al note that while having sufficient wealth is well represented among the recipes for happiness relationships within a couple including a happy marriage were mentioned as sources of happiness with a moderate frequency meanwhile optimism is considered a personality trait that can predict high levels of subjective wellbeing and overall happiness according to various authors various authors believe that optimism is an inherited personality factor with a stable effect on daily fluctuations in attitudes emotions and behaviours nicaragua with an estimated population of 55 million inhabitants is one of the countries in latin america with the lowest levels of development 158 of nicaraguas population lives on less than 125 dollars a day and 458 live below the national poverty line león the countrys second most important city after the capital has a population of approximately 185000 inhabitants estimates suggest that more than half the citys inhabitants live below the poverty line and that there are major pockets of population living in extreme poverty this study was prompted by the lack of research on wellbeing and overall happiness among women in poverty who are victims of ipv in the poorest countries who are in addition heavily stigmatized and subject to very difficult life circumstances method sample the participants in the research were 136 women living in poverty who were victims of intimate partner violence in león a group that is difficult to access and which lives under a particularly severe range of stressful situations those meeting the criterion for inclusion in the sample were women living in poverty who had suffered from violence inflicted by their spouse or partner access to the interviewees was possible thanks to the support provided by various associations and institutions working with women living in poverty in león including the commissariat for women of the nicaraguan national police the interviewees whose mean age was 3167 years old had a mean of 223 children on average they began living with the partner who subjected them to the assaults at a mean age of 1991 years old and had cohabited or lived with their assailant for a mean of 916 years other characteristics of the women in poverty who are victims of intimate partner interviewed are listed in table 1 as can be seen in table 1 almost half of the women in poverty who are victims of ipv who were interviewed lived in cohabiting couples while one in five were separated or divorced the majority of the interviewees had no education higher than primary level and a large percentage had no income of their own although most of them did some work from which they obtained income this exceeded 50 dollars a week for a small percentage of the interviewees one third of the women interviewed lived with their assailant who in these cases tended to be the main contributor to the household income procedure after locating each woman in poverty who was a victim of intimate partner violence the interviewer made contact explained the objectives of the research and the treatment that the data would be subjected to and sought informed consent for the interview 516 of the women were interviewed in their own homes 389 in the commissariat for women of the nicaraguan national police in león and 95 at the headquarters of various associations and nongovernmental organisations which collaborated with the research the data was collected using a structured interview designed for that purpose which circumvented the problems caused by some difficulties with reading and comprehension among some of the women in poverty who are victims of ipv interviewed due to some of the interviewees limited ability as regards reading and comprehension we used an instrument that combined illustrations with explanations by the interviewers shown in figure 1 to gather the information on overall happiness which of the following faces best represents your overall level of happiness although collecting information on overall happiness is complex according to schimmel people regularly think about happiness and as pointed out by karma and karma they tend to have a fairly clear idea of what happiness is while there is some disagreement on how best to measure overall happiness authors such as easterlin and veenhoven emphasize that despite not being perfect the use of subjective indicators adequately reflect the respondents feelings regarding their happiness in different countries and cultures in order to facilitate comparisons between interviewees according to their happiness the overall happiness variable was dichotomized to distinguish between women who said they were unhappy from those who said they were happy the interview included the scale of perceived social support a spanish adaptation of the mspss scale consisting of 12 items which include information on individuals perceived social support in three areas family friends and significant others the instrument was answered using a likert scale with four response options 1almost never 2sometimes 3often 4always or almost always the database was developed and processed using the spss statistical analysis and data management system the data obtained was used to undertake descriptive analyzes that included information on women in poverty who were victims of intimate partner violence when making comparisons the 2 chi square statistic was used for nominal variables and the student t test for independent samples was used for continuous variables results the results obtained show that more than half of women in poverty who are victims of ipv in león say that they are happy and most had positive expectations for the future table 2 shows the overall level of happiness expressed by the women interviewed and their future expectations as table 2 shows 536 of the interviewees said that in general they were happy however 162 said they felt at least a little unhappy as regards expectations for the future most believe that their future would be better than the present and only 37 believed that their situation in the future would be worse than when the interview took place the relationship between the overall level of happiness and future expectations of women in poverty who are victims of ipv is shown in table 3 table 3 shows that there is a direct relationship among the women interviewed between feeling happy and having positive expectations for the future such that the women who said that they had best future expectations were those among whom a higher percentage said they were happy there are no statistically significant differences between the women who said they were happy and those who said they were unhappy according to basic demographic characteristics such as age number of children or being married or part of a de facto union versus being single separated or divorced there are also no statistically significant differences between women who said they were happy and those who said they were unhappy in terms of issues such as living with the assailant compared to not living with him the duration of the relationship with the assailant prior to cohabitation the age at which they began living with the assailant the length of time the assailant and victim continued to cohabit and the duration of the abusive situation similarly no statistically significant differences between happy and unhappy interviewees were observed depending on the circumstances in which the first situation of abuse occurred or the frequency of abuse when it took place the relationship between the overall level of happiness of women in poverty who are victims of ipv and the time elapsed since the last episode of abuse is shown in table 4 as shown in table 4 the time elapsed since the last episode of abuse seemed to influence the overall level of happiness expressed by women in poverty who are victims of intimate partner violence so that a smaller percentage of the interviewees who had suffered the most recent episode of abuse during the three months prior to the interview say they are happy substantially higher percentages of women who had suffered from aggression more than 6 months before the interview was conducted said they were generally happy and this was especially true among those that said that over a year had passed since the most recent assault both the personal and family incomes of women in poverty who are victims of ipv appear to be related to the overall happiness reported the percentage of happy women was lower among the interviewees with no personal income or with income of less than 25 dollars a week than among women with incomes of more than 25 dollars a week similarly a lower percentage of happy women was observed among interviewees with incomes of less than 25 dollars per week than among those declaring that their incomes exceeded 25 dollars per week table 5 contains information on the relationship between the overall happiness among women in poverty who are victims of ipv and filing an official complaint against their abuser table 5 shows that a higher percentage of women in poverty who are victims of ipv who had never filed a complaint against their assailant were happier than those who had filed official complaints furthermore the lowest percentage of happy women was among those who had an ongoing complaint at the time of the interview followed by those who had filed an official complaint at some point but had subsequently withdrawn it in terms of the social support available to the women in poverty who are victims of ipv interviewed there were differences between the mean scores on the scale of perceived social support for women who said they were happy and those who said they were unhappy with interviewees who said they were happy having higher mean scores on the scale of perceived social support the relationship between overall happiness and various aspects related to perceived social support and satisfaction with social relations among women in poverty who are victims of ipv is shown in table 6 as can be seen in table 6 the highest percentages of women in poverty who are victims of ipv who said they were happy were those who did not feel alone or abandoned those who had someone to turn to if they needed support or were in need those who felt very satisfied with their relationship with their partner and those who were a little satisfied with their relationship with their friends no statistically significant differences between the interviewees were observed in terms of feeling happy and unhappy as regards their level of satisfaction with their relationship with their family conclusions and discussion the overwhelming majority of the women in poverty who were victims of ipv interviewed in león are optimistic as regards the future and more than half say that they are happy this is despite the poverty in which they live the stigmatization they suffer from in their social context and intensity of the stressful life events that have had to deal with which include intimate partner violence easterlin notes that even when the perception of happiness experienced remains constant people tend to think that they were worse off in the past and that they will be much better off in the future in this regard women in poverty who are victims of ipv present a clear relationship between being happy and having positive future expectations despite having been subjected to powerful stressors such as intimate partner violence and living in poverty there is a tendency for interviewees to remain optimistic regarding their future this is especially marked among those who say they are happy the overall feeling of happiness seems to induce optimistic cognitions leading to better expectations for the future their optimistic expectations for the future may in turn positively influence their feeling of overall happiness optimism is considered an inherited personality trait that predicts overall happiness by various authors with a stable incidence on daily fluctuations in attitudes emotions and behaviours in this respect the optimism shown by the interviewees may help explain the substantial percentage of women who are happy despite the difficult situations they are going through or have gone through furthermore different studies have stressed the existence of a positive relationship between happiness and income level and note that the individuals personal financial situation may play an important role in accounting for happiness however the significant percentage of poor women interviewed who are happy calls into question the principles that emphasize the importance of income for happiness the interviewees present a low capacity for consumption meaning that the association between utility and wellbeing reported by several studies is questionable according to schimmel the substantial percentage of poor women who say they are happy could arise from the fact that their opportunities to meet their absolute needs are not compared with other members of their society to whose standards of living they may aspire a lower percentage of the women interviewed with personal or family income of less than 35 dollars a day who could be considered as living in extreme poverty said that they were happy than among the women earning higher incomes who could meet their basic needs to a greater extent and who mostly said they were happy according to the results reported by schimmel when the women interviewed have sufficient resources to meet their basic needs they have a high probability of being happy the data collected seem to reinforce the idea mentioned by rojas that people living in poverty are more than mere consumers and there are other important things in their lives beyond money that help them to be happy overall happiness appears to be based on the satisfaction that people find in different areas of their life and as such the different circumstances that surround people and which are secure and stable elements in their life may affect the generation of feelings of happiness in general terms in this regard two of the circumstances that most consistently predict high overall levels of happiness are being married and being sufficiently wealthy to meet basic needs however among the women in poverty who are victims of intimate partner violence although there is a relationship between having enough resources to meet basic needs and being happy no differences were observed in terms of their overall happiness expressed as regards living as part of a couple or otherwise this lack of a relationship may be due to the ipv experienced since the women interviewed who do not live with their partner would be less prone to suffering from this kind of violence and this could affect their perception of overall happiness however these questions are consistent with those reported by caunt et al who observed that while sufficient wealth is strongly represented among the recipes for happiness relationships within a couple including happy marriage are identified as sources of happiness with moderate frequency in general social relationships and stable ties with family friends partners and community are good predictors of subjective wellbeing and overall happiness and may be a factor that helps to explain the high percentage of women in poverty who are victims of ipv who say they are happy while living with a partner does not appear to influence the overall happiness of the women interviewed maintaining a very satisfactory relationship with a partner does seem to have positive effects on the overall happiness reported despite the situations of great adversity experienced by the interviewees under very favourable conditions their relationship may therefore be an important source of social support with positive effects on their wellbeing and overall happiness the influence of social support on the overall happiness of the women interviewed is also reflected in the higher percentage of happy women among the interviewees with high scores on the scale of perceived social support among those who said they did not feel alone or abandoned and those who had someone to turn to in the event of difficulties or need according to the results reported by various authors social relationships are important for happiness while the lack thereof or social relations of poor quality appear to have a negative impact on happiness caunt et al suggest that relationships with family and friends are a very important factor in individuals wellbeing and this is especially true when the family income is low however there is no clear relationship between overall happiness and satisfaction with relationships with friends among the poor women interviewed the highest percentage of happy women is among those who say that they are not satisfied with their relationship with their friends and the absence of a statistically significant relationship between reported overall happiness and satisfaction with their relationship with their family is especially noteworthy when analyzing the relationship between overall happiness and the issues surrounding ipv suffered by the interviewees we observed that the variable that affects happiness to the greatest extent is the time elapsed since the women had suffered the most recent episode of abuse such that the longer this period the higher the percentage of women who say they feel happy the women find it more difficult to be happy in general terms when they have recently suffered from an episode of abuse however the interviewees presented a great deal of ability to overcome difficulties as the percentage of women who said that they were happy one year after the most recent episode of abuse was extremely high the other aspects concerning the ipv suffered by the interviewees included the lack of a relationship between feeling happy or unhappy and circumstances as relevant as cohabiting with the assailant the length of the relationship with him prior to cohabitation the age at which they began to live together the amount of time the assailant and victim continued to live together how long the abusive situation lasted its frequency and the circumstances in which the first incidence of abuse arose the influence of these factors on the overall happiness of the interviewees appears to diminish after a sufficient length of time has elapsed since the last episode of abuse suffered and in this respect the women present a high level of resilience finally it is noteworthy that the highest percentage of happy women were those who had never filed an official complaint against their partner and the lowest percentage of happy women was observed among those who maintained an ongoing complaint at the time of the interview followed by those who at some point had filed an official complaint against their partner but had subsequently withdrawn the complaint filed filing a complaint especially in the recent past or when the complaint is ongoing seems to have a negative effect on the overall feeling of happiness probably due to the high levels of stress that it entails for those making the complaint on this basis in order to improve the wellbeing of women in poverty who are victims of ipv it seems relevant to provide them with some degree of optimism to face the future to this end the people and organizations working with this population should supply them with counselling psychological support and training in coping strategies this would empower women with effective strategies to rely on when meeting the main challenges that they are confronted with simultaneously it would be relevant to design policies specifically aimed at giving support to either women who have experienced ipv recently or those who are currently in the process of reporting their aggressors a circumstance that seems to create a major stress factor with a negative impact on their wellbeing it is undoubtedly a matter for concern that 16 of women in poverty who are victims of ipv in león state that they feel at least a little unhappy and that 4 believe that they will feel worse in the future however what is really remarkable is that more than half of the women interviewed feel happy and that 85 are convinced that they will be able to achieve a better quality of life in the future with some effort and perseverance the ability of the women interviewed to cope with adversity and their positive expectations for the future despite their situation are factors that provide an optimistic note as regards the opportunities for women in poverty who are victims of ipv for normalizing their circumstances and gaining access to a better quality of life

the paper analyzes various aspects of overall happiness expressed by 136 women in poverty who are victims of intimate partner violence ipv in nicaragua a country with low levels of development the information was gathered using a structured interview results obtained show that despite the hardships they face half of the women in poverty who are victims of ipv say they are happy and the vast majority are optimistic about their future the main sources of happiness among the interviewees are in areas outside their economic life and are mainly associated with social relations

introduction neoliberaldominated urban policies and uneven geographies contemporary cities are characterized by the inequality reflected in uneven geographies of qualityoflife conditions in the age of neoliberaldominated urban policies and influenced by globalization process in many cities the gap between better and worseoff areas is increasing wacquant offers a useful sketch of the neoliberal state model that originated in the united states but has been taken up by elites across the globe including india 1 as a political project aiming to remake the nexus of market state and citizenship from above article environment and urbanization asia 2 2 223234 this mode of statecraft suits urban middle classes oriented to the future enamoured with raising their cities to international levels and those who have the resources to compete in the formalizing job market live in a legitimate flat and secure needed services the ethos of selfresponsibility and entrepreneurialism mixed with consumerism and faith in technology positions them as the candidate to represent the implied good urban citizen in city development plans largescale urban renewaldevelopment projects and egovernance initiatives the link between capitalism neoliberal urbanization and the middle class have been well established and it is useful to view the present battles over urban space as well as inequalities and illegitimate occupancy in regards to the neoliberal states interest in increasing capital accumulation and middleclass interests in modernizing the cityscape the middle class is becoming active in civil society and demanding their right to the city at the neighbourhood level this usually takes the form of citizen or housing societies demanding that officials enforce or create regulations to deal with urban blight in their residential areas and other public spaces they wish to enjoy more at the higher levels this takes the form of filing public interest litigations to use the courts to pressure municipal public officials to enforce rules and regulations often resulting in numerous evictions and demolitions as well as the closure or relocation of urban informal industries to the periphery less personalized but just as effective corporate economic interests and state officials friendly to their cause leverage arguments of obsolescence 2 and rent gaps 3 to rationalize which areas get targeted for urban renewal or development these argumentsblight rent gaps and obsolescenceare mutually reinforcing they both tend to aestheticize antipoor politics and neoliberal practices to elevate exchange value over use value and to elevate the demands of the middleclass and elite over the needs of the poor and working classes while close scrutiny would often reveal informal aspects in middle class and elite modes of occupancy these are not the focus of public interest litigation and their legitimacy is never seriously questioned concern about uneven geographies and the egovernance response there is growing interest in understanding and explaining uneven geographies 4 this relates to the concern of levelling off qualityoflife conditions at global national and local level at global level the millennium development goals include a clear commitment to improve the lives of slum dwellers at national level india adopted the mdgs setting its own targets and setting up propoor policies and reforms in urban areas within specific programmes such as the jawaharlal nehru national urban renewal mission programme one of the responses at local level to address the jnnurm requirements is the implementation of information and communication technology tools or egovernment tools in the city of kalyandombivli this is listed in the approved city development plan as the introduction of a system of egovernance under the egovernance section of the kalyandombivli municipal corporation city development plan it is also indicated that the project has been already replicated at various municipalities within and outside maharashtra the egovernance project has received accoladesawards at state national and international level asia 2 2 223234 one of the components of the egovernance system in kalyandombivli is the module called complaints and redressal system in general these ict innovations are introduced to promote local governance by improving quality of life and increasing efficiency and transparency in the response to citizens demands and needs however it should be noted that egovernance tools are embedded in larger forces of neoliberal policies and class antagonisms over space and value these forces impact how and why local governments take up ict thus to view them as apolitical or neutral tools would miss the ways they could possibly contribute to exacerbating rather than treating inequalities it is also important to keep in mind the role that the private ict sector plays in the uptake of egovernance tools the framing of governance problems and being amenable to technological and informational fixes they benefit in the form of lucrative contracts with the local state also there is economic incentive for them to maintain the localities creating dependence upon them by obfuscating knowledge transfer to city officials and employees egovernance tools and ict innovations in general are being pushed by private sectorconsultants that benefit from pushing governance problems as technology deficit and information deficit problems environment and urbanization at this point it is important to highlight that not all inhabitants enjoy citizenship rights chatterjees work offers an important directive to avoid the erasure of unequal social life he argues that concepts of civil society and citizen need to be divided in two into civil and political society and citizens and populations civil society is the domain of middle and elite classes who are able to comply with private property laws tax responsibilities and participate in the professional economya situation where the links between civil society the state and the market are clear and reinforcing however the urban poors citizenship status is fragile at best given the illegality or quasilegality of their work and occupancy therefore the state and powerful market actors do not regard them and their organizations as having the same rights or ability to participate in governance as civil society rather the poor are populations who occupy political society populations rest upon negative normative assumptions that imply deviance and degrees of deservingness and that rationalize the adverse incorporation of certain groups when it comes to claiming and using their citizenship rights what population the poor belong to is more determinate of the form and content of their relationships with the state and markets than their fragile citizenship status political society 5 engages in constant negotiations over what different poorer groups and areas can claim and at what price since these claims come from those whose productive activities and means of place making are objects of stigma and illegality these arrangements are often ad hoc vary from case to case and are off the record fieldwork in kalyandombivli shows that these negotiations do not occur over egrievance redressal systems poorer inhabitants tend to be offline in that they do not have access to computers or even basic knowledge of how the internet works let alone english proficiency also they are used to going to party workers or ward councillors when they have an issue and avoid going to the municipality where they have learned to expect rudeness and disregard past experience and lack of knowledge result in them mainly selfexcluding from this mode of citizen engagement egovernance romanticism this article relates to a wider research programme that explores the role of spatial information infrastructure in reducing urban deprivations in indian cities there is a general belief that more and better information can lead to more efficient planning and decision making and subsequently more effective urban governance in terms of inclusion at the same time some authors recognize that within decision making policy choices and decisions are value judgements and cannot be determined by information on the contrary in a real policy process issues such as ideology interests institutional norms and practices and prior information play a key role in influencing decisions the optimism towards information rests upon assumptions of a polity marked by citizens equally disposed to partake of these tools and that government is interested in forming inclusive cities more than it is interested in being able to compete for capital and middleclass inhabitants while maintaining its avenues of rent seeking from the poors insecure position in the city in addition the idea that more information leads to more equitable outcomes is always assumed but never yet to be proven the elevation of access to information as a human right combined with the faith in technology to overcome present governance issues of corruption incompetence and inefficiency have caused many to celebrate egovernance uncritically and view it divorced from contexts where social political economic and digitaldivide inequality are the norm egovernanceegovernment tools claimed potentials and unnamed limitations egrievance redressal systems are public feedback mechanisms with the characteristic that the interactions between the citizens and the complaints they send to the government can be traced back it is because of that characteristic that egrievance redressal systems and public feedback mechanisms are considered the key to increase transparency in egovernment initiatives egrievance redressal systems are also considered as part of participatory mechanisms of accountability to citizens which presuppose that citizens should be encouraged to participate in service delivery there is a general positive view about the potentials and the capacities that egovernance and egrievance redressal systems in particular have they are usually presented as an opportunity to increase openness and transparency within the public administration to support efficient city management and to monitor effectiveness in the response to grievances and to provide information for infrastructure problems identification the limitations listed are more related to scaling up the technical infrastructure than questioning whether these systems are able to capture the requirements of the most deprived and influence policy and actions there is also an absence in the debate on the exclusionary practices that these systems may entail those critical of growing statecreated grievance and public feedback mechanisms cite the issues highlighted in the former section and this mode of participation as being better labelled as administrative incorporation they argue that administrative incorporation both individualizes and thus depoliticizes citizengovernment relationships by bypassing party and politicians for issues of bureaucratic accountability it limits what is open to participationcitizens who can access these systems are allowed to make commentsrequests related to a particular servicedepartment or to an already established process but not regarding more substantive issues of whose interests and needs policies and processes are oriented towards additionally taking into account that in the present informational age some areas are bypassed by technology resulting in switchedoff areas one could expect thatdespite the environment and urbanization asia 2 2 223234 opportunities describedegrievance redressal systems might be hindering further the capacity of deprived groups to channel complaints or put them in relative disadvantage with groups which are pluggedin or live in switchedon areas egrievances might be highly dependent on ict access in this study the data produced by an egrievance redressal system is analyzed to identify what sorts of complaints are submitted where and whether there is a relation with areas of multiple deprivations data and methods for the analysis of the egrievances and multiple deprivations different databases and methods were employed 6 the analysis of the egrievance redressal system is based on the list of all egrievances submitted in the year 2007 which contains data on pending and solved complaints in particular the submission date sector and type of complaint response to the complaint and some kind of geographical reference like an indistinct address or landmark in addition interviews and smallscale workshops with local officials and councillors but also local selfhelp groups from poorer areas and employees of the poverty alleviation cell took place in november 2008 to investigate the role and use of the egrievance redressal system for the mapping of multiple deprivations spatially disaggregated databases from the indian census of 2001 were used to construct an index of multiple deprivations as designed in baud et al while household tables referring to basic services and households assets could be obtained for health wards only population data like number of literate or employed inhabitants were provided for the 96 electoral wards this limited the construction of the imd to only social and human capital aspects 7 in order to analyze the spatial pattern of both the grievances as well as the imd the data had to be matched to the geographical boundaries of the ew levels in 2001 there were only 96 ews corresponding identically with the population tables while in 2007 the ew boundaries were considerably rearranged resulting in a new map with 107 wards data processing and mapping sound analysis with the available data is quite a challenge for example the list of grievances contained some kind of geographical reference however this was insufficient to match it with the ew boundaries therefore they had to be manually geocoded with the help of kdmc staff to locate spatially the grievances it was necessary to manually assign an ew number to each of the complaints this was managed by using planning office maps and attributes such as the address and landmarks combined with staffs tacit knowledge of the city since the data refer to the year 2007 the kdmc staff used the 107 ew classification moreover knowledge on the 96 ews might not have been available among the current staff since the census 2001 ew boundaries are not used locally furthermore it was not possible to obtain the complete list of census variables for the 96 wards financial and physical deprivation had therefore to be omitted from the imd in addition it is more environment and urbanization asia 2 2 223234 logical to relate grievances to population data however as population was only available for the 96 wards of 2001 the population reference for the 107 ward is only an estimate based on the assumption that population is equally distributed and that there were hardly changes in the spatial distribution the quality of the geographical boundaries is just sufficient for visualizing spatial patterns though not appropriate for doing metric calculations or accurate spatial overlays 8 after assigning the ew number to the grievances list the resulting table was exported to a geographic information system software to geocode the complaints using the ew number as the key commonality in that way a polygon map containing the geographical boundaries of the different wards was attached to an attribute table containing the list of complaints the total number of complaints per ward were standardized by the estimated total population per ward the final value per ward represents the number of complaints per 1000 inhabitants apart from the mapping statistical analysis was applied to the complaints data specifically frequency tables of groups and variables mapping the imd followed the same procedure first the table was imported to arcgis and then geocoded using the 96 ew boundaries finally the resulting maps were visually compared namely the map displaying the index of multiple deprivation and the concentration of complaints per wards the resulting maps where also exported to google earth for visualization and discussion with a group of ward councillors local selfhelp groups from poorer areas and employees of the poverty alleviation cell analysis of complaints from egrievance system in kdmc the kdmcs egrievance system is part of the egovernance programme initiated by the kdmc in 1999and implemented in 2002 the objective was of creating a system driven municipal corporation with highest levels of transparency accountability and citizen servicing standards with the following claimed benefits for the citizens timebound service delivery transparency and accountability in corporations functioning hasslefree interactions with quicker response time for all the services objectiveness in decision making leading to more impartial and transparent governance from the objective we see that the crosscutting claimed benefits are both transparency and efficiency in terms of accessibility to different groups the implementation of the programme took into consideration that the egovernance tools could be accessible via the internet but also via a group of public offices called citizen facilitation centres it is also interesting to note the participation of the public and private sector in the development and implementation of the egovernance programme this includes the indian institute of technology national centre for science and technology and tata institute of fundamental research vjti and mumbaibased abm knowledgeware ltd some of the usual potentials of egovernance are being claimed in kdmcs egrievance system despite receiving several awards and being replicated in other municipalities an analysis of some local newspapers suggests that there are some limitations the egovernance system does not necessarily environment and urbanization asia 2 2 223234 speed up the resolution of complaints and some people still prefer to have facetoface interactions to place a complaint or they are not aware of the existence of the system the latest also was mentioned during the interviews with ward councillors a similar result was found in a case study carried out in another asian city with a grievance redressal system showing that resolving complaints in urban services still necessitates further underthetable payments or the influence of powerful intermediaries the same study shows also the lack of awareness and that small proportion of citizens are willing to proceed with formal complaints mechanisms the reported feeling is that there will be no followup to their complaint and that officials are often unavailable or indifferent the kdmcs egovernance programme is a source of pride for the municipal corporation 9 also the middle class feels that it is a move in the right direction however interviews with local politicians and department heads and workers show that while improving the storage and retrieval of data it will have no effect on the power and money politics of the city that shape uneven development nor on the poors dependency on political society and clientelism in fact none of the poorer inhabitants we spoke to even knew about the egrievance system and none of the ward councillors reported using it or directing their constituents to do so if development is at heart a political issue over who gets what when how where and why then ict is as likely to exclude as it is to include poorer areas and groups the analysis of the mode of delivery of the complaints in 2007 shows that more than 90 per cent of all complaints in kdmc are delivered by hand only 6 per cent are submitted online and just a negligible proportion used the phone for filing the complaint that 90 per cent of the complaints are delivered by hand shows that citizens still prefer to deliver the complaints face to face this could also be explained by the limited access to ict or by the lack of awareness of submitting complaints online the analysis of the kdmcs egrievance system allows the identification and the distribution of different categories of complaints table 1 shows frequencies of the complaints data for the year 2007 in that year four types of complaints were registered in particular water supply drainage storm water drainage and encroachment while the first three rather deal with malfunctioning of government services complaints about encroachment refer to the displeasure of citizens behaviouractivities according to the data the major problems are drainage and water supply with respect to water supply about 60 per cent of the complaints concern no water supply shortage in water supply and leakage in water lines while the major problems of drainage address the cleaning and maintenance of the drainage infrastructure namely the cleaning of septic tanks and environment and urbanization asia 2 2 223234 the number of complaints with respect to encroachment are considerable these are complaints submitted by citizens who are displeased about unauthorized constructions and development or unauthorized stalls or labour activities along the road and footpaths from the description of the resolution of some of the complaints it is found that in many cases these are actually complaints about activities which are not against rules or specific regulations this is an example of what we mentioned before as the pressure exerted by citizens demanding that officials enforce or create regulations to deal with urban blight this also shows that the information produced by the egrievance redressal systems cannot be taken exclusively as a proxy of selfexpressed needs it remains for further research to investigate and differentiate the categories of complains which purely refer to needs thatif not satisfiedmight affect the quality of life of the most deprived and those which reflect the wants and discontent of some citizens with urban blight 10 the visual comparison of the maps shows that the complaints do not necessarily concentrate in the most deprived areas according to the imd when these maps were shown to city officials politicians and selfhelp groups from poorer areas no one felt that they accurately reflected the areas in environment and urbanization asia 2 2 223234 the city with the greatest need for water and drainage improvements this suggests that the egrievances redressal system does not guarantee a narrowing of the gap between the different sections of the city nor does it necessarily capture the requirements of those in the most need conclusions the main findings show that there is a mismatch between deprived areas and selfexpressed need areas probably reflecting different strategies open to households to cope with the absence or malfunctioning of urban services and the differential capability to demand public intervention and exert pressure against urban blight the capacity of egovernment tools to reduce the gap between deprived and welloff areas is not mainly dependent on the introduction of sophisticated ict tools but on more complex process of integration the level of penetration of these tools both in terms of citizen uptake and administrative asia 2 2 223234 utility is shaped by local socioeconomic inequalities and traditional modes of politics administration and streetlevel delivery this triggers the need to better explain track and spatially identify profiles of inclusion exclusion and adverse incorporation the dynamics and many of the characteristics underpinning uneven development within cities will be missed if we rely too much on technology and government databases to determine need additionally the impact that this tool has had on the usual way poorer groups local officers and politicians deal with area needs appears to be minimal thus the more kdmc and other municipalities in similar contexts push for this type of citizen engagement and service provision the less inclusive these municipalities are likely to become visàvis poorer groups and places however even if these tools are combined with more qualitative ground truthing and data from other sources to better reflect need and service inequalities the real impact that this more accurate source of information would have on triggering propoor policies might remain low given the limited citizenship of the urban poor and firstorder governance priorities notes 1 for how tenants of neoliberalism have been taken up and adapted in india see chopra fernandes and heller 2 something outofdatecan be a product place identity practice or concept in terms of urban renewal it is a place or structure that is past its prime and is stubbornly trying to avoid modernization 3 whitehead andmore discuss how the issue of urban redevelopment in mumbai is being determined by the gap between existing rents and rent that could be accumulated if land was put to higher and better use 4 the monitoring of these growing inequalities across the cities as well as the identification of pockets of deprivation in certain locations has received the attention of recent research studies with focus on cities in the south 5 populations their associations patrons locallevel politicians and bureaucrats and streetlevel service providers 6 the usefulness of geocoding complaints and aggregating them at the electoral ward level was discussed with the heads of kdmcs information technology department it was agreed that this type of analysis would allow them to benefit from this data reserve and also it would be a learning opportunity for the staff in regards to increasing their familiarity with spatial analysis via a geographical information system in this context kdmc made available a list of all egrievances submitted in the year 2007 7 social capital is described by the percentage of people in scheduled cast human capital is the combination of percentage of literate people percentage main worker and the number of households dependants 8 the inconsistency in the data and in particular the mismatch between administrative boundaries probably relates to a lack of standards in spatial information and a lack of coordination among different organizations and different government levels 9 kdmc has pride of being one of the few ulbs urban local body in the country to implement these reforms environment and urbanization in most effective and scientific manner at kdmc today egovernance has become the basic for delivering good environment and urbanization asia 2 2 223234 governance to the citizens recently administrative reforms and public grievances goi has declared golden icon award to kdmc egovernance project for outstanding performance in citizen centric centre service delivery 10 in fact needs should be differentiated from wants needs can be satisfied and quantified and wants can be met and are related to personal desires smith also indicates that to assert a need is to appeal to some external standard however implicitly which may legitimate something that would otherwise merely be a want

contemporary cities are characterized by the inequality reflected in uneven geographies of qualityoflife conditions when these inequalities are a matter of concern local governments usually assert their intention to respond to citizens needs and deprivations it is in this context that information and communication technology ict tools are being incorporated in indian cities to promote local governance by improving quality of life and increasing efficiency and transparency in the response to citizens demands and needs depending on the institutional environment and how information is created processed and disseminated these egovernment tools can exacerbate existing exclusionary practices the objectives of this article are twofold first we want to explore how a local egrievance redressal system reflects selfexpressed needs second we want to investigate whether there is a mis match between selfexpressed needs and deprived areas this helps to answer the question how these systems capture the requirements of the most deprived the main methods used are geocoding and spatial visualization of the processed information results show that the selfexpressed needs do not necessarily concentrate in the most deprived areas this suggests that the egrievances redressal system does not guarantee a narrowing of the gap between the different sections of the city nor does it necessarily capture the requirements of those in the most need

introduction schoolbased sexeducation programs are the primary means by which adolescents in the netherlands receive information and skills related to safe sex communication about sex and managing relationships 1 a multitude of interventions have been developed globally for sex education of youngsters in school 23 although sometimes proven effective other interventions show only shortterm or no effects 14 besides due to an ineffective content these inconsistent findings may also be explained by inadequate implementation not being completely or correctly implemented can greatly undermine the effectiveness of an intervention 5 indeed the impact of schoolbased health education programs is often attenuated by inadequate teacher implementation 6 implementation is thus a crucial aspect of planning and delivering successful health education programs yet it receives insufficient attention 578 there are few published accounts of the process of implementation of interventions once they have been formally adopted by schools particularly in relation to sex education little is known about if how or how well the material is covered research conducted in the implementation field has tended to focus primarily on the adoption stage 9 considerably less effort has been devoted to determining whether and how new programs are actually used in classrooms after being adopted the assumption is often made that adoption at the organizational level will result in adoption and implementation at the teacher level however program adoption does not guarantee implementation and teachers initial attempts will not necessarily result in continued use of the program 5 understanding the factors that influence each of these stages is therefore crucial in explaining and improving the effectiveness of schoolbased sexeducation programs specifically or schoolbased interventions in general this study attempts to fill that gap by focusing on all the stages in the diffusion process providing a holistic explanation of the adoption and implementation behavior of teachers in the school context the present study addresses the promoting and inhibiting factors of teacher adoption implementation and maintenance of a dutch schoolbased sexual education program called long live love the lll program is one of the most successful evidencebased programs in the field of schoolbased sex education in the netherlands targeted at adolescents in secondary vocational schools the effectiveness of previous versions of this program has been largely accredited to the quality and extent of its implementation 1011 in the current study teachers classroom implementation of lll is evaluated and the determinants of the implementation process are examined long live love in the dutch education system schools and teachers are autonomous in their selection and use of health education programs without the interference of external authority sex education is also provided on a voluntary basis mostly by biology teachers 12 lll is the most widely used evidencebased teacherdelivered program for sexual education in the netherlands proving it to be a worthwhile intervention 11 over 50 of vocational schools have bought the program 13 the first version of lll was developed 24 years ago and was shown to produce desirable student learning outcomes when correctly applied 11 since then the lll curriculum has been revised three times and another revision is in progress the last evaluation however was done in 2002 14 in order to improve successful implementation of the future lll curriculum and other schoolbased health promotion programs an uptodate evaluation of factors influencing adoption and implementation is necessary lll is a relational and sexual education program composed of 26 learning activities divided over six lessons of one hour each 22 of these activities are core and 4 are optional lll is designed to provide students with communication and negotiation skills to enable safe sex practices it compromises a teachers manual a student magazine and dvd the main objective is the prevention of stdshiv and unplanned pregnancy 13 the presented framework will guide the evaluation of the lll program research framework the general outline of the research framework for this study was derived from an integration of rogers diffusion of innovations theory the theory of planned behavior social cognitive theory and from previous research on innovation in aids education in dutch schools 1215 rogers diffusion theory 16 describes implementation as a decisionmaking process consisting of different stages awareness of an innovation through spreading information about the program potential user receiving requesting and processing information the formation of an intention to buy and use the program initial use and continued use of the program 5 the tpb claims that intention is the most important predictor of behavior 17 according to paulussen et al 18 intention and behavior in this context can be considered synonymous for adoption and implementation respectively adoption thus refers to the intention of teachers to use the curriculum during sexual education only once a program l schutte et al has been adopted can it be implemented implementation of the curriculum refers to performance of the behavior the actual use of the program the implementation stage has been defined by two dimensions quality and quantity quantity or extentcompleteness is how much of the curriculum is taught quality or fidelity is the measure in which the program has been implemented as intended by the developers different factors influence each stage in the diffusion process the framework used in our study included the adoption of a revised version of lll and the implementation and the continuation stages of the current version of lll adoption of the revised lll program was focused on instead of the current lll program because all respondents included in the study have already adopted the current lll program and there was more interest in inquiring what factors need to be taken into consideration to promote adoption of the revised lll furthermore past experience with programs has been found to influence future use of it 12 19 20 21 the framework is presented in fig 1 the determinants that influence each of these stages were investigated these determinants have been placed into four categories curriculumrelated beliefs interactive context information sources and demographic variables three clusters of curriculumrelated beliefsattitudinal normative and selfefficacy beliefswere assumed to affect curriculum adoption implementation and continuation most directly these curriculumrelated beliefs in turn may be influenced by the other three categories the interactive context and information source are believed to influence teachers adoption decision and implementation and continuation behavior either directly or indirectly teachers curriculumrelated beliefs teachers classroom implementation is best explained by their curriculumrelated beliefs which include their attitudinal normative and selfefficacy beliefs toward that particular innovation 182223 perceived importance and feasibility of student learning outcomes are assumed to capture teachers attitudes toward classroom sexual education 18 also under attitude are teachers benefits and instrumentality 12 important individuals might provide normative standards for teachers decision to implement a new program 18 subjective norms are conceptualized as the attributed normative beliefs of important social referents such as students colleagues and parents 17 social support involves the affective andor instrumental support expected of social referents in the teachers environment namely the governing body colleagues teaching the same and different subjects and the parent association 23 selfefficacy refers to ones perceived ability to perform a particular behavior in this case teachers ability to implement the lll curriculum in their classrooms with confidence 24 selfefficacy is often found to be a strong predictor of the implementation of curriculum innovations especially for sex education 1225 teachers are expected to deliver more of the program with higher integrity if they have a more positive judgment of the curriculum if they think that others believe they should use the curriculum and the more they are able and skilled to work with the curriculum teachers experience with the program in turn will influence their intention to use lll again and or to use the revised lll their intention is expected to be higher if their attitude toward the program is positive if they believe other teachers also intend to use the program and if they have the skill and ability to work with the program 23 in the netherlands a study about the adoption and implementation of hivaids education among 956 dutch secondary schools showed that teachers decision making was most strongly related to highly specific adoptionrelated beliefs schoolbased sexeducation program in the netherlands 15 similarly hoekstra et al 26 investigated teachers intentions to use schoolbased health education programs on selfdevelopment and antibullying factors that influenced teachers intention to use the programs were social norms and outcome expectations concerning the prevention program as well as instrumentality interactive context the interactive context consists of environmental and organizational conditions in which teachers have to implement sexual education in their school the interactive context refers to a schools formal sexual education policy governing body support the frequency of collegial interaction about sexual instruction the extent of use of sexual education curriculum by colleagues and the students response to the curriculum teachers have to teach in collaboration with their colleagues and within the boundaries set by the policy of their school 23 curriculum implementation is thus assumed to be facilitated by a clearly stated school policy in the schoolwork plan or their own curriculum work plan 27 and by interactions of teachers with the school management and their colleagues about instructional matters 28 in case conditions of frequent collegial interaction are not present at a school perceived behavior of colleagues may operate as a descriptive norm for strengthening teachers own implementation decision 29 students reactions • external consultant • teacher training general lll specific demographics • teachers • schools • fig 1 framework for investigating the correlates of teachers lll implementationdecision process adapted from paulussen et al 17 l schutte et al to the curriculum are expected to influence the extent of implementation with positive reactions resulting in more of the program being used 30 information source the information source refers to support from external consultants namely the municipal health services and additional training for teachers to implement the innovation in the netherlands the mhs is responsible for regional health promotion and supports schools in delivering health education programs attending teacher training and receiving external consultation can facilitate adoption and implementation by enhancing teachers skills and selfefficacy with regard to sexual education 15 it has been shown that the provision of preimplementation training increases the likelihood that teachers will implement the curriculum fully and with integrity 31 previous studies found that implementation dose was associated with having received training on that specific curriculum 20 31 32 33 a study examining the extent of schoolbased tobacco prevention curricula found that trained teachers were more likely to implement and to implement more of the curriculum than untrained teachers 34 demographic variables several demographic characteristics of both teachers and their schools may influence adoption and implementation of lll such as teachers gender age years of experience with lll schools denomination and class composition other variables to complement the determinant study several constructs that are not represented in the framework were added namely what lll program components teachers use in their lessons the hours they spend on teaching the lll program and the extent of familiarity with the program prior to using it as this could influence implementation behavior 35 additionally openended questions were included to reveal teachers reasons for their intentions to continue using the current lll program or to adopt the new lll program method participants and recruitment a list from the educational publisher of teachers who have ordered the lll program since 2006 was used to recruit teachers a questionnaire was sent by post to a total of 610 teachers who are working or have worked with lll a total of 130 teachers from 110 schools completed the questionnaire a response rate of 213 twentyfive questionnaires were returned due to incorrect addresses or teachers no longer working in those schools nonresponders got a reminder by post email and eventually by telephone and were given 2 more weeks to fill out the questionnaire no official nonresponse research was conducted due to a shortage of time and schools closing for the summer holiday the participating schools were well distributed over the different regions of the netherlands half the schools had no religious background and a small school size with 58 of teachers having a class compositions of predominantly native students of the participating teachers 104 were female the mean age was 44 years years of teaching experience ranged from 1 to 42 years whereas years of experience teaching sexual education ranged from 1 to 34 and years of experience with lll ranged from 1 to 10 about 94 were teachers of biology and healthcare procedure a crosssectional study of teachers who provide sexual education at secondary vocational schools in the netherlands using or having used the lll program was conducted teachers received an envelope containing an official letter with instructions for filling out the questionnaire and a schoolbased sexeducation program in the netherlands returnenvelope in which they could send back the filled out questionnaire free of charge a 10euro gift voucher as well as the option to participate freeofcharge in the sex education workshops were offered as reward teachers were given 2 weeks to complete and send back the questionnaire anonymity and confidentiality were preserved throughout the study measures the items included in the questionnaire were based on the scales used by paulussen et al 15 and wiefferink et al 23 implementation and continuation refer to the current lll program whereas adoption refers to teachers intention to use the new lll that is currently under development dependent variables completeness or extent of use of lll was expressed as the percentage of the program being implemented for each of the 22 core learning activities in lll teachers were asked if they had completed that activity the completeness of implementation of the other four activities was not included in the analyses as these were optional in the end completeness was calculated for each teacher by adding up all the activities they completed per lesson dividing them by the total number of activities and multiplying them by 100 fidelity or quality of use was measured by asking teachers to indicate per lesson how well they followed the instructions in the teachers manual the scores per lesson were added up for each teacher and divided by the total number of lessons to produce an average continuation of current lll was measured with one item do you intend on using the current lll program next school year for your sexual education lessons teachers were asked in an openended question to explain their intention level adoption of the revised lll program was measured with one item do you intend on using the revised lll program in the coming years for your sexual education lessons adoption has been conceptualized as teachers intentions to use the innovation in various other studies 12151823 teachers were asked in an openended question to explain their intention level independent variables table i shows an overview of the independent variables their internal consistency reliabilities scales and items other variables in relation to lll teachers were asked whether they used the dvd teacher manual and student magazine in the lll lessons how familiar they were with the program before using it and how many hours they had spent on teaching the lll program extent of familiarity with the program was measured on a 4point scale from i only bought the program to i reviewed the program completely and thoroughly statistical analysis descriptive analyses were first conducted to get an overall picture of the research sample next pearsons correlation coefficient was used to reveal the correlations between the independent variables and the outcome variables backwards stepwise multiple regression analysis was then used to identify factors associated with these outcome variables all independent variables were entered at the same time for each outcome variable respectively only variables with significant bivariate associations were included in the regression equations to understand how much variation in the outcome variables can be l schutte et al results means standard deviations and intercorrelations of the study measures are shown in table ii the correlations and explained variances will be discussed per diffusion stage to identify the most important determinants and gain insight into how much of the variance in the diffusions stages can be explained by these determinants implementation of lll approximately half the teachers report having relational and sexual education somehow formally established in school more than half of participating teachers had not received a training in sex education at all whereas 38 had received a training specifically for the use of lll and 35 had received a general training in sex education the majority of teachers did not have any contact with the mhs in the past 4 years those who did have contact predominantly received a training specifically for lll from the mhs teachers generally spent 212 h teaching the lll program depending on how much time they had available and needed to complete the program furthermore teachers were familiar with lll the majority of them had reviewed the program completely and thoroughly before use few teachers only superficially reviewed the program or solely bought it completeness on average teachers implemented 641 of the 22 learning activities included in the analyses each activity was completed by over 80 of the teachers except homework activities all components of the lll program were used by over 90 of the teachers completeness correlated significantly with numerous factors namely teacher benefits instrumentality subjective norm social support and selfefficacy student response contact with the mhs following a training specifically for lll spending more hours on lll fidelity and extent of familiarity with the program teachers were more likely to use more of the program if they saw benefits in its use for themselves if they found the program practical to use if they believed that others appreciate and support their use of lll to give sexual education and if they believed they are capable of using lll they also used more of the program if they receive positive responses from students are trained by the mhs in the use of lll and if they were more familiar with the program additionally teachers who spent more teaching hours on lll and who delivered the program as prescribed use more of the program the regression analysis revealed that 432 of the variance in completeness is explained by these determinants fidelity in general teachers tend to follow the lessons as prescribed or slightly modify their lessons especially lessons on risks of unsafe sex negotiating condom use and resisting social pressure to practice unsafe sex were considerably modified compared with the rest as shown in table ii the most important correlates of fidelity are instrumentality selfefficacy training for lll years of experience and extent of familiarity with lll teachers are more likely to implement the program as prescribed if they find the program to be practical and useful in practice if they believe they are capable of using lll if they follow a training specifically for lll and if they were more familiar with the program on the other hand teachers who have worked with lll for longer years appear to modify their execution of the program and diverge from the prescription the regression analysis indicated that 25 of the variance in fidelity is explained by these determinants continuation of current lll the intention level of the group to continue using the current lll was generally high factors that appear to significantly predict and explain intention to continue using lll are schoolbased sexeducation program in the netherlands instrumentality subjective norm social support selfefficacy student response governing body support school policy completeness and hours spent on lll as shown in table ii these variables predicted 302 of the total variance in intention to continue using the current lll consequently teachers are more likely to reuse the current lll program if they find the program practical believed that others appreciate and support their use of lll to give sexual education and if they believe they are capable of using lll receiving positive responses from their students experiencing support from the school management in their implementation of lll and established school policy for sex education and taking more time for teaching lll also predict higher intentions for continuation of lll explanations for intention level were reported by teachers in the openended questions of the questionnaire teachers with higher intentions to continue using the current lll were more positive about the curriculum and believed it appealed to students other teachers are happy to use this program until something better appears on the market explanations for lower intention levels are that teachers find the material outdated especially the dvd and prefer to wait for a new version some teachers claimed the material no longer appeals to students due to being outdated whereas others found the program lacking modernday information or found the program too timeconsuming some teachers simply were no longer teaching subjects in which lll was usually provided adoption of revised lll the intention to use the revised lll was high table ii shows the predictors of intention to use the new lll program namely teacher benefits instrumentality subjective norm and social support followed by intentions to continue using the current lll version these factors explained 23 of the variance in intentions to adopt the new lll explanations for a level of intention to adopt the revised lll program were reported by teachers in the openended questions of the questionnaire teachers with higher intentions to adopt the revised lll program namely had hopes and expectations that the new program will be an improvement on the previous version lower intention levels to adopt the new lll can be explained by teachers uncertainty about the content of the new program and a preference to judge for themselves first discussion the current study has attempted to provide insight into the promoting and inhibiting factors of adoption implementation and continuation of the schoolbased sexeducation program long live love different factors influence each stage in the diffusion process and understanding factors influencing each of these stages is essential for successful implementation 30 the different stages are however dependent on one another and complementary a positive result of this study is that most of the lll program is delivered and that teachers generally do this with relative integrity on average teachers carried out approximately twothirds of the activities to be implemented from the program and delivered the lessons as prescribed or only modified them slightly this is a promising result as several studies indicate that programs are frequently modified during implementation 36 37 38 and teachers do not always implement programs according to specific guidelines 30 intentions to continue using the current lll were relatively high as was the intention to adopt the revised lll teachers curriculumrelated beliefs were found to be important for all stages of the diffusion process implementation was especially related to following a training specifically for lll greater instrumentality of the program higher selfefficacy and greater familiarity with the program teachers who followed the schoolbased sexeducation program in the netherlands guidelines of the lll program more closely also completed more of the program these findings are similar to a process evaluation study of a schoolbased adolescent sexual health intervention in rural tanzania where teachers delivered the program to primary school students with remarkable integrity and this fidelity was enhanced by a training course 39 teacher curriculumrelated beliefs and information source variables are therefore essential for implementation 4041 fidelity was however hindered in our study when teachers had more years of experience with lll several studies indicate that programs are frequently modified in the process of implementation 30 36 37 38 years of experience with a program may lead to reinvention of it by the user to accommodate the changing circumstances in schools and diversity in composition of classrooms in time 36 37 38 continued use of lll was positively related to interactive context variables and curriculumrelated beliefs furthermore the more of the curriculum the teacher completed and the more hours they spent on lll the higher the intention to continue using lll information source variables did not correlate with continued use adoption of the revised lll was predominantly related to curriculumrelated beliefs namely teacher benefits instrumentality subjective norm and social support also teachers who had a higher intention to continue using lll were also more likely to adopt the new lll information source variables and interactive context variables did not correlate with adoption selfefficacy correlated with adoption but not significantly this runs counter to the findings of other studies in which selfefficacy appeared to be a dominant predictor of teachers decision making on innovations 23 perhaps with a higher power selfefficacy would have been found to be significant one possible explanation why selfefficacy was not a dominant predictor of adoption might be based on the correlations between outcome beliefs instrumentality subjective norms and teacher benefits on the one hand and selfefficacy on the other hand this would correspond with the theory of bandura that selfefficacy predicts outcome beliefs and other cognitions and that these factors in turn predict behavior 24 another explanation might be that teachers efficacy is less dominant during the stage of adoption than during implementation 30 to date only one study is comparable to the current one the sexual health and relationships safe happy and responsible program in scotland 9 the share study examined factors that impeded or facilitated the implementation of a teacherdelivered sexeducation program for youth results showed that fidelity was aided by intensive teacher training classroom compatibility and senior management support while it was hindered by competition for curriculum time brevity of lessons and teachers limited experience and ability in use of roleplay 9 paulussen 15 found that teachers adoption and implementation behaviour of hiv programs were most strongly related to teacher beliefs as this study also suggests generally teachers will teach best in areas for which they are best prepared have effective materials and techniques and for which they receive recognition and support from school administrators and colleagues 34 results of this study show that adoption is predominantly related to individual level factors whereas implementation and continuation are also influenced by external factors namely information source variables and the interactive context respectively teacher training is an information source variable that is especially important in stimulating complete and correct use of lll it has been identified previously as a major determinant of success in the implementation of schoolbased programs 4243 preimplementation training has been found to increase the integrity with which teachers implement a curriculum 37 44 45 46 because it enhances teachers skills that are relevant to the intervention l schutte et al program 19 in the netherlands teacher training in sexual health promotion is provided by the mhs continued use of lll is largely dependent on conditions that enable structural embedding of lll namely a supportive school management and school policy formally establishing sexual education in the school also observing positive student responses reinforces implementation behavior of teachers 12 in south africa ongoing engagement and support of teachers were also found to play an important role in their ownership of an aids prevention curriculum and partially explained continued use of the program 47 support motivates teachers to implement the program and in doing so correctly they are likely to experience further success in changing their students behavior in the classroom which in turn leads to continued program use 19 school policy has also been found to be essential in contributing to a successful diffusion process 111227 the study had some limitations due to the crosssectional design of this study conducted at one moment in time it is impossible to determine whether the teacher curriculumrelated beliefs precede teachers implementation behavior or if they are a result of it no present conclusions can be drawn about causality only associations unless a longitudinal study is conducted also the same measures were used to predict implementation and continuation of the current lll as adoption of the revised lll which could limit interpretations of the adoption results past experiences with a program have however been found to predict future use 12192021 additional methodological limitations of the study are selfreports by teachers a selfselected sample limited measurements on the outcome measures of adoption and continuation with a single item and lack of assessment of student outcomes an effectiveness study was however conducted in 2001 where lll was found to have positive outcomes for students proving that it is a worthy program 14 process evaluation remains essential for examining the quality and extent of program implementation and understanding the effects of interventions 48 observation of fidelity and rapport would have further validated the results of this study with this study we hope to share lessons for successful implementation in the school setting the results reveal that each stage of the diffusion process is influenced by different kinds of factors this implies that it is necessary to consider all three stages when planning and evaluating the implementation of interventions it also implies that different strategies are needed to enhance adoption implementation and continuation of an innovation as the diffusion theory suggests 16 to enhance adoption the focus should be predominantly on teacher curriculumrelated beliefs presenting the personal benefits of using the intervention providing support for use of it and developing a practical and easytouse intervention implementation is further supported by equipping teachers with knowledge and skills through training to promote quantity and quality of implementation continuation is attained by a supportive school policy and climate of personal support for teachers 11 the implication for health education is that in addition to addressing more traditional factors such as training and teacher beliefs the program planners should also consider the climate of the organization 49 these broader contextual factors may support or inhibit teachers efforts at program implementation 19 much needed insight has been provided for the facilitating and inhibiting factors influencing the different stages of the implementation process of a schoolbased sexeducation program lll this information becomes especially relevant in the field of health promotion intervention development where the importance of implementation is being increasingly acknowledged 5 understanding the determinants of the implementation process of lll will not only benefit the extent and quality of implementation of the future updated lll program or provide inspiration for the systematic development of an implementation strategy but also provides possible explanations for effectiveness of such curricula and why these may succeed or fail when conducted in a realworld setting the schoolbased sexeducation program in the netherlands suggested recommendations may lead to improved implementation of schoolbased sexeducation programs internationally and locally contributing significantly to a betterequipped and knowledgeable youth concerning sexuality and relations long live love conflict of interest statement none declared

implementation of health education programs is often inadequately considered or not considered at all in planning developing and evaluating interventions with the focus being predominantly on the adoption stage little is known about the factors influencing the implementation and continuation stages of the diffusion process this study contributes to the understanding of factors that promote or impede each stage of the diffusion process in the school setting using the sex education program long live love lll as an example a survey integrating different diffusionrelated concepts was completed by 130 teachers results showed that teacher curriculumrelated beliefs were associated with all stages in the diffusion process although adoption of lll was predominantly related to teacher curriculumrelated beliefs implementation completeness and fidelity and continued use of lll were also enhanced by contextual factors namely teacher training and interactive context variables school policy governing body support and student response respectively the results of this study can be used to optimize the adoption implementation and continuation of schoolbased sexual health promotion programs

introduction in the contemporary world the internet is becoming an important part of peoples daily life 1 it is widely used in diverse areas of life such as education academic activities and research information exchange interpersonal communication commerce science and entertainment 23 internet becomes available and affordable at homes schools colleges libraries and internet cafes 4 recently the prevalence of internet users has increased rapidly with the current estimated worlds number of internet users in 2019 is 43 billion 5 in ethiopia internet users increased from 360000 in 2008 forming 43 of the population 5 to 16437811 internet users in 2019 forming 149 of the countrys population 6 while use of internet has enhanced the social and economic wellbeing of people 2 poor personal control over its use has become a concern 7 owing to increasing dependence on the internet for various aspects of lives 8 though debates on conceptualization and diagnosis are ongoing the scientific community agreed that problematic use of digital technologies is associated with mental health problem 9 various terms and conceptualizations are used in the literature to label problematic use of digital technologies such as internet addiction 10 compulsive computer use 11 or problematic internet use 12 though these competing definitions have various views and perspectives on the problem the common concern for both is problematic use of digital technologies harms individuals 12 for the sake of consistency problematic internet use defined as excessive use of the internet that causes disturbances or harm to the individual 12 is adopted in this study problematic internet use is a compulsive behavior related to online activities in which individuals have inability to control internet usage despite its negative consequences 2 it is reported that piu leads to marked functional impairments in several aspects of life 1314 including social isolations 1516 unfriendly behavioral patterns 1718 attention deficit hyperactivity disorder 19 physical ill health 20 and performance and work difficulties 21 piu is a global phenomenon especially among university students 22 23 24 possible reasons suggested for this are universities provide free and unlimited access to the internet students are away from parental control and without anyone monitoring what they do online and students are encouraged by faculty members to use different internet applications 16 in addition the universities settings foster a new student culture which necessitates the internet as a tool for communication information sharing and community formation 2526 with a broader education quality improvement initiative in higher institutions the government of ethiopia has deployed improved information communication technologies within the universities 27 these institutions provide free and unlimited access to the internet hence students may use the internet more so than other population groups in the country 28 whether such context contributed for piu behavior among university students in ethiopia is not assessed to date efforts to explain risk factors for piu have identified a wide range of variables 29 being male 3031 adolescent ages 1 poor academic performance and family income 32 33 34 anxiety and depression 32 and low selfesteem 34 35 36 weak family support and low parental supervision 3437 peer pressure 38 and having free and easier internet access 3339 were noted contribute for developing piu internet use variables as risk factors for piu are also established age at first internet use 35 and online activities on the internet such as social networking 40 41 42 online gaming 3133 42 43 44 frequency and length of internet use 45 online entertainments 46 and watching online pornography and online gambling 44 have been found more predictive of piu the existing literature appeared that sociodemographic background factors and online activities people engaged in the internet are predictors of piu however to the authors knowledge no research has been conducted taking into consideration all of them simultaneously in addition as most studies on risk factors have been conducted in overseas our understanding of the risk factors for piu in ethiopian context is limited hence in this study we estimated the prevalence of piu and examined sociodemographic background factors and online activity variables as potential risk factors for piu the findings may assist the prevention and management of piu among students based on the existing literature we hypothesized that the types of online activities in which students are engaged significantly predict piu when sociodemographic background factors are controlled conceptual framework we adopted problem behavior theory 47 as a conceptual framework for the study the theory is often used by researchers who investigated adolescents misbehaviors 12 problem behavior theory specifies three fundamental systems personality perceived environment and behavior the background and socialization variables affect the personality and perceived environment systems and have a distal impact on behavior the personality and perceived environment systems have proximal impact on the behavior 47 in this study similar variables were adopted the students sociodemographic background variables were grouped in one category as control variables and the online activity variables in other category as predictor variables and their hierarchical importance in predicting the piu were assessed identifying the hierarchical importance of risk factors for piu may help to design tailored intervention methods and materials study setting design and sample an institutionbased crosssectional study was conducted in bahir dar university from february to march 2018 the university has five campuses through education quality improvement initiative in higher institutions free wifi is available in all campuses and private internet cafe ´services are also available around the campuses at the time of the survey the university enrolled more than 25000 undergraduate students of which 14884 are regular program students a single population proportion formula was used to estimate the sample size with 5 precision 95 confidence and a 10 nonresponse rate there is no prior report about the estimated proportion of population with piu in ethiopian universities therefore we assumed this proportion to be 50 to increase the sample size of this study the university is stratified by campuses and departments and students in each department are stratified by years of study we selected two departments randomly from each campus and students from year i to year iv were asked to participate in the study to obtain representative sample we used multistage stratified random sampling technique thus to reduce the error that might incur during such multistage stratification we multiplied the sample size by two therefore the total sample size for the study was 844 students data obtained from 32 students were not complete hence excluded the sample size was proportionally allocated to the selected departments based on the number of regular students enrolled in the departments then systematic random sampling technique was used to select respondents from each selected department selected students were approached through their section mentors assigned by selected departments the inclusion criteria included regular class undergraduate student reside in the university dormitory used internet at least for six months and not diagnosed with anxiety or depression disorders for a year and above study procedure the study received ethical approval from ethical review committee of bahir dar university we initially developed the instrument in english and then translated into amharic to ease understanding prior to the main study a pretest was conducted on 25 regular undergraduate students to check reliability and suitability of the instrument a week before data collection we communicated selected departments with formal letter and we selected students who would participate in the study written consent of individual participants was obtained after being fully informed of the study purpose and procedures it was also made clear to the respondents that participation was voluntary and there would be no direct benefit or reward we ensured confidentiality by removing all personal identities from the questionnaire at each department the questionnaires were self administered in a free lecture hall when students had free period the investigators and two research assistants were available throughout the administration of the questionnaires to answer questions from individual students measurement online activities in our exploratory qualitative study we learned that students mainly use the internet for academic works social networking and entertainment a few informants also shared that they exercise online gaming significant association between these online activities and piu behavior was reported 48 thus in this study students were asked whether they have been engaging in the internet for these online activities responded as yesno sociodemography characteristics sociodemographic background characteristics such as age sex year field of study and academic performance were also collected these attributes are reported have important role for piu behavior 3249 selfesteem the tool was developed to measure what respondents feel about themselves and what they think others think of them it was adapted from rosenberg 50 selfesteem test questions the tool consisted of 10 items with four point responses ranging from 1 to 4 the value ranges from 10 to 40 higher value indicating higher selfesteem the internal consistency of the items in this study was good parental support the tool was adapted from zimet and colleagues 51 developed to measure perceived social support it was used to measure students perception of their parents support after they enrolled into the university the instrument has seven items with four point responses ranging from 1 to 4 in this study the items have good internal consistency the score ranges from seven to 28 higher score indicating greater parental support peer pressure this tool was developed to assess the tendency of individuals to affiliate with likeminded friends it was adapted from steinberg and monahan 52 developed to measure resistance to peer influence the instrument has seven items with four point responses ranging from 1 to 4 the score ranges from seven to 28 with higher scores indicating greater peer pressure the internal consistency of the items in this study was 10 was adopted to measure the level of internet use in this study the test has been widely adopted globally to measure the internet addiction levels of individuals 53 in assessing the degree to which respondents internet usage affected their daily routine productivity social life psychological dependence and time management 54 respondents were asked to rate items on a fivepoint likert scale item scores are added to create a final score between 20 and 100 young suggested that a score of 2049 points indicates an average online user who has complete control over their usage a score of 5079 reflects frequent problems due to internet usage and a score of 80100 indicates that the internet is causing severe problems in the users life 10 the tool was pilot tested and the internal consistency of the items was very good internet addiction test the 20item internet addiction test developed by young data analysis all returned questionnaires were checked for completeness and consistency of responses manually after cleaning raw data were entered into spss for windows versions 21 for analyses descriptive analysis was used to summarize the background characteristics of the respondents their online activities and to determine the prevalence of piu between groups comparisons were performed using the chisquare test of independence for categorical variables and one way anova for continuous variables hierarchical multivariate logistic regression models were used to assess the relationship between independent variables and outcome variable the sociodemographic background variables were entered into model i model ii added online activities variables to model i those variables with significant association to the outcome variable during bivariate analyses were entered during multivariate analyses model i was nested into model ii the overall fit of each logistic regression model was assessed by using its model chisquare and goodnessoffit indices we used model chisquare and goodnessoffit indices to determine the improvement observed in model ii relative to model i in explaining the dependent variable 185556 in addition to the indices of the overall model fit and model chisquare change in nagelkerkes r 2 was evaluated as an approximate estimate of the amount of variance in the dependent variable accounted for by the models those variables with significant association to the dependent variable during bivariate analyses were entered into the multivariate logistic regression models to test whether each individual factor had a significant relationship with piu wald statistics were used multicollinearity among independent variables was checked using tolerance and variance inflation factor values the tolerance value ranged from 0578 to 0955 and the range of vif was from 1047 to 1730 ethical consideration the study received ethical approval from ethical review committee of bahir dar university a week before data collection we communicated selected departments with formal letter and we selected students who would participate in the study written consent of individual participants was obtained after being fully informed of the study purpose and procedures it was also made clear to the participants that participation was voluntary and there would be no direct benefit or reward we ensured confidentiality by removing all personal identities from the questionnaire results background characteristics of respondents eight hundred twelve students participated in the study respondents age ranged from 18 to 27 years old with mean age of 2138 years students fields of studies were social sciences law and land administration engineering textile and agriculture majority of the respondents were 2 nd year students followed by 3 rd year and fourth year and freshman the four most important online activities of students were social networking entertainment academic works and online gaming respondents cumulative grade point average ranged from 184 to 392 with mean grade point average 305 respondents means scores on parental supervision selfesteem and peer pressure were 2007 3084 and 1295 respectively prevalence of internet addiction in this study the prevalence of sever piu was 18 and mild piu was 334 the prevalence rate including mild and severe piu regarding online activity variables use of internet for social networking was the strongest predictor of piu students using the internet for social networking were more likely to have piu than those who did not use the medium for such purpose compared to students who were not using the internet for online gaming students using the medium for online gaming were more likely to be internet addicted risk factors for internet addiction the findings also indicated that sociodemographic background variablesseniority in the university selfesteem academic performance parental support and peer pressure were significant risk factors for piu junior students were less likely to have symptoms of piu behavior than senior students with one point increase in grade point average students were 193 times less likely to have symptoms of piu increasing selfesteem and parental support were protective of piu on the other hand students with increasing peer pressure were more likely to have symptoms of piu discussion this study investigated the roles of online activities on piu behaviors in a sample of undergraduate regular program students in bahir dar university in this sample of students 334 and 18 were classified as having mild piu and severe piu respectively considering the similarity of measurement tools used the results are comparable to the rates of 371 and 29 reported among university students in jordan 57 the results in the current study are higher than the rates of 104 and 08 reported among medical college students in india 58 on the other hand the results in this study are lower than the rates of 592 and 65 reported in namibia and the rates of 703 and 47 reported in uganda university students 59 and the rates of 565 and 78 reported for malaysian undergraduate students 60 the rate of severe piu in the current study is also lower than the rate of 102 among nigerian 61 university students variations in the prevalence of piu could be due to cultural diversity among communities and the time frame when the research was conducted 3032 even so the findings in our study has demonstrated that piu is relatively higher in ethiopia despite internet penetration is much more limited than other countries 27 as we hypothesized the analyses of factors for piu revealed that students online activities significantly predicted students piu behaviors when sociodemographic background variables are controlled compared to the model that included sociodemographic background variables the inclusion of online activities improved the fit of the model predicting piu behavior the results corroborate previous studies that online activities people engaged in the internet are risk factors for internet addiction 33426263 of all the online applications examined in this study social networking was the strongest predictor of piu the finding corroborates previous research 40 41 42 reporting that engagement in online social networking is most important risk factor for piu social networking applications are used mainly to maintain and establish offline and online networks 40 that their excessive uses has a variety of negative consequences for the individual 63 the other internet online application that significantly increased the risks of piu in this study was online gaming playing online games increased the risk of piu on the internet by 1175 this finding is consistent to the existing literature 33 42 43 44 63 documenting positive association between online gaming and piu online gaming has been identified as potentially addictive as it requires large amount of commitment and time investment from the player which may in turn contribute to the development of maladaptive behaviors that reinforce gaming 64 our findings that engagements in social networking and online gaming have been increased the risk of piu on the internet highlighted that the usage of some online activities are potentially problematic as overuse can result in a variety of negative consequences 40 thus university officials and other concerned bodies may put regulatory mechanisms in place to limit the usage of potentially problematic internet applications such as social networking and online gaming this study also demonstrated that sociodemographic background variables such as selfesteem academic performance and number of years stayed in the university parental support and peer pressure significantly associated with piu the current finding revealed that higher level of selfesteem was protective of piu the result supports previous studies 34366265 reporting that lower selfesteem was related to piu consistent with previous studies 233132 the finding in this study revealed a statistically significant negative relationship between academic grade point average and piu gencer and koc 66 noted that students with poor academic performance may experience stress and may develop low selfesteem therefore they use the internet as a way to cope these stressors others 16 argued that individuals with piu often experienced lack of sleep since they stay awake during latenight hours in order to surf through various web pages the lack of sleep causes lack of concentration and loss of interest in everyday lectures resulting in reduced reading of the course material and eventually lower marks at exams our findings did not indicate whether poor academic performance or piu is precursor for the observed relationship therefore future longitudinal study is called for uncovering such causal relationships in this study the proportion of students with piu sequentially increased with increasing years spent in the university this finding is consistent with previous studies in nigeria 61 reporting the likelihood of internet addiction among university students vary with respect to year of study in that senior students were more likely to show piu symptoms than their juniors this could be attributed to the fact that parents might have limited support for senior students students who successfully accomplished universitys expectations in each year will be seniors in turns these students may have sufficed time to use internet excessively for different purposes on the other hand as seniority increases students may be expected to accomplish difficult tasks accordingly that might cause stress and students might use the internet as a method to cope the context 16 though these explanations are intuitive the current result that senior students are significantly more likely to piu behavior than their junior counterparts is informative for the university administrators to design interventions to inculcate responsive internet use behavior at the beginning of students university life this study identified inverse relationship between parental support and students piu such negative association between parental support and adolescents piu was repeatedly reported in studies conducted in different communities 336768 good social support of families and friends buffers from psychological stress in individuals 69 and stimulates an individual to improve ones perceived efficacy to lessen the negative consequences of the stressful experience 70 wu et al also suggested that lack of social support is both the cause and consequence of piu 33 hence consolidating familial ties and promoting helpful relationships might prevent piu in adolescents 71 on the other hand positive significant relationship was found between peer pressure and the risk of piu every unit increase in peer pressure score increased the odds of piu risk by16 social norm theory assumes that adolescents beliefs about the norms that are prevalent among their peers influence their behavior 72 through descriptive and injunctive peer norms 73 descriptive peer norms are adolescents perceptions about the quantity and frequency of a certain behavior among peers injunctive peer norms are beliefs about the approval of a behavior among peers 73 in this study it is not clear whether the students perceptions of their peers internet use behavior or their approval of internet use that serve as factors for piu regardless of the direction the current findings highlighted the importance of peer pressure in students piu behavior thus programs designed to reduce piu behavior may focus on students perception of normative behavior limitations this study has limitations that should be considered we assessed internet use status of students using iat the most commonly used measure of internet addiction 74 though strong internal reliability estimates of iat have been established 75 researchers have reported different factor structures 76 which suggests a potential lack of construct validity of the instrument 74 the absence of evaluation of the validity of the cutoff scores also limits its usefulness as a potential screening tool 77 some items also have been considered outdated or vague as that need to be removed or improved 78 future research may assess the concurrent validity of iat with recent tools of the 844 students 812 students fully completed the questionnaire the participants were obtained from a single government university which might not be representative of the entire university students in ethiopia data were collected using self administered structured questionnaire students may give responses which they believed to be expected or acceptable thus there might be measurement bias we also collected data only from students who participated in the study the lack of data from significant others is the limitation of the study in this study the purposes of internet use were measured categorically as yesno such binary scoring did not indicate the amount of internet use hence likely to lead to inflated prevalence of each activity future research that will consider the time spent online of each activity within a day a week will yield better evidence also students may engage in the internet for more than one purpose or some online activities may have combined purposes such combined uses may be the greatest risk for piu future research may discover such mingled proofs being informed by the exploratory qualitative results we did not assess watching online pornography and online gambling activities as potential risks for piu previous study 3146 reported that these online activities are risks for piu hence future research may incorporate these variables to understand what kinds of internet use cause the greatest risk in addition the crosssectional nature of the study limited the interpretation of the findings in terms of causeeffect relationships there are also many factors this study did not assess including environmental influences and intrapersonal influences future research may attempt to address these factors into consideration to predict risk behaviors for students piu studies on factors contributing to responsible internet use behavior are also needed to assess the assets in and outside students so that interventions and programs which can foster such behavior can be developed and implemented conclusion this study assessed the influence of online activities as risk factors for piu among undergraduate regular program students in bahir dar university the findings indicated that social networking entertainment academic works and online gaming are important activities students are doing online more than a third of the students showed symptoms of piu the hierarchical logistic regression results revealed that students engagement into online activities improved the model explaining the piu when sociodemographic background variables are controlled students who are engaging in the internet for social applications such as social networking and online gaming were more likely to show piu the findings in this study are important and timely as the internet has become the primary medium for information access in our universities thus university authorities need to be aware of the prevalence of piu and its antecedents so that interventions can be designed to prevent adverse outcomes interventions should focus on identifying students with piu creating awareness on the its negative effects counseling services to develop students self image introduce a regulatory mechanisms to limit the usage of potentially problematic internet applications and promoting responsible use of the internet at the beginning of students university life the data underlying the results are attached as supporting information

problematic internet use piu among youth has become a public health concern previous studies identified sociodemographic background risk factors for piu the effects of online activities on youth piu behavior are not well investigatedthis crosssectional study assessed the roles of online activities for piu behavior of undergraduate students in bahir dar university north west ethiopia data were collected from 812 randomly selected regular program students recruited from 10 departments respondents completed a pretested structured questionnaire hierarchical logistic regression models were used for analysesthe results indicated that social networking 755 entertainment 736 academic works 709 and online gaming 216 are the important online activities students are engaging in the internet about 33 and 18 of students showed symptoms of mild and severe piu respectively taking online activities into account improved the model explaining piu behavior of students online activities explained 46 of the variance in piu using the internet for social networking aor 7078 95 ci 391312804 and online gaming aor 2175 95 ci 14193335 were risk factors for piuthe findings revealed that more than a third of the respondents showed symptoms of piu online activities improved the model explaining piu behavior of students thus university authorities need to be aware of the prevalence of piu and introduce regulatory mechanisms to limit the usage of potentially addictive online activities and promoting responsible use of the internet

introduction lowand middleincome countries including argentina an upper middleincome country have not benefited from the decline in smokingrelated deaths that highincome countries have experience since the 1980s in 2003 argentina signed the framework convention for tobacco control an international treaty that aims to reduce the demand and supply of tobacco while this treaty has still not yet been ratified by the national congress other tobacco control policies implemented in argentina have resulted in a decline of smoking prevalence by 50 between 2004 and 2012 however since 2012 the smoking prevalence in argentina has remained unchanged today argentina has one the highest smoking rates in latin america 6 million adults currently smoke consequently smoking is directly responsible for nearly 1 million years of healthy life lost each year in argentina and is the cause of 132 of all deaths in people over the age of 35 a total of 44851 preventable deaths annually to decrease the current smoking rates in lmics and their public health impact it is imperative to develop and implement interventions that reach and engage individuals in smoking cessation treatment transgender is an umbrella term for persons whose gender identity gender expression andor behavior differs from that typically associated with the sex to which they were assigned at birth research on the prevalence of cigarette smoking among transgender individuals living in lmics is limited but existing evidence suggests that rates are higher than the general population for example a communitybased crosssectional study with 734 transgender adults living in india reported that 644 of study participants currently used a form of tobacco another example is a communitybased crosssectional study with 206 transgender and nonbinary youth the minority stress model may explain the higher prevalence of cigarette smoking among transgender individuals msm proposes that along with experiencing the everyday stressors shared by the general population there are certain stressors unique to minority groups additional research is needed to assess the prevalence and correlates of cigarette smoking among transgender individuals living in different lmics especially research that considers the diverse cultural legal clinical and economic settings of different lmics the purpose of the present study was thus twofold to assess the prevalence of current cigarette smoking among transgender women in argentina and to examine the unique associations of current cigarette smoking with demographic and psychosocial factors these results will inform future smoking cessation interventions among transgender women in argentina methods study design this study is a secondary data analysis of the transcitar baseline data transcitar is a prospective cohort study of transgender individuals living in the metropolitan area of buenos aires argentina the details of transcitar have been described elsewhere study procedures were approved and monitored by fundacion huespeds institutional review board measures the transcitar baseline survey was developed with members of the transgender community and collected information on sociodemographic characteristics eg gender identity age educational level place of birth social and income assistance housing situation and engagement in sex work the baseline survey additionally assessed participants perceived health status depressive symptoms and suicide attempts participants were asked if they currently smoke or have smoked cigarettes alcohol use disorder and substance use were assessed with the alcohol use disorder assessment of substance use included use of marijuana cocaine cocaine paste ecstasy heroin lysergic acid diethylamide crack popper and amphetamines participants were also asked about lifetime experiences of physical and sexual violence perpetrated by partners clients andor the police they were also asked about lifetime experiences of gender identity stigma perpetrated by healthcare workers and the police lastly participants were asked if they had ever been arrested study surveys were administered by transgender peer navigators analyses only participants who selfidentified as transgender women were included in the analysis this determination was due to their high representation in the transcitar study moreover previous studies conducted in argentina have identified that transgender men and nonbinary individuals have different demographic and psychosocial factors compared to transgender women for example compared to transgender women transgender men have higher educational levels and lower levels of unstable housing frequencies and percentages were calculated for categorical variables and means and standard deviations for continuous variables fishers exact test was used to compare proportions in categorical variables and crude odds ratios were reported and student ttest was used for continuous variables significant associations with current cigarette smoking were tested in an unadjusted logistic regression model followed by a logistic regression model adjusted for all significant associations statistical analyses were performed using the statistical package for the social sciences v290 sample size estimating a current cigarette smoking rate of 40 in a sample of 356 participants insures a margin of error of 5 moreover with the general guideline of 10 events per variable 356 participants is an adequate sample size for a logistic regression model accommodating 10 variables results sample a total of 393 transgender women were included in the study participants mean age was 320 years old half of the participants had not completed high school 308 were born in a country other than argentina and 689 migrated to buenos aires from other parts of the country almost half of participants reported receiving social and income assistance and unstable housing more than threequarter of participants reported participating in sex work at some point in their lives most participants perceived their health as good very good or excellent a third of participants met criteria for depression and one quarter reported a past suicide attempt a total of 199 of participants screened positive for hazardous alcohol drinking in the prior year 631 of participants reported using at least one substance 461 reported marijuana use 298 reported cocaine use and 51 reported ecstasy use half of participants reported physical violence perpetrated by partners clients andor the police and 296 reported sexual violence from those same groups moreover 237 and 298 of participants reported experiencing gender identity stigma from the police and healthcare workers respectively less than half of participants reported a prior arrest prevalence and correlates of current cigarette smoking a total of 417 of participants reported current cigarette smoking the median age of cigarette smoking initiation was 16 years had completed less education were more likely to be born in argentina more likely to have migrated to buenos aires from other parts of the country more likely to report a history of sex work more likely to perceive their health as excellent more likely to screen positive for hazardous alcohol drinking more likely to report any substance and cocaine use in the past year more likely to experience gender identity stigma from the police in the past year and more likely to being arrested in their lifetimes results of the unadjusted logistic regression model are presented in table 2 after controlling for all significant associations education level of less than high school hazardous drinking and any substance use in the last year were positively and independently associated with current cigarette smoking discussion to the best of our knowledge this is the first study to assess the prevalence of current cigarette smoking among transgender women in argentina and to examine the unique associations of current cigarette smoking with demographic and psychosocial factors in this study 417 of transgender women reported current cigarette smoking more than double the rate for cisgender women univariate analyses demonstrated that current cigarette smoking was significantly associated with education external and internal migration sex work alcohol and drug use experiencing gender identity stigma from the police and being arrested however in the final multivariable model only education hazardous drinking and any drug use remained associated with higher odds of current cigarette smoking frontiers in public health 04 frontiersinorg in 2021 wolfordclevenger et al conducted a systematic review of correlates of tobacco and nicotine use among transgender and gender diverse people guided by the msm findings from our study support prior research demonstrating that police discrimination indicators of poverty and indicators of stress are associated with an increased likelihood of cigarette use however our findings challenge prior research by indicating that engagement in sex work was not associated with cigarette use importantly our findings shed light on new identityrelated factors of the msm that are correlated to current cigarette smoking specifically our study findings show that external migration was associated with decreased likelihood of cigarette use among transgender individuals external migration due to gender identitybased stigma and oppression experienced in their home country has been reported one possible explanation that external migration is associated with a decreased likelihood of cigarette use is that in this study the majority of participants who emigrated to argentina were born in countries with lower prevalence of cigarette use compared to argentina moreover external migration has been reported as a protective factor against smoking in other countries in the general population interestingly internal migration was associated with increased likelihood of cigarette use one possible explanation for this phenomenon is that in this study the majority of participants who migrated to buenos aires came from the northwest region of argentina a region that produces tobacco more research is needed to understand the mechanisms underpinning these correlates while assessing the correlates of current cigarette smoking among transgender women in argentina it is important to note that argentina has been praised for having one of the worlds most progressive transgender rights laws in 2012 argentina passed the ley de identidad de género which allows transgender individuals to be treated according to their gender identity and have their personal documents registered with the appropriate name and gender under this comprehensive law modifying personal data is free and does not require a lawyer moreover the ley de identidad de género mandates gender affirming treatments and procedures to be included in the programa médico obligatorio which guarantees medical coverage throughout the public and private health systems despite the existence of this law 29 of participants regardless of smoking status reported experiencing gender identity stigma from healthcare workers in the past recently transgender activists passed the cupo laboral travesti trans a law reserving 1 of argentinas public sector jobs for transgender individuals the cupo laboral travesti trans aims to reduce the high levels of social vulnerability faced by transgender individuals in argentina these laws if correctly implemented have the potential to influence cigarette smoking indirectly by addressing the social determinants of health among transgender individuals the transcitar study has the potential to evaluate the longitudinal impact of these comprehensive laws on the social determinants of health and consequently the health and wellbeing of transgender individuals strengths and limitations the study has several methodological limitations first this study purposely focused on transgender women given their high representation in the transcitar study future studies with appropriate representation of transgender men and nonbinary individuals should assess the prevalence and correlates of current cigarette smoking among these communities second as there are no official registries of transgender women in argentina the recruitment strategy was convenience sampling and thus findings may not be representative of transgender women in argentina third the study was solely conducted in buenos aires limiting participation by transgender individuals from other parts of argentina fourth the study did not assess the number of cigarettes smoked per day nor type of cigarettes limiting the ability to examine whether different levels of cigarette smoking were related to different demographic and psychosocial factors fifth data are selfreported and there is a possibility that participants felt compelled to offer socially desirable responses lastly as a crosssectional investigation of the transcitar baseline data it was not possible to determine the causal nature of any of the observed associations despite the methodological limitations this study has several strengths first this study is among a small but growing number of reports on the prevalence and correlates of current cigarette smoking among transgender individuals in lmics this information is urgently needed to develop and implement interventions to decrease the current smoking rates in lmics second this study builds upon an established history of research with the transgender community third this work is grounded in principles of communitybased participatory research cbpr is a partnership approach to research that involves community members organizational representatives and researchers across all phases of research study results were reviewed and discussed with members of the transgender community lastly this study benefited from an adequate sample size to assess the prevalence of current cigarette smoking among transgender women in argentina and to examine the unique associations of current cigarette smoking with demographic and psychosocial factors conclusion among transgender women in argentina current cigarette smoking was more than double the rate for cisgender women current cigarette smoking was associated with education hazardous drinking and any drug use these results will inform future smoking cessation interventions among transgender women in argentina data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement the studies involving humans were approved by the fundacion huespeds institutional review board the studies were conducted in accordance with the local legislation and institutional requirements the participants provided their written informed consent to participate in this study 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

objective to assess the prevalence of current cigarette smoking among transgender women in argentina and to examine the unique associations of current cigarette smoking with demographic and psychosocial factors methods this study is a secondary data analysis of the transcitar a prospective cohort study of transgender individuals living in buenos aires argentinabaseline data the baseline survey collected information on sociodemographic characteristics perceived health status depressive symptoms suicide attempts current cigarette smoking alcohol use disorder and substance use participants were also asked about lifetime experiences of physical and sexual violence perpetrated by partners clients andor the police and experiences of gender identity stigma in the past year from healthcare workers and the police lastly participants were asked if they had ever been arrested fishers exact test was used to compare proportions in categorical variables and student ttest was used for continuous variables significant associations with current cigarette smoking were tested in a logistic regression model adjusted for all significant associations results a total of 417 of participants n 393 reported current cigarette smoking compared to their nonsmoking counterparts participants who reported current cigarette smoking 1 had completed less education 2 were more likely to be born in argentina 3 more likely to had migrated to buenos aires from other parts of the country 4 more likely to report a history of sex work 5 more likely to perceive their health as excellent 6 more likely to screen positive for hazardous alcohol drinking 7 more likely to report any substance and cocaine use in the past year 8 more likely to experience gender identity stigma from the police in the past year and 9 more likely to being arrested in their lifetime all ps 005 after controlling for all significant associations education level of less than high school aor 179 95 ci 102212 hazardous drinking aor 265 95 ci 130537 and any substance use in the last year aor 214 95 ci 116394 were positively and independently associated with current cigarette smoking conclusion among transgender women in argentina current cigarette smoking was more than double the rate for cisgender women current cigarette smoking

introduction a large body of research shows that social isolation and loneliness have detrimental health consequences 1 2 3 4 for example social isolation has been shown to be associated with an increased risk of coronary heart disease and stroke 5 dementia 6 and mortality 2 similarly loneliness is associated with a wide range of physical and mental health outcomes such as physiological measures like increased blood pressure and depressed immune system 78 reduced cognitive function 9 and mortality 3 both social isolation and loneliness are related to increased health care use 10 11 12 13 that social isolation and loneliness are serious concerns is increasingly being recognized by policy makers for example in the united kingdom the campaign to end loneliness is tackling loneliness by providing service organizations with information on how to approach the issue 14 social isolation and loneliness are often discussed alongside each other however they are conceptually different social isolation is typically defined in terms of the objective availability of social contacts or frequency of contact with social network members 1 in essence social isolation relates to whether a person is alone or part of a social network 15 typically composed of family or friends but also the broader community environment through engagement in social activities 16 17 18 19 20 in contrast loneliness which is sometimes referred to as perceived social isolation 8 refers to the perception that intimate and social needs are not being met 121 it can arise from the perceived discrepancy between the quantity of social relationships that a person has versus what they want 22 thus a person can be socially isolated but not lonely and vice versa in order to mitigate health risks it has been recommended that both concepts should be considered in research 3 although both social isolation and loneliness can be conceptualized as lying on a continuum cutoffs are commonly used to identify individuals who are socially isolated or lonely 17 23 24 25 26 27 28 a cutoff approach is essential to determine the prevalence of social isolation and loneliness as well as from an intervention perspective to identify individuals who are socially isolated or lonely previous research shows that a substantial proportion of adults are socially isolated or lonely anywhere from less than 10 to 50 of middleaged and older adults have been identified as being socially isolated or lonely 2324 29 30 31 32 prevalence estimates vary widely as there are no standard measurement tools particularly to assess social isolation and no standard cutoffs to identify individuals who are socially isolated or lonely given their high prevalence estimates and welldocumented negative physical and mental health consequences 1 2 3 4 5 6 7 8 9 preventing social isolation and loneliness and providing supports to those who are socially isolated or lonely is critical a first step in this direction is to identify the factors that place individuals at risk of social isolation and loneliness the present study aims to address this issue by focusing on both personal and geographic risk factors in a national sample of middleaged and older canadians in doing so this study can help to identify individuals who might benefit from clinical interventions designed to reduce social isolation or loneliness 33 34 35 36 it may also help policy makers identify geographic areas most in need of resources to support at risk individuals factors associated with social isolation and loneliness numerous studies have focused on identifying factors that are related to social isolation and loneliness personal characteristics that increase the likelihood of being socially isolated or lonely include very old age being single or widowed living alone having less education and having low income or financial strains 37 38 39 there is less consistency in results for sex differences women have been found to be more likely to be lonely than men in some studies although this effect tends to disappear when other factors are controlled for in the analyses 3738 for example older women are more likely to be widowed and live alone than older men both factors linked to loneliness yet other studies show that men are more likely to be lonely and socially isolated than women 2740 studies also suggest that the factors that predict social isolation and loneliness differ for women and men 2741 for example mobility problems have been shown to predict loneliness for women but not men 41 these findings highlight the importance of considering possible sex andor gender differences in analyses as they may suggest different targets for interventions for men versus women although social isolation and loneliness have negative health consequences 1 2 3 4 5 6 7 8 9 the relationship is likely reciprocal in nature numerous studies have examined whether healthrelated factors are also possible risk factors for social isolation or loneliness 40 41 42 43 44 for example using data collected at twoyear intervals over an 8year time span barlow et al 42 demonstrated that whereas individuals with many chronic conditions at baseline showed an increase in loneliness over time the level of loneliness remained low over the 8 years for individuals with few chronic conditions these health effects may be due to reduced social contacts for example mobility problems may make visiting family or friends difficult or impossible thus leading to social isolation or loneliness although many studies have examined personal characteristics in relation to social isolation and loneliness there is a relative paucity of research on whether geographic factors are related to social isolation or loneliness one to date underresearched issue in this respect is whether there are urbanrural differences in social isolation and loneliness one the one hand one might hypothesize that rural areas might be associated with a greater likelihood of social isolation and loneliness given sparsely populated regions long distances and lacking infrastructure particularly lack of transportation options which can interfere with social participation 4546 moreover migration can result in families being separated 4748 which may also lead to social isolation or loneliness on the other hand rural residents often have strong community connections 4950 which may be advantageous in terms of reducing the likelihood of social isolation and loneliness indeed research findings regarding urbanrural differences in social isolation and loneliness have been inconsistent whereas some studies indicate that rates of loneliness and social isolation are higher in urban relative to more rural areas 285152 others show greater loneliness in rural areas in bivariate analyses 5354 or no urbanrural differences when controlling for other factors 2654 moreover studies show that the factors related to loneliness or social isolation are different for people living in rural versus urban areas 2855 a recent study that focused on loneliness in one metropolitan area further showed that the likelihood of loneliness was higher in areas further away from the city centre relative to the city centre 56 suggesting that there are differences even within urban centres overall the inconsistency in findings suggests the need for further research on possible urbanrural differences in social isolation and loneliness including the need to examine different types of urban areas the sociodemographic characteristics of the place where people live also warrant examining that such characteristics particularly socioeconomic disparities impact health has long been known and has been researched extensively 57 however there is a paucity of research on whether such factors relate to social isolation and loneliness specifically one study that examined this issue showed that older individuals in financially more deprived neighborhoods in england were lonelier that their counterparts in financially better off neighborhoods 58 in sum although previous research has examined risk factors of social isolation and loneliness studies have predominantly focused on personal characteristics the present study contributes to the existing literature by examining not only personal characteristics but also the role of geographic factors including urbanrural differences and arealevel sociodemographic differences in social isolation and loneliness the use of a national canadian dataset allowed us to capture a wide variation in sociodemographic characteristics across different areas examining geographic factors is useful as it may identify whether socially isolated or lonely individuals cluster into certain geographic areas as such it can help policy makers and services providers target resources at specific areas 14 such as enhancing opportunities for social participation transportation or adapting the built environment to foster social participation thus the main objective of the present study was to examine the relationship between personal and geographic factors and social isolation and loneliness among middleaged and older canadians moreover we examined whether similar risk factors would emerge for women versus men consistent with previous research that showed that the predictors of loneliness differed for women and men 2741 methods data sources this study involved a crosssectional analysis of baseline data from the canadian longitudinal study on aging 5960 baseline data were used as the clsa has only recently been launched and followup data were at the time the present study was conducted not yet available clsa consists of two cohorts the comprehensive cohort involves participants who were randomly selected within agesex strata from among individuals residing within 25 km of a data collection site in ten sites across canada these participants were interviewed in their own homes with computerassisted interview instruments they also came to data collection sites for additional computerassisted interviews and comprehensive assessments the tracking cohort consists of a randomly selected sample from the 10 canadian provinces that completed computerassisted telephone interviews participant exclusion criteria were could not communicate in one of the two national languages english or french cognitive impairment at time of contact resident of the three territories fulltime member of the canadian armed forces resident in a longterm care institution and living on federal first nations reserves or other first nations settlements clsa participants provided written consent before participating in the study public access census data from 2016 were used to derive geographic variables clsa questionnaire data were linked to census data via the first three digits of participants postal code postal codes are used by canada post for the purpose of sorting and delivering mail with fsas representing geographic areas as of 2011 there were 1638 fsas in canada 61 the present study received ethics approval from the university of manitobas health research ethics board study sample a total of 51338 participants living in 1558 fsas participated in the clsa baseline of these fsas with less than 10 participants were excluded from analyses as estimates of social isolation and loneliness are less meaningful for these fsas our final sample included 48330 participants aged 45 to 85 from 977 fsas because of missing values on some variables the unweighted sample size in the analyses for social isolation was 47752 for loneliness the final sample size was 47818 a comparison of fsas that were included in the analyses to those excluded indicated that they were comparable clsa participants were also similar for example 51 of clsa participants in the included fsas were female and 56 had a household income of less than 20000 compared to 502 and 63 respectively in the excluded fsas measures social isolation social isolation has been defined in different ways in previous literature 1 conceptually our definition was guided by the convoy model of social relationships according to which individuals are surrounded by a series of social network ties that range from closest to less close 62 spouses tend to play a key role in peoples social networks followed by children siblings and friends consistent with the finding that a variety of social network members play an important role in peoples lives 1920 contact with these network members has been used to define social isolation in previous research 16 17 18 a social isolation index was derived based on five sets of questions 1 marital status 2 living arrangements 3 when participants last got together with each of the following social network members living outside of their household children siblings close friends and neighbors 4 retirement status and social participation in eight activities in the past 12 months the social participation questions were recoded such that response categories 4 and 5 were coded as 0 and response categories 13 were coded as 1 the recoded variables were then summed to create a new score ranging from 08 similar to previous research 16 17 18 we allocated one point when each of the following conditions applied 1 living alone and not married or in a common law relationship 2 got together with friends or neighbours within the past 6 months or less frequently or reported having no friends or neighbors 3 got together with relativessiblings within the past 6 months or less frequently or reported having no relatives or siblings 4 got together with children within the past 6 months or less frequently or had no children a fifth criterion was that one point was allocated if participants were retired and had little social participation this resulted in a social isolation index ranging from 05 with higher scores reflecting greater social isolation as we were interested in identifying socially isolated groups of adults and their associated characteristics we subsequently dichotomized the social isolation index there are no established cutoffs in the literature to define individuals who are socially isolated for the present purposes we classified individuals with scores 35 on the index as socially isolated and those with scores 02 as not socially isolated this cutoff was chosen as it classifies people with at least half of the criteria that make up the social isolation index as being socially isolated as contact with social network members is only measured in terms of inperson contact in the clsa the cutoff in part also ensures that individuals who may have had contact with some social network members via other means only are not identified as being socially isolated for example individuals with no family living close enough to allow frequent direct contact would not be considered socially isolated unless they also met one other criterion sensitivity analyses were also conducted with a 25 cutoff given that clsa contains two cohorts we compared the percent socially isolated in each cohort the percentage of participants identified as socially isolated using a 3 cutoff on our social isolation index was relatively similar in the tracking cohort compared to the comprehensive cohort loneliness as the clsa baseline questionnaire does not contain a loneliness scale a singleitem loneliness question that is part of the cesd depression scale 63 was used questions focus on the past week and participant were asked how often did you feel lonely and the remaining categories as not lonely the percent of participants classified as being lonely was similar in the tracking versus comprehensive cohort personal factors personal factors included age sex education household income functional status and chronic conditions age was categorized into four categories sex was coded as 0 women and 1 men education was dichotomized as 0 secondary school or less and 1 at least some postsecondary education household income was included as an overall measure of the financial resources available to an individual it was measured by asking participants to give the best estimate of the total household income received by all household members from all sources before taxes and deductions in the past 12 months as a considerable number of participants did not answer the question a missing category was also included in order not to lose these individuals from analyses this also allowed us to determine if individuals who did not answer the question differed systematically from those who did functional status was assessed using the older americans resources and services multidimensional functional assessment questionnaire 64 the scale includes seven questions related to activities of daily living and seven questions related to instrumental activities of daily living for each question participants responded whether they can complete the task without help with some help or are completely unable to perform it the items can be used to categorize individuals into no functional impairment mild impairment moderate impairment severe impairment and total impairment as most participants had no functional impairment responses were dichotomized 0 no functional impairment and 1 at least some functional impairment chronic conditions were measured with a list of 33 conditions such as osteoarthritis respiratory conditions and cardiaccardiovascular conditions with participants asked if a doctor had diagnosed them with the condition an index was created by summing affirmative responses geographic factors a ruralurban variable is available in the clsa data the variable was added by clsa based on a statistics canada definition and postal code conversion file 6566 urban core refers to census metropolitan areas with a population of at least 100000 or census agglomerations with a core population of at least 10000 secondary core refers to a population center within a cma with at least 10000 residents that was the core of a ca but has now been merged with an adjacent cma urban and secondary cores were combined in the present study urban fringe refers to population centers within a cma or ca that are not contiguous with the core or secondary core with fewer than 10000 residents urban population centres outside cma and ca are defined as settlements outside cma and ca with a population of at least 1000 and a population density of 400 persons or more per square kilometer rural is defined as areas within cma or ca not classified as core or fringe or areas not defined as population centres a not defined category was also included for which no urbanrural information was available although the ruralurban variable was considered a geographic variable in this study it should be noted that it was not measured at the fsalevel unlike the other geographic variables fsas are not necessarily aligned with the statistics canada ruralurban definition this means that some fsas contain both rural and urban areas as defined by statistics canada in the analyses ruralurban was treated as an individuallevel variable other geographicbased variables were derived from 2016 public access census data for each fsa we selected census variables that were similar to individual predictors of social isolation and loneliness including percent of women percent of the population aged 65 and percent of the population living alone census data further contain the percent of the population aged 65 or older with low income based on the aftertax lowincome cutoffs statistics canada defines the licoat as an aftertax income threshold below which a family is expected to spend a larger share of its income on food shelter and clothing than the average family 67 the percent of the population whose first language was not one of the two official languages was also included as a way to assess the ethnic diversity of areas analyses data were analyzed using multilevel analyses given the nested nature of the data using sas version 94 given that social isolation and loneliness were defined as dichotomous outcomes logistic regressions were conducted using proc glimmix a series of analyses were conducted for the two outcome variables first in model 1 variables measured at the individuallevel were entered into the regression model this included personal characteristics as well as the ruralurban variable which as noted above was not available at the fsa level second in model 2 variables measured at the fsalevel were added this approach was taken for both the full sample and subsequently for women and men respectively for loneliness all variables were included in the analyses for social isolation variables that were included in its definition were excluded in the analyses as was the fsalevel variable percent living alone given that it was strongly correlated with living alone effects were evaluated for significance at p 01 results sample characteristics are displayed in table 1 table 2 shows descriptive statistics for fsalevel measures there was considerable variation across the 977 fsas for example the percent individuals aged 65 ranged from 4 to 402 the prevalence of social isolation and loneliness by personal characteristics is shown in table 3 overall the prevalence of social isolation was 51 but varied widely across personal characteristics correlations between geographically defined measures and social isolation and loneliness are shown in table 4 weak but statistically significant correlations emerged between all measures and social isolation except for the percent women for loneliness weak correlations emerged between the percent 65 with low income and the percent living alone results of the regression models for social isolation are provided in table 5 in the final model for the total sample being 4554 years old was associated with reduced odds of social isolation relative to being 7585 years old having less than postsecondary education and a household income higher than 20000 was also associated with reduced odds of social isolation conversely being male having functional impairment and more chronic conditions was associated with increased odds of being socially isolated moreover the higher the percent 65 and percent 65 with low income in an fsa the higher the odds of being socially isolated noteworthy is that whereas living in an urban core was related to increased odds of social isolation in model 1 without fsalevel variables for both the total sample and women this was no longer the case when fsalevel variables were added in model 2 in model 2 a higher percent 65 with low income and higher percent 65 in general were associated with increased odds of social isolation results were somewhat different for women versus men among women older age higher education low income more chronic conditions and a higher percent 65 with low income were all significantly associated with increased odds of social isolation in model 2 among men only low income functional impairment and a higher percent 65 with low income were associated with higher odds of social isolation results were also similar in the sensitivity analyses for which we defined social isolation in terms of a 2 cutoff on our social isolation index again all personal characteristics were significantly associated with social isolation among the geographic factors only the percent 65 and the percent 65 with low income were associated with social isolation for loneliness significant associations only emerged for personal characteristics moreover results were similar for women and men both younger women and men reported being more lonely than their oldest counterparts not being married or in a commonlaw relationship living alone having a household income of less than 20000 functional impairment and more chronic conditions all increased the odds of being lonely discussion several key findings emerged in the present study overall using our definitions the prevalence of social isolation and loneliness was 51 and 102 respectively but there was substantial variation across personal characteristics in prevalence rates being older male having a low income functional impairment and more chronic conditions were all associated with increased odds of being socially isolated as was somewhat counterintuitively a higher education level the finding for education is consistent with a swedish study that showed that individuals with higher education compared to those with less education had less dense local family networks which may be due to migration patterns 47 a similar issue may be at play in the present study in that more highly educated younger individuals as compared to those with less education may be more likely to move for job opportunities or conversely more highly educated older individuals may be more likely to move to retirement communities both scenarios would result in individuals having less direct contact with family members for loneliness being younger being male living alone and having a low education level low income functional impairment and more chronic conditions increased the odds of being lonely consistent with previous research 3738 in addition marital status emerged as a major factor related to loneliness while all nonpartnered states emerged as a risk factor for loneliness this was particularly the case for widowed men for whom the odds of being lonely were more than four times higher than their marriedcommonlaw counterparts similar results for widowed men have been found in previous research 41 these findings underscore the profound impact that losing a partner has 68 for men the impact of losing a spouse may be compounded by the relative lack of a diverse social network in the present study men were more likely to be socially isolated than women indicative of a smaller social network with whom they have frequent contact which suggests that they may not have other network ties that could at least in part compensate for the loss of a partner it is noteworthy that although the factors associated with social isolation and loneliness were similar for women and men there were two exceptions both related to age effects whereas younger women aged 4554 were less likely to be socially isolated than their older counterparts they were more likely to be lonely for men social isolation did not differ across age groups yet younger men were more likely to be lonely than older men on the one hand these findings highlight that social isolation is not synonymous with loneliness consistent with what has been argued in the literature 11521 and that one can be lonely regardless of the frequency of contact with social network members in this respect a recent study with young adults and middleaged adults aged shows that social network size frequency of contact with network members and social participation was not consistently related to loneliness 69 on the other hand our finding that older adults were less likely to be lonely than younger individuals may suggest that older adults may adapt to a shrinking social network perhaps by adjusting their expectations of how frequent contact with social network members should be alternatively as predicted by socioemotional selectivity theory older adults may intentionally prune peripheral social network members in order to focus on close emotionally meaningful relationships as opposed to maintaining contacts that are less emotionally satisfying 70 in terms of geographic factors of interest was whether an urbanrural difference would emerge for social isolation and loneliness previous research as to whether individuals living in rural areas are more socially isolated and lonely than their counterparts in urban areas or vice versa has led to inconsistent findings 51 52 53 54 in the present study living in a large urban center relative to a rural area was associated with an increased likelihood of social isolation for the total sample and for women however this effect was no longer significant when fsalevel factors were included in the analyses this may suggest that this effect is either weak or related to other factors that are correlated with urban centers in particular the percent 65 year old residents with low income in other words it may be that living in a city was related to social isolation because cities are more likely than rural areas to have socioeconomically deprived neighborhoods this interpretation is consistent with previous research that shows that social exclusion is clustered into socioeconomically deprived neighborhoods 58 and well as the literature on the negative health consequences associated with living in poor neighborhoods 57 from an intervention perspective the findings suggest that in order to reduce social isolation support and resources could to some extent be targeted at certain areas particularly city neighborhoods with a high proportion of older adults who live on low income the concept of agefriendly communities 71 which has been gaining increasing attention in the last decade on the part of policy makers is relevant in this respect an agefriendly community or city provides supports in the physical and social environment such as aspects of the housing environment public spaces and opportunities for social participation 71 making communities more agefriendly may enhance social connectivity 72 and may provide one approach to reducing social isolation the finding that geographic variables were not associated with loneliness again supports the view that loneliness is conceptually different from social isolation reflective of the perception of whether ones contact with other people is sufficient the present findings suggest that these perceptions are dependent on personal characteristics but not where people live loneliness may also result from social isolation and may function as a mediator or moderator between social isolation and health outcomes examining these relationships was beyond the scope of the present paper but should be examined in future research the present study is not without limitations although a wide range of measures regarding social networks are available in clsa contact with social network members is measured in clsa only in terms of inperson contact other modes of contact with friends and families are not captured there are also no measures in clsa that assess the quality of relationships as such it is possible that a person with a very a small social network may in fact have sufficient emotional support whereas an individual with a large social network may lack support moreover the data are crosssectional in nature and as such it cannot be inferred that the personal and geographic factors examined here predict social isolation and loneliness for example it is equally plausible that social isolation and loneliness are risk factors for developing health problems 1 2 3 4 5 6 7 8 9 and individuals with certain characteristics may selfselect into certain geographic areas the data may also exclude the most socially isolated and lonely individuals as they may not participate in research our geographic unit of analyses were fsas although they are meaningful in terms of defining areas of residence some fsas are large examining sociodemographic characteristics at a smaller geographic scale could provide a more detailed assessment of geographic correlates of social isolation and loneliness lastly urban and rural are varyingly defined in canada 73 using a different definition might have yielded different results for example differentiating between degrees of rurality may be useful in future research given the very remote areas that exist in canada different results might also have been obtained if we had been able to use a ruralurban definition at the fsa level in the analyses consistent with the other geographic variables in this study in conclusion the present study adds to the literature by examining not only personal factors associated with social isolation and loneliness but also geographic factors a strength of the study is that it was based on a national sample of canadians aged 45 to 85 the findings may assist researchers and policy makers in identifying individuals at risk of social isolation and loneliness they also provide a foundation for further researcher once followup data become available such as a more in depth analysis of the role of lowincome neighborhoods in social isolation and loneliness an examination of the relationship between social isolation and loneliness and physical and mental health problems and the potential mediational or moderating role of loneliness in the relationship between social isolation and health outcomes the data used in this study come from the canadian longitudinal study on aging all interested researchers may apply for access to these data through clsa subject to review by the data access committee ethics approval and signing of a data sharing agreement data are provided only once a data sharing agreement is in place between mcmaster university and the researchers institution for more information about data access see conclusion

a large body of research shows that social isolation and loneliness have detrimental health consequences identifying individuals at risk of social isolation or loneliness is therefore important the objective of this study was to examine personal eg sex income and geographic ruralurban and sociodemographic factors and their association with social isolation and loneliness in a national sample of canadians aged 45 to 85 yearsthe study involved crosssectional analyses of baseline data from the canadian longitudinal study on aging that were linked to 2016 census data at the forward sortation area fsa level multilevel logistic regression analyses were conducted to examine the association between personal factors and geographic factors and social isolation and loneliness for the total sample and women and men respectivelythe prevalence of social isolation and loneliness was 51 and 102 respectively but varied substantially across personal characteristics personal characteristics age sex education income functional impairment chronic diseases were significantly related to both social isolation and loneliness although some differences emerged in the direction of the relationships for the two measures associations also differed somewhat for women versus men associations between some geographic factors emerged for social isolation but not loneliness living in an urban core was related to increased odds of social isolation an effect that was no longer significant when fsalevel factors were controlled for fsas with a higher percentage of 65 year old residents with low income were consistently associated with higher odds of social isolation

acknowledgement i would like to express my deepest appreciation to everybody who inspired me helped me and contributed directly or indirectly to accomplishing this thesis first i would like to thank my supervisors dr omar nouali and pr faiçal azouaou for their guidance advice and support i am thankful to the members of my thesis committee for accepting to read evaluate and comment on this thesis résumé le développement récent dinternet et technologie a fait un grand progrès en matière des outils qui facilitent la collection des données sur les réseaux sociaux ouvrant ainsi de nouvelles opportunités pour lanalyse de ces derniers cette analyse sinteresse à létude des relations sociales elle permet de dévoiler les propiétés caractérisant les structures sociales une des propiétés importantes des réseaux sociaux est la présence des groupes denses applelés communautés la nature dynamique des interactions au sein des réseaux sociaux représente un grand challenge lors de la détection des communautés les contributions dans cette thèse sarticulent autour de deux axes le premier axe aborde le problème de détéction de communautés dynamiques et recouvrantes nous proposons un framework appelé olcpm basé sur les méthode de percollation de cliques et de propagation de lables olcpm permet de découvrir les communautés recouvrantes et il est capable de traiter des réseaux dynamiques à granularité très fine le deuxième axe aborde le problème de détéction de commuanutés à plusieurs échelles temporelles nous proposons une première méthode pour lanalyse des communautés à multiples échelles temporelles le réseau dynamique est étudié à différentes échelles temporelles les communautés stables sur une période de temps sont détéctées pour chaque granularité les deux contributions sont validées et testées sur des réseaux synthétiques et réels watts and strogatz 1998 barabási and bonabeau 2003 list of figures powerlaw distribution of node linkages example of the dendrogram or hierarchical tree the circles represent nodes in the graph the horizontal cut in red corresponds to a partition of the graph into three main communities 32 calculation process for louvain algorithm blondel et al 2008 33 resolution limit of modularity optimization fortunato and barthelemy 2007 alltoall interslice coupling appropriate for categorical slices reprinted from mucha et al 2010 grows with node 5 when adding edge when the edge is added the communities 1 2 3 4 and 4 5 6 grow with node 7 and then merged the resulting community takes the identity of the one that contains more nodes by adding edge a new community 3 5 6 7 is created 83 43 examples of adding an edge with two internal endpoints the communities 1 2 3 4 and 2 5 6 7 grow with the nodes of adjacent kcliques 1 3 5 2 3 5 formed when adding the edge and then merged missing points correspond to computation time above 1000s temporal scales correspond to window sizes and are divided by 2 at every level from 167 681 200s to 10132 189s our and ourmp corresponds to our method using or not multiprocessing 121 rationale new references added to the survey in rossetti and cazabet 2018 are marked with list of tables 33 corebased methods and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with 34 updating methods using global optimization and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with 35 updating methods using a set of rules and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with methods falling in the category of icd by multiobjective optimization and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with 37 methods falling in the category of icd by network smoothing and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with 38 methods in the category of fixed memberships fixed properties and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with thesis context the study of complex networks referred to as network science has become a highly active field in the last few decades with a broad variety of applications the latter ranges from technological systems like the internet and world wide web biological systems such as the nervous system or protein interactions to transportation infrastructures such as roadways airlines power grids waterways pipelines and others one of the most prominent applications in the field falls within the domain of social network analysis the study of social networks has a deep root in sociology featuring pioneering work on sociometry by moreno in 1934 moreno 1934 social networks have seen spectacular growth in recent years mainly due to the advent of the information age and the internet which have made the collection of enormous amounts of social data possible the latter paved the way for promising perspectives on the study of social networks the aim of social network analysis is to analyze relationship patterns among social entities and to understand the general properties and features of the whole network the graph theory is at the heart of the research conducted in this field a graph consists of a set of nodes representing social actors within the network and a set of edges between pairs of nodes representing interactions between those actors the graph theory has been successfully drawn upon to identify and characterize hidden patterns often nontrivial in social networks over the past years researchers have studied different structural properties of social networks among the most important and revolutionary findings are the small world property by watts and strogatz 1998 the scale free by barabási and albert 1999 and the community structure by girvan and newman 2002 the small world property means that the average distance between any pairs of nodes in the network is small due to the existence of few longdistance connections six degrees of separation concept by milgram 1967 the scale free property means that nodes in the network have heterogeneous link connections while a few nodes have high degrees most nodes have a very low degree community structures are believed to be one of the most prominent features of social networks a community is characterized by the existence of a collection of nodes where nodes within a collection tend to interact more with each other than with the rest of the network radicchi et al 2004 for instance in social networks individuals within the same community often share similar properties such as interests social ties location occupation etc the ability to detect such community structures could be of great importance in a number of research areas such as recommender systems boratto et al 2009 deng et al 2014 email communication moradi et al 2012 epidemiology kitchovitch and lió 2011 criminology ferrara et al 2014 marketing and advertising mckenziemohr andsmith 1999 fenn et al 2009 etc in collaboration networks where nodes represent researchers and edges represent coauthorship links between researchers community detection can discover groups of researchers working in the same area and may thus help to find researchers with expertise in a given area in online networking sites like facebook an example of a network representing acquaintances for a particular user the community detection can find users social circles such as family work colleagues or college friends rendering it useful for recommender systems in facebook statement of the problem the present thesis falls within the domain of social network analysis therefore special attention is paid to the analysis of community structures in social networks this field offers interesting yet challenging problems this thesis addresses the essential issues facing community detection in particular in the context of social networks we aim to investigate the following issues overlapping community detection early work focused on the simplest form of the community detection problem which is the partitioning of the networks into disjoint communities where each node belongs to a unique community however a more realistic form seems to be overlapping community structure in realworld networks notably in social networks communities are not always disjoint from each other in fact nodes in social networks tend to be part of several groups at once for instance individuals often belong to familial and professional circles scientists collaborate with several research groups etc such shared nodes called overlapping nodes play a crucial role in the network it servers as a bridge between different groups the application of disjoint community detection methods on such networks may lead to misleading characterization of their overlapping community structure this problem prompts the urgent need to consider the overlap feature for discovering community structures in social networks dynamic community detection social networks are dynamic by nature their social entities and interactions evolve constantly this evolution is characterized either by adding or removing nodes or edges from the network for instance in online social networks like facebook changes are introduced by users joining or withdrawing from the network or by people adding each other as friend as the network evolves over time the community structure may undergo various changes also known as critical events palla et al 2007 proposed six types of events that may occur during the evolution of communities birth growth shrink merge split and death the communities can grow or shrink as members are added or removed from an existing community as time goes by new communities can be born and old communities may disappear two communities can become closely related and merged into a single one or conversely a single community can split into two or more distinct ones even though many methods have been proposed to deal with the problem of community discovery in dynamic networks this problem remains a serious challenge detecting community structures at multiple temporal scales characterizing the network evolution several algorithms have been proposed in recent years to discover evolving community structures but no method has yet been proposed to deal with the multiscale temporal evolution property of social networks in fact fluctuations in social networks can be observed at yearly monthly daily 13 contributions hourly or even smaller scales for instance if one were to look at interactions among workers in a company or laboratory one could expect to discover clusters of people corresponding to meetings andor coffee breaks interacting at a high frequency for short periods project members interacting at a medium frequency for medium periods coordination groups interacting at low frequency for longer periods etc communities may exist therefore at different temporal scales short medium and large periods the question that may arise here is how to detect such community structures at the different scales characterizing the network evolution contributions the contribution of this thesis is twofold first the first two issues about finding overlapping and evolving community structures are addressed hence olcpm boudebza et al 2018 an online algorithm based on clique percolation and label propagation methods is proposed to carry out the analysis olcpm can detect overlapping communities and works on temporal networks with a fine granularity by locally updating the community structure olcpm delivers significant improvement in running time compared with previous clique percolation techniques the experimental results on both synthetic and realworld networks illustrate the effectiveness of the method second as a response to the third challenge about the multiscale temporal evolution aspect we propose an algorithm to detect stable community structures by identifying change points within meaningful communities boudebza et al 2019 unlike existing dynamic community detection algorithms the proposed method is able to discover stable communities efficiently at multiple temporal scales the effectiveness of the method is tested on synthetic networks as well as on highresolution timevarying networks of contacts drawn from real social networks structure of the thesis this thesis is organized as follows chapter 2 introduces the essential background information on social network analysis it provides the key concepts notations and measurements used in sna the purpose of this chapter is to ease the reading of the rest of the manuscript chapter 3 presents a literature review about community detection the concept of community and the main approaches for static community detection are first presented the problem of dynamic community detection is addressed thereafter reviewing in the process the existing methods for dynamic community detection chapter 4 presents our first contribution which pertains to the detection of dynamic overlapping community first the rational basis of this proposal is expressed then the fully dynamic network formalism we proposed to model evolving graph is introduced after that the proposed framework olcpm for detecting overlapping dynamic communities is thoroughly explained the last part in this chapter reports the experimental process conducted to assess the effectiveness of the proposed framework chapter 5 is devoted to the description of our second contribution on the temporal multiscale detection of stable communities in link streams initially we provide a view to both link stream analysis and changepoint methods which are the roots of the proposed method moreover the proposed method is further described the experimental results on both synthetic and realworld networks are then discussed the main outcomes of this study are discussed to the end of this chapter finally chapter 6 summarizes the key findings of this thesis and sheds light on similar potential research paths introduction this chapter presents background information on social network analysis which is intended to facilitate the reading of the manuscript at first we outline the key concepts definitions and main representations behind the social network perspective then we provide an overview of social network analysis measurements at the end of this chapter we present the common features of social networks the expert reader can skip this chapter and go directly to the next one which is a literature review on dynamic community detection related concepts this section introduces the basic concepts used around social network analysis and aims to enable the reader to make link between these different concepts network or graph a mathematical structure to model pairwise relations between objects it is composed of a set of nodes representing objects and a set of edges representing relations between pairs of nodes in network science the terminology network node and link refers to real systems in mathematics the terms graph vertex and edge refer to the mathematical representation of these networks barabási 2013 in this manuscript the two terminologies are used interchangeably complex networks networks to model complex systems in the real world a complex system is a system made up of a large number of components interacting with each other in a nontrivial way simon 1991 reflecting a complex pattern that is neither completely regular nor completely random watts and strogatz 1998 examples of complex systems include biological systems technological systems social systems etc social networks a subset of complex networks in which the vertices are social actors and the edges represent some form of social interaction between them such as familial friendship and collaboration ties between people trade relations between countries etc newman 2010 network science an interdisciplinary field that has emerged in the 21st century focusing on the study of patterns of connections within complex systems in many areas such as biology computer science and social science barabási 2013 social network analysis a subpart of network science focusing on the relationships and the interconnected behavior of social actors what are social networks social network refers to the articulation of a social relationship ascribed or achieved among social entities laumann and pappi 2013 two main components can clearly be distinguished the social entities termed actors are most commonly persons but in principle it could be any entity that can be connected to another entity such as organizations countries web pages scientific papers and so on social relationships or ties could include for example friendships collaborations trade web links citations resource flows information flows exchanges of social support to name a few wasserman and faust 1994 types of social network social networks can be categorized either by the nature of interacting entities or according to the properties of ties among these entities network mode the term mode refers to a distinct set of social actors or nodes on which ties of a specific kind are measured between pairs of actors wasserman and faust 1994 ties can be measured on one two or even more sets of actors the number of distinct sets of actors a network contains refers to the number of modes ties measured on a single type of actor result in onemode networks as an example students friendship networks twomode networks contain ties between two distinct sets of actors a typical example is the affiliation networks and each individual is linked to the event he attends to twomode networks can easily be converted to onemode networks but it often involves a loss of information one simple transformation of the previous twomode network example can be done as follows we keep only one set of actors individuals for example then we link every two individuals if they attend at least one common event links can be weighted to indicate the number of common events between individuals one or twomode networks are the most extensively studied while three mode networks are rarely studied because of their complex structure type of ties the ties between actors can be of different types borgatti et al 2009 identify four broad categories of ties similarities social relations interactions and flows similarities occur when actors share common characteristics and properties such as spatial and temporal proximity comembership in groups and events or demographic characteristics social relations include kinship role relations sentimental ties or cognitive awareness interactions refer to behaviorbased ties such as speaking with helping flows are those tangible and intangible things that are transmitted through interactions such as resources information or influence representations for social network there are many ways to describe social networks in this section we will introduce two representations the sociometric representation which is considered as the ancestor of all representations and the graphtheoretic representation which is nowadays one of the most useful ways for representing networks sociometric representation sociometry was first proposed by moreno 1934 in his famous book shall we survive this approach has generated a great deal of interest among the sociomatrix encodes the same information as a sociogram but with a great advantage to deal with large networks for which it is often difficult to attraction relationship sarah yassmine yara ali lina amine anes maya sarah 0 0 0 0 0 0 0 0 yassmine 0 0 1 0 1 0 0 1 yara 0 1 0 0 0 0 0 1 ali 0 0 0 0 0 0 0 0 lina 0 1 1 0 0 0 0 0 amine 0 0 0 1 1 0 1 0 anes 0 0 0 0 0 1 0 0 meryam 0 0 0 0 0 0 1 0 rejection relationship sarah yassmine yara ali lina amine anes maya sarah 0 1 0 0 0 0 0 0 yassmine 1 0 0 0 0 0 0 0 yara 1 0 0 0 0 0 0 0 ali 0 0 0 0 0 0 1 1 lina 0 0 0 1 0 0 0 0 amine 0 0 0 0 0 0 0 0 anes 0 0 0 1 0 0 0 0 maya 0 0 0 1 0 0 0 0 graphtheoretic representation since the late 1940s the graphtheoretic representation is used as a key formalism to study social networks this representation provides a straightforward yet powerful way to represent actors and their relations a graph consists of a set of points representing actors and a set of lines connecting pairs of actors definition of graph suppose we have a set of actors in the graphtheoretic representation these actors are represented by vertices or nodes we denote v v 1 v 2 v 3 v n the set of nodes containing n actors we denote e the set of all existing ties between each pair of actors in v if a tie exists between two actors v i and v j we denote it by the tuple mathematically a graph can be described by the two sets v and e we denote the graph as g this notation represents one set of actors of the same kind and one kind of relationship between the set of actors the graph can be also represented through an adjacency matrix this representation has the advantage of being more useful for computation graph models the concept of the graph can be extended to take into account different properties of nodes and edges and thus several graph basedmodels are proposed directed graphs if the relation between pairs of actors is directional the tie is distinct from the tie in such a case the graph is referred to as a directed graph and the ties are refereed as arcs note that at most there can be n ties and at least 0 ties directed graphs are adopted for representing social networks with symmetric relationships such as follow influence relationships or interactions in phone call networks undirected graphs in nondirected graphs the order of actors in a pair of ties no longer matters when one actor relates to the second the second relates to the first hence we cannot distinguish between and in this case at most there can be n2 ties nondirected graphs are well suited for representing asymmetric relationships like the neighborly relationship coauthorship kinship and marriage links weighted graphs graphs can be extended to take into account the intensity or strength of a tie by assigning to it values called weights weighted graphs are often used to model communication networks in such networks weights on edges denote the occurrence of interactions between people labeled graphs these graphs are well suited to model social networks with different types of relationships between each pair of nodes there can be multiple labels each of which represents a type of relationship in a social network like facebook for example the labels friend family favorite etc can be used to type relationships attributed graphs graph models have also been extended for representing the attributes of the actors by associating discrete or continuous valued attributes on nodes bipartite graphs are commonly used to model twomode networks like affiliation networks using two types of nodes network analysis a whole body of research has been devoted to characterizing and analyzing social networks properties since the graph theory was introduced therefore a variety of measurement methods are developed these methods are often tailored according to their levels of analysis and are mainly classified into three levels elementlevel grouplevel and networklevel brandes and erlebach 2005 in this section we discuss some graph basedmeasurements for each level of analysis in order to formulate these measurements we assume that we have a network represented by the graph g containing v nodes and e edges the following section presents preliminary concepts that are on the basis of most of the network measurements we are going to introduce we assume that the graph is simple ie unweighted nonlabeled onemode and nonattributed preliminaries degree we define the degree of a node i ∈ v denoted by deg the number of edges that are incident with it or equivalently as the number of its adjacent nodes the degree of a node goes from 0 if the node has no incident edges to v 1 if the node has edges with all nodes in the graph in a directed graph a node i has two variants of degrees the outdegree denoted deg which describes the number of edges that have their origin in i and the indegree denoted deg which represents the number of edges that have their destination in i paths and distances a path among two nodes u v ∈ v is defined as the sequence of edges that are crossed during a visit starting from u and ending in v the length of a path is the number of edges it contains we denote p the length of the path p furthermore the geodesic distance is the shortestlength path connecting a given pair of nodes it is defined as d g min p p is a path from u to v the eccentricity is the greatest geodesic distance between a given node v and any other in the network it is defined as e max i∈v v d g elementlevel measurements the key question addressed in the elementlevel analysis is how to assess the relevance of nodes or edges it is generally dealt with centrality measurements centrality centrality indices are used to quantify the most important nodes or edges node centrality is often used as an indicator of power influence popularity and prestige of actors on edges the centrality is typically used to measure how much communication or flow passes through a link there is a large number of different centrality measures that have been proposed over the years the most important are degree centrality this centrality also referred to as neighborliness centrality ranks nodes according to the number of neighbors freeman 1978 c d deg the higher the degree the more central the node is the degree centrality is often used to find people with many social connections closeness centrality it measures the distance of a node to all other nodes in the graph the node with a small total distance is considered to be the most important the most accepted closeness distance definition is that formulated by freeman 1978 the author defined centrality as the reciprocal of the total geodesic distance from a given node to all other node c c 1 i∈v d g in the context of information diffusion this measure is often used to find individuals who can quickly spread information to all the other people in the network betweenness centrality is another wellknown measure proposed by freeman 1978 it quantifies the number of times a node acts as a bridge along the shortest path between two other nodes in the network it is defined as c b i j v∈v σ ij σ ij where σ ij is the total number of shortest paths between the nodes i and j and σ ij is the total number of shortest paths between the nodes i and j that passe through the node v a node is the more central the more shortest paths run through it betweenness centrality highlights actors which are well connected to the rest of the nodes within the network such actors are called bridges they serve as a liaison between different graph regions in the diffusion of information bridges enable information to spread into unconnected parts of the network the centrality measures discussed above are designed for nodes but most of them can be easily adapted to measure edge centrality grouplevel measurements the main question here is to identify cohesive groups in the network ie groups having strong linkages among its members such groups are typically founded by common goals interests preferences or other similarities components and cliques are among the most common ways to conceptualize group cohesiveness component also called connected component which is a maximal connected subgraph ie a subgraph in which every node can be reached from every other node and which does not contain any other connected subgraph clique cliques are a typical example of cohesive groups this concept originated as early as 1949 luce and perry 1949 in sociology a clique is defined as a set of nodes such that there is an edge between every pair of nodes in this set in other terms a clique is a complete subgraph the discovery of cohesive groups is a fundamental issue in social network analysis it is known as community detection the latter will be discussed extensively in chapter 3 networklevel measurements the question addressed at this level is to characterize the global properties of the network the most important network measures are diameter average degree mean geodesic distance density clustering coefficient and degree distribution diameter the diameter of a network is the maximal geodesic distance between any pair of nodes in the network or in other terms it is the maximum of the eccentricity of the set of nodes in the network diam max uv∈v d g in the context of social network analysis this metric gives an idea about the proximity of pairs of actors in the network indicating how far two nodes are in the worst of cases average degree also called graph degree is simply the mean of the degrees of all nodes in a network the average degree can be used to measure the global connectivity of a network costa et al 2007 more precisely deg i∈v deg v 2e v mean geodesic distance this metric measures how far apart on average any pair of nodes lie in the network it represents the average shortest path distances for all pairs of nodes in the network as follows dist g 1 v uv∈v d g density the density measures the network connectedness it is defined as the ratio between the number of edges actually present in the graph and the maximum possible number of edges that can be present in the graph d e v 2 its value ranges from 0 if no edges are present to 1 if all possible edges are present ie the graph is complete the density may give insights into certain phenomena such as information spread through the network transitivity the transitivity also known as clustering coefficient was proposed by luce and perry 1949 it measures the extent to which two nodes adjacent to any node are adjacent to each other in other words if there is a tie from x to y and also from y to z then there is probably a tie from x to z it is defined as the ratio of the number of closed triples to the total number of triples in a realworld network most nodes have a relatively small degree but a few nodes have a very large degree being connected to many other nodes social network properties like most complex networks social networks share some common features among the most wellknown properties are the smallworld property the scalefree feature and the presence of community structures small world smallworld networks are networks that exhibit simultaneously two properties the small world effect and the high clustering small world effect the small world effect was outlined since the seminal experiments by milgram 1967 it means that the mean geodesic distance between any pair of nodes is relatively small watts and strogatz 1998 as noticed in milgrams experiment that actors in social networks were separated by six degrees of social contacts on average this characteristic is quantified using the average shortest path distance over all nodes in the network this distance scales logarithmically with the number of nodes meaning that between any two nodes the expected distance is o the smallworld phenomenon is common in even in sparse networks ie those in which the number of links is much smaller than the maximum number of links the network can have high clustering most large realworld networks and especially social networks exhibit a high clustering coefficient it has been observed that two nodes having a common neighbor are more likely to be connected to each other in a friendship network for example people tend to be friends with the friends of their friends this property can be quantified by the clustering coefficient smallworld networks are different from regular lattices and random networks as noticed by watts and strogatz 1998 they are halfway between a regular lattice and a totally random network regular lattices are highly clustered but do not exhibit the smallworld effect in general while random graphs show the smallworld effect but do not show a high clustering regular lattice small world random 1 figure 22 small world feature watts and strogatz 1998 scale free social networks also exhibit a highly heterogeneous degree distribution which follows a powerlaw albert and barabási 2002 the term scale free means that whatever the scale at which we observe the network looks the same ie the power law is preserved regardless of the scale community structure community structure is one of the most prominent observed features in social networks a community is a subgraph that has high connectivity within its members and comparably fewer connections with the rest of the network extracting the community structure of a network is called community de degree of nodes fraction of nodes 1 figure 23 powerlaw distribution of node linkages barabási and bonabeau 2003 tection it is of great importance since it offers insight into the networks structure and functionalities this feature will be discussed in detail in the following chapter conclusion this chapter introduced the concepts representations and measurements of social network analysis which provide the necessary background to understand the problems addressed in the rest of the thesis it also presented the social networks features one of the most important of these features is the community structure the latter represents the main subject of this thesis and it will be discussed in detail in the next chapter introduction this chapter presents a literature review on community detection at first the concept of community is introduced along with an overview of the classical static methods for community detection following this the issue of dynamic community detection in timeevolving networks is then addressed in the light of that each of the concept of dynamic community and dynamic network models are presented followed by a review of the current literature on dynamic community detection methods community definition a community is traditionally defined as a subgraph that consists of a set of nodes that are more densely connected to each other than to the other nodes in the rest of the network fortunato 2010 porter et al 2009 a generally accepted definition is still lacking since it may not always be straightforward to give a precise definition of what more densely connected means as a matter of fact the definition is subjective and may depend on the context of the application researchers in many fields eg social science computer science and physics have drawn up several definitions these definitions can broadly be classified into two main categories fortunato 2010 namely local definition and global definition local community definition to some extent the community can be viewed as an autonomous entity which is separated from the whole graph it is therefore examined independently from the rest of the graph focusing only on its nodes and maybe its direct neighbors many local criteria are used to identify communities complete mutuality reachability vertex degree and the comparison of internal versus external cohesion tang and liu 2010 communities can be defined as a perfect cohesive group where all its members are connected to each other luce and perry 1949 in graph theory this corresponds to a clique a maximal complete subgraph in which all nodes are adjacent to each other such a criterion is too strict especially for social networks which are known to have many triangles but few larger cliques more relaxed definitions of cliques have been proposed in order to comply with the general characteristics observed in realworld social networks some methods use the reachability property ie the existence of a path between nodes in the kclique based community two nodes can be considered as belonging to the same community if there exists a path between the two nodes of length no more than k another criterion to define a cohesive group uses the nodal degree and requires a relatively large number of adjacent nodes within the group in the context of social network analysis two complementary definitions were proposed 1 a kplex is a maximal subgroup in which each node is adjacent to all other nodes of the subgroup except at most k of them seidman and foster 1978 2 a kcore is a maximal subgraph in which each node is adjacent to at least k nodes of the subgraph seidman 1983 these two definitions impose conditions on the minimal number of absent or present edges communities can be defined by comparing the internal and external cohesion of a subgraph radicchi et al 2004 proposed the definition of strong community which is a subgraph that requires that the internal degree of each node is greater than its external degree this stringent condition can be relaxed into the definition of weak community radicchi et al 2004 for which it suffices that the internal degree of the subgraph exceeds its external degree global community definition the community can be defined by considering the whole network this is particularly appropriate in the case in which subgraphs cannot be taken apart without seriously affecting the functioning of the system fortunato 2010 there exist many global criteria to identify communities the most wellknown of which is the modularity proposed by girvan and newman 2002 this criterion is based on the idea that a random graph has no meaningful community structure and thus the null model is used as a term of comparison to verify whether the graph displays a community structure the null model is a randomized version of the original graph where edges are rewired at random under the constraint that the expected degree of each vertex matches the degree of the vertex in the original graph newman and girvan 2004 the modularity compares the partition of real networks with their randomized part in the null model a subgraph is a community if the fraction of edges inside the subgraph exceeds the expected fraction of edges that the same subgraph would have in the null model the community structure can be detected by optimizing the modularity to find the optimal partition this criterion will be discussed more thoroughly in section 332 another important measurement is the map equation by rosvall and bergstrom 2008 it is based on the principle of the minimum description length grünwald 2000 whereby any regularity in the data can be used to compress it by considering the community structure as a set of regularities in the network and the path description of the random walk on the network as the data to compress communities can be detected during the compression of the path description static methods for community detection nowadays there is a vast literature in the field of community detection a broad variety of algorithms have been developed for the identification of static communities the approaches for the latter can be roughly classified into graph partitioning hierarchical clustering modularity optimization clique percolation and label propagation community detection algorithms in this section we provide a brief overview of these approaches the comprehensive overview of the community detection techniques can be found in fortunato 2010 fortunato andhric 2016 331 traditional methods graph partitioning the community detection has its roots in graph partitioning the latter consists in partitioning the graph into a predefined number of subgraphs so that the number of edges between the subgraphs is minimal the representative algorithm of graph partitioning methods is kernighanlin algorithm kernighan and lin 1970 the kl algorithm is a heuristic optimization method which introduces a gain function q in the process of dividing communities the value of q represents the difference between the number of edges inside the communities and the number of edges connecting between them spectral bisection method by barnes 1982 is also one of the famous graph partitioning algorithms this method is based on the spectral properties of the laplacian matrix algorithms for graph partitioning are of limited use because it is necessary to provide as input the number of communities which is almost impossible to know unlike graph partitioning hierarchical clustering does not require to specify the number of clusters to be generated as input however one of the problems with hierarchical clustering is that it produces many partitions from which we need to identify the appropriate one hierarchical clustering partitional clustering in this approach the community detection is formulated as a data clustering problem that aims to separate the set data points into k disjoint clusters such as to minimizingmaximizing a given cost function based on distance measure between nodes one of the most popular partitional clustering algorithms is the kmeans by macqueen et al 1967 the algorithm starts from k initial centroids where k is the desired number of clusters each data point is then assigned to the closest centroid based on euclidean distance then the mean of the resulted collection of data points is calculated and centroids are updated to mean value the assignment and update steps are repeated until the centroids stop changing spectral clustering spectral clustering refers to the class of methods using the eigenvectors of a matrix to find graph partitions it was introduced in the early 1970s with the work of donath and hoffman 2003 who first used similarity matrices and of fiedler 1973 who proposed using the normalized laplacian matrix the most common form of spectral clustering involves three main gaussian kernel etc modularitybased approaches a large number methods has been suggested to find optimal community structures modularity is one of the most widely used technique in optimization based methods the present subsection first introduces modularity and then presents the most popular techniques for modularity optimization it discusses at the end the resolution limit problem which modularity suffers from modularity definition modularity has been initially introduced as a stopping criterion in the algorithm of girvan and newman newman and girvan 2004 d i d j 2 and hence the expected fraction for links in a community c is given as dc 2e 2 where d c i∈c d i modularity can be defined as q c∈c q c c∈c   e in c e 2e in c e out c 2e 2   where e in c e is the number of links inside the community c accordingly 2e in c e out c is the fraction of links within the community c the equation 31 can also be expressed in equation 32 and 33 q 1 2e c∈c ij∈c a ij d i d j 2e q 1 2e ij∈v a ij d i d j 2e δ where a ij is an element of the adjacency matrix between nodes i and j δ is the kronecker delta symbol which indicates whether the nodes i and j belong to the same community δ 1 otherwise δ 0 higher modularity usually means better community structure the modularity can be either positive or negative it takes values between 1 and 1 a positive value indicates the possible presence of community structure if each node is a community itself the modularity is always negative and it is zero when taking the whole graph as a single community modularity is the basis of many methods for community detection it is often used as a quality function to be optimized modularity optimization is known to be nphard problem so one usually employs heuristics or approximation algorithms the most popular of these algorithms will be presented in the following section greedy optimization newmans greedy algorithm newman 2004 was the first algorithm to maximize modularity it is an agglomerative hierarchical clustering method where initially each node in the graph is considered as a single community then they are merged iteratively in order to get the greatest value increase of modularity only those communities sharing one or more edges can be merged at each iteration another wellknown method is the louvain algorithm by blondel et al 2008 that is a heuristic greedy algorithm for detecting communities in weighted graphs it is also based on modularity optimization louvain method has two phases 1 first it assigns each node to a different community as singleton communities then it tries to reassign the node to the community of its neighbor that resulted in the greatest modularity increases if no increase is possible then the node stays in its own original community the process is repeated until no further increase in modularity can be achieved 2 the algorithm then builds a new network called supergraph in the way that communities identified from the first step are contracted into supernodes edges between supernodes are weighted with the sum of the weights of the edges between the represented communities at the previous step selfloop represents edges between nodes of the same community the two phases of the algorithm are then repeated iteratively until the contraction does not reduce the number of nodes note that the modularity gain at the first step is always computed for the original network the louvain algorithm is illustrated in figure 32 the algorithm is extremely fast and produces good solutions in practice fortunato 2010 simulated annealing simulated annealing is a probabilistic metaheuristic for the global optimization problem which avoids the risk of getting trapped in a local minimum it was first employed for modularity optimization by guimera et al 2004 at first the algorithm starts by partitioning the network into random partitions then in each iteration both random local and global moves take place based on modularity gain local moves shift a node randomly from one module to another while global moves consist of splitting and merging modules extremal optimization extremal optimization is a metaheuristic technique for combinatorial optimization problems that first appeared in the field of statistical physics by boettcher 1999 it basically operates on optimizing a global variable by improving extremal local variables this technique was applied for modularity optimization problem by duch and arenas 2005 the authors used modularity as the global variable to optimize and define node fitness as a local variable in the extremal optimization process the proposed heuristic evolves as follows it starts by randomly splitting the network into two partitions of equal number of nodes then at each iteration it moves the node with the lowest fitness from its own community to another community the shift changes the community structure so the fitness of many other nodes needs to be recalculated the process repeats until it cannot increase modularity after that it generates subcommunity networks by deleting the intercommunity edges and proceeds recursively on each subcommunity network until an optimal state with a maximum value of modularity is reached spectral optimization spectral optimization applies the classical sepctral clustrening approach for modularity optimization for instance in the popular work by newman 2006 modularity is reformulated in terms of eigenvectors of a new representation matrix for the graph called modularity matrix resolution limit despite the huge success of modularity optimization one drawback is that it suffers from the problem of resolution limit this problem has been discussed in the study by fortunato and barthelemy 2007 the authors have proved that there is some scale depending on the network size beyond which smaller communities cannot be detected even when they are well defined and loosely connected to each other this problem has a great impact in practice since most real world networks contain communities of very different sizes the resolution limit stems from the definition of modularity and in particular from the null model which presupposes that each node can interact with every other node this however is not the case for large world networks in which every node interacts only with a portion of the network in order to resolve this problem many researchers proposed modified versions of modularity multiresolution modularity reichardt andbornholdt 2006 arenas et al 2008 modularity desnsity li et al 2008 etc figure 33 resolution limit of modularity optimization fortunato and barthelemy 2007 a network made of identical cliques of size m connected by single links if the number of cliques is larger than about √ l the partition with modularity optimization corresponds to clusters containing two or more cliques clique percolation method most community detection algorithms are designed to identify disjoint communities and therefore are not suitable for detecting overlapping communities however in many realworld networks it is natural to find nodes that belong to more than one community at the same time the clique percolation method by palla et al 2005 was among the first methods for detecting overlapping communities in this method a kclique is rolled over the network to other cliques sharing k1 nodes in this way a community is composed of the union of all kcliques that can be reached from each other by rolling on the network the algorithm works as follows 1 find all maximal cliques a clique is maximal if it is not included in a larger clique create cliqueclique overlap matrix each entry in the matrix indicates the number of nodes shared between the respective cliques 3 erase every offdiagonal entry smaller than k1 and every diagonal element smaller than k in the matrix and replace the remaining elements by one 3 0 0 2 0 4 1 3 0 1 4 1 2 3 1 5 0 0 0 0 0 1 0 1 0 0 1 0 0 1 0 1 1 0 0 1 0 1 0 1 0 0 1 0 1 1 0 label propagation method the label propagation method is a simple and fast community detection method which was originally introduced by raghavan et al 2007 in the initial stage the algorithm assigns a unique label to each node then an iterative process is followed where each node updates its label to the one shared by the largest number of its neighboring nodes the process is repeated until convergence ie the label of each node in the network no longer changes communities are then obtained by considering groups of nodes with the same label palla et al 2007 have introduced six types of events to characterize the evolution of communities birth growth shrink merge split and death dynamic communities cazabet and amblard 2014 proposed a new operation resurgence the continue event is often considered in the community life cycle in the following we describe these events in detail birth a new community emerges if it has never been observed before death the dissolution of a community occurs when it does not appear in the next times growth a community grows when new nodes join the community making its size larger than in the preceding time shrink a community shrinks when it loses some of its nodes the size of this community is thus reduced compared to that in the previous time merge a merge occurs if two distinct communities or more are combined into a single community at the next time split it may occur that a single community splits into two or more communities resurgence a community vanishes for a period then comes back without perturbations as if it has never stopped existing it should be noted that not all these events may be handled in the same community detection method also the way how to deal with these events may differ from one method to another depending on their purpose and their area of application several methods proposed formal definitions of these events asur et al 2009 formalized five of the eight events described above let c i and c i1 denoting the set of clusters observed at two consecutive times i and i 1 respectively continue 1 if v k i v j i1 a cluster is a continuation of another cluster if the two clusters share the same nodes km erge 1 if ∃ c j i1 such that ∩v j i1 m ax k v k i ∩ v j i1 c k i 2 v k i ∩ v i1 c l i 2 two clusters merge if there exists a cluster in the next time step that contains at least k of the nodes belonging to their union and the renewal of these two clusters is at least 50 ksplit 1 if ∃ c k i1 c l i1 such that ∩v j i max k v k i1 ∩ v j i1 c k i1 2 v l i1 ∩ v j i1 c l i1 2 a cluster splits if k of its nodes are present in two different clusters in the next time step f orm 1 if ∃ no c j i such that v k i1 ∩ v j i 1 a new cluster appears if none of the nodes in the cluster were grouped together at the previous time step dissolve c k i 1 if ∃ no c j i1 such that v k i ∩ v j i1 1 a cluster vanishes if none of the vertices in the cluster are in the same cluster in the next time step table 31 formal definition of events characterizing community evolution asur et al 2009 the definition has some weaknesses the authors consider only events between consecutive snapshots they do not discuss basic events like contraction or growth the definition of events is restrictive in some cases the community may continue even it loses some of its nodes a community may form not only with one overlapping node the definition of continue and form events considers only nodes the authors do not impose any restrictions on edges this may allow the continuation of a community that loses all its edges when it should rather be a death or the emergence of a new community without any edges the dependency on the parameter k to define merge and split events the final result depends on the value of k several other definitions have been proposed similarly to asur et al 2009 greene et al 2010 and bródka et al 2013 proposed descriptions based on matching techniques chen et al 2010 characterize community dynamics by tracking community core evolution dynamic network models like many networking systems social networks are dynamic by nature friendships communications collaborations between social entities may shift over time for instance not all friendships last forever some of them fade away over time in a research laboratory some researchers only have shortterm collaborations while some others have rather long and sustainable research collaborations this dynamic is of much importance to provide a complete understanding of the network system researchers have proposed many representations to deal with timevarying networks we can distinguish three broad approaches aggregated graphs model series of snapshots model and temporal networks in this section each of these models will be discussed aggregated graphs model a straightforward way to handle a dynamic network is to simplify it into a single static network by aggregating all contacts between each pair of nodes in a single edge one can build a binary static network where nodes are only linked or not but obviously a lot of information is lost another alternative is to incorporate the frequency of interactions between nodes by constructing weighted networks all these approaches can never retain all temporal network evolution information it does not allow longitudinal analysis for instance tracking the evolution of communities series of snapshots model the evolving network is modeled through a series of snapshots each of which is a static network representing the state of the network at a given time there are two basic ways to construct a snapshot either by capturing the contacts that exist at a given time step or by aggregating all contacts during a given period of time the main issue of this approach is to determine the temporal granularity ie the right number of temporal steps or time windows tracking communities across network sequences can be difficult if important temporal information is lost between snapshots temporal networks temporal networks conserve all known temporal information there are two main models series of contact and interval graph holme and saramäki 2012 in a sequence of contact each interaction is represented as a triple where i and j are the interacting entities and t is the time when the relationship is activated in an interval graph interaction is represented as a quadruplet which means that i is involved in contact with j from t to t δt in these models only the temporal information about interactions is represented there is no temporal information about nodes literature review on dynamic community detection the main goal in this section is to review relevant methods and algorithms proposed so far for the problem of dynamic community detection this section is organized as follows 1 as a first step we will present an overview of the main existing surveys on dynamic community detection the different classifications proposed by four surveys aynaud et al 2013 hartmann et al 2016 rossetti and cazabet 2018 dakiche et al 2019 will be discussed 2 the survey proposing the most reliable classification of those surveys will then be extended and enriched by reviewing many diverse methods and algorithms especially recent ones 3 then we will present the advantages and drawbacks of each class of approaches 4 at the end of this section we will discuss the main findings and observations taken from this survey existing surveys given the growing interest in dynamic community detection and the increasing number of methods being proposed in this topic several related surveys have been conducted by different researchers aynaud et al 2013 hartmann et al 2016 dakiche et al 2019 rossetti and cazabet 2018 proposing different classifications aynaud et al 2013 distinguished three classes 1 twostage approaches which first discover timeindependent communities at each time step and then identify the community evolution by matching communities across different time steps 2 evolutionary clustering methods that simultaneously optimize the clustering quality and the temporal smoothness thus requiring the current network topology and the communities found in the previous time step 3 coupling graph clustering methods which detect community structure on a graph built by adding links between instances of nodes at different time steps the survey by hartmann et al 2016 identify two categories 1 online approaches which use information about the network topology and community structure in the previous time steps 2 offline approaches which use information from both previous and subsequent time steps this survey focuses only on online methods the latter are divided into two subcategories i temporal smoothness methods which compute communities from scratch at each time step and ii dynamic update approaches which update communities found in previous time steps the survey by cazabet and amblard 2014 extended by rossetti and cazabet 2018 proposed a taxonomy of three classes corresponding to different dynamic community definitions 1 instantoptimal approaches which only consider the current state of the network temporal tradeoff approaches which only consider past and present clustering and past network topology 3 crosstime approaches which consider the entire evolution in both network topology and clustering each of these classes is divided into subcategories corresponding to different techniques used to find communities matching the underlying definition dakiche et al 2019 adopted a classification inspired from the one proposed by cazabet and amblard 2014 they distinguished four classes 1 independent community detection and matching methods which correspond to twostage approaches 2 dependent community detection methods which require the current network topology and the community structure found in the previous time step simultaneous community detection on all snapshots which corresponds to coupling graph methods 4 methods working on temporal graphs which update the network at each network change regarding these literature reviews most of them are not comprehensive the proposed classifications do not always cover all the techniques of dynamic community detection since some methods particularly recent ones do not fit into any category also some of the classifications are overlapped since some methods can be classified under more than one category the survey by rossetti and cazabet 2018 seems to be more exhaustive and reliable it provides an indepth overview of dynamic community discovery approaches approaches for dynamic community detection given the robustness and the exhaustiveness of the survey by rossetti and cazabet 2018 we will opt for their classification in our review our goal is not to rewrite the original survey but rather to extend it by adding some relevant methods which are not included in the survey especially recent ones figure 36 illustrates the relevance of such an extension as it includes more recent methods the following methodology is adopted in this review we will use the taxonomy by rossetti and cazabet 2018 a twolevel classification the highlevel distinguishes three classes corresponding to different dynamic community definitions each of these classes is divided into subcategories corresponding each class we will present its dynamic community definition and we will outline its subcategories we will not describe all the methods presented in the survey by rossetti and cazabet 2018 for each subcategory of approaches we will present only some representative methods and the rest of the methods will just be cited we will extend the survey by rossetti and cazabet 2018 by categorizing and reviewing new relevant methods which are not already presented in the survey with a particular emphasis on recent ones a table will be provided to summarize all the reviewed methods for each category of approaches for ease of reading each subcategory of approaches will be marked by two horizontal lines the listed methods will be distinguished by formatting their citations with bold font the newly added methods will be marked by a star instantoptimal this category of approaches proposes to adapt static community detection methods to the dynamic case in such a category the network evolution is modeled as a snapshot model ie a sequence of temporal steps at first an optimal partition is calculated for each snapshot using any static algorithm then the evolution of the community structure is tracked over time by comparing the obtained optimal partitions either between consecutive snap rossetti and cazabet 2018 shots or even between far apart snapshots an example of instantoptimal methods are community matching approaches also called twostage approaches aynaud et al 2013 which comprise two main steps a static community detection step and an iterative matching step to align communities found in successive snapshots based on the matching technique used to compare optimal partitions methods in this class can be classified into similaritybased approaches and corenodes based approaches based on the scope of their matching each of these two subcategories in turn can be divided into iterative matching and multistep matching similaritybased approaches similaritybased approaches are the most popular in the instantoptimal class these approaches use a quality function to measure the similarity between communities in adjacent time steps or in far apart time steps communities with the highest similarity are considered as part of the same dynamic community the method by hopcroft et al 2004 is one of the earliest methods in this subcategory it starts by identifying natural communities that remain stable under multiple clustering runs iterative clustering algorithm by jain et al 1988 is used at this step then it tracks them over time by matching similar successive communities the authors proposed the following match ing function match m in c 1 ∩c 2 c 1 c 1 ∩c 2 c 2 where c 1 and c 2 are the communities to match palla et al 2007 extended the original clique percolation method palla et al 2005 to the dynamic case first the cpm palla et al 2005 is applied on each time step to find communities then it is applied to the joining graphs for pairs of consecutive time steps finally the resulting communities are matched with communities between consecutive time steps while finding the communitycentric events the authors used the jaccard index jaccard y ∩y x∪y to measure relative overlap value between two communities the cluster x at time t 1 is matched to the cluster y which has the largest overlap at time t asur et al 2009 proposed a an eventbased method at first they 31 in section 34 the matching in this method is simply to compute events between consecutive snapshots it is implemented as bit operations on timestamp cluster membership matrices several works with the same rationale have been proposed by different researchers notably by greene et al 2010 sun et al 2015 bóta et al 2011 bródka et al 2013 zhu et al 2016 i̇lhan and öğüdücü 2015 rossetti 2020 in sun et al 2015 proposed a matrixbased algorithm to identify community evolution events first they applied the louvain algorithm blondel et al 2008 to detect communities in each snapshot then they built two correlation matrices to describe the relationship between communities in each pair of adjacent snapshots based on these matrices they defined decision rules to detect the evolution of events bóta et al 2011 proposed a method capable of handling communities found by any nonmonotonic community detection algorithm the authors extended the basic community events described in palla et al 2007 by introducing five events growmerge contractionmerge growsplit contractionsplit and obscure case they adopt the same methodology of palla et al 2007 the n algorithm bóta et al 2010 is used to find communities and the community matching is performed on union graphs between consecutive snapshots according to a set of rules based on sizes of communities bródka et al 2013 suggested the ged method to discover group evolution ie events which may occur in social groups continuing shrinking growing splitting merging dissolving and forming to enable the analysis of group evolution the authors introduced a new measure called inclusion which respects both the quantity and quality of the group the authors in zhu et al 2016 reconstructed the event framework by asur et al 2009 and proposed the concept of community attributes to analyze the difference of communities between consecutive snapshots i̇lhan and öğüdücü 2015 proposed an eventbased framework to track similar communities and identify events over time louvain algorithm blondel et al 2008 is applied to discover communities the set of communities at consecutive snapshots are matched with each other using a custom measure called community similarity two communities are similar if the ratio of their mutual members exceeds a threshold significant events of the communities are identified based on this matching measure to detected events such as survive grow and shrink a metric called fluctuation is proposed to compute the percentage of increasedecrease in the number of community members the authors proposed also a time series model to predict community features the angel algorithm by rossetti 2020 is a nodecentric method for detecting overlapping communities in both static and dynamic networks the dynamic variant of angel works as follows first communities in the different snapshots are extracted using the static variant of angel then the precision score p recision x∩y x is used to match communities between consecutive snapshots in both directions this makes it possible to identify the different events in community lifecycle other methods use the same approach based on similarity to match communities between different snapshots not only between consecutive time steps the works by falkowski andspiliopoulou 2007 falkowski et al 2006 goldberg et al 2011 tajeuna et al 2015 and mohammadmosaferi and naderi 2020 fall in this category in the work by falkowski andspiliopoulou 2007 falkowski et al 2006 the authors used the concept of community survival graph a graph built by representing communities detected at different time steps as nodes which are linked via edges based on their overlap similarity then the hierarchical edge betweenness clustering algorithm newman and girvan 2004 is run on this graph to find final communities overlap y ∩y m in goldberg et al 2011 suggested a framework for tracking community evolution by identifying evolutive chains of communities for each snapshot a set of communities are extracted using any static algorithm communities are then linked via a strength measure for each community a valid maximal chain of communities is constructed a chain is valid if the strength of its weakest link is above a threshold and it is considered as maximal if it is not a proper subchain of any other valid chain tajeuna et al 2015 proposed a method which initially identifies the community structure at each time step by using infomap algorithm rosvall and bergstrom 2008 and then proceeds to build a matrix that counts the number of nodes shared between each pair of communities the individual rows of the obtained matrix are then used to capture the trace of the communities that should be compared over all time points the authors proposed a new similarity measure named mutual transition to compare communities and a set of rules to capture significant transition events a community can undergo the recent work by mohammadmosaferi and naderi 2020 put forward a mappingbased method to identify community evolution first communities are detected for each time step members of each community are then mapped to a pair which includes a time window and community index community mapping is defined using two kinds of similarities partially similar communities and very similar communities it is implemented using pythons hashmap table 32 lists similaritybased methods and the key elements describing their rationale category reference key elements iterative hopcroft et al 2004 natural communities static iterative clustering by jain et al 1988 matching function palla et al 2007 clique percolation method palla et al 2005 joining graph community events jaccard index overlapping communities asur et al 2009 event based method bit operation cluster membership matrices greene et al 2010 eventbased moses static algorithm by mcdaid and hurley 2010 jaccard index rules characterizing community evolution sun et al 2015 matrix based algorithm louvain algorithm correlation matrix decision rules bóta et al 2011 basic and obscure community events n algorithm bóta et al 2010 union graph rules bródka et al 2013 group evolution inclusion measure eventbased method zhu et al 2016 event framework community attributes i̇lhan and öğüdücü 2015 eventbased framework louvain algorthim blondel et al 2008 community similarity measure flactuation measure time series model rossetti 2020 nodecentric method method overlapping communities precision score community lifecycle events multistep falkowski andspiliopoulou 2007 falkowski et al 2006 community survival graph overlap similarity hirachical edge betweenness clustering algorithm newman and girvan 2004 goldberg et al 2011 evolutive chain of communties strength measure valid maximal chain tajeuna et al 2015 infomap algorithm rosvall and bergstrom 2008 matrix of common nodes mutual transition measure mohammadmosaferi and naderi 2020 mapping communities infomap rosvall and bergstrom 2008 and leiden algorithms traag et al 2019 partially similar communities very similar communities hashmap table 32 matchingbased methods and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with other methods in dhouioui and akaichi 2014 rosvall and bergstrom 2010 takaffoli et al 2011 bourqui et al 2009 fall also in this category corebased approaches in this subcategory the matching is reduced to only specific nodes called corenodes instead of all members in communities corenodes represent the most stable subset of nodes in a community and they should not move through time core nodes can be identified in different ways by using centrality criterion kcore decomposition etc two communities are matched if they share the same core nodes wang et al 2008 proposed a method called commtracker in which core nodes are distinguished from ordinary nodes based on both the community topology and the node weight the authors defined community core ie a significant group of nodes in a community as each node v in the community that satisfies u∈neighbors d v d u 0 community core nodes are then used to establish the evolving relationships among communities at successive snapshots two clusters are matched if their community cores share the highest similarity value beiró et al 2010 apply their static submodular algorithm albert and barabási 2002 for each snapshot and to evaluate the similarity between communities in successive snapshots they count the coincident nodes in the central hub of both communities to find a communitys central hub they used the kcore decomposition which consists of identifying the largest subgraph induced by the community nodes in which each node has a degree equal or bigger than k chen et al 2010 introduced the notion of graph representatives and community representatives to detect and track community dynamics representatives of a graph at t are nodes that also appear in the graph at t 1 community representative is the node that has the minimum number of appearances in other communities of the same graph first they find graph representatives in each snapshot and they enumerate the communities in each graph using the graph representatives as the seeds they then use community representatives to establish the relationship between the communities from different time steps at final decision rules are used to decide the type of community dynamics rossetti and cazabet 2018 are marked with to the original survey rossetti and cazabet 2018 for more detail temporal tradeoff in these approaches communities at an instant t are defined as a tradeoff between optimal solution at t and known past in other words communities at t depend on the actual network topology at that time and the past network topology andor past partition it does not depend on future topological perturbations the community detection process in such approaches can be summarized as follows 1 detect communities on the initial network state 2 for each temporal step t that follows detect communities at t using graph at t and past information in such a process both dynamic network models can be used when handling temporal networks communities are usually updated by considering local modifications in the network on the contrary when handling snapshot models communities are often calculated for the whole network approaches in this category may be classified into two main categories according to how the communities are calculated updating approaches which update communities found previously at each network evolution based on the strategy used to update communities the authors in rossetti and cazabet 2018 distinguished two subcategories updating by using global optimization and updating by using local rules informed community detection approaches which run communities from scratch at each network evolution while considering information in the previous steps two main strategies are used in these approaches using multiobjective optimization or using network smoothing updating by global optimization these approaches work as follows first the community structure at the initial network state is calculated then the partition found at t is used as a seed to initialize a global optimization process at t 1 quality functions and heuristics used in the static case can be used here the method by aynaud and guillaume 2010 is a typical example in this category the authors proposed the stabilized louvain method a dynamic variant of louvain blondel et al 2008 all these methods use the louvain algorithm to detect communities on each snapshot they differ in the way to initialize this algorithm in the method by he and chen 2015 the community structure of the first snapshot is initialized by using the louvain algorithm then at each time step t a small network is constructed according to the network structure at t and the community information at t1 and then the louvain algorithm is used to detect communities in this newly constructed graph chong and teow 2013 proposed an incremental batch method that can handle large and complex network changes communities are derived from the initial network using the louvain technique for subsequent snapshots the following technique is applied first nodes that are directly affected by network changes are initialized to singleton communities and all other nodes retain their previous community memberships then the louvain algorithm is applied to the resulting structure et al 2004 algorithm is used to detect the initial modular structure of the network table 34 lists updating methods using global optimization and the key elements describing their rationale other methods falling in this category can be found the original survey rossetti and cazabet 2018 table 34 updating methods using global optimization and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with updating by set of rules these approaches define a set of rules to update the community structure according to each network change should make the lost in modularity as low as possible table 35 lists updating methods using a set of rules and the key elements describing their rationale other works falling in this category can be found in the original survey icd by multiobjective optimization methods in this subcategory try to balance both partition quality and temporal partition coherence at the same time for each snapshot so that a partition found at t represents the natural evolution of the one found at modularity louvain algorithm blondel et al 2008 table 35 updating methods using a set of rules and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 for finding dense dynamic communities in interaction networks the goal of the proposed method is to find communities that satisfy the two requirements dense interactions that occur within a number of short time intervals the first requirement is formulated as the densest subgraph problem for finding the optimal set of nodes given a set of time intervals and the second is formulated as the maximumcoverage with multiple budgets problem ie finding the optimal set of time intervals for a given set of nodes the method works in an alternating fashion it starts from an initial time interval and obtains a solution by iteratively solving the two problems until uniform crossover and random mutation are used as genetic operators table 36 lists methods falling in the category of icd by multiobjective optimization and the key elements describing their rationale other methods in this category can be found in the original survey icd by network smoothing methods in this subcategory first search for communities at t by running the community detection algorithm not on the graph as it at t but on a version of it that is smoothed according to the past network evolution then communities are usually matched between snapshots contrary to the instantoptimal methods in which the matching is based on the previous partition the matching here is based on the previous network state cumulative stable contact a csc exists between two nodes if and only if their history contact duration is higher than a threshold community core which is resulted in partitioning a reduced network containing only useful links the whole process is divided into timestamps nodes and their connections can be added or removed at each timestamp and historical contacts are considered when detecting the community core also community cores can be tracked through incremental computing which can help to recognize the evolution of community structure table 37 lists methods falling in the category of icd by network smoothing and the key elements describing their rationale reference key elements kim and han 2009 particle and density based clustering information theory based mapping xu et al 2013a xu et al 2013b stable community core cumulative stable contact incremental computing guo et al 2014 weighed networks evolutionary matrices node strength guo et al consensus community particle swarm optimization table 37 methods falling in the category of icd by network smoothing and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with crosstime approaches that fall in this category do not consider independently the different steps of the network evolution all steps of evolution are studied si 1 evolution of node memberships if nodes can switch between communities along time evolution of community properties if communities can appear or dis appear along the studied period or not based on the above constraints four categories can be distinguished fixed memberships fixed properties fixed memberships evolving properties evolving memberships fixed properties evolving memberships evolving properties fixed memberships fixed properties methods in this category assume that communities remain unchanged throughout the studied period nodes can not change their memberships and communities can not appear or disappear in doing so they seek the best partition on average over a period of time to improve the solution most methods suggest splitting the network evolution into homogeneous periods of time by detecting dramatic changes in the networks aynaud and guillaume 2011 proposed a framework for detecting a unique community partition that is relevant for almost every time step during a given period called the time window to detect such partition the authors proposed two modularitybased methods the first method consists of building a sum network which is a weighted graph representing the union of all snapshots in a given time window t each edge of the sum graph is weighted by the total time during which this edge exists in t then they apply louvain a static community detection method on that network the second method consists in defining the average modularity over a set of time steps as follows q avg 1 n t∈t q this average modularity is then optimized by modifying the louvain method as follows 1 redefine the quality gain in the first phase as the average of the static gains for each snapshot of t 2 change the way to build the super graph in the second one as follows given a partition π the same transformation as for the louvain is applied on every snapshot of t independently to obtain a new evolving network between the communities of π the authors in sun et al 2007 proposed graphscope method for discovering communities and monitoring their changes in directed bipartite stream graphs the method is based on the minimum description length principle by grünwald and grunwald 2007 the primary idea underlying this work is to find the minimum encoding cost for the description of a time sequence of graphs and their partitions in communities to do so an incremental process is proposed which first constructs graph segments by grouping similar consecutive snapshots so that the encoding cost is minimized then within each segment finds the best partition of sourcedestination nodes that yields a smaller encoding cost the change point remarks the beginning of the new graph segment using the same principle of mdl tan et al 2014 proposed a method to discover the community transition for individual users in dynamic networks it starts by constructing a trajectory to represent the evolution of communities then a trajectory segmentation approach is proposed to discover the best partition that yields minimum encoding cost table 38 lists methods in the category of fixed memberships fixed properties and the key elements describing their rationale another work which falls in this subcategory is proposed by duan et al 2009 table 38 methods in the category of fixed memberships fixed properties and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with fixed memberships evolving properties these methods do not allow nodes to switch communities they also assume that communities are not homogeneous throughout the studied period of time the activity within a community can increase or decrease over time for example nodes can interact more actively during some recurrent periods they assign to each community a temporal profile that corresponds to the evolution of their activity the reasoning to add this kind of edge is to allow dynamic patterns to be more easily unveiled a random walk clustering is performed on the tensor to discover a predefined number of dynamic communities table 39 lists methods in the category of fixed memberships evolving properties and the key elements describing their rationale reference key elements gauvin et al 2014 nonnegative factorization time adjacency matrix threeway tensor sarantopoulos et al 2018 three dimensional tensor intertimeframe edges random walk clustering table 39 fixed memberships evolving properties methods and the key elements describing their rationale other methods in this subcategory can be found in the original survey gauvin et al 2014 matias andmiele 2017 evolving memberships fixed properties these methods permit nodes to switch between communities because they use stochastic block models the number of communities and their density is fixed for the whole studied period table 310 lists methods in the category of evolving memberships fixed properties and the key elements describing their rationale reference key elements yang et al 2009 dynamic stochastic block model transition matrix bayesian inference online learning offline learning ludkin et al evolving memberships evolving properties methods in this category do not set out any restrictions on the way to search communities nodes can change their memberships and communities can appear or disappear and they can change their activity in time jdidia et al 2007 introduced the first method in the class of crosstime approaches the evolving network is viewed as a single evolving graph where edges are defined as follows there is an edge between the node and the node if they have a common neighbour k there is an edge between and if i and j are neighbours at time t there is an edge between the same node and if i is present at t and t 1 communities are identified by applying the walktrap algorithm pons and latapy 2005 on the constructed graph mucha et al 2010 adopted a modularity based method for multilayer networks the method is general and it can handle different multilayer networks multirelational networks dynamics networks etc the idea is as follows 1 first they build a multislice network that encompasses the variation of connections each layer has an adjacency matrix describing connections between nodes belonging to the previously considered slice 2 then they use the multislice generalization of modularity on the resulting network the authors introduced a coupling parameter that links nodes across network slicesthe new modularity is given as q multislice 1 2µ ijsr a ijs γ s d is d js 2m s δ ij c jsr δ where 2µ jr d jr is a normalization factor a ijs is the adjacency between i and j in the slice s of the network γ s the resolution parameter of the slice s d is j a ijs is the strength of node i in slice s 2 alltoall interslice coupling appropriate for categorical slices reprinted from mucha et al 2010 ping local clusters to identify dynamic communities using a t partite graph the number of local clusters is given as input of the senmf algorithm m s ij a table 311 lists methods in the category of evolving memberships evolving properties and the key elements describing their rationale reference key elements jdidia et al 2007 single evolving graph walktrap algorithm pons andlatapy 2005 mucha et al 2010 multilayer networks multislice network multislice modularity viard et al 2016 stochastic block models link stream ma and dong 2017 evolutionary nonnegative matrix factorization spectral clustering 3dimensional adjacency matrix local clusters table 311 evolving memberships evolving properties methods and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with other methods in this subcategory can be found in the original survey advantages and drawbacks of dynamic community detection approaches in this survey we have listed three main classes of approaches for dynamic community detection instantoptimal approaches temporal tradeoff approaches and crosstime approaches each class of approaches has its own advantages and drawbacks a summary of the major strengths and limitations of each class is provided in table 312 and the details will be discussed hereafter 312 a comparison of the advantages and drawbacks of the three classes class instantoptimal approaches the key strength of instantoptimal approaches is that it reuses existing static community detection methods and matching techniques the main drawback of these approaches is related to the instability of static algorithms indeed most of them are often nondeterministic so the same algorithm run on the same graph can yield different communities thus it is not possible to distinguish between changes due to the evolution of the community structure and changes due to the instability of algorithms besides these approaches have a very high complexity due to the high number of runs of the detection and matching however since the communities at each step are detected independently it is possible to run the detection for multiple steps in parallel and this could significantly reduce their temporal complexity methods in this category work only on the snapshot network model which fails to capture the full temporal evolution of the network temporal tradeoff approaches these approaches tackle the issue of instability that affects instantoptimal approaches while keeping a similar principle searching partitions at each time step approaches updating communities at each network evolution has the advantage of being very fast some approaches in this category enable handling all the evolution steps in the network this could be very important when handling highly dynamic networks despite all these advantages these approaches still have some weaknesses for example methods calculating communities from scratch at each network evolution have high complexity another shortcoming is the difficulty of parallelization since the communities at each step are based on communities found in a previous step another drawback of these methods is the absence of any guarantee that the communities found represent an optimal solution at the global level more precisely these methods suffer from the risk of community drift in which the solution can be dragged away from an originally relevant one another consequence is that communities found by these algorithms at step t depend on the particular sequence of previous graph modifications the same graph produced by a different graphs history would yield a different partition crosstime approaches approaches in this category do not have the problems of instability and community drift affecting the two categories of approaches mentioned above the limitation of these approaches is that it is not possible to handle a realtime community detection since the computation of communities at each new network modification requires all the topological history of the network positioning our contributions with respect to the state of the art from this review of the literature we can highlight significant research gaps that still need to be addressed on the topic of dynamic community detection especially when dealing with social networks in this section we will show how our contributions are the answer to the issues we have observed in this review to do so we use table 313 which summarizes the comparison between some methods of dynamic community detection given the large number of methods being presented in this survey the comparison is restricted to only some representative methods from each class of approaches the two methods we propose in this thesis are also taken into consideration for comparison the following comparison criteria are used here approach indicates the class of approaches to which the method belongs io tto or ct network model refers to the type of the dynamic network model used by the method sn tn stability indicates if the method suffers or not from the instability problem no drifting indicates if the method suffers or not from the community drift problem overlapping indicates if the method can detect overlapping community structures or not multitemporal scale indicates if the method can detect community structures at multiple temporal scales or only on one temporal scale reference approach network model stability no drifting overlapping multitemporal scale asur et al 2009 io sn hopcroft et al 2004 io sn palla et al 2007 io sn tajeuna et al 2015 io sn wang et al 2008 io sn chen et al 2010 io sn aynaud and guillaume 2010 tto sn aktunc et al 2015 tto sn nguyen et al 2011b tto tn chakrabarti et al 2006 tto sn xu et al 2013a xu et al 2013b tto tn aynaud and guillaume 2011 ct sn xu et al 2013a xu et al 2013b ct sn ludkin et al 2018 ct sn mucha et al 2010 ct sn jdidia et al 2007 ct sn boudebza et al 2018 tto tn boudebza et al 2019 ct tn table 313 comparing dynamic community detection methods as illustrated in table 313 the existing dynamic community detection methods have a number of weaknesses these limitations are to consider when designing new methods as our interest in this thesis lies on highly dynamic social networks the community detection in such networks has to meet some particular requirements temporal networks snapshot models fail to capture the full temporal evolution of networks to deal with social networks and other highly evolving networks it is therefore more appropriate to use a temporal network representation methods working on temporal networks are few compared to those using snapshot models despite their efficiency in handling highly dynamic networks some of these methods are computationally expensive as they require repetitive computations of communities at each network change therefore the majority of recent methods adopt local computations to minimize the computational cost like the method by nguyen et al 2011b the stability of detection the stability is an important aspect to take into account when designing community detection algorithms for dynamic networks in general and in particular for highly dynamic networks the instability problem affects only the two classes of instantoptimal approaches and temporal tradeoff approaches like those based on modularity asur et al 2009 or random walk tajeuna et al 2015 this problem arises from the use of nonintrinsic community definitions ie when the community definition depends on the whole network a community can be modified as a result of some changes in an unrelated part of the network and this could lead to misleading results it may also occur when using stochastic community definitions ie when the algorithm reaches different results on the same or slightly modified network different solutions have been proposed to mitigate this problem one uses sable communities hopcroft et al 2004 other searches for community core wang et al 2008 or stable community core xu et al 2013a xu et al 2013b etc crosstime approaches do not suffer from the instability problem as they propose to study simultaneously all the network evolution steps methods using deterministic definitions resolve naturally this problem like kclique community definition in the cpm method by palla et al 2007 no community drifting the risk of community drift is also an important aspect to consider the community drifting problem may affect only temporal tradeoff approaches and in particular updating approaches this problem occurs when using stochastic community definitions like modularity as partitions evolve based on local optimal solutions it is not guaranteed to yield an optimal solution at the global level overlapping communities social networks are well known to exhibit highly overlapping community structures ie nodes often belong to multiple communities at once most methods in literature focus on detecting disjoint communities and are no longer adapted to find overlapping communities the bestknown exception is the clique percolation method by palla et al 2007 the methods we propose in this thesis are meant to meet these requirements our first method boudebza et al 2018 falls into temporaltrade off approaches it is a variant of the cpm method palla et al 2005 working on temporal networks the temporal complexity is reduced by adopting local updating of communities the use of the kclique community definition allows to naturally resolve the problems of instability and community drift and enables overlaps between communities our second method boudebza et al 2019 falls into crosstime approaches thus it does not suffer from the instability problem and the risk of community drifting as all the network evolution steps are studied simultaneously it also works on temporal networks this method is the first to consider a multiple temporal scale analysis to detect community structures given the generality of this method both overlapping and nonoverlapping communities can be detected conclusion in this chapter we have reviewed the literature on the topic of community detection in dynamic networks a large amount body of research has shown a great deal of interest in this topic even though several approaches have been proposed for detecting communities in dynamic networks there are still many challenges ahead especially when dealing with dynamic social networks as noted previously these challenges are mainly related to the community definition and the dynamic network representation most of the existing community definitions are stochastic and extrinsic which often lead to the problems of instability and community drift in addition to that a few definitions deal with community overlaps which is a natural property of many realworld networks especially social networks while the majority of them are designed for disjoint communities which are neither appropriate nor realistic to find overlapping communities unlike temporal networks snapshot network models cannot capture the full temporal network evolution so they are not suitable to model highly evolving networks which is the case for most real networks like social networks within this model we often have to choose a temporal granularity to analyze communities which could lead to misleading results in community detection if the chosen scale is not good the methods to be presented in chapter 4 and chapter 5 are suggested as solutions to these issues introduction no wonder the previous chapter demonstrated a plethora of methods to help discover communities from dynamic networks but the latter is subject to many challenges these challenges are mainly related to the model used to represent the dynamic network or to the community definition the way to model the dynamic network has a direct impact on the community discovery process for instance the snapshot network model can not capture the full temporal network evolution so it is not suitable to model highly evolving networks which is the case for most real networks like social networks on the contrary temporal network model is the most suitable in this case in recent years several authors have proposed methods allowing to work on dynamic graphs provided as a stream in this case there are too many modifications of the network to run a complete algorithm at each step therefore these methods update communities found at previous steps based on local rules these are some examples of such methods xie and szymanski 2013 nguyen et al 2011b cazabet and amblard 2011 rossetti et al 2017 the use of stochastic and nonintrinsic community definitions in these algorithms arises some weaknesses first the absence of any guarantee that the communities found represent an optimal solution at the global level this is because communities at each step are based on communities found in a previous step by applying a set of local rules more precisely these methods suffer from the risk of community drift in which the solution can be dragged away from an originally relevant solution the second limitation is that communities found by these algorithms at step t depend on the particular sequence of previous graph modifications the same graph produced by a different graphs history would yield a different partition another important challenge facing dynamic community detection lies in detecting overlapping communities most methods are designed for disjoint communities and do not consider the overlap property between communities this latter is considered as one of the most important properties of realworld networks in particular for social networks in such networks individuals often belong to several social groups one of the most prominent methods to reveal overlapping and evolving community structures was proposed by palla et al 2007 the latter falls into the category of community matching approaches the clique percolation method palla et al 2005 is used to extract the community structure at each time step of an evolving network then communities in consecutive time steps are matched this method works on snapshot models and it is not suitable for highly evolving networks nevertheless it provides an interesting community definition which can naturally fix the previously mentioned problems arising from stochastic and nonintrinsic community definitions in rationale for an online version of cpm the cpm method thanks to its community definition has interesting properties compared with other popular methods such as louvain and infomap blondel et al 2008 rosvall andbergstrom 2008 it is deterministic ie two runs on two networks with the same topology will yield the same results communities are defined intrinsically ie each community exists independently from the rest of the network unlike methods using a global quality function such as the modularity girvan and newman 2002 that suffer from resolution limits fortunato and barthelemy 2007 binding the size of communities to the size of the network communities can overlap ie a node can be part of several communities these properties represent an advantage when working with social networks and with dynamic networks in particular a wellknown problem with the discovery of evolving communities is the socalled instability of methods aynaud and guillaume 2010 which can be summarized as follows because community detection methods are unstable the difference observed in the partition between two consecutive periods of the network might be due either to significant changes in the network or to random perturbations introduced by the algorithm itself this problem is due to the usage of stochastic methods as two runs on very similar networks can yield very different results if the algorithm reaches different local maxima nonintrinsically defined communities as a modification of a community might be due to changes introduced in an unrelated part of the network given these observations cpm appears as a natural candidate to be used for dynamic community detection the method adapting cpm to the dynamic case palla et al 2007 however suffers from at least two weaknesses for which we propose solutions in this chapter one due to cpm itself and other to its adaptation to the dynamic case all cliques need to be discovered anew at each step both in the new graph snapshot and in a joint graph between snapshots at t and t 1 which is computationally expensive for networks with many steps of evolution nodes must belong to a clique of size at least k to be part of a community and as a consequence some nodes might not be affected to any community as most social networks have a scalefree degree distribution a large number of nodes remain without a community to circumvent these issues we propose a new twostep framework for detecting overlapping and evolving communities in social networks first built upon the classical algorithm cpm we introduce an online cpm algorithm to identify the core nodes of communities in realtime to do that we propose to use stream graph as a network model at every change in the network the community structure is updated at the local scale this allows significant improvements in computational complexity compared with dynamic cpm palla et al 2007 second to deal with the coverage problem of cpm we propose a label propagation postprocess and thus nodes not embedded in any community will be assigned to one or more communities as the original cpm method the proposed framework falls into the class of temporal tradeoff approaches and more precisely it is part of updating approaches using a set of rules stream graph in this section we introduce our own formalism for evolving graphs which is better suited to deal with stream graphs ie graphs whose modifications occur as a flow not necessarily known a priori this formalism has the same expressivity as interval graphs networks are often represented by a graph g where v is the set of nodes and e is the set of edges between nodes we represent dynamic graphs as an ordered sequence of events which can be node addition node removal edge addition or edge removal we use the following notations inserting or removing a node is represented as triples where v is the node e is the event observed among or remove and t is the time when the event occurs inserting or removing an edge is represented as quadruplets where u and v are endpoints of the edge e is the event observed among or remove t is the time when the event occurs note that this formalism for edges is identical in nature to an interval graph but is more convenient for stream algorithms as new operations can be added at the end of the ordered sequence of events without affecting previous ones olcpm framework our framework comprises two main steps first we propose to adapt the classical algorithm cpm palla et al 2005 for static overlapping community detection to deal with evolving networks we propose an online version of cpm called ocpm this algorithm is based on analyzing the dynamic behaviors of the network which may arise from inserting or removing nodes or edges ie every time a change is produced in the network we update locally the community structure alongside the involved node or edge as stated earlier cpm may not cover the whole network ie some nodes have no community membership to deal with this problem we assume that the communities corresponding to ocmp contain core nodes and we propose a way to discover the community peripheral nodes in the second step of our framework we extend ocmp using label propagation method and we propose olcpm these proposals will be presented in detail in the next section ocpm online clique percolation method this section proposes the first step of our framework olcpm an online clique percolation method this method takes two inputs se chronologically ordered sequence of events which models networks modification following the format or as defined in section 43 the parameter k which determines the clique size it is an integer value greater than or equal to 3 the ocpm method maintains after each modification three elements g the current state of the network ac the set of currently alive communities dc the set of dead communities it is therefore possible to know the community structure status at every network modification step definition of the ocpm algorithm the core of the ocpm algorithm can be defined by an algorithm that updates the current state of all variables according to a sequence of events add a new edge when a new edge appears we add this edge to the graph g according to the type of edge we distinguish two cases v ← v n e ← e ∀ i n or j n if then removeinternaln ode end break end remove edge case do e ← e if then removeintrnaledge i j t when inserting an external edge ie both its endpoints are outside any community we check if one or more new kcliques in all other cases ie when a new edge appears with one or two internal extremities we check all kcliques created when adding this edge and not belonging to any community then all adjacent kcliques are grouped together and for each group we check if there are other adjacent kcliques included in any community to which belongs any node in this group if they exist the corresponding communities will grow with the nodes of this group and they can eventually be merged function algorithm delete node in this case we remove the node from the graph g and all its edges are removed as well if the node is external ie it does not belong to any community the community structure is not affected and no action is performed until the next event when the split function deals with these two cases after the community shrinking its structure is recalculated keeping the principle of cpm checking all maximal cliques of size not less than k the resulting community having the largest number of nodes keeps the identity of the original one where the others have new identities the algorithm 44 describes this case 2 3 4 5 6 7 8 shrinks ie it loses this node and all its edges and then splits into two communities 5 6 7 8 and 1 2 3 by removing the node 6 the community 1 2 3 4 shrinks and the community 3 5 6 7 dies delete edge first we remove the edge from the graph g the removal of an edge with two endpoints belonging to the same community follows the same mechanism as internal node removal the communities to which belong the two extremities of this edge may split or die for each of them we check whether it still contains kcliques if so we use the function split to check whether or not the community is divided into smaller parts otherwise this community dies for all other types of edges the community structure does not change algorithm 45 remove internal edge input i j t ac dc g output update ac dc 1 for c ∈ c ij ∀cm cm ∈ do 2 kc ← kcliques 3 if kc ∅ then4 death 41 actions that can be performed according to graph events brackets denotes events that can only follow the preceding community event complexity of the algorithm instead of computing all kcliques for the whole network at each event occurring in the network ocpm updates the community structure on the local scale and thus only the community structure alongside the node or the edge involved in the event is recomputed for certain events like adding or deleting an isolated node or deleting an external edge the community structure does not change and hence the computational time saving reaches its maximum for instance if we have n kcliques when such an event is produced the computational time savings will be n times the average time for calculating kcliques for other events the computational time saving is also significant see section 451 for an empirical evaluation of time complexity community tracking process one of the difficulties when tracking the evolution of communities is to decide which community is a continuation of which our framework allows a trivial matching in the case of continuation of communities in the case of merge and split deciding which community keeps the original identity is a wellknown problem with no consensus in the literature cazabet and amblard 2014 in ocpm we took the simple yet reasonable decision to consider that the largest community involved in a merge or split have the same identifier as the mergedsplit one this strategy can be replaced without altering the algorithm logic a more advanced process could be added to solve problems of instability eg communities merging and quickly splitting back to their original state olcpm online label propagation cpm this section describes the second step of our framework a postprocessing based on label propagation is set out on the output communities of ocpm to discover the peripheral nodes this module is called olcpm online label propagation cpm there is a twofold reason for using a postprocess extending corecommunities found by ocpm in a network evolving at fast path one can update corecommunities efficiently after each event and run the postprocess only when the current state of communities needs to be known thus saving computation time it is known that the periphery of communities is often not well defined and unstable as seen earlier and because ocpm is deterministic and it searches for corecommunities it reduces this instability problem by using the label propagation mechanism only as a postprocess for analysis communities at t do not depend on the periphery of communities that might have been computed at t 1 but only on the stable part found by ocpm olcpm algorithm first each corecommunity spreads to neighboring peripheral nodes a label containing its identity and a weight representing the geodesic distance between this neighboring node and any other node in the corecommunity each peripheral node has a local memory allowing the storage of many labels the label propagation process is based on breadthfirst search when all labels have been shared nodes are associated with all communities with which they have the shortest geodesic distance note that nodes can therefore belong to several communities if they are at the same distance of community found by ocpm this algorithm is defined formally in algorithm 49 figure 46 presents an illustration of this process growth c12 c11 c11 c21 c11 c22 c11 c22 c21 c22 c21 c21 c12 experiments in this section we begin by evaluating the effectiveness of ocpm algorithm thus we compare the time complexity of ocpm with the dynamic version of cpm palla et al 2007 second we are interested in the quality of the communities that olcpm is able to find considering both synthetic and realworld networks note the full code of the proposed framework olcpm and the datasets used in the experiments are available at the following web site olcpmsciwebnet measuring ocpm time complexity gain for highly dynamic networks in this section we compare the empirical time complexity of the original dynamic version of cpm palla et al 2007 and our proposed version we generate synthetic dynamic networks and compare how the running time of both algorithms varies with the properties of the network and of its dynamic note that we compare ocpm only with cpm because both algorithms try to solve the same problem ie they have the same definition of communities other streaming algorithms like xie and szymanski 2013 nguyen et al 2011b cazabet and amblard 2011 rossetti et al 2017 have an ad hoc definition of communities introduced together with the method and does not have the same properties such as being deterministic and not being dependent on the network history their time complexity is in theory similar to the one of ocpm generation of dynamic networks with community structure we propose a simple process to generate dynamic networks with realistic community structures first a static network is generated using the lfr benchmark lancichinetti and fortunato 2009a the most used benchmark for community detection then for this network we generate a stepbystep evolution in order to conserve the network properties we define an atomic modification as the following process 1 choose randomly a planted community as provided by lfr 2 select an existing edge in this community 3 select a pair of nodes without edges in this community 4 replace the selected existing edge with the selected notexisting one we define a step of evolution as the combination of a atomic modifications in order to test the influence of the number of modifications between steps we test different values of a note that we use synthetic networks instead of real networks at this step since we are only interested in measuring the time complexity of algorithms synthetic networks are mostly criticized for having unrealistic community structures while here we are mainly interested in the size and rate of evolution of the networks it allows controlled experiments with real evolving networks changes in the structuresize of the network could affect computation time at each step and we could not control the number of modifications between snapshots or vary the size of networks while keeping constant properties experimental process the lfr benchmark lancichinetti and fortunato 2009a is as of today one of the most widely used benchmark to evaluate community detection methods it is known to generate realistic networks with heterogeneous degrees and community sizes it has the following parameters n is the network size k is the average degree of nodes kmax the maximum degree t1 and t2 are powerlaw distribution coefficients for the degree of nodes and the size of community respectively µ is the mixing parameter which represents the ratio between the external degree of the node with respect to its community and the total degree of the node minc and maxc are the minimum and maximum community size respectively on is the number of overlapping nodes om is the number of community memberships of each overlapping node in order to obtain realistic networks we first generate an original network with n nodes using the lfr benchmark with fixed parameters k 7 maxk 15 and µ 04 other parameters stay at their default values in order to test the influence of the network size we test different values of n as can be seen in figures 47 and 48 the time complexity of both algorithms as expected olcpm is appropriate to deal with stream graphs in which modifications are known at a fine granularity as the cost of each update is low on the contrary dycpm is appropriate to deal with network snapshots ie a dynamic network composed of a few observations collected at regular intervals measuring olcpm communities quality to quantify the quality of communities detected by olcpm framework we used both synthetic and realworld networks with ground truth community structure we remind the reader that communities found by dycpm and ocpm are identical the difference lies only in the label propagation postprocess of olcpm normalized mutual information is used as the measurement criterion this measure is borrowed from information theory danon et al 2005 and widely adopted for evaluating community detection algorithms it measures the similarity between a ground truth partition and the one delivered by an algorithm as the original definition is only well defined for partitions a variant of the nmi adapted for covers have been introduced by lancichinetti and fortunato 2009b this variant is the most used in the literature for comparing overlapping communities we used the original implementation by the authors 1 the nmi value is defined between 0 and 1 with a higher value meaning higher similarity static synthetic networks we use the lfr benchmark lancichinetti and fortunato 2009a to generate realistic artificial networks we use two different network sizes small networks and large networks and for a given size we use two ranges for community size small communities having between 10 and 50 nodes and large communities having between 20 and 100 nodes we generate eight groups of lfr networks in the first four networks µ ranges from 0 to 05 while om is set to 100 for small networks and 500 for large networks in the other networks µ is fixed to 01 and on ranges from 0 to 500 for small networks and from 0 to 2000 for large networks all these networks share the common parameters k 10 maxk 30 t1 2 t2 1 on 2 the parameter settings are shown in table 4 as can be seen from figure 49 and figure 410 the nmi scores of ocpm and olcpm are substantially equivalent for k 4 and k 5 in most cases olcpm achieves the highest results except for the two cases where the community structure becomes very fuzzy or the value of µ is large 2 the value of µ is large in these cases olcpm performs similar or worse than cpm especially for higher value of k when the community structure becomes too fuzzy for cpm the irrelevant corecommunities provided are probably worsened by the postprocess as a conclusion we can consider that in situations in which cpm finds meaningful communities in a network the proposed postprocess improves the solution dynamic realworld networks in order to evaluate the community detection results of our framework olcpm on real temporal networks we leverage a highresolution timevarying network describing contact patterns among high school students in marseilles france fournet and barrat 2014 pc classes on physics and chemistry and psi classes on engineering studies these classes represent the expected groundtruth community structure we construct a dynamic network composed of 216 snapshots each corresponding to 1 hour of data nodes correspond to students and there is an edge between two nodes in a snapshot if the corresponding students have been observed in interaction at least once during the corresponding period the constructed dynamic network is used into two sets of experiments the first experiments compares the two algorithms of our framework olcpm and ocpm while the second compares the olcpm with other methods comparing ocpm and olcpm in this set of experiments we compute the communities at each step using both dycpm and olcpm then for each snapshot we compute the nmi according to lancichinetti and fortunato 2009b results are displayed in figure 411 we show results for k 3 and k 4 which yield the best results the average nmi over all snapshots is provided in dycpm k3 dycpm k4 olcpm k3 olcpm k4 figure 411 nmi values of olcpm and dycpm palla et al 2007 for k 3 and k 4 on sociopatterns collaboration networks fournet and barrat 2014 we can observe that the average nmi of olcpm is higher than the original dycpm and that values of nmi are also higher for most snapshots the longitudinal visualization of figure 411 illustrates the relevance of studying the evolution of a network with a fine granularity only looking at this plot we can see that the class structure is not always present in the data for instance we can observe that there is no community structure during evenings and weekends or that the community structure is less observable during several days around lunchtime one can then look in more detail to the communities found and their evolution to interpret these observations in this example we were able to run dycpm because of the small size of the network the restriction to onehour interval and the limitation to 9 days of data but as shown previously it would not be possible to extend this analysis to a much larger number of steps due to the increase in complexity comparing olcpm with other methods in this set of experiments we compare our framework against three stateoftheart community detection methods the method by greene et al 2010 we used a costume implementation which uses the louvain method for community detection and the jaccard coefficient to match between communities in consecutive snapshots with a minimal similarity threshold of 03 the method by falkowski et al 2006 the implementation used for this method run the louvain algorithm in each snapshot then uses the jaccard coefficient with a minimal similarity threshold of 03 to match any community with any other one in any other snapshot constituting a survival graph louvain algorithm is then applied on this survival graph yielding dynamic communities the method by guo et al 2014 we use a naive implementation of this method which creates at each snapshot a new graph combining the graph at this step and a graph in which edges are present between any two nodes belonging to the same community in the previous step the method has is a parameter to tune how important is the weight of the current topology compared with previous partition this parameter is set to 09 for each method we compute at each step the similarity between the obtained communities and the ground truth the normalized mutual information lancichinetti and fortunato 2009b is used as similarity measure to enhance legibility we kept out only nonempty snapshots results are displayed in figure 412 and figure 413 in table 44 we summarize the average nmi over all time steps for each method as can be seen the average nmi for ocpm for the three values of k is lower than for all other methods the results are significantly improved by applying the post processing for k 3 olcpm reached a score equivalent to the best one obtained in the method by falkowski et al 2006 and other methods on sociopatterns collaboration networks fournet and barrat 2014 method average nmi ocpm 0031 olcmp 0095 ocpm 0012 olcpm 0066 ocpm 0003 olcpm 0025 greene et al 2010 0040 falkowski et al 2006 0099 guo et al 2014 0066 conclusion this chapter introduced a novel framework for the problem of detecting overlapping dynamic community structures within social networks the proposed framework boudebza et al 2018 meets three requirements it is built on a deterministic and intrinsic community definition it is capable of detecting overlapping communities and it works on steam graphs which are suitable for modeling social networks we proposed ocpm an online version of the clique percolation method palla et al 2005 working on a fully dynamic network model ie described as flows of events where nodes or edges can be added or removed over time instead of calculating all kcliques for the whole network at each event occurring in the network our method updates only the community structure alongside the node or the edge involved in the event this local update of the community structure provides a significant improvement in computational time to cope with the covering problem of cpm we proposed olcpm algorithm a postprocess on ocpm based on label propagation applied on peripheral nodes ie nodes that do not belong to ocpm communities the experimental results of our framework in both artificial and realworld networks exhibit good performance in both computing time and quality detection in chapter 5 we will address another problem of dynamic community detection related to the use of snapshots models we will also propose a solution to avoid the problem of determining the right temporal scale within snapshot models introduction in recent years studying interactions over time has witnessed a growing interest in a wide range of fields such as sociology biology physics etc such dynamic interactions are often represented using the snapshot model the network is divided into a sequence of static networks ie snapshots aggregating all contacts occurring in a given time window the main drawback of this model is that it often requires to choose arbitrarily a temporal scale of analysis the link stream model latapy et al 2017 is a more effective way for representing interactions over time that can fully capture the underlying temporal information under this model the main challenge is to mine more efficiently and smoothly both temporal and topological structures realworld networks evolve frequently at many different time scales fluctuations in such networks can be observed at yearly monthly daily hourly or even smaller scales for instance if one were to look at interactions among workers in a company or laboratory one could expect to discover clusters of people corresponding to meetings andor coffee breaks interacting at high frequency for short periods project members interacting at medium frequency for medium periods coordination groups interacting at low frequency for longer periods etc an analysis of communities found at an arbitrarily chosen scale would necessarily miss some of these communities low latency ones are invisible using short aggregation windows while highfrequency ones are lost in the noise for long aggregation windows a multiple temporal scale analysis of communities seems therefore the right solution to study networks of interactions represented as link streams to the best of our knowledge no such method exists in the literature in this chapter we propose a method having roots both in the literature on change the remainder of this chapter is organized as follows in section 52 we present the roots for the method we propose namely streaming methods and changepoint detection then we describe the proposed framework in detail in section 53 we experimentally evaluate the proposed method on both synthetic and realworld networks in section 54 origin of the method our contribution in this chapter relates to two active body of research i streaming methods for dynamic community detection and ii changepoint detection the aim of the former is to discover groups in link streams while the objective of the latter is to detect changes in the overall structure of a dynamic network this section briefly presents both categories which are the basis of our proposal streaming methods as highlighted in our review about dynamic community detection most methods consider that the studied dynamic networks are represented as sequences of snapshots with each snapshot being a wellformed graph with meaningful community structure see for instance mucha et al 2010 greene et al 2010 some other methods work with interval graphs and update the community structure at each network change eg rossetti et al 2017 cazabet andamblard 2011 however those methods are not adapted to deal with link streams for which the network is usually not wellformed at any given time using them on such a network would require to first aggregate the links of the stream by choosing arbitrarily a temporal scale the little research that exists to handle link streams has nonetheless some limitations for instance due to the usage of stochastic block model the method by viard et al 2016 provides only a single partition of the nodes that is considered constant through time it is therefore impossible for nodes to switch between communities appear disappear or change behaviors another interesting method is the one introduced by viard et al 2016 it is not dedicated to the detection of communities but rather to maximal ∆ cliques ie groups of nodes having at least one interaction between all of them during a userdefined period ∆ this method requires to fix a unique granularity using a time period ∆ compared to those methods the solution we propose is able to i discover communities at multiple temporal scales without redundancy and ii allow nodes to belong to several communities at different periods and different temporal scales similarly tingting et al 2018 formulated the problem of changepoint detection as clustering of hypernetworks first they construct a weighted hypernetwork where nodes represent the snapshots and weights represent similarities between snapshots based on structural feature and similarity measurements then community detection is run on this hypergraph at final they serialize the community detection results in chronological order where each snapshot is labeled by its community identity this method can detect i local changes ii global changes and iii isomorphic changes changepoint detection we also note that our work is related to the one by masuda and holme 2019 the authors seek to identify sequences of system states in data streams the idea is to i transform a data stream into a sequence of snapshots ii measure the pairwise distance between snapshots iii run a clustering algorithm on the matrix distance and categorize snapshots into discrete states from those methods our proposal keeps the principle of stable periods delimited by change points and the idea of detecting changes at local and global scales but our method differs in two directions i we are searching for stable individual communities instead of stable graph periods and ii we search for stable structures at multiple levels of temporal granularity method the goal of our proposed method is i to detect stable communities ii at multiple scales without redundancy and iii to do so efficiently thus we adopt an iterative approach searching communities from the coarser to the more detailed temporal scales at each temporal scale we use a threestep process 1 seed discovery to find relevant community seeds at this temporal scale 2 seed pruning to remove seeds that are redundant with communities found at higher scales 3 seed expansion expanding seeds in time to discover stable communities we start by presenting each of these three steps and then we describe the method used to iterate through the different scales in section 534 our work aims to provide a general framework that could serve as a baseline for further work in this field we define three generic functions that can be set according to the user needs cd a static community detection algorithm on a graph g qc a function to assess the quality of a community defined by the set of nodes n on a graph g css a function to assess the similarity of two sets of nodes n 1 and n 2 see section 535 on how to choose proper functions for those tasks we define a stable dynamic community c as a triplet c with cn the list of nodes in the community cp its period of existence defined as an interval eg cp t 1 t 2 1 means that the community c exists from t 1 to t 2 and cγ the temporal granularity at which c has been discovered we denote the set of all stable dynamic communities d seed discovery for each temporal scale we first search for interesting seeds a temporal scale is defined by a granularity γ expressed as a period of time we use this granularity as a window size and starting from a time t 0 by default the date of the first observed interactionwe create a cumulative graph for every period t 0 t 0 γ t 0 γ t 0 2γ t 0 2γ t 0 3γ etc until all interactions belong to a cumulative graph this process yields a sequence of static graphs such as g t 0 γ is a cumulated snapshot of link stream g for the period starting at t 0 and of duration γ g γ is the list of all such graphs given a static community detection algorithm cd yielding a set of communities and a function to assess the quality of communities qc we apply cd on each snapshot and filter promising seeds ie high quality communities using qc the set of valid seeds s is therefore defined as s qc θ q ∀g ∈ g γ ∀s ∈ cd with θ q a threshold of community quality since community detection at each step is independent we can run it in parallel on all steps this is an important aspect for scalability 1 we use right open intervals such as a community starting at tx and another one ending at the same tx have an empty intersection which is necessary to have coherent results when handling discrete time steps seed pruning the seed pruning step has a twofold objective i reducing redundancy and ii speed up the multiscale community detection process given a measure of structural similarity css we prune the less interesting seeds such as the set of filtered seeds fs is defined as fs ≤ θ s ∨ ∀s ∈ s ∀c ∈ d where d is the set of stable communities discovered at coarser scales sp is the interval corresponding to the snapshot at which this seed has been discovered and θ s is a threshold of similarity said otherwise we keep as interesting seeds those that are topologically not redundant ie having similar structure or temporally not redundant ie appearing at several scales in other words a seed is kept if it corresponds to a situation never seen before seed expansion the aim of this step is to assess whether a seed corresponds to a stable dynamic community most static algorithms suffer from a major drawback when dealing with temporal networks the instability problem this problem has been identified since the early stages of the dynamic community detection field aynaud and guillaume 2010 in few words the same algorithm ran twice on the same network after introducing minor random modifications might yield very different results as a consequence one cannot know if the differences observed between the community structure found at t and t 1 are due to structural changes or to the instability of the algorithm this problem is usually solved by introducing smoothing techniques rossetti and cazabet 2018 our method uses a similar approach but instead of comparing communities found at step t and t 1 we check whether a community found at t is still relevant in previous and following steps recursively in order to select the most relevant stable communities we consider seeds in descending order of their qc score ie the seeds of higher quality scores are considered first due to the pruning strategy a community of the lowest quality might be pruned by a community of the highest quality at the same granularity γ multiscale iterative process until then we have seen how communities are found for a particular time scale in order to detect communities at multiple scales we first define the ordered list of studied scales γ the largest scale is defined as γ max gdθ p with gd the total duration of the dynamic graph since we need to observe at least θ p successive steps to consider the community stable γ max is the largest scale at which communities can be found we then define γ as the ordered list γ γ max γ max 2 1 γ max 2 choosing functions the proposed method is a general framework that can be implemented using different functions for cd qc and css this section provides explicit guidance for selecting each function and introduces the choices we make for the experimental section community detection cd any algorithm for community detection could be used including overlapping methods since each community is considered as an independent seed following literature consensus we use the louvain method blondel et al 2008 which yields nonoverlapping communities using a greedy modularitymaximization method the louvain method performs well on static networks it is in particular among the fastest and most efficient methods note that it would be meaningful to adopt an algorithm yielding communities of good quality according to the chosen qc which is not the case in our experiments as we wanted to use the most standard algorithms and quality functions in order to show the genericity of our approach quality of communities qc the qc quality function must express the quality of a set of nodes wrt a given network unlike functions such as modularity which express the quality of a whole partition wrt a given network many such functions exist like link density or scaled density labatut and orman 2017 but the most studied one is probably the conductance leskovec et al 2009 conductance takes into account both internal density and outgoing edges and is defined as the ratio of i the number of edges between nodes inside the community and nodes outside the community and ii the sum of degrees of nodes inside the community its value ranges from 0 to 1 since our generic framework expects good communities to have qc scores higher than the threshold θ q we adopt the definition qc1conductance community seed similarity css this function takes as input two sets of nodes and returns their similarity such a function is often used in dynamic community detection to assess the similarity between communities found in different time steps following greene et al 2010 we choose as a reference function the jaccard index a measure of similarity between pairs of sample sets it is defined as the size of the intersection divided by the size of the union of the sample sets given two sets a and b it is defined as j a∩b a∪b choosing parameters the algorithm has four parameters θ γ θ q θ s θ p defining different thresholds we explicit them and provide the values used in the experiments 1 θ γ is datadependant it corresponds to the smallest temporal scale that will be studied and should be set at least at the collection rate for synthetic networks it is set at 1 while for sociopatterns dataset it is set to 20 seconds 2 θ q determines the minimal quality a seed must have to be preserved and expanded the higher this value the more strict we are on the quality of communities we set θ q 07 in all experiments it is dependent on the choice of the qc function 3 θ s determines the threshold above which two communities are considered redundant the higher this value the more communities will be obtained we set θ s 03 in all experiments it is dependent on the choice of the css function 4 θ p is the minimum number of consecutive periods a seed must be expanded in order to be considered as stable community we set θ s 3 in all experiments the value should not be lower in order to avoid spurious detections due to pure chance higher values could be used to limit the number of results experiments and results the evaluation of community detection algorithms is a difficult task and to the best of our knowledge we are the first to have to evaluate multiscale dynamic community detection the validation we propose here encompass three main aspects i the validity of communities found and ii the multiscale aspect of our method iii its scalability we conduct two kinds of experiments on synthetic data on which we use planted groundtruth to quantitatively compare our results and on real networks on which we use both qualitative and quantitative evaluation to validate our method bility in order to increase variability the temporal scale of the community is determined by the probability of observing an edge between any two of its nodes during the period of its existence set as 10d as a consequence a community of duration 10 will have edges between all of its nodes at every step of its existence while a community of length 100 will have an edge between any two of its nodes only every 10 steps on average since no algorithm exists to detect communities at multiple temporal scales we compare our solution to a baseline communities found by a static algorithm on each window for different window sizes it corresponds to detect match methods for dynamic community detection such as greene et al 2010 we then compare the results by computing the overlapping nmi as defined in lancichinetti et al 2009 at each step for those experiments we set t 5000 n 100 p 10n we vary the number of communities sc figure 51 represents the synthetic communities to find for sc 10 and the communities discovered by the proposed method we can observe a good match with communities discovered throughout multiple scales we report the results of the comparison with baselines in figure 52 we can observe that the proposed method outperforms the baseline at every scale in all cases in terms of average nmi but also for most timesteps in nmi computed at that step the important implication is that the problem of dynamic community detection is not only a question of choosing the right scale through a window size but that if the network contains communities at multiple temporal scales one needs to use an adapted method to discover them validation on real datasets we validate our approach by applying it to two real datasets because no ground truth data exist to compare our results with we validate our method by using both quantitative and qualitative evaluation we use the quantitative approach to analyze the scalability of the method and the characteristics of communities discovered compared with other existing algorithms we use the qualitative approach to show that the communities found are meaningful and could allow an analyst to uncover interesting patterns in dynamic datasets the datasets used are the following qualitative evaluation for the qualitative evaluation we used the primary school data stehlé et al 2011 collected by the sociopatterns collaboration2 using rfid devices no community ground truth data exists to validate quantitatively our findings we therefore focus on the descriptive information highlighted in the sociopatterns study stehlé et al 2011 and we show how the results yielded by our method match the course of the day as recorded by the authors in this study in order to make an accurate analysis of our results the visualization has been reduced to one day and we limited ourselves to 4 classes 3 120 communities are discovered in total on this dataset we created three different figures corresponding to communities of length respectively i less than half an hour ii between half an hour and 2 hours iii more than 2 hours the following observations can be made communities having the longest period of existence clearly correspond to the class structure similar communities had been found by the authors of the original study using aggregated networks per day most communities of the shorter duration are detected during what are probably breaks between classes in the original study it had been noted that break periods are marked by the highest interaction rates we know from the data description that classes have 2030 minutes breaks and that those breaks are not necessarily synchronized between classes this is compatible with observation in particular with communities found between 1000 and 1030 in the morning and between 400 and 430 in the afternoon most communities of medium duration occur during the lunch break we can also observe that most communities are separated into two intervals 12001300 and 13001400 this can be explained by the fact that children have a common canteen and a shared playground as the playground and the canteen do not have enough capacity to host all the students at the same time only two or three classes have breaks at the same time and lunches are taken in two consecutive turns of one hour some children do not belong to any communities during the lunch period which matches the information that about half of the children come back home for lunch stehlé et al 2011 during lunch breaks and class breaks some communities involve children from different classes see the community with darkgreen color during lunchtime or the pink community around 1000 for short communities when classes 2b and 3b are probably in a break at the same time this confirms that an analysis at the coarser scales only can be misleading as it leads only to the detection of the stronger class structure ignoring that communities exist between classes too during shorter periods quantitative evaluation in this section we compare our proposition with other methods on two aspects scalability and aggregated properties of communities found the methods we compare ourselves to are an identify and match framework proposed by greene et al 2010 we implement it using the louvain method for community detection and the jaccard coefficient to match communities with a minimal similarity threshold of 07 we used a custom implementation sharing the community detection phase with our method the multislice method introduced by mucha et al 2010 we used the authors implementation with interslice coupling ω 05 the dynamic clique percolation method introduced by palla et al 2007 we used a custom implementation the detection in each snapshot is done using the implementation in the networkx library hagberg et al 2008 for the methods identify and match dycpm and our approach the community detection phase is performed in parallel for all snapshots this is not possible for mucha et al since the method is performed on all snapshots simultaneously on the other hand dycpm and identify and match are methods with no dynamic smoothing for each temporal granularity on the math overflow network the task accomplished by our method is of course not comparable since it must not only discover communities but also avoid redundancy between communities in different temporal scales while other methods yield redundant communities in different levels nevertheless we can observe that the method is scalable to networks with tens of thousands of nodes and hundreds of thousands of interactions it is slower than the identify and match approach but does not suffer from the scalability problems as f the two other ones in particular the clique percolation method is not scalable to large and dense networks a known problem due to the exponential growth in the number of cliques to find for the method by mucha et al the scalability issue is due to the memory representation of a single modularity matrix for all snapshots in table 51 we summarize the number of communities found by each method their persistence size stability density and conductance table 51 average properties of communities found by each method communities number of communities found persistence number of consecutive snapshots size number of nodes stability average jaccard coefficient between nodes of the same community in successive snapshots density average degreesize1 q 1conductance discussions we have shown using real and synthetic data the added value of our method compared with existing ones that consider only structures at an arbitrarily chosen temporal scale this method is to the best of our knowledge the first to tackle the problem of multiple temporal scales as an exploratory work it has limitations on which we will discuss in this section that offer interesting extension possibilities we will start with the computational complexity then we discuss the difficulty in interpreting some results computational complexity we proposed several mechanisms to make the complexity of the method tractable i a pruning mechanism limits the number of seeds to consider ii an exponential decrease of the studied scales limits the number of temporal scales to consider the main bottleneck is the large number of communities found that need to be performed at the finer temporal scales although each detection is fast because graphs at fine scales are smaller and sparser compared with coarser scales the number of steps can still be prohibitive for networks studied for a long period at a small minimal scale this problem is common with all dynamic community detection methods based on snapshots as an initial solution we proposed to perform community detection in parallel for all snapshots a future direction of research that could help to solve this problem is to implement targeted community detection since most communities found are discarded anyway either due to the quality threshold or to the pruning process heuristics or statistical selection procedures could be implemented to target only the time periods with the highest chances of finding new interesting seeds results interpretation another limit of the method is that it yields a large number of stable communities which can represent a challenge for interpretation the problem is mainly due to communities found at the finest temporal scale and is even worst with other dynamic community detection methods such as greene et al 2010 that suffer from the instability problem we nevertheless propose future directions of research that could mitigate this difficulty 1 stable intermittent communities in this work we consider two stable communities composed of similar nodes at different nonoverlapping periods as distinct one stable community corresponds for instance to one particular meeting considering such communities as being part of the same stable intermittent community could greatly reduce the complexity of the result at the cost of introducing approximations as the question of nearlysimilar communities will arise 2 hierarchical organization of stable communities another way to simplify the results would be to take into account the hierarchical relations both temporal and structuralbetween communities for instance a group of twenty individuals belonging to the same group forms a long lasting stable community but some members of this group might be involved in a large number of shorter stable communities eg subgroup meetings lunch breaks etc considering those as subgroups of the larger one in a hierarchical ordering would greatly simplify the method outcomes conclusion to conclude this work only scratches the surface of the possibilities of multipletemporalscale community detection we have proposed the first method for the detection of such structures that we validated on both synthetic and realworld networks highlighting the interest of such an approach the method is proposed as a general extensible framework and its code is available 4 5 as an easy to use library for replications applications and extensions conclusion and future work conclusion this thesis tackles one of the most important problems in social network analysis which is community detection in particular we focused on dynamic community detection which takes into account the evolutionary nature of social networks despite the considerable body of the existing literature on dynamic community detection significant research gaps remain as stated previously in chapter 3 these research questions are related to the way we define a dynamic community and how to model the dynamic network most existing definitions of dynamic communities are stochastic and extrinsic which therefore pose the socalled instability problem aynaud and guillaume 2010 furthermore most community definitions do not consider the overlapping property which is a natural common property in social groups the dynamic network model has a great impact on the community detection unlike snapshot models temporal network models are suitable to deal with highly evolving networks but their higher complexity to analyze remains problematic snapshot models often require an arbitrary chosen temporal scale of analysis which could lead to misleading results communities of short duration are lost in the noise for large temporal scale while communities of large duration are invisible using a fine temporal granularity to address these concerns two frameworks have been developed the first framework proposed a method to detect dynamic communities while i considering certain specificities related to the highly dynamic nature of social networks and to the overlapping property of social groups ii avoiding the instability problem and iii achieving a good computational complexity the second framework proposes a first method to detect stable communities through a multiple temporal scale analysis the method is capable of discovering communities of very different lengths for both frameworks we conducted experiments with both synthetic and realworld data sets to assess their applicability the experiments have shown that the algorithms achieve the goals they are designed for what follows is a quick summary of each of these contributions olcpm framework to discover overlapping and evolving communities in social networks in chapter 4 we presented our framework for detecting overlapping dynamic community structures within social networks defined by olcpm boudebza et al 2018 olcpm is based on clique percolation and label propagation methods at first we proposed ocpm a dynamic version of the clique percolation method cpm by palla et al 2005 intended to work on fine grained dynamic networks the community structure is updated at each event occurring in the network ie addition or removal of nodes or edges thanks to the deterministic and intrinsic nature of clique based communities we were able to adopt a local update strategy thus only communities whose nodes or edges are involved in the event are recomputed this strategy was very useful it significantly enhanced the efficiency of our method at second we extended our method using label propagation method and we proposed olcpm to deal with the limitation of cpm method concerning the covering problem ie some nodes do not belong to any community communities found by ocpm are considered as core nodes we proposed a label propagation method to discover the peripheral nodes of these corecommunities we have made the discovery of the periphery of ocpm communities as a post process to i save computational time and ii to reduce the instability problem we conducted experiments on both synthetic and realworld social networks in order to assess the effectiveness of our framework the results revealed a high performance of our method in terms of time complexity and quality detection detecting stable communities in link streams at multiple temporal scales in chapter 5 we proposed an original method for discovering stable communities at multiple temporal scales boudebza et al 2019 from a temporal network we created snapshots with exponentially decreasing window sizes what we called temporal scales at each temporal scale we used a three step process i seed discovery at this step we detect communities at each snapshot then only those interesting are selected ii seed pruning redundant communities at lower scales are pruned according to those found at larger ones iii seed expansion here we search for stable communities ie we check whether a seed stays relevant in adjacent snapshots the proposed method is general thus any static community detection algorithm can be used to find communities at each snapshot any local quality function can be used to find the best seeds in static snapshots and any similarity measure can be used to avoid community redundancy the validation of our method was a difficult task because we were the first to propose a multiscale dynamic community detection we conducted two sets of experiments the first set of experiments was conducted on synthetic networks a network generator is proposed to produce a network with dynamic communities at different scales then we compared communities found by our method with the planted one and also with the communities found by running a baseline dynamic algorithm greene et al 2010 at the different scales the results showed the efficiency of our method in detecting stable communities at multiple scales the second set of experiments was conducted on real world networks we tested the accuracy of our method on sociopatterns dataset and since the absence of ground truth data we used knowledge highlighted on their study to validate our finding we also tested our method on math overflow dataset we compared our proposition with other methods on two aspects scalability and aggregated properties of communities found the results obtained were very promising future work encouraged by our results which indicate that the proposed approaches are appropriate to efficiently analyze the dynamics of community structures within social network future work could be for example to improve and to extend the proposed methods or to explore other important challenges in the field in what follows we will briefly discuss examples for future work in the two directions the olcpm method has some drawbacks some of which are related to cpm itself like the dependency of the parameter k we intend to propose a heuristic for finding appropriate values of k currently the postprocess is run from scratch at each step and although it is not as costly as a cliquefinding problem running it at each step for a large network can become very costly for future research it will be interesting to extend olcpm by developing an online version of the postprocess the work carried out to uncover communities at multiple temporal scales is novel in this regard further investigations and improvements are needed we have already proposed many strategies to reduce the complexity of our method in the pruning step we proposed the exponential decreases of the temporal scales and the parallelization of community detection to find the initial communities other methods like heuristics or statistical selection procedures could be implemented to target only the periods where there is high probability to find interesting seeds and this could reduce the number of runs for community detection another limitation of our method lies in the large number of stable communities it yields this makes interpretation of results very difficult hierarchical organization of relations both temporal and structuralbetween communities could greatly simplify the methods outcomes an essential challenge in dynamic community detection concerns the characterization of complex events during the community evolution cazabet and rossetti 2019 as stated earlier the community evolution is characterized in eight events birth death growth contraction merge split continue and resurgence most existing community detection algorithms handle simple community evolution scenarios such as birth shrink and death in snapshots network models and they are not suitable for handling more complex scenarios in fine grained networks like link streams models in real scenarios communities are susceptible to evolve gradually for example a shrink event can be expressed in different ways a node moving to another community a node leaving the network or a newborn community with a subset of its nodes and maybe of other nodes therefore a potentially interesting avenue for future research is to explore formalism to represent such complex community evolution scenarios another important challenge is related to the evaluation of dynamic communities this is still an extremely difficult task since there is no universally accepted definition of a community the evaluation is often performed using synthetic networks with planted community structures where the communities found by an algorithm on the generated network are compared with the ground truth communities on the same network since there are many well established benchmarks for evaluating static community detection methods such are gn girvan and newman 2002 and lfr lancichinetti et al 2008 benchmarks these static generators are largely adopted for the dynamic case by generating a series of static networks with planted communities each representing a step of the network evolution the point here however is that there is no possibility to assess the smoothness of communities since each network is generated randomly even though there have been a few benchmarks which are directly designed for the dynamic case the evaluation of dynamic communities remains an open and complex problem in this thesis we have proposed methods to detect community structures while considering the temporal evolution of networks however many valuable network datasets contain information about nodes and links the integration of the semantic dimension of a social network could provide valuable information when characterizing the community structure some of the existing community detection solutions use attributed graphs to represent the network semantic other representations like ontologies defined within the semantic web framework boudebza et al 2015 can provide rich description of social networks and thus may offer new opportunities for studying community detection reference key elements chakrabarti et al 2006 evolutionary clustering snapshot quality cost history cost adjacencysimilarity matrix kmeans agglomerative hierarchical clustering lin et al 2009 probabilistic model snapshot cost temporal cost mixture model chi et al 2007 evolutionary spectral clustering snapshot cost temporal cost historical network state historical partition preserving cluster membership preserving cluster quality messaoudi and kamel 2019 bat algorithm modularity normalized mutual information mean shift algorithm liu et al 2020 modularity normalized mutual information migration operator genome representation gao et al 2016 leader nodes snapshot modularity history modularity rozenshtein et al 2014 alternating optimization densest subgraph maximum coverage with multiple budget li et al 2017 modularity attribute similarity locusbased adjacency character string multiindividual mutation operator neighborhood correction strategy hillclimbing strategy chen et al 2020 intimacy evolutionary behaviours weighted similarity matrix differential equations iteration model jiao et al 2018 constraint common cluster markov steadystate matrices similarity matrices community membership matrices gradient descent algorithm nonnegative matrix factorization said et al 2018 genetic algorithm clustering coefficient modularity uniform crossover random mutation table 36 methods falling in the category of icd by multiobjective optimization and the key elements describing their rationale new references added to the survey in rossetti and cazabet 2018 are marked with here we detail some functions used in our algorithm kcliques stable communities discovered by the proposed method figure 51 visual comparison between planted and discovered communities time steps on the horizontal axis nodes on the vertical axis colors correspond to communities and are randomly assigned we can observe that most communities are correctly discovered both in terms of nodes and duration validation on synthetic data to the best of our knowledge no existing network generator allows to generate dynamic communities at multiple temporal scales we therefore introduce a simple solution to do so let us consider a dynamic network composed of t steps and n different nodes we start by adding some random noise at each step an erdosrenyi random graph erdös and rényi 1959 math overflow stack exchange interaction dataset paranjape et al 2017 a larger network to evaluate scalability publications the work presented in this thesis has been published in two papers 1

recent developments in the internet and technology have made major advancements in tools that facilitate the collection of social data opening up thus new opportunities for analyzing social networks social network analysis studies the patterns of social relations and aims at discovering the hidden features embedded in the structure of social networks one of the most important features in social networks is community structure densely knit groups of individuals the dynamic nature of interaction in social networks often challenges the detection of such community structures the contributions in this thesis fall into two categoriesthe first category highlights the problem of identifying overlapping communities over time to carry out such analysis a framework called olcpm online label propagation and clique percolation method is proposed it is an online algorithm based on clique percolation and label propagation methods olcpm has two main features the first one is its ability to discover overlapping communities while the second is its effectiveness in handling finegrained temporal networks as for as the second category is concerned it emphasizes on the problem of analyzing communities that are embedded at different temporal scales for example in networks of interaction such as emails or phone calls individuals are involved in daily as well as occasional conversations we propose a first method for analyzing communities at multiple temporal scales hence the dynamic network link streams is studied at different temporal granularities and coherent communities called stable communities over a period of time are detected at each temporal granularity the two proposed approaches are validated on both synthetic and realworld datasets

introduction the growing prevalence of covid19 has forced the pandemic to be the center of state and national policy in the united states as of july 5 2020 the cdc documented over 130000 covid19 deaths in the us 24 and this number increased to over 300000 covid19 deaths by december 28 2020 62 this increase in deaths is not uniformly distributed and several counties are experiencing much higherthanaverage death rates 49 it is hypothesized that social determinants have contributed to these disparities in covid19 mortality 1 which we investigate social determinants such as a countys access to healthcare rates of education indicators of health and economic status have greatly impacted other diseases 14 so these factors may play a similar role in covid 19 an increasing amount of literature highlights that social determinants of covid19 place socioeconomically disadvantaged populations at heightened risk abrams and szefler reviews emerging literature to discuss the stark inequality of covid19 infection rates and outcomes among several groups 1 this work recognizes that social determinants such as housing problems race smoking nutrition overcrowding poverty and comorbidities may compromise an individual to covid19 ahmed et al is another among the many to describe the disproportionate effects of covid19 among the socioeconomically disadvantaged highlighting access to healthcare as one of the many determinants that are potentially critical in covid19 mortality 2 fieldingmiller et al studies a few select social determinants to find that dense population in urban counties nonenglish speakers farm workers and impoverished groups in nonurban counties are at increased risk 22 overall the literature emphasizes that quantifying the social determinants of covid19 is a crucial step in addressing the existing health inequalities yet there is a lack of wellcontrolled diverse screening of the social determinants associated with covid19 moreover as the covid19 pandemic is rapidly changing temporal analysis is needed to understand how the effects of these socioeconomic factors respond to the implementation of systemic protections to address the gap in the current literature and leverage readily available data this study identifies and compares which social determinants are associated with countylevel changes in covid19 mortality rates on july 5 and december 28 2020 through this temporal analysis we uniquely utilize a comprehensive list of comorbidities social determinants and the impact of differing state policies to explore the nationwide effect of socioeconomic disparities relationships to covid19 using pandemic mortality data updated to july 5 and december 28 2020 then the highrisk factors are used as controls for two social determinant association studies one using the covid19 mortality data updated until july 5 and one using covid19 mortality data updated until december 28 these dates were selected to avoid the volatile increase in covid19 infections in the two weeks following major us holidays 41 40 social determinants are evaluated at each time point to find which ones affect covid19 mortality both the two initial analyses and the two followup association studies utilize negative binomial mixed models to analyze county level data results are statistically corrected for possible false discoveries further sensitivity analysis with different model variants and additional timeseries analysis are also validated this study design is summarized in figure 1 countylevel covid19 mortality data on july 5 and december 28 2020 was sourced from john hopkins university center for systems science and engineering 19 while covid19 mortality rates change over the course of this study the data for highrisk factors and social determinants are longterm characteristics of a county and remain constant throughout this study data for highrisk factors and social determinants were sourced from the us census 10 county health rankings 54 jhucsse 19 the center of disease control wonder 67 american lung association 6 and several other data sources the same risk factor and social determinants datasets were used for the july 5 and december 28 2020 analyses since they were measured before the pandemic all data is publicly accessible and all methods and results are reproducible the full r code and a supplementary document with complete list of data sources can be found on the rensselaer idea github1 identifying highrisk factors for covid19 using july 5 and december 28 2020 data a robust set of controls needed to be established before screening for social determinants 40 to find the most important risk factors we considered the guidelines from the cdc using extensive metaanalysis the cdc recognized that those suffering from several diseases and ethnic minorities are at a higher risk for severe illness and death due to covid19 26 our analysis accounts for these welldocumented risk factors using available data for the racial distribution in the us 10 as well as data for several of the highest risk comorbidities such as the prevalence of cardiovascular death diabetes and copd 65467 income and education levels were used to briefly explore socioeconomic status 2 a breakdown of population density by quartile was used as a proxy to categorize the urban or rural identity of a county additionally temporal variables such as days since first infection and days since a mask is required were included to adjust for disease progression and emerging policy in each state as this would greatly affect mortality rates of any region 19 as several other metrics of policy were previously tested and had little significance in aggregate data they were omitted from this analysis 18 variables were scaled by subtracting the mean from each data point and dividing by the standard deviation using countylevel data for the entire us negative binomial mixed models were used to find the significant highrisk factors the modeling method was a generalization of those used in a prior study on the impact of air pollution on covid19 mortality 68 the county covid19 mortality rate was used as the observed variable the following explanatory variables were used percent of county that is african american percent of county that is hispanic percent of county that is native american percent of county that is asian percent of county that is white percent of county with less than a highschool education percent of county that is above the age of 65 percent of county that has diabetes percent of county with copd percent of adults in the county who smoke population density in quartiles days since first infection days since mask required available hospital beds per county population median household income of a county and cardiovascular death rate an offset to scale for population and a term to account for random variance at the state level was also included 186869 this analysis was performed twice using covid19 mortality data updated up to july 5 2020 and up to december 28 2020 the extracted output from this model is the the ratio of change in covid19 mortality rate per 1 standard deviation increase in each explanatory variable we refer to this output as mortality rate ratio 68 in this initial analysis of highrisk factors these explanatory variables reveal the important baseline effects that must be controlled for when screening for social determinants screening for social determinants the same high risk factors from the methods above were used as controls for the two social determinant screenings this study design allows for the identification of unique social determinants that are distinguishable from the already recognized highrisk factors for the social determinant screening 40 negative binomial mixed models were used in the association analysis to individually test 40 variables that represent a wide range of social determinants this set of determinants included metrics of a countys mental health physical health rates of disease economic status housing burdens education demographics and multiple death rates sourced from county health rankings 54 the analysis produces a mrr for each of the 40 determinants at each of the 2 time points a complete list of the tested explanatory variables and their sources can be found in the supplementary document 1 this analysis was performed using the covid19 mortality data from both july 5 2020 and december 28 2020 producing two sets of statistically significant social determinants associated with covid19 mortality statistical testing each explanatory variable in the highrisk models and each variable in the 40 social determinant association models were tested for statistical significance using a wald test 66 the benjaminihochberg procedure 7 was used to adjust pvalues for multiple hypothesis testing in the social determinant screening our models showed robustness in this process as the false discovery rate was acceptably below 005 at 00297 and 0012 for july 5 and december 28 models respectively a 95 confidence interval was also produced for each terms mrr the 95 confidence interval and the pvalue is indicated displayed on each bar on figures 2 3 and4 to test performance and fit the procedure from wu et al was followed 68 the negative binomial mixed model for the highrisk factors using july 5 2020 data was compared to zero inflated fixed negative binomial and spatial correlation variants these models were compared to the negative binomial mixed model using aic and bic the main highrisk model was also analyzed at 16 different time points for robustness additionally variants of the model that excluded new york city data and excluded counties with less than 10 cases were analyzed for robustness statistical variations produced no significantly different results model was also robust to shortterm timeseries analysis any changes in results due to different sample stratification can be found in the supplementary document all analysis was conducted in r 48 using the lme4 package and visualizations were created using microsoft excel notebooks to reproduce all results can be found on the rensselaer idea github results the results from the high risk analyses on july 5 and december 28 data were aggregated with the results from the two social determinant screenings then this combination of analysis was categorized by relevance into 3 distinct sections for temporal comparison healthcare socioeconomic quality of life and race and age demographics for each of the corresponding section figures the mrr of each term is presented as a multiple of 1 a mrr above 1 indicates a predicted increase in mortality and a value below 1 indicates a predicted decrease in mortality a term is considered statistically significant if its 95 confidence interval does not cross the threshold of mrr of 1 healthcare the healthcare category combines the prevalence of smoking and prevalence of copd from the highrisk analyses with several social determinants related to quality of healthcare and other metrics of population health these results are presented in figure 2 socioeconomic quality of life the socioeconomic quality of life category combines the median household income population density education days since first infection and days since mask required variables from the high risk factors analyses with several social determinants that define a countys living and working conditions these results are presented in figure 3 race and age demographics the race and age demographics category combines the racial composition of a county and percent of county above 65 years old from the high risk analyses with the social determinant of percent of county that is less than 18 years of age these results are presented in figure 4 discussion this study conducts temporal analysis of social determinants and comorbidities at the national scale with a wide variety of controls and county level data from july 5 and december 28 2020 we reveal the highrisk factors and the specific social determinants of a county that affect the mortality rate of covid19 healthcare this section discusses the results presented in figure 2 53 counties that were illequipped for their population prepandemic may continue to be inadequate to their populations during a pandemic leading to more covid19 deaths a high percent of uninsured individuals also indicates poor access to health care in general those without access to health insurance will not be given thorough preventative care often resulting in undiagnosed health problems or severe illness 30 which may result in more covid19 deaths as these determinants were found to have an mrr above 1 we recognize that poor healthcare is associated with increased covid19 mortality one standard deviation increase in average number of physically unhealthy days in the county and percent of county population with poor or fair health was associated with a 129 and 147 covid19 mrr on july 5 respectively by december 28 only the effect of percent of county with poor or fair health remained statistically significant these findings suggest that counties with poor health outcomes before the pandemic have poor covid19 outcomes unhealthy counties may have a high prevalence of common underlying health conditions which places them at increased risk to covid19 as recognized by the cdc 51 poor access to healthcare also has a likely role in the increased covid19 mortality rate in these counties as poor mental and physical health has been linked to socioeconomic disadvantage 65 however it is possible that the decreasing statistical significance for physically unhealthy days and the decreasing mrr of poor or fair county health indicate that the effect of socioeconomic disadvantage and poor healthcare decreases throughout the pandemic 4 one standard deviation increase in a countys cancer death rate was associated with a 111 times increase in covid19 death rate on july 5 2020 this mrr decreased to 106 by december 28 higher cancer death rate can result both from increased incidence and unfavorable outcomes due to poor access to healthcare high cancer mortality rates indicate that a community has insufficient prevention early diagnosis and treatment 60 low income communities are notably at a disadvantage for cancer treatment due to a lack of resources as wealth disparities are noted as the most common cause of health disparities 4 we recognize cancer prevalence as a likely comorbidity and predictor of poor healthcare which increases risk of covid19 suicide mental health provider rate and excessive drinking we observed a statistically significant negative relationship between ageadjusted suicide rate and excessive drinking with covid19 mortality rate the impact of these effects approached an mrr of 1 by december meanwhile the relationship between mental health provider rate and covid19 mortality which is statistically insignificant in july has a statistically significant mrr of 095 in december this suggests a complex relationship between the pandemic and the recent epidemic of deaths of despair deaths from suicide overdose alcoholism and selfharm alcohol is a coping strategy for mass stress and isolation and consumption increased greatly after the pandemic began 38 suicide rates are higher in less urban areas and lower in more urban areas while the reverse is true for covid19 mortality rates 37 while supporting effective social distancing social isolation is a major risk factor for suicide 11 the negative relationship of suicide and alcohol consumption with covid19 deaths are likely only temporary as suicide rates and alcohol abuse are likely to increase during the pandemic 34 however the emergence of higher mental health provider rates as a protective determinant suggests that mental health has a nontrivial intricate relationship with covid19 and further work is needed to fully understand what we observe vaccination rates and annual mammogram rates in medicare ffs influenza vaccination rates among medicare fee for service users was determined to have a 114 mrr in july but was not significant in december inversely annual mammogram rates among medicare ffs users was statistically insignificant in july but had a 106 mrr in december one explanation for this result is that elderly groups in community care and those with preexisting conditions like cardiovascular disease vaccinate and get screened for breast cancer more frequently 831 of medicare ffs users are above the age of 65 43 and flu vaccinations are more common in individuals above 65 years old compared to those between 18 and 64 years old 23 flu vaccination rates are also higher in patients with comorbidities like cardiovascular disease in comparison to patients without cardiovascular disease 3 similarly as there is an increased risk of breast cancer with age increased mammogram screening among ffs users may represent elderly populations and groups with comorbidities 25 these groups are more vulnerable covid19 26 so the overall observed relationship between mammogram and vaccination rates in ffs users may reflect an underlying relationship between atrisk groups and covid19 however as there are severe geographical racial and socioeconomic disparities in influenza vaccination rates 35 future analysis of vaccination mammogram rates and covid19 mortality is needed to reveal more about this complex relationship lung disease surprisingly one standard deviation increase in adult chronic lung disease in a county was associated with a statistically significant decrease in covid19 mortality rate in december but was not significant in july rather than protective the cdc identified several lung diseases as a possible covid19 comorbidity 28 while previous literature has observed this effect in asthma this effect was not previously reported in other lung diseases 18 as the tested copd factor has no statistical significance at july or december it suggests that lung disease other than copd may have an increased statistical importance moreover pediatric asthma was observed to have the opposite effect to adult chronic lung disease pediatric asthma was statistically insignificant on july 5 but was associated with a 115 mrr by december 28 as increased transmission of covid19 has been implicated in youth the predicted increase in mortality from pediatric asthma may indicate a risk from greater youth populations in a county 20 overall further analysis with specific lung disease subtypes is needed to better characterize the observed associations with lung disease sexually transmitted diseases one standard deviation increase in chlamydia prevalence rate and hiv prevalence rate was associated with a 109 and 107 times increase in covid19 mortality rates by july 5 by december chlamydia and hiv prevalence had mrrs of 104 and 105 chlamydia prevalence has been linked to minority women populations and is related to several increases in mortality like cervical cancer and various inflammatory conditions 1532 hiv prevalence is an indirect metric of highrisk behaviors such as unsafe sex and intravenous drug use 29 both hiv and chlamydia prevalence also indicate significant burdens on healthcare resources 4547 we theorize that the prevalence of both of these stds likely increase a countys covid19 mortality rate directly and indirectly 416 sleep hospital bedspopulation diabetes cardiovascular disease and exercise several other highrisk factors and determinants that were statistically insignificant by july 5 were observed to be significant by december 28 percent of county with insufficient sleep hospital beds per population prevalence of diabetes and death rate cardiovascular disease were all associated with increased covid19 mortality meanwhile percent of county with access to exercise opportunities was associated with a decrease in mortality diabetes and cardiovascular disease have been recognized as comorbidities which may increase risk of severe complications from covid19 infection 26 regular exercise has been previously associated with positive health outcomes and we observe that it continues to have a protective role in covid19 17 in contrast insufficient sleep has been linked to an increased chance of severe chronic diseases like diabetes 58 and we find that this destructive effect may extend to covid19 the ratio of hospital beds per population is one measure of available healthcare resources and a higher ratio is traditionally implicated with more urbanization 1361 so our results may suggest an increased risk of covid19 in urban environments rather than a direct relationship between hospital beds availability and increased covid19 mortality rates other healthrelated factors the other healthrelated factors we tested were statistically insignificant in the highrisk models and social determinant analyses in both time points infant mortality rate ratio of primary care physicians to population ratio of primary care clinicians other than physicians to population prevalence of smoking and prevalence of copd appear to lack significance in aggregate data despite some of these factors having literature about interactions with covid19 26 including a large number of terms in the models may have diminished the effect of these factors it is also possible that these factors may be regionally significant and further analysis is needed at the subnational level socioeconomic quality of life this section discusses the results presented in figure 3 disease progression the temporal variable of days since first infection has a high statistically significant mrr of 223 for july 5 but was not observed to be significant by december 28 we likely observe that an early incidence of covid19 in a county is associated with the greatest increase in covid19 mortality likely due to outlier metropolitan areas like new york city it is also possible that as the pandemic progressed the improved clinical experience of treating covid19 appropriate resources and better compliance with social distancing is responsible for the statistically insignificant finding in december income one standard deviation increase in county median income was associated with a 123 times increase in covid19 mortality however this changed to show a protective value of 095 mrr by december in a traditional view of social determinants higher income is associated with lower rates of disease 9 one explanation for our initial finding between income and covid19 is that urban counties where income is higher 8 were disproportionately affected by covid19 in the initial months over time the traditionally implicated protective benefits likely had a greater impact on health outcomes which is responsible for the protective mrr by december immigrant communities one standard deviation increase in percent of individuals not proficient in english was associated with a 149 increase in covid19 mortality in july this decreased to a mrr of 107 by december as of 2013 the percentage of limited english proficient people who were foreign born was 813 70 hence these results suggest that immigrant populations are at higher risk from covid19 which is supported by previous work 22 historically immigrants suffer from poverty and many immigrants are barred from receiving healthcare programs such as medicare in their first 5 years of living in the us additionally undocumented immigrants are not eligible for any public programs it is estimated that around 45 of documented immigrants and 65 of undocumented immigrants do not receive healthcare this leaves the population much more vulnerable lep immigrants also receive lower quality of care and understanding of their medical condition due to language barriers in treatment 70 additionally the observed decrease in mrr from 149 to 107 is consistent with the trend about the effects of socioeconomic disadvantage on covid19 as discussed above overall immigrant populations are recognized to be at a higher risk for severe outcomes due to lower access and poorer quality of care 424 poverty severe housing problems one standard deviation increase in overcrowding a measure of poor socioeconomic status 16 was associated with a 127 covid19 mrr by july 5 this variable is defined as the ratio of residences with more than one person per room to the total number of housing units in a county overcrowding is a metric of severe housing problems previously associated with poor mental health outcomes 59 tuberculosis 59 and several other diseases 46 beyond signifying poor socioeconomic status there is also physical risk with any infectious disease from overcrowding due to close proximity of potential carriers 5 the mrr for overcrowding decreased to 106 by december 28 which is consistent with the decreasing trend in other explorations of socioeconomic disadvantage and covid19 in this study however despite the decreasing effect the mrr of overcrowding in a county is still associated with a significant increase of covid19 mortality in contrast however percent of county with severe housing burden defined as families spending more than 50 of their income on housing was negatively associated with covid19 mortality rate similarly percent of county that is food insecure defined as percent of population without adequate access to food was also negatively associated with a covid19 mortality rate both of these social determinants are implicated in socioeconomically disadvantaged counties and are related to lower access to healthcare 5055 one possibility is that systemic socioeconomic intervention during the pandemic may be responsible for this finding which some literature highlight as a possible method to combat the expected negative effects of poverty 42 68 although the impact of air pollution is observed to be decreasing over time and may need further study education one standard deviation increase in percent of adults in county without high school education was associated with a 115 and 113 covid19 mrr in july and december respectively average grade performance defined as the outcomes of 3rd grade reading scores compared to the national average was associated with a 086 mrr in july but had no statistical significance by december high school graduation rate in a county was associated with no statistical significance at either time point education is a wellstudied determinant of adolescent health 64 and lower high school graduation has been specifically linked to poorer health outcomes in the past 39 moreover grade performance is a metric for available educational opportunities 21 and a predictor of future health outcomes 31 our findings suggest that a countys educational resources and quality as reported by average grade performance and graduation rate may have some protective effects in july but have no measurable effects by december however the consistent destructive relationship between the percent of adults without a high school education and covid19 still suggests that poor education can increase health risks motor vehicle mortality rate and long commute one standard deviation increase in motor vehicle mortality rate was associated with a 113 covid19 mrr on july 5 increased motor vehicle mortality rate has been associated with counties with high uninsurance and high concentrations of ethnic minorities 36 as discussed above those with poor health care and certain minorities have an increased risk to covid19 additionally increased motor vehicle mortality rate is also associated with populations under the age of 18 36 which we did find to be significantly associated with increased covid19 while this effect of motor vehicle mortality decreased to 105 mrr in december 28 we observed a statistically significant 096 mrr in december for percentage of county that drives alone and has a commute over 30 minutes while this social determinant is traditionally associated increased obesity less physical excercise and worse mental health 52 we hypothesize that the transition to working from home may have a role in the protective mrr while physical health benefits of working from home still need to be further elucidated other benefits like mental health have been welldocumented 44 overall it is likely that the relationship between motor vehicle mortality rate long commutes while driving alone and covid19 has factors beyond the scope of this study so future work is needed to fully understand this relationship social association and death rate from all causes the relationships from countys social association rate and cumulative death rate from all causes were both statistically insignificant in july but had significant covid19 mrrs of 109 and 111 by december respectively although social association of a county through membership associations has been previously associated with positive health outcomes increased social interaction may lead to a higher number of covid19 deaths 56 meanwhile counties with high rates of all causes of mortality before the pandemic likely suffer from a mix of negative underlying living healthcare and working conditions it is likely that the effects of both of these social determinants were statistically obscured by other factors in july but the larger amount and more reliable data over time reveal their significance in december other socioeconomic factors the other factors related to socioeconomic status that we tested were statistically insignificant in the highrisk models and social determinant associations at both times these include percent of county that drives alone to work percent of county that are homeowners a countys segregation index death rate from assault presence of water violation unemployment rates and days since mask required as discussed above including a large number of terms in the model may have diminished the effect of these factors and they may need further analysis at regional levels race and age demographics this section discusses the results presented in figure 4 race our results suggest that race was a better predictor of covid19 in july than in december counties experienced 125 and 118 mrr increases in covid19 mortality per standard deviation increase in hispanic and native american populations by july 5 respectively these mrrs decreased to 111 and 107 by december 28 respectively additionally while percent of african americans and asians in a county was associated with 139 mrr and 102 in july there was no statistically significant relationship in december meanwhile percent of county that is white was not statistically significant in either time point historically ethnic minorities have disadvantaged access to healthcare occupational opportunities higher chronic stress lower access to quality education and more housing problems which can contribute to health outcomes 27 we conclude these racial inequalities have a role in the increased covid19 mortality rate but they are observed to have a decreasing impact throughout the progression of the pandemic age in contrast we observe an increasingly strong relationship between age and covid19 while neither percent of county above 65 years old nor percent below 18 years old was significant by july both terms were significant by december 28 while other literature has recognized elderly populations as at risk 26 we additionally find that an increase in youth in a county is associated with an increase in covid19 mortality youth have been suspected to be a source of transmission 20 which may be responsible for this finding conclusion overall we identify that counties with hispanic and native american ethnic minorities populations under 18 and above 65 years of age worse healthcare resources higher social association higher prevalence of comorbidities like pediatric asthma and diabetes and cardiovascular disease more overcrowding higher motor vehicle mortality earlier exposure to covid19 higher vaccination rates and mammogram screenings among medicare ffs users and higher air pollution continue to have an increased risk of covid19 mortality like other diseases 14 we recognize that the severity of covid19 is greatly worsened by socioeconomic inequality additionally the temporal trends observed in this study suggest that the policies implemented during this pandemic may have been effective as the impact of several socioeconomic metrics appear to significantly decrease over time however future analysis is needed to further support this finding and to additionally explore the decreasing impacts of air pollution and income and the increasing impact of age demographics care must be taken in contextualizing these results due to inherent limitations of countylevel ecological studies the relationships observed in aggregate data cannot be translated from the county level to individuals from an ecological study alone rather these studies identify useful trends and hypotheses for future analysis at the individual level 63 accounting for possible confounds is also essential in ecological studies which we achieve by including several controls in every model other limitations of the study stem from the availability and accuracy of the data literature suggests that both the reported counts of infection and the reported covid19related deaths have inconsistencies 1257 and the lack of proper testing has also been highlighted 33 moreover changes in reporting measures and standards of care over the study period may result in a regression to the mean which should also be considered in temporal analysis as more detailed information becomes available it would prove useful for future study to verify our results using clinical and individuallevel data further investigation of the relationship between covid19 and adult chronic lung disease may be especially valuable as there is currently varying evidence additionally the relationships between covid19 poverty air quality income age motor vehicle mortality rate vaccination rate breast cancer screening rate mental health and alcohol consumption need to be elucidated in more detail these analyses may reveal further interactions between social determinants and covid19 mortality

this study examines how social determinants associated with covid19 mortality change over time using us countylevel data from july 5 and december 28 2020 the effect of 19 highrisk factors on covid19 mortality rate was quantified at each time point with negative binomial mixed models then these highrisk factors were used as controls in two association studies between 40 social determinants and covid19 mortality rates using data from the same time points the results indicate that counties with certain ethnic minorities and age groups immigrants prevalence of diseases like pediatric asthma and diabetes and cardiovascular disease socioeconomic inequalities and higher social association are associated with increased covid19 mortality rates meanwhile more mental health providers access to exercise higher income chronic lung disease in adults suicide and excessive drinking are associated with decreased mortality our temporal analysis also reveals a possible decreasing impact of socioeconomic disadvantage and air quality and an increasing effect of factors like age which suggests that public health policies may have been effective in protecting disadvantaged populations over time or that analysis utilizing earlier data may have exaggerated certain effects overall we continue to recognize that social inequality still places disadvantaged groups at risk and we identify possible relationships between lung disease mental health and covid19 that need to be explored on a clinical level• applied computing → health informatics

introduction various approaches to identity issues of identity are seen to be relevant not only to language learners but also to language teachers teacher educators and researchers there is an increasing interest in the ways in which advances in technology have impacted both language learner and teacher identity but most of all it is globalization people migrations and tourism that are considered to have an immense impact on identity construction what is identity as weinreich puts it a persons identity is defi ned as the totality of ones selfconstrual in which how one construes oneself in the present expresses the continuity between how one construes oneself as one was in the past and how one construes oneself as one aspires to be in the future for norton identity is mostly seen from the perspective of how a person understands his or her relationship to the world how that relationship is structured across time and space and how the person understands possibilities for the future across years different schools of thought took a different perspective on the concept of identity essentialistexistentialists such as erikson mead and turner perceived it as developmental throughout life stages and importantly interactional for postmodernists ones identity was changeable and defi ned by context and selfdetermined but constructed through interaction with others different communities and the individual roles taken up in different contexts for vygotsky and also block identity meant an ongoing process of negotiation and reshaping identity depending on a present position in the community of practice or in other words discourse community norton in her numerous publications on identity on the other hand emphasized the power angle in constructing ones identity which she saw in varied institutions representing for example the legal and educational systems on a macrolevel and mundane daily social inetraction and access to material resources on a microlevel defi ning and constructing language identity the concept of identity is a complex construct embracing various aspects of the self in the context of communication and interaction it is obviously language that becomes the basic variable and tool in identity construction language expresses identity as a relationship between ones sense of self and different means of communication understood in terms of language a dialect or sociolect as well as multimodality language is a social practice as it constructs and is constructed by a variety of relationships thus it impacts identity because of the diverse positions from which language learnersusers can participate in social life identity is constructed as multiple subject to change and a site of struggle according to block learnerslanguage users participate in diverse learning contexts where they position themselves and are positioned in different ways this multidimensional postioning allows learners to construct and negotiate multiple identities through language reframing relationships a learner may be a highly motivated language user but may nevertheless have little investment in the language practices of a given classroom or community which may represent different value systems than those of an individual motivation is a primary factor but it is individual investment understood as a meaningful connection between a learners desire and commitment to learn a language that contributes to construction of ones complex identity also an extension of interest in identity and investment concerns the imagined communities that language learners may aspire to join when they learn a new language contextual differences irrespective of somewhat different perspectives taken on identity it is perceived as contextuallygrounded thus when talking about for example an immigrants language identity and a school learners identity we will be faced with totally different contexts participating in identity construction though both the idea of investments and of imagined communities constitute signifi cant contributing factors generally three major contexts and environments of language identity development can be distinguished these are adult migration the foreign language classroom the second language classroom and immersion the adult migration context here the speakers of the target language community are adult immigrants of the target language country their reasons for immigrating are varied searching for work or for better standards of education for political reasons or in a globalized world to be able to reunite with their families fresh immigrants fi nd themselves in a new environment surrounded by a new language perhaps totally unknown just partially learnt or acquired over time with a desperate need for acculturaltion to integrate with the new community they undergo bitter experiences of culture shock the more distant l1 and l2 cultures are the bigger the effect they experience language shock and initially the inability to communicate in simple daily situations the older they are the more diffi cult it is for them to overcome their ego boundaries however in contrast their continuous exposure to language and immersion in it the need for survival and to improve their quality of life are strong motives for the reconstruction of identity to fi t in better with the outgroup a certain degree of integration is observable that in later stages may lead to assimilation often this degree will be the selfchoice of an individual selected studies on immigrants language identity are discussed by block and a selection of them is outlined in table 1 source focus of the study et al a longitudinal sociolinguistic study of how migrants position themselves in a new socioculturallinguistic context language use and communication breakdown often marked by the feelings of inferiority and powerlessness broeder goldstein a case study of 27 portuguese immigrant women of loweducational and profession background in toronto decribing how they position themselves in a new work place following the traditional model of male hegemony and of focus on family life in a subordinate position the role of present community is pointed out norton a case study of fi ve immigrant women of various nationalities in canada and their fairly turbulent lifestories of struggles with isolation or determination to belong focusing on the social context of the subjects and also the role of the past teutschdwyer a case study of a polish immigrant in the us who fi rst integrated well in his halfamerican family but then moved to polish ethnic surroundings the study demonstrates how language development impacts ones positioning in immigrant life a report solely based on the subjects perception of his experiences block a smallscale study of six in a spanishspeaking community in london their language development due to extensive participation of ones ethnocommunities or on the contrary forming an emergent community of educated spanish speakers living and working in london on the basis of research into adult migrants identity it is observed that their critical experiences lead to changes in positioning themselves in society their continuous immersion most strongly impacts their sense of self and identity foreign knowledge becomes the strongest means of mediating ones position where low levels of l2 competence may lead to a possible declassing of individuals due to their verbal inability to express themselves and consequent failure to be wellunderstood as the data shows for example in the case of women a visible change of their position for the better is observed with the development of their language skills the work place of immigrants and the public sphere where they function also impacts their fi rst language and culture maintenance resulting in the emergence of a new perspective on their l1 and motherland various positions and thus individual identities of subjects can be observed from denial of immigrant status to being cosmopolitan and integrating into the new community pavlenko talks about competing identities when she expresses her own identity experiences as a multilingual adult migrant to the united states from ukraine guilt over linguistic and ethnic disloyalties anxiety about the lack of wholesome oneness sadness and confusion by being oneself as divided a self in between a self in need of translation formal instruction in a foreign language classroom context the second context in which language identity is created is school or any other environment which offers formal instruction in a foreign language so we are dealing here with foreign language learners at school language school or in onetoone tutorials the focus of foreign language learning is developing fl competences for instrumental andor integrative reasons a future job or perhaps living in some other country in order to join some imagined communities however for the most part the immediate motivation is to get educational credits and degrees what is characteristic here is that these learners have a limited exposure to language input mostly in the classroom geared towards programme requirements and the number of hours assigned to a language course in the programme of studies in a given institution a standard language model is provided which is often semiauthentic if not a classroom language model the procedures of formal instruction lead to a conscious process of learning based on language rules controlled practice and resulting in rigidly established assessment measures individual investment going beyond classroom practice is a desired factor in becoming a successful fl user in relation to the construction of identity positioning in a group in relation to a teacher or other peers in class dynamics leads to a negotiation of identity it is both a learner and a teacher that are involved in this negotiation processs l1 use and the perception of its role in a fl class is an important positioning factor as well as the desire to join fi rst a class community of practice then perhaps a fl community if seen as desired ones individual assessment of ones position in a class and in relation to the teacher is a strong factor in identity construction table 2 offers a few examples of this identiy formation context selected from blocks overview block assumes that foreign language ie target language mediated positions are not very visible in a formal instruction context in contrast to language competence development itself positioning evolution can however be observed in actual language use in the classroom and beyond by forming communities of practice block strongly believes that the fl context relatively unfertile ground for tlmediated identity work contrasts markedly with naturalistic adult migrant settings where there is a potential for partial or full immersion in the tl multimodality it also differs signifi cantly from the study abroad context where fl classroom instruction gives way to being there which increases the potential for immersion in tlmediated environments and the emergence of new tlmediated subject positions table 2 formal instruction settings source focus of the study liddicoat and crozet a study of a fl classroom instruction on interlanguage pragmatics by means of awarenessraising tasks and their infl uence on learners identity belz 2002 a study of multilingual written production as a way of reconceptualizing the self as language user and creator lantolf and genung a case study of an academic learning a fl at the university based on a learner diary it demonstrates how fl learners position themselves against their chinese teachers which resulted in change of motive to learn the role of family background is emphasised in this a military father developed the subjects obedience to orders which in the end prevailed over the subjectss beliefs about good teaching block a case study of a fl learner in spain and her evolving attitudes towards the teacher and presenting onself as a problem student developing her textual identity by participating in writing activities the study presented in this article is either to confi rm or reject the above assumption that language identity is only emergent in the context which involves at least some form of immersion in the target community either on immigration or during the study abroad period discussed below formal instruction and immersion in the second language a study abroad period the modern world allows and promotes travel not only for tourism but also for contracted work and for study purposes for example in the mobility programmes of the european union so popular with students across europe this context is an amalgam of former contexts where formal instruction is offered at the institution of work or study but the one that is also based on immersion in the language and culture of the target country however importantly for ones identity construction this context usually offers higher social status and economic standards for the subjects compared with those of migrants group in terms of communication opportunities they are afforded both in the classroom where the second language becomes a lingua franca for a multlingual group of students but most importantly beyond the classroom in daily encounters with the native community so there is an unlimited exposure to sl beyond the classroom additionally developing crosscultural awareness and openness to other cultures without necessarily having to integrateassimilate is a shared characteristic of this group of people research on simultaneous formal instruction and immersion in the second language focuses mostly on study abroad periods and has already gathered quite a substantial number of studies published in regular journals in thematic collections of research papers but also in academic journals solely devoted to this context as is the case of study abroad research in second language acquisition and international education frontiers the interdisciplinary journal of study abroad or a pioneering collection of studies on sa edited by b f freed under the title second language acquisition in a study abroad context these studies relate mostly to linguistic development but also to growing awareness and intercultural sensitivity openness to otherness and tolerance thus dealing directly with issues of bimultilingual identity block overviews numerous studies which in one way or another refl ect identity formation and focus on issues of national identity sexual harassment gender positioning and teacherstudent situations in various university institutions in the united states and europe however he observes that there is still a gap in studies whose major concern is identity formation in study abroad periods also the participants in these studies are usually recruited from the united states europe and only to some extent from asia with a lack of studies involving african or south american students table 3 offers some examples of research on the study abroad context in terms of issues pertinent to the identity formation of their participants although this context is similar to the adult migrant environment in its immersion aspect at the same time positioning will be different with the temporary nature of stay these two contexts also differ in terms of subject profi les as in study abroad both the students backgrounds and often younger age are dissimilar from the migrants personal characteristics this is a signifi cant adventage for sa students over migrants however there are also some factors for sa students that may impede their language imrpovemnt and identity formations such as for example formal instruction different in form and content from home experiences of foreign language learning the novelty of teaching methods may become a real challenge on the other hand the development of intercultural awareness and intercultural communicative competence in the case of fl exible ego boundaries a strong need to belong by joining the local community will undoubtedly impact formation of a new identity alternatively this period can turn into an experience of confrontation of l1 and l2 group identities derving from rigid ego boundaries in the latter case an impeded language development and increased reticence towards the l2 community at hand will be observed in a sa period classrooom and beyond experiences of learning using and functioning in l2 become a part of socializing with new peers and also local students and a new community however again as pellegrino observes stripped of the comfortable mastery of their fi rst language and culture and societal adrointness learners in immersion environment such as study abroad often report feeling as if those around them may perceive them to be unintelligent lacking personality or humor or as having thr intellectual development of a small child table 3 formal instruction and immersion in the second language the study abroad context source focus s wilkinson the study demonstrates that a sa period is the time of becoming more aware of ones national identity and its enhancement expressing the feelings of either superiority or inferiority towards the target group d gabryśbarker a case study of an erasmus student focusing on her development of language awareness but fi rst of all an intensive development of language identity and intercultural awareness and openness to other cultures during a threemonths stay at an english university c kinginger f whitworth an examination of the perceptions of femininity in different national contexts and becoming more aware of its cultural manifestations initially expressed as rejection and diffi culties with immersion in the french context and way of being seeing their surrounding thorugh american lenses l polanyi the study demostrates how lack of language skills makes the female subjects postion themselves as helpless receivers of sexual advances not being able to express their feelings and thus exposed to sexual harassment the need to develop language strategies to defend themselves impeded the development of their academic language competence while focusing on enhancement of their defensive verbal strategies in russian v pellegrino the case of a sa student positioning herself in the host family environment taking up the role of a learner and the host family as a superior in the teacher position which resulted in low selfesteem and selfrespect and low coping potential source focus j jackson despite a generally positive attitude to study abroad and the efforts institutions make to encourage mobility programmes the researcher questions the assumption that immersion will always lead to development of higher levels of language competenece or intercultural sensitivity thus more openness and internationalization the results and observations made on the basis of study abroad periods in relation to both language development intercultural sensitivity and also identity are quite diverse and determined by a a variety of not only contextual factors but most of all individual factors and differences in the affective and cognitve functioning of the subjects participating in the studies such a period is seen as a challenge for ones identity thus coping strategies and an ability to either integrate or reject come from ones personal predisposition and openness tolerance of ambiguity but also the intensity of life experience in international contacts a sample study of multilingual identites in formal instruction settings methodology of the study was block right in suggesting that there is very little identity construction occurring in a purely formal instruction context this study intends to offer some discussion observations and comments as to language identity formation occuring in a formal context of learning a fl in the students l1 country the main objective of the study was to make a comment on the perceptions multilingual language learners have of their own multlilingual identities the data was collected from a sample of twentyeight multlingual students of english at the university level whose l1 was polish l2 english l3 german all of them were preservice teachers of englsh as a foreign language in their fi nal ma semester they all attended an introductory lecture in multlingualism and became familiar with the basic terminology as well as participated in numerous refl ection sessions on what multingualism is and what it means to be multilingual the data presented here comes from one of such sessions where written responses from the students encouraged them to refl ect upon the concept of language identity and their own mulilingual identities the subjects were asked to refl ect upon their language identities in fi ve written tasks the fi rst task focused on their general perceptions of identity as a concept expressed by associations task 1 what do you associate language identity with next the subjects were instructed to think of similes that would best describe their identitites in the different languages they know it was assumed that metaphors give us a framework for thinking and refl ect the way we experience understand and interact with the world around us task 2 my l1 identity is like … taks 3 my l2 identity is like … taks 4 my l3 identity is like … the last task in the study consisted of refl ections in a form of personal narratives of approximate 450 words in which the subjects commented on the following task 5 how does using each of the languages you know affect your verbal and nonverbal behaviour language identity of fl learners in response to task 1 what do you associate language identity with the students expressed their views on language identity as a part of ones holistic identity emphasizing the need to be fl uent to talk about ones language identity in a given language language identity was very strongly associated with the affective functioning of a person and expression of emotions also li meant for the subjects a strong sense of belonging to a given group or community but equally important were ones idiosyncratic qualities li expresses internalization of historic cultural and symbolic values facts and issues important for a given language community but not only this exposure and international contacts were also delineated as signifi cant factors in defi ning ones language identity in task 2 a whole variety of similes expressed different perceptions of mother tongue identifi cation in my l1 identity is like … statements a constant possibility to develop language and express myself the key descriptors that appeared in the metaphoric expressions show that l1 identity means • something cosy and familiar home apartment • something safe a lifebuoy • something indispensable breathing air heartbeating • something valuable a precious ring • something free a bird fl ying freely in task 3 the subjects refl ected upon their fi rst foreign language english the key descriptors that can be inferred from the above similes express the dynamic character of the subjects l2 identities • something developmentalchallenging growing tree branches a hobby a physical training an adventure a garden being a traveller • something changeable a chameleon • something complementary a soulmate a piano • something usefulindispensablenice a toolbox an alldirections ticket a mobile phone a cupcake • something to hide behind a dressa make up • something precious a chest of treasures in the last task based on metaphors the subjects refl ected upon their perceptions of l3 identity climbing a tree which is unusually high an obstacle which is diffi cult to overcome as was in the case of l2 similes also here in its key descriptors of l3 identity its dynamic character is emhasised but this time with an element of challenge and diffi culty as l3 identity is seen as • something diffi cult happening a long journey an adventure climbing a tree • something challenging a hedgehog unusually high tree • something to work on a diamond in the rough an obstacle on the way • something to cope with cleaning a shed daily challenges • something offering security a parachute • something illusoryunstable a ghost a never ending story a snowdrop • something of a playinauthenticity a stage presence comparing the perceptions of l1 l2 and l3 identities it can be observed that there are many more descriptors in the case of l2 and especially l3 the metaphors present more unique patterns there is less predictability and more diversity and as a consequence less stability and more fl uctuation in these refl ections on the other hand there are almost clearly designated qualities characteristic of each language identity where • l1 identity is expressed as an inherent quality of each personpersona affective in nature • l2 identity is developmental indispensable and allowing to grow as a person satisfying ones needs but cognitive ones • l3 identity is challenging scary and illusory not fully surfaced and still under construction verbal and nonverbal behaviours in multiple languages in the last task of the study the subjects were asked to write a short refl ective text of 450 words on the following topic comment on how using each of the languages you know affects your behaviour in other words the object of the examination of the studentsnarratives were their behavioural patterns as expressions of the subjects different perspectives on their multiple language identities the general belief expressed was that language learning means learning new culture and behaviours as each language has different patterns of behaviour body language and views and as such it is a powerful and full of surprises process at the same time two other distinctive perspectives on the infl uence of individual languages on behaviour of the subjects were revealed different perspectivedifferent profi les of multlinguals perspective one was taken by an overwhelming majority of the students who believe that languages change our personalities and expose us to confusing behavioural situations and therefore being multilingual means a complex way of being different temperaments and behaviour it is emphasized that language is our personality and its use determines and describes us thus we are a different person in each language discovering oneself in each to form a coherent whole to illustrate the above here are examples of texts by subjects refl ecting on the above my identity consists of four languages i am open and more direct when i speak silesian i am more elegant and serious when i speak polish i am more comfortable when i speak english and fi nally i am easygoing when i speak german i have different memories and experiences connected with these languages which helped me become who i am now i learn a lot combining these languages and cannot imagine who i would be without them i am more organised determined and stronger because i know that i can achieve what i plan or have somewhere in my mind a stable and deeply rooted native language identity somehow made a ground to form my other identities developing language identity prompted me not only to improve myself as a language learner but mainly as an active participant of my school community from an extreme introvert and a shy person i was gradually transforming into a more openminded and selfconscious girl the last but not least important component of my multilingual language identity is being a teacher this is the place where all my three languages meet infl uence the way i function and perceive the world they also have a tremendous impact on the way i teach i know three languages and in each of them i am a different person furthermore i am proud that i can learn something about my personality behaviour comes not so much from profi ciency as a character of different languages these multilinguals see themsleves as possessing complex identities which impacts the changes in their personality and results in becoming more openminded tolerant and expressing more positive feelings as being a multilingual is like taking a journey open doors to new paths and new thinking views developmental motivator it also results in developing confi dence confi dence given by others eg in authentic communication versus insecurity in formal instructional settings these changes make one more aware of oneself and becoming more complete different languages and the learning processes involved and functioning in these languages in different contexts make a multilingual take different positions this perspective was very well expressed by pavlenko in the words speaking a different language means being a different person belonging to a different community character type emotional type i feel like i have a different personality in french when i speak dutch i feel like a more precise person perspective two expressed by 20 of the students sees languages is enriching us but not changing our personality thus functioning in l2 is like being an actress playing a role on the stage whereas in not very welldeveloped l3 we may feel like a child not an adult the above approach to mulitngual identiy is expressed in the following words of the subjects by being a multilingual person i have the ability to understand other people and i am more tolerant and open maybe i do not see myself as a truly multilingual person because i am very attached to polish language for me my multilingual identity means something very personal and intimate in my opinion identity means not only the way we communicate by using a language but also the culture traditions and history which are intrinsic part of a language identity all these elements make me a hundred percentage polish although i know four languages there is only one that i can fully identify with and it is my native language polish the process of language identity development is dynamic and it can change any time so maybe at some point in future i will identify with some foreign language that would for some reason become extremely important for me it is believed by the subjects in this group that all languages infl uence thinking but not behaviour and l1 shows who i am creates me as a person l2 is just a tool verbal and nonverbal behaviour in different languages the subjects comments in the narrative demonstate different patterns of both verbal and nonverbal behaviour when functioning in different languages as was expected l1 verbal behaviour is described as automatic spontaneous adjusted to a situation but also fast chaotic incoherent resulting from the safety of expressionbeing understood at the same time l2 verbal expression is often either abundant and upbeat it can be assumed this it is the case of more confi dent and extrovertic multilinguals when compared with inhibited fully controlled students who see using l2 like in a stage performance at the same time it does not preclude identifying with and belonging to a larger community interestingly the subjects seem to experience more security outside class and in communication with nss than in a controlled classroom situation where they postion themselves as learners subjected to the teachers authority and power traditionally understood in the case of l3 verbal behaviour seems overwhelmingly to focus on form and not content it is fully monitored and also stressful due to lack of language abilitycompetence as was the case of l2 l3 use seems more natural outside the classroom as they consider this use to be less stressful nonverbal behviour in l1 functioning is abundant and uncontrollable in the case of a gesture person thus it seems that the use of gestures maybe an innate idiosyncratic personality trait and as such it should not transfer to the other languages known to an individual at the same time it has to be pointed out that gestures or nonverbal communication in general become a conscious communication strategy in foreign language contexts the subjects believe that in l2 their gestures are frequent and more expressive but mostly controlled and used to gain confi dence and as such function as a compensatory strategy in the teaching context it becomes a didactic tool used successfully in a fl classroom to communicate meaning or to give feedback in the case of l3 use the subjects clearly declare their unawareness of their gestures or conscious avoidance of gestures because of unfamiliarity with nonverbal signs in l3ln here somehow gesture use is not perceived as a legitimate communication strategy the only situation that was pointed out was the use of gestures in stressful situations and to express negative emotions some of the students report on l2l3ln transfer of gestures characteristic of the target language it seems that nonverbal behaviour expressed by gestures across languages is perceived as performing welldefi ned functions in the context of teaching learningusing a given language • in l1 gestures are an expression of ones personality • in l2 gestures constitute a compensatory communication strategy demonstrating an affi nity with l2 • in l3ln gestures are an expression of affectivity or a occasionally a deliberate communication strategy it is interesting that the subjects who are mulitnguals with an extensive experience of learning and using foreign languages in varied contexts from formal to informal perceive nonverbal behaviour as being comprised solely of gestures neglecting other important nonverbal dimensions such as for example proximics eyecontact or tactile aspects of co mmunication final comments constructing language identity in response to blocks reluctance to acknowledge that foreign language learnersusers in formal instruction contexts form unique identities this study clearly demonstrates certain tendencies in how these learners see their mulilingual identity the multlingual identity of a fl learneruser as diagnosed in this study shows that being multingual means a complex way of being in which the use of a particular language from ones repertoire is welldefi ned l1 identity is inherent and affective l2 identity is developmental and fulfi ls mostly cognitive needs whereas l3 identity is still under consruction and presents a multilingual with a challenge in conclusion these perceptions and also the differences between multilinguals complex identities derive from the present past and desires for the future they emerge in the social practice of each language in varied contexts and through unique relationships with other people each time choosing different positions it has all to do with relations of power as was expressed in confi dence of language use beyond the classroom versus inhibition in the teachercontrolled context of a foreign language classroom the complextiy of multilingual identity construction originates from diverse learning contexts where the natural context versus formal instruction impacts roles and how one positions onself not to mention motivation and investment in language practices not without signifi cant impact is also the starting age of learning a given foreign language as adult learners will defi nitely have already formed their l1 identity and thus be a little more limited in integrating different attitudes values and beliefs pertinent to forming ones identity at the same time a strong desire to join an imagined l2l3 community may help overcome the above barriers one of the tools in this study was an explicit metaphor which is conducive to developing refl ective attitudes here of young multlinguals future teachers of a fl to become aware of themselves as individuals with complex identities resulting from their functioning in multiple languages constructing identities through metaphors is a good example of awareness raising metaphoric perceptions expand understanding of the underlying cognitive and affective aspects of multilingual identities they demonstrate integration of various factors and areas of life to form an understanding of what being a multilingual is as a process of becoming both a unique person and a social being as one of the subjects says being a multilingual means being unique something that links my three languages is the fact that they make me multilingual and special i am special because i have a gift of languages but also because i work hard to improve my profi ciency being multilingual is equal to being selfreliant and fulfi lled it is also being independent and autonomous in different situations i am a happy multilingual who knows herself and knows that my languages are one of the sources of that happiness

becoming more and more a multidisciplinary domain of study the development of research in second language acquisition and even more visibly in multilingualism has moved away from its sole focus on cognitive aspects to socialaffective dimensions consequently research in these areas makes more extensive use of research methodology characteristic of social sciences the focus on identity brings together issues of social context and the construction of ones identity through negotiation of who we are how we relate to the outside world and how we position ourselves in relation to others pavlenko 2001 language is the main tool in this construction negotiation through the acquisitionlearning and use of multiple languages in relation to the development of ones multilingual identity the major distinction has to be made between acquiring a language in its natural context the case of ones mother tongue or immigration and learning it in formal contexts block 2014 believes that the issue of identity can only be studied in a natural environment of language acquisition and not in a formal instruction context this article aims to confi rm or reject the above belief based on evidence from various studies of biand multiple language users and how they perceive their identities and their relation to the languages in their possession it includes a pilot study of trilingual language learners and their understanding of how the individual languages they know l1 l2 l3 build their identities and the way they enrich impoverish or challenge who they see themselves to have been by birth gabryśbarker 2018 the issues discussed relate to external other people situations contexts and internal identitybuilding factors individual affectivity personality features

distress after emergencies is very common with adverse psychosocial consequences and functional impairment for many who may never meet the criteria for mental health disorder 1 2 3 however a recent international review concluded that we understand little about the course of psychosocial distress after major incidents 4 understanding how people react and behave and their psychosocial and mental health needs before during and after major incidents is crucial to planning and delivering responses the psychosocial effects of extreme events can be influenced by a complicated combination of primary and secondary stressors 5 primary stressors arise directly from the event such as being injured or fearing for ones life secondary stressors do not inherently have their base in the event but in prior life events and societal responses to the disaster such as personal or financial losses and may be amenable to action to reduce their effects recent research has resulted in a growing awareness of the importance of secondary stressors and their potential to exacerbate and lengthen peoples experiences of distress following major events 1 6 7 8 however there is a dearth of research identifying which secondary stressors are particularly associated with mass terrorist events and how they can be targeted through effective timely psychosocial interventions research on the psychosocial and mental health effects of terrorist attacks has been predominantly quantitative and focused on identifying specific psychopathology usually posttraumatic stress disorder and depression within large cohorts of survivors these studies privilege the prevalence of signs and symptoms and neglect survivors personal experiences in terms of their experiences of distress over time and its impact on their everyday lives recently research has demonstrated that qualitative approaches can provide valuable insights into peoples experience of psychosocial distress and its course which is lacking in quantitative approaches 9 10 11 principles and models of psychosocial care and mental healthcare although most people do not require access to services that deliver specialist mental healthcare after major incidents the majority of people are likely to benefit from lower level but nonetheless important psychosocial interventions provided by their families friends colleagues or statutory and nonstatutory organisations 2 there is some evidence indicating that people who are distressed may not develop disorders if they are offered sufficient support in a timely manner 1 williams and kemp have created what they call the psychosocial approach 1213 informed by patel 14 it distinguishes people who are distressed from those who require biomedical interventions and advocates aiding the greater number of distressed people through lowerintensity psychosocial care psychosocial care sets out to bolster the recovery environment ensure that affected people are able to sustain their social connectedness and provide social support 1516 this approach is now embedded in guidance from nhs england and nhs improvement 17 although there is evidence of the effectiveness of specialist therapeutic interventions for disorders there has been less knowledge regarding the optimal provision of psychosocial care for the large proportion of people who develop mental health needs but do not meet threshold criteria for disorders 1819 this represents an important gap in the literature use of psychosocial care and mental healthcare after mass terrorist events the literature on peoples use and experience of psychosocial care and mental healthcare after mass traumatic events is scarce apart from a few recent notable exceptions there have been very few studies that reflect survivors voices 10112021 consequently relatively little is known about survivors experiences of services this is an important gap in the literature it is essential to learn more about these experiences to identify the aspects of care that meets survivors needs and strengthen their preparedness for future incidents 22 unmet healthcare needs after major incidents are associated with higher levels of psychosocial distress posttraumatic stress somatic symptoms and reduced social support it is also unclear whether the unmet needs reported are because of a lack of healthcare or receiving unsatisfactory care 22 unidentified barriers may prevent people from seeking or accepting care people who develop distress in the wake of terrorist attacks may be reluctant to seek help although the psychosocial factors underlying this restraint are not clear 23 the manchester arena bombing implementing psychosocial care and mental healthcare in practice on 22 may 2017 a suicide bomber detonated an improvised explosive device in the foyer of the manchester arena killing 23 and injuring 239 children and adults approximately 19 500 people were present at the arena and a high number of children and young people were involved the incident triggered an immediate response from the multiagency partnership in greater manchester that established the nhs manchester resilience hub which facilitated an assertive outreach and screen model with both public health and clinical components 24 the hub was operational 7 weeks after the incident the hub invited concert attendees to complete online screening questionnaires on stress anxiety mood and functioning using a customised web portal this screening was repeated at 3month intervals in the first year then 6month intervals and annually after 3 years respondents were assessed and allocated to psychosocial care pathways according to their level of need as we write over 3500 people have used the services provided by the hub this cohort presented an opportunity to increase our understanding of their experiences and the course of distress among survivors following the incident at the arena as well as the part that social factors such as family and personal relationships support services and the wider community have played in their coping and recovery objectives the objectives of the research reported here were to enhance understanding of the development expression mediation and mitigation of distress among people following the manchester arena event to identify what experiences of psychosocial care after the incident have helped or hindered people in their coping and recovery and to use participants experiences to learn how to better deliver and target effective psychosocial care following major incidents in future the whole study is reported in this paper and another there are cogent reasons for separating the two papers first it was not practical to combine them given the breadth and depth of each paper second they cover different dimensions of the psychosocial response to major incidents in this paper we explore survivors distress experiences and opinions about the statefunded support services the other paper explores the informal support afforded by families friends and wider social relationships method outline the study used crosssectional design and qualitative research methods employing semistructured interviews to identify the experiences of people who registered with the hub in greater manchester and their opinions about what interventions assisted them or otherwise the full interview schedule is in the supplementary material available at 20222 the interview was organised around the following topic areas the social context before the event experiences at the event and immediately afterward and social influences on coping and recovery the interviews were conducted with targeted groups of adult participants who showed personal responses to the routine screening measures adopted by the hub that were consistent with one of the three broad patterns in which people respond to emergencies and disasters 25 26 27 constructing the sample for the qualitative research all hub registrants were invited to indicate whether they wished to participate in future research and this created a subset of registrants from which the sample was drawn a purposive diversity sample was constructed from people in this subset who met the eligibility criteria on the basis of the scores of eligible persons on the manchester hub screening measures which included the trauma screening questionnaire 28 the patient health questionnaire9 29 the generalised anxiety disorder7 30 and the work and social adjustment scale 31 the measures are standardised and validated with established clinical cutoff points eligible people were defined as those who were directly affected by the arena event had at least one assessment on the hubs psychometric screening measures at the 3and 6month postevent time points and were aged ≥18 years on the date of their initial assessment there were no direct refusals to take part in the study from any of the hub registrants who were invited to participate however some people were unable to respond within the time frame of the study the researchers endeavoured to ensure the sample contained people with a spread of age home addresses inside and outside greater manchester and varying degrees of exposure to the incident and that parents and young people were represented an important criterion for choosing the sample size was to ensure that our cohort included people with a range of responses to the incident our perception following rigorous analysis of the interview transcripts is that we achieved thematic saturation within each of the three distress subgroups with the final sample size of 18 participants definitions one of the challenges in peoples experiences of major incidents is agreeing definitions of the terminology used one term that requires greater clarity is distress there are two broad approaches to defining it first some of the literature refers to distress being composed of symptoms of anxiety depression or posttraumatic stress disorder 32 at the outset we used the results of the screening measures to define in this way the levels of distress experienced by three groups of participants three subgroups were defined for this study mild moderate and severe response people in the mild response subgroup had initial screening scores as follows tsq score 6 phq9 score 09 gad7 score 59 and wsas score 110 people in the moderate response subgroup had initial screening scores as follows tsq score 6 andor phq9 score of 1019 or a score of 1 on the phq9 selfharm item andor gad7 score 1014 andor wsas score 1120 people in the severe response subgroup had initial screening scores as follows tsq score ≥6 andor phq9 score 2027 or a score of ≥2 on the phq9 selfharm item andor gad7 score ≥15 andor wsas score ≥21 the second common use of distress is in relationship to emergencies to depict people who have a range of experiences that are anticipated and usually much broader than symptoms of common mental disorders other accounts organise these potential experiences into emotional cognitive social and physical domains 33 we report our judgements of our participants experiences by examining the transcripts of 18 interviews and report the frequencies of these experiences reported by participants compared with reports in the disaster literature this research allows us to offer a third approach to defining distress on the basis of the experiences of people who say that they have been or are distressed conducting the qualitative interviews each of the 18 participants undertook a single semistructured interview conducted by one of two researchers by telephone the interviews were conducted over a 4month period between october 2019 and january 2020 participants were asked about their experiences at the time of the bombing and in the intervening period each interview lasted up to 1 h and focused on their experiences and interpersonal factors that appeared to them to have helped or hindered their recovery each participant was enabled to have a person of their choice present to support them and was offered followup support noone asked for a supporter to join them and one person took up the offer of support each interview was recorded with the permission of the participant and was transcribed verbatim each transcript was read by three researchers and the interviewers and broad themes were identified each transcript was then subjected to detailed thematic analysis by three researchers to identify important and common psychosocial themes the emergent themes were mapped consent each participant gave consent in writing to take part in the interview our recording their interview and its verbatim transcription and our use of the anonymised data in this research ethical approval ethical approval was provided by the uks integrated research application system process analysis the approach to thematic analysis was theorydriven and inductive in this paper we focus on participants accounts of the psychosocial care provided by the support services we set out to identify experiences of importance to participants within the broad question of support after the incident but which were not known to us a priori each transcript was read by five of the authors including the two interviewers and the issues that seemed important to the interviewees were coded each transcript was then subjected to detailed thematic analysis by jd js and rw 34 they independently coded and developed suggestions on themes before coming together to compare their definitions and merge and split themes as appropriate they agreed a thematic structure through this iterative process which was tabulated with definitions and examples for easy visual inspection and its reliability was further checked by asking someone from outside the project thomas redmond pennine care nhs foundation trust uk who used it with a subsample of the data results at interview participants were asked about their experiences at the arena in the immediate aftermath of the attack this provided detailed information in relation to what they witnessed on the night and their immediate responses their experiences were categorised as low medium or high exposure based on the following criteria people in the lowexposure subgroup experienced pandemonium and perceived threat to life people in the mediumexposure subgroup experienced pandemonium perceived threat to life and witnessed mild blood injuries people in the highexposure subgroup experienced pandemonium perceived threat to life and witnessed serious blood injuries and dead and dying people the levels of exposure of the three response subgroups are presented in table 1 statistical analysis confirmed that there was no evidence that the three response groups differed significantly in their level of exposure the overarching thematic structure of the study is shown in table 2 the results reported in this paper are organised around two domains experiences of distress and experiences of psychosocial care the superordinate themes and themes are illustrated by verbatim exemplars from the transcripts of the interviews mild moderate and severe denotes the extent of their initial reaction based on their 3or 6month screening scores domain 1 experiences of distress superordinate theme the patterns of distress theme 1 distress is universal a minority of the interviewees showed elevated scores on the screening tools indicating that they might have or might be developing a mental disorder however all interviewees were clearly distressed in terms of being demonstrably affected by their experiences based on their own accounts the following extract illustrates how one of the interviewees with mild distress described their reaction to the event … for the first 6 months after i couldnt enjoy activities without feeling guilty … that people had died and got injured … id think a bomb was gonna go off like its gonna happen right now … i started having a panic attack … at the time i was like … freaking out i was … physically shaking and i cant breathe and everything is really intense like every noise was so much louder than before participant 18 another person with mild distress on the hubs screening tools and not considered to require followup by the hub made a plea on behalf of everyone in distress who might not come to the early attention of support services through the hubs outreach and screen programme i wrote a big thing back to them the hub saying like even though i dont feel suicidal and all of the things youre asking … just because i dont tick all of the boxes on this and youre not worried about me doesnt mean im not suffering … because we were still traumatised just in a different way participant 17 based on the interviewees accounts there were no significant differences between the mild moderate and severe groups in terms of their experiences of stress or distress before the event or at the time of exposure at the arena theme 2 the duration of distress interviewees accounts of the course of their distress were reflected by the changes in their screening scores over time at 2 years the scores of everyone with moderate initial scores now had scores indicative of mild distress by contrast the severe scores group was less likely to show signs of recovery based on their screening scores a greater proportion of people with higher initial distress at first screening reported more enduring distress compared with those with milder distress all people in the mild group reported improvements in their initial distress at interview however some in this group were still troubled by persistent fears of recurrence and anxiety about their safety in public places and impaired functioning most people in the moderate and severe distress groups reported some improvement in their distress over time those in the moderate group were more likely to report improvement than the severe group however many in the moderate distress group were still experiencing some distress at the time of interview this predominantly involved fear of recurrence hypervigilance in public places and social avoidance in addition some people with moderate initial distress were resigned to enduring some form of longterm distress despite having received therapeutic intervention theme 3 the variety of distress people reported a wide range of features of distress after the arena incident 33 the frequencies of these experiences are summarised in table 3 under the headings of emotional cognitive social and physical reactions fear of recurrence and hypervigilance in social gatherings or public places were the most commonly reported forms of distress that invariably accompanied each other this was a common and uniform pattern in all distress groups avoidance and social withdrawal were the most commonly reported social reactions after the event some social withdrawal was a consequence of active avoidance of large crowds and fears of recurrence in most instances social withdrawal was not associated with avoidance of reminders or fear of recurrence many interviewees simply reported that they preferred to stay at home after the event and lost interest in being with other people and attending preevent social activities … for a long time i stopped socialising with people because i found it really hard to relate to people i still find it quite hard to make friends if that makes sense participant 10 interestingly the patterns of social withdrawal differed across the distress groups in the mild group it tended to be relatively shortlived with no more than a few days or weeks however some people in the moderate group and all of the severe distress group reported social withdrawal in the days and weeks immediately after the event that became more enduring in some cases social withdrawal was linked to longterm changes in lifestyle friendships and social group memberships regarding their emotional reactions many interviewees described being upset andor tearful after the event and this form of acute distress was common in all subgroups more persistent emotional reactions and low mood lasting for months or longer were only reported by people in the severe distress group physical reactions except for hyperarousal were more likely to be reported by people with higher levels of initial distress for example sleep difficulties loss of appetite somatic complaints and physical inability to perform everyday functions were reported by some people with moderate distress and many with severe distress in terms of longterm effects on physical health one person with moderate distress reported that they had developed irritable bowel syndrome in the aftermath of the attack and another person with severe distress stated that they had been diagnosed with stressrelated angina following the event shame or guilt were common emotional responses in both the acute phase and the longer term only a minority of people in the mild group reported this as a feature of their experience of distress in contrast shame and guilt were more likely to be reported by people in the moderate distress group and by everyone with severe distress the most common reason interviewees gave for feeling shame or guilt related to the intensity and duration of their distress many felt that they were weak or inadequate for experiencing distress at all … and a few weeks after i started to feel really guilty that i was even affected at all because i hadnt been physically hurt or lost someone … i still think its not ok for me to sit and wallow because nothing happened to me participant 17 guilt was also a feature of the accounts given by some interviewees who were parents they described the guilt they experienced for exposing their children to the attack and their perceived inability to provide adequate support afterward another parent felt guilty about leaving with their daughter and neglecting injured people one young person stayed to assist and experienced guilt about perceived deficiencies in the care they delivered however reports of survivor guilt were very uncommon theme 4 the meaning of distress the ways people made sense of their distress and the meaning that they attributed to it are important in understanding their suffering a number of participants for example were surprised by the intensity of their distress postevent its duration and the impact it had on their everyday lives often they reported their personal experiences of distress as atypical of them and as a threat to their perceptions of agency and selfcontrol other people were surprised by the severity of their distress compared with their perceptions of the extent of their exposure and the physical effects of the event as they struggled to make sense of their feelings they tended to make selfevaluations that were predominantly negative … it took me by surprised at how it made me feel and for how long … yeah because i think when it came to that november when i got some help i just thought well why am i still feeling like this i wasnt hurt i wasnt injured i didnt see anything so what on earths wrong with you … participant 12 superordinate theme the secondary stressors compounding peoples experience of distress many interviewees described events policies and practices that were not inherently based in or consequential to the incident itself but which became sources of substantial stress and compounded their experience of distress arising from the event these secondary stressors tended to be reported more frequently by people with higher initial distress and more enduring reactions the most common exacerbating stressors were the responses of services friends and family work settings the media and wider society the stress associated with the response of psychosocial and mental healthcare services was a recurring theme and related mainly to problems getting access to timely support or unhelpful experiences of care we are reminded that as well as being helpful services and the ways in which they respond to people who use them may also be secondary stressors this theme is highlighted later in this analysis theme 5 relationship stressors as reported in our other paper partners close friends and families were preferred for sharing personal experiences of distress and chosen sources of emotional support early on however peoples negative perceptions of some peoples responses to them inhibited further sharing and in some cases compounded their distress by affecting their coping and recovery … that made it distress worse … she wasnt a mum to me at that point it was a good 6 months where she was my mum but she wasnt being a mother … but at the time she didnt see what was happening like i did blame her a lot for a lot of it … participant 13 theme 6 work stressors the majority of interviewees were employed at the time of the arena event their experiences of the responses from people at work were mixed initial responses were predominantly positive participants felt that work colleagues provided emotional support and employers readily provided instrumental support in the form of reduced duties or paid leave however some felt that this support was relatively shortlived and evaporated over time as employers became impatient and their expectations of their employees return to preevent levels of performance increased in some cases people were forced to take longterm sick leave or resign from their jobs because of the stress caused by the lack of understanding and support from employers i had a really bad experience with work … after about 6 months i had to leave because i felt like i was being bullied … i was like the perfect employee … but because of the ptsd posttraumatic stress disorder i was having panic attacks … it was kind of they lost any sort of empathy or patience with me … so they started saying things … like you know its convenient that you have panic attacks at work and … try living sort of 247 with this sort of thing participant 10 theme 7 stresses on parents many parents described the stress of identifying services for their children and their concerns about their childrens recovery they reported that the distress they suffered that was directly associated with the event was compounded by stress arising from their roles and responsibilities as parents which became secondary stressors having to constantly be there to support daughter … it made things quite difficult obviously as a single parent i do have to work … i did take unpaid leave … youre a parent … and i am also a nurse and then that kind of comes out as well now looking back on it it has been really tough participant 14 theme 8 the response of the media many interviewees reported that exposure to news and social media coverage of the event exacerbated their distress some interviewees felt that the responses of news or social media were a direct and substantial source of stress that compounded their distress facebook was very brutal and very nasty just people making comments that were not very understanding and putting really horrible stuff that kinda worsened me participant 18 theme 9 perceived neglectwhat about us there were also perceptions that peoples psychosocial experiences and mental health needs were viewed as less important than the needs of bereaved and physically injured people in wider society this apparent inequity was both a source of personal stress and also affected their perception of entitlement to support i cannot tell you how negative it made me feel about myself when theresa may and everybody was on the news saying our thoughts are with the bereaved and the injured people and im sat at home my life had just gone before me … and im thinking i shouldnt feel like this because im okay i walked away why do i feel like this theyve not mentioned us so we should be okay and then it went on and on and on and we never got mentioned … participant 7 theme 10 the public responses of solidarity the public response to the event through social and cultural acts of solidarity that were intended to demonstrate empathy and compassion were sometimes experienced as a substantial source of added stress some interviewees reported feeling disconnected from the public and cultural displays of support and this compounded their distress i dont think it was helping that i was having to go into manchester every day and see all the we love manchester signs … it was just getting worse and worse and worse and i begrudged every single sign i saw and i hated it and it wound me up you know … it really aggravated me participant 8 in other cases interviewees experienced stress and disconnection from public displays of solidarity because they perceived them as inauthentic media driven and incongruent with their everyday experiences of personal support superordinate theme reluctance to seek help from services the interviewees turned to a wide range of support services for help with their distress however an initial reluctance to seek help from these services was a common theme in our interviews theme 11 i should be able to deal with this on my own some peoples reluctance to seek help from support services was based on negative selfevaluation of their ability to cope with distress in some cases reluctance was reported by people who were experiencing severe levels of distress i dont deserve to ring them … i should be strong enough to deal with all of this myself participant 8 in other cases it was based on the interviewees perception that the event was less stressful for them than for others and therefore their distress did not warrant support i feel like … like i know that i am lucky but then it makes me think like well some people did see a lot more and they need it support more than i need it so like man up participant 2 the following extract demonstrates how selfdenigration can result in some people dropping through the net of psychosocial care the charity organisation said somebody else will be in touch to take over but they never got in touch … i should probably have picked up the phone and got in touch …well i wont do that because im just wasting peoples time… participant 12 theme 12 the needs of others are greater than mine some people believed that care was only available to support people with greater needs in some cases they gave altruistic reasons for their reluctance to approach services i didnt necessarily ring them the hub because i just thought there is probably other people who wont be getting the same level of support as me participant 4 sometimes reluctance was based on the belief that support services were having to prioritise their response based on a hierarchy of needs this made some feel that they were less important and unentitled to support in the sort of early days where the only coverage was … the dead the deads families the injured you know and anyone else who was in the foyer and then everyone witnesses you sort of get put in this hierarchy and you dont feel like youre entitled to … the feelings that youre having participant 10 domain 2 experiences of psychosocial care services interviewees experienced a wide variety of psychosocial care from a range of services and gave detailed accounts of how this ameliorated their distress and facilitated coping and recovery however interviewees also reported unhelpful experiences in relation to accessing psychosocial care and perceived shortcomings in what was provided by services superordinate theme the importance of early access to appropriate care theme 1 not knowing where to go many interviewees reported that they made active efforts to identify sources of formal support in the weeks after the attack but did not know where they could obtain an appropriate service some reported relying on internet searches to find appropriate help and support the majority of the interviewees as reflected in the people at the arena and those supported by the hub were living outside greater manchester at the time of the event some perceived that services were centred in manchester and were not accessible to them i felt annoyed as all the help and support seemed to be based in manchester and i had nowhere to go … and i got pure rage and i sent over a really angry email to the woman who had written…saying that the language in it was all exclusive and…it excludes threequarters of the country… participant 1 theme 2 early help it wasnt early enough some interviewees thought that there could have been more immediate efforts to reach out to people who were affected by the event so that they did know where to turn if they were seeking psychosocial care for example some reported that the first outreach contact they received from the hub some months after the event did not come soon enough i mean i think the first screening … obviously we got the email from the hub to say … i think the first one wasnt until quite a few months i think 4 or 5 months after the attack … i think something more immediate would have been appropriate participant 3 some felt that the delays in accessing psychosocial care were not favourable to their coping and recovery i think if we would have got help sooner … the problem with having it 6 months down the line is youve started to recover a little bit for some things but then you have to go back and relive it again so it takes me backwards … participant 12 many parents felt that it was difficult to get early help and advice about the best ways in which they could support their children they described how this acted as a secondary stressor in that it compounded their own personal distress moreover they felt that earlier access to appropriate psychosocial care might have enabled them to provide better support for their children and reduce their childrens suffering i think for me particularly and as a parent who was there just to be able to know where to get help and support and advice from quicker than i did … because i did go out looking for it and i couldnt … i felt it might not have stopped the things that happened but it would have given me a bit of reassurance that it was what we were doing the right thing to do participant 14 theme 3 knowing that support is out there many people described how being aware that services were available and accessible if needed helped to mitigate their distress having information about whence they could turn if they decided to ask for help gave reassurance the following extract illustrates how this benefit was realised through retaining an information leaflet distributed by an official support service in manchester in the days following the event …there were people handing leaflets out so i took one and i kept that on my desk for a long time and just looking at it thinking i dont deserve to ring them …i shouldnt be ringing them i should be strong enough to deal with all of this myself but having it on my desk was a bit of reassurance that if i ever felt like i needed it that i could call it… so maybe just having that information there was helpful in a way that i didnt realise at the time participant 8 some interviewees when describing the hub referred to the benefits of just knowing that they had a service available to them at the end of the telephone if and when needed others thought that regular email contact from the hub provided them with emotional support because it signified that their distress was not forgotten what i did appreciate was that i continued to get emails even though they were … sent to everyone it wasnt like they stopped after a certain amount of time … just to know that someone cares and they know it has affected your life and always will participant 17 theme 4 encountering barriers to accessing support many interviewees reported that it was unhelpful to repetitively encounter barriers when attempting to access care indeed some thought that the stress of encountering service barriers compounded their experiences of distress and thus acted as a secondary stressor the barriers came in a variety of forms including for example being turned away for not meeting services threshold criteria for care and the delay of long waiting lists there were several people who were experiencing severe distress early on who found long waits in accessing adult mental health service assessment unhelpful a number of parents reported how unhelpful it was to experience long waiting lists watchful waiting responses and what they perceived as inadequate interim support from child and adolescent mental health services when their children were experiencing acute distress … she was clearly showing signs of ptsd posttraumatic stress disorder quite early on … anyway they child and adolescent mental health services said weve got a waiting list if you are concerned still in 8 weeks then call us back … and they sent out a trauma leaflet which arrived second class 2 weeks later and it was addressed to daughter but it was an adults trauma leaflet participant 1 in one case having encountered a series of hand offs and wrong doors in seeking suitable care a young person described how the stress of struggling to find appropriate care deterred them from seeking official support and caused them to turn to selfmedication … then it got to new year and it just went downhill from there i was in contact with the hub and they were saying try this place this place and this place… i dont know how many people i went to and they were like no so one particular place i went to … she was basically just very dismissive of it the enhanced outreach and screen model of the hub was generally experienced as helpful by the interviewees however some who experienced the screening algorithm with its inherent threshold criteria as a barrier in accessing psychosocial support … instead of generalising everybody and sending them the same stuff and then if they dont tick the right boxes then they wont get contacted or whatever maybe more a oneonone … participant 17 theme 5 being enabled to find the right help many people reported that it was helpful to have advice from the hub and other sources in finding and accessing care when they did not know where to go or when they were encountering barriers this sometimes involved signposting them to suitable or alternative psychosocial or mental healthcare services in other cases it involved fasttracking or procuring psychosocial support and therapy services … we found it relatively quick getting therapy … and im very very grateful to the resilience hub for bringing that forward like they did … but its not happened for everybody unfortunately participant 7 superordinate theme care is available but is it the most appropriate care theme 6 experiences of primary care in the early aftermath many interviewees turned to their general practitioners when seeking assistance with their distress they gave a variety of reasons for seeking support from primary care the most common was suffering severe levels of distress that affected their everyday functioning they also included difficulty sharing distress with others getting a sick note for work concerns about impaired memory and parents seeking advice on supporting their children the majority reported that the consultations with their gp were unhelpful many described encountering limited knowledge of the psychosocial effects of major incidents and appropriate support services and inappropriate offers of care the following extract highlights how one interviewee was apparently surprised and disappointed by the gps response to their distress and the offer of care it was about what to expect … and he gp goes right ill print this leaflet off and he said to me you are pretty much ticking all of those boxes and i went i know i know that … it was almost like he was teaching himself as he was reading the letter participant 1 some were more openly critical of the care offered by their gp and did not feel that it was suitable for their psychosocial needs at the time i just knew that i had mild mood and anxiety … i just feel bad but not depressed … and ive got family that have got mental health issues so i … knew that i was different from them … i was going to the doctors gp and they were saying take these pills you will feel better im saying no i dont want to take those pills i want people to talk to me and help me to get through this rather than block it out participant 16 a number of parents consulted their gp for advice in relation to how best to support their children the majority stated that they were left disappointed by the care that was provided … the girls i still kept them off school they were just exhausted and i phoned my gp and i was like so we have been at this what do i do … and then my gp was like i have absolutely no idea he was like i have never encountered this… i didnt know where else to go for advice … so i did feel a little bit sort of helpless really because i didnt really know what the best things to do was really or what to do participant 14 theme 7 the importance of authoritative validation and invalidation a salient theme in relation to helpful psychosocial care was the experience of authoritative validation authoritative validation can be defined as the recognition or affirmation of a persons distress and entitlement to care by a person who is perceived to have specialist knowledge or expertise in relation to the psychosocial effects of major events authoritative validation both confers positive connotations to a persons distress and seeking support and it challenges any negative selfevaluations ie people seeing their distress or helpseeking as a sign of weakness or inadequacy in the first example the interviewee describes how the first telephone contact with a professional at the hub changed the way in which they viewed their distress and provided some relief … it the hub was quite cathartic … i was really upset when i got off the phone but in a good way because i could see that there was like a light at the end of the tunnel … and i know times a healer and you have to wait certain things out … because i didnt know if i was going crazy if it was a normal thing participant 1 in other cases authoritative validation involved making the distress understandable to a person which draws on the science of how people react to and recover from traumatic events however examples of authoritative invalidation were also prevalent in accounts of experiences with services these experiences can be powerful in exacerbating distress and act as secondary stressors i wanted someone neutral in terms of the therapist … where i could kind of say those things that i wouldnt necessarily say to my mum … that was when i started having cbt cognitivebehavioural therapy which at this point was … a massive step back to be honest … im here to talk about the fact that i have been part of a terrorist attack … she said to me well you have 16 sessions from your doctor and if you were to abandon the sessions then you might not necessarily get the care again in the future participant 15 theme 8 promoting social connectedness this last theme concerns participants experiences of local support groups family days and workshops that were organised by the hub and other support services many interviewees reported benefitting from the opportunity to attend formal group events organised by services some people would have liked these events to have been provided sooner also some people who did not have the opportunity to attend a formal group said they would have liked this form of support participants said these events were helpful because they were a means of making connections with other people who have shared experience who later became important sources of support in coping adapting and recovery … there was two people i actually met from the hub workshop last year so i still keep in contact with them … so yeah i have met people through this experience and … i can talk to them and they can talk to me … not compare our experiences but kind of help give each other ways to … cope participant 11 we do not develop this theme in detail here because our other paper covers informal support in more detail discussion the qualitative interviews produced rich and detailed accounts of survivors experiences of distress over time its impact on their everyday lives and their perceptions of and experiences with services a key finding is that distress during and after incidents is ubiquitous but not necessarily a function of psychopathology including mental illness this supports a more dimensional and dynamic as opposed to a categorical view of distress in that people differed in the degree of distress they experienced over time rather than in kind 3536 this draws attention to unresolved matters in the use of language one of those is the way in which the term distress is used based on the research reported here we recommend use of the term as it is applied during and after emergencies to depict people who have a range of experiences that are anticipated and usually much broader than symptoms of common mental disorders viewing distress as a group of symptoms of undiagnosed disorders is less helpful the common experiences that the distressed people we interviewed reported included feeling upset fear anxiety fear of recurrence of the event excessive vigilance at social gatherings and in public places avoiding uncomfortable feelings and social withdrawal reexperiencing was less common and anger and moral distress were rare none of the interviewees spoke in terms that suggest they experienced shock and numbness this suggests that the view of distress that is often used in mental healthcare and portrayed in publicfacing leaflets may unintentionally reduce the chances of peoples needs being recognised it is important to recognise distress because the numbers of people affected are much greater than the numbers who screen positive for a possible mental disorder this means that screening scores should not be used as a proxy for the potential need for services because there are likely to be people who are distressed but do not report severe levels of mental health symptoms who are likely to wish to use services also it may be necessary to adjust the lists of the common features of distress that are often included in information leaflets and digital resources in the introduction we drew attention to recent reviews 4 opining that relatively little is known about the spectrum and course of psychosocial distress apart from the broad categories or trajectories of response the study reported here on peoples actual experiences provides valuable insight into distress which has not been the case with research more focused on identifying symptoms of psychopathology consistent with previous work on major events the intensity of initial distress was strongly associated with enduring and debilitating distress 37 however there were some reactions which have drawn less attention in previous research that appear to be associated with certain subgroups of distressed people physical reactions for example such as sleep difficulties loss of appetite somatic complaints and physical inability to perform everyday functions were reported by people with higher levels of initial distress and more enduring functional impairment as indicated by symptoms on screening tools this association has also been reported elsewhere 2138 and more recently in a longitudinal study after the terrorist attacks in norway in 2011 39 we also found shame and guilt to be common emotions in the acute phase that were more often associated with longer duration of distress hence the results from this study underscore the body of literature which indicates that shame has significant involvement in the intensity and course of distress following major incidents 40 shame is likely linked to enduring distress through a web of bidirectional psychosocial mechanisms we think that somatic reactions and shame might serve as early markers of the risk of more severe and enduring difficulties it may be important to include them in enhanced psychosocial screening and in targeting psychosocial interventions to mitigate the risk of distress becoming chronic however we acknowledge that these provisional findings namely that certain types of distress may be specific to certain subgroups need to be pursued in future grantfunded research from the interviews we identified the importance of assisting people to overcome the worrying tendency of certain participants to isolate themselves in the short and longer terms social withdrawal which was not associated with reminders of the event or fear of recurrence was common early on when it tended to be short lived however some people who were moderately or severely distressed reported early social withdrawal that became more enduring in some of these cases social withdrawal was linked to longterm changes in lifestyle friendships and membership of social groups having functioning social networks is a key predictor of wellbeing and recovery from major incidents 4142 both shortand longerterm social withdrawal could limit access to particularly valued forms of support after events therefore our view is that an early outreach programme is required to help people to avoid the risks of their withdrawing from social contacts the recovery trajectories and the enduring nature of distress found in our transcripts broadly fit with the existing literature 4344 however the screening data and our participants accounts suggest that the existing literature underestimates the number of people who take a long time to recover and distress may be intense and persist over lengthy periods of time this finding underscores the longlasting health and social consequences of disasters the implication is that planning should take account of these longer trajectories not only for groups of people who suffer mental disorders but also for people whose distress does not come to the attention of services in the beginning of this paper we highlighted the important role that secondary stressors can play in compounding and maintaining distress after major events and noted that our current understanding of the role of secondary stressors in the context of terrorist attacks is limited our findings advance our understanding they elucidate the common and potent stressors that affected our interviewees coping and recovery they show that inappropriate responses from their immediate friends and families in the form of social invalidation of their distress acted as an important secondary stressor inappropriate responses to their distress from their wider social context such as those from employers the media and the public were also substantial secondary stressors this finding suggests that although social support is often considered protective a more nuanced multidimensional understanding of social support should recognise that inappropriate forms of social support are not only unhelpful but may function as secondary stressors potentiate distress and be detrimental to coping and recovery however we emphasise that inappropriate forms of psychosocial and mental healthcare can also function as secondary stressors for example authoritative invalidation and encountering barriers to accessing support services our analysis has also highlighted that the predicaments of many parents in worrying about their children acted as secondary stressors the difficulty associated with identifying appropriate psychosocial care combined with increased caring responsibilities when coping with their own personal distress were a common experience the secondary stressors that emerged from the analysis were reported more frequently by people with higher initial and more enduring levels of distress in our opinion it is likely that there is a twoway rather than a linear relationship between distress levels and secondary stressors importantly we argue that all of the stressors were consequential socially mediated and preventable with timely and appropriate psychosocial care and intervention previously we cited previous studies that highlighted the association between unmet healthcare needs and higher distress posttraumatic stress somatic symptoms and social support this paper advances our understanding of the relationship between unmet care needs and distress which should be seen as important targets for more effective intervention in future first our findings indicate that the ways in which people appraise their subjective experiences exacerbate their suffering and make them reluctant to approach formal caring services we found that as people struggled to make sense of their distress they were often selfcritical of their apparent inability to cope and recover many perceived this as a personal weakness and felt that they should be strong enough to manage their distress on their own people who felt that their distress was in some way invalid or that services were prioritising others were reluctant to seek help previous studies have shown that selfappraisal moderates emotional sharing and seeking help from informal sources of support such as friends and families 4546 we think that our study is among the first to show that this process underlies an intrinsic reluctance to seek help from official support services perhaps preventive psychosocial interventions might focus on reducing negative selfappraisals that compound experiences of distress and reluctance to seek help second given these negative tendencies our participants reported that finally receiving validation of their suffering and their entitlement to care particularly from someone who they perceived to have special expertise changed the ways in which they perceived their distress and eligibility for psychosocial care which in turn facilitated coping and adapting this finding is consistent with the theoretical work of maercker and horn 47 who argue that social acknowledgement has an important effect on psychosocial adaptation to the primary stressor after adverse events authoritative validation can be viewed as a specific source and type of social acknowledgement that is a crucial component in psychosocial care however people also report that being told that their experiences are normal can be invalidating with good intentions it is likely that service providers were trying to convey its okay to not be okay however the message that came through to our interviewees was that their distress was so minor that it was just part of the normal experience thus the problem with normalising reactions to major events is that it can minimise peoples experience of distress and delegitimise their need for care this is particularly concerning given that there is growing evidence that invalidating experiences can be more powerful than validating experiences 4546 finding that some people experienced authoritative invalidation as a secondary stressor that compounded their distress and mitigated coping and recovery is of particular concern this emphasises the importance of ensuring that processes of validating peoples experiences by people whose opinions they respect are available this raises an important matter for messaging and for the availability of services it suggests that improvements to delivering the wellbeing and psychosocial agendas is necessary with more focus on social and authoritative validation in services responses when distressed people did decide to seek care some did not know how to find the right care and thought that active outreach from the hub should have been provided earlier some felt that the delays in accessing psychosocial care were not favourable to their coping and recovery and acted as a secondary stressor in addition many parents felt that it was difficult to get access to early help and advice about the best ways in which they could support their children they described how this compounded their personal distress and if available this kind of care might have enabled them to provide better support to their children who were also affected in contrast learning that outreach services were available and easily accessible to them if needed helped to mitigate peoples distress the implication of these findings is that people require early and open access to authoritative sources of information and emotional support many interviewees reported that it was unhelpful to recurrently encounter barriers when attempting to access more specialist care some people thought that the stress engendered by these barriers also exacerbated their distress and acted as a secondary stressor people benefitted from the assistance provided by the hub in finding care when they did not know where to go or were encountering barriers this finding emphasises the importance of planning care pathways and the importance of outreach it argues for coordinating outreach and offering the expertise of authoritative practitioners employed at hubs by specialist mental health services our interviews indicate that people who are affected regard the advice of their gps as important many of our interviewees visited their gps during the early response to seek validation and advice and in some cases referral this finding is consistent with recent research that shows that gps are the primary or first healthcare provider to whom people turn in the immediate aftermath of terrorist attacks 102021 our interviewees described variable responses some encountered limited knowledge of the psychosocial aspects of major incidents and available services and inappropriate offers of help including medication to our knowledge only one previous study has investigated peoples experiences of consulting gp services after a terrorist attack 10 this also found that most thought their gp had not been helpful or provided inappropriate care unhelpful experiences of primary care can have adverse consequences it can reduce further attempts at helpseeking and in some cases exacerbates distress and affects coping and recovery we think that this information confirms the vital role of gps and the importance of briefings for them to expand their knowledge the findings from our interviews substantiate the importance of peoples social connectedness and social support the hub in partnership with other services was instrumental in organising local support groups family days and workshops people who attended these events benefitted from authoritative validation useful information and advice importantly they valued the social connection with others who shared the experience moreover the relationships that developed from these events became important sources of longerterm social support and enabled coping adapting and recovery indeed several interviewees called for earlier facilitation of survivors groups and signposting to online groups for people with shared experience this reinforces the finding that people who are distressed need psychosocial interventions based on the principles of psychological first aid and particularly their need for social connectedness and social support 134849 taken together these findings support the view that more emphasis on psychosocial interventions is required in early outreach responses the ubiquity of distress the apparent limitations of psychiatric screening measures and the important role that psychosocial processes play in moderating distress and facilitating coping demonstrate the need for more attention to be given to the wellbeing and psychosocial agendas in future service responses to incidents strengths and limitations selfreports and historical and subjective accounts of early distress and experiences of social support have inherent recall bias 50 hence selfreport might be a potential limitation of the study for example we acknowledge that depression or dysthymia at the time of interview may have played a role in shaping or colouring our participants accounts of their lived experiences before the incident second it is possible that some survivors may have elaborated or falsified their experience of the event and the aftermath however our interviewers spent at least an hour with each participant and the level of detail in their accounts and their affective responses were consistent with their accounts conveyed conviction and were powerful the researchers also spent considerable time reading and rereading the transcripts of the interviews and it appeared that the participants accounts of their experiences contained a level of detail that was consistent with their reported level of postevent distress on the screening moreover our access to longitudinal screening data over 3 years mitigated this limitation in that participants historical and subjective accounts could be crosschecked with their initial and serial screening scores hence we were not persuaded that elaboration or falsification were major factors influencing the data there is good evidence that prior mental health problems female gender and younger age are key predisaster risk factors 51 having children affected by the event has also been associated with poor mental health outcomes 43 perhaps because of greater concern responsibilities and stress during and after the event severity of exposure is also a key risk factor in peoples responses postevent often showing a doseresponse relationship 18 this study selected a purposive sample representing the range of initial distress and recovery trajectories and exposure levels age family status and geography 45 we acknowledge that our sample has a gender bias in that it was predominantly female as such it was representative of the audience at the arena and the research positive cohort this gender bias could have implications for the interpretation of some of our findings we recognise that the subset of hub registrants from which our sample was drawn may not be fully representative of the much larger group of 19 500 people who were in attendance at the arena this wider group may have had somewhat different experiences given that they did not feel the need to use the hub another limitation is selfselection bias in the sample derived from the hub all participants had responded to active outreach and completed screening measures volunteered for research and consented to recruitment to this particular study this could have attracted more people with more severe distress however this inherent bias was mitigated by recruiting a purposive sample of people that included those with mild and moderate distress reactions the study explored participants subjective experiences of distress helpseeking and psychosocial care using qualitative methods this is rare in the existing literature on major events it has privileged survivors voices and demonstrates that qualitative approaches can provide valuable insights into peoples experiences of distress and its course which is lacking in quantitative approaches notwithstanding its strength the findings are based on only a small sample and might not be representative of all survivors a largerscale quantitative survey study is in progress to offset this potential weakness which we hope will reduce the risk of false interpretations a further limitation of this qualitative research study is that it has not been possible to pursue one of our original objectives that is to identify any possible underlying causal psychosocial mechanisms or processes mediating participants experience of distress our largerscale survey study and the subsequent quantitative data analysis will address this omission a strength of the study is that it explored the use and experiences of a wide range of both existing and newly established postevent support services a limitation is its specificity in that the findings may only have relevance to relatively wellresourced care systems that have the advantage of universal healthcare coverage and an active outreach programme in conclusion the study enhances the understanding of peoples natural common reactions and psychosocial processes and experiences of services and psychosocial care following the manchester bombing our conclusion is that it is very important for all of the agencies to come together well before any incident to agree a comprehensive plan using a tripartite framework as published by murray et al 52 that provides a way of understanding and responding to the many psychosocial and mental health effects of critical incidents these interventions fall into the categories of supporting the wellbeing of everyone affected providing support and focused psychosocial interventions to meet the needs of people who are struggling or have become distressed but who do not reach the threshold for specialist mental health assessment and treatment and identifying assessing and meeting the needs of a smaller number of people who may develop conditions that require specialist mental health assessment and possibly treatment this approach to major incidents is now included in recently published guidance for the national health service in england 17 this conclusion has several implications it is important to be aware of the potential duration of the effects of incidents on people who are affected although a minority of people require mental health services there is a much larger group of people who become distressed who do not require specialist mental healthcare but who do require psychosocial care provision for this group of people may not be adequate after many incidents the authors observe that there is a substantial agenda within all services for developing awareness of peoples needs after incidents and another for training and developing practitioners we think that our findings have implications for policy by enabling planners to take them into account when they design services for responding to events as well as for practitioners when incidents occur data availability the data from the qualitative interviews are not publicly available because they contain information that could compromise the privacy of the research participants correspondence john stancombe email supplementary material supplementary material is available online at declaration of interest

distress after major incidents is widespread among survivors the great majority do not meet the criteria for mental health disorders and rely on psychosocial care provided by their informal networks and official response services there is a need to better understand their experiences of distress and psychosocial care needsthe aims of our study were to enhance understanding of the experience of distress among people present at the manchester arena bombing in 2017 identify their experiences of psychosocial care after the incident and learn how to better deliver and target effective psychosocial care following major incidentswe conducted a thematic analysis of semistructured interviews with 18 physically noninjured survivors of the manchester arena attack who registered with the nhs manchester resilience hubdistress was ubiquitous with longlasting health and social consequences initial reluctance to seek help from services was also common early and open access to authoritative sources of information and emotional support and organised events for survivors were viewed as helpful interventions inappropriate forms of psychosocial and mental healthcare were common and potent stressors that affected coping and recoverythis paper extends our understanding of how people react to major events provision for the large group of people who are distressed and require psychosocial care may be inadequate after many incidents there is a substantial agenda for developing awareness of peoples needs for psychosocial interventions and training practitioners to deliver them the findings have substantial implications for policy and service design

introduction one of the oldest and most common forms of response bias studied in social science the social desirability bias is defined as an individuals propensity to respond in a way that is viewed favourably by society alike many forms of response biases social desirability bias causes misreports either by faking good or bad responses making the scientific inquiry of any social phenomenon challenging 1 selfreport surveys which are commonly used in attitudinal research are particularly vulnerable to such bias surveys that ask of sensitive or intrusive topics increases an individuals tendency to misreport for fear of social disapproval or embarrassment the tendency to misreport depends greatly on the sensitivity of the context and the magnitude of its confounding effect therefore varies while there are alternatives to selfreport measures that can improve the precision of data such as dietary or physical activity surveillance used in health research these alternatives incur larger administrative costs participant burden and intrusion 23 selfreport thus remains a popular method due to its ease of administration minimal costs and greater nonmaleficence what is considered to be socially acceptable depends largely on culture since such a bias is greatly attributed by sociocultural norms past research that are typically based on homogeneous and individualistic cultures may not be generalizable to a multicultural society in asia collectivistic societies that strive for cooperativeness and sensitivity may exercise more of such a bias than individualistic societies 4 however empirical data on the effects of social desirability bias is lacking in collectivistic societies similarly it is also unclear if westernderived constructs of social desirability can be generalized to a nonwestern population that is also multicultural 5 social desirability bias has been largely neglected in aspects of attitudinal research where there is a greater cause for concern of misreporting misreporting on lifestyle issues such as smoking physical exercise or dietary habits may in turn confound precision greatly needed to inform health policy 6 7 8 research has shown that social desirability bias is readily exercised by children and adults alike on selfreporting dietary intake for instance 910 individuals with a less than ideal height or weight tend to selfreport within the range deemed to be socially acceptable 11 similarly there is also a tendency to overreport physical activity levels to a significant degree 12 in singapore epidemiological research on physical and mental health are becoming increasingly apparent to name a few the national population health survey conducted by the ministry of health that began in 1998 13 the national youth survey commenced in 2002 14 the wellbeing of the singapore elderly population study which involved older persons above the age of 60 started its first iteration in 2010 15 the singapore mental health study which focused on nationwide mental health surveillance was initiated in 2009 16 and finally the knowledge attitudes and practices survey on diabetes commenced in 2019 17 all of which are ongoing epidemiological research with a central aim of providing uptodate representative data on the health and wellbeing of singapores population it is crucial to note that none of the existing local health research have studied the impact of social desirability bias at this juncture not enough is understood of the effects of such a bias on selfreported physical health and lifestyle concernsindicators that are typically captured in existing local epidemiological research if such effects exist how much of selfreport data is attributed to such a bias and which groups have a greater tendency to exercise such a bias understanding the direction and magnitude of the bias is thus necessary so as to address it singapore is a multiethnic and multicultural citystate in southeast asia with a population of approximately 4 million residents to the best of knowledge this is the first study to report the sociodemographic correlates of social desirability bias and its impact on selfreported lifestyle behavioursdietary habits and physical activity specifically results of the study will be beneficial for understanding the current level of bias if any in a multiethnic asian population methods data were drawn from a large crosssectional study called the knowledge attitudes and practices study which is a nationwide survey conducted between 2019 and 2020 to understand the kap of diabetes in relation to lifestyle factors in singapore the full details of the studys protocol and design have been published elsewhere 17 briefly singapore residents were randomly selected from a national administrative registry and were subsequently approached by trained interviewers at their households to complete a set of questionnaires an additional hundred diabetes cases were conveniently sampled all participants completed written informed consent and were compensated an amount for their participation an overall response rate of 662 was achieved which was expected result 1718 chisquare analyses between responders and nonresponders were conducted to ascertain response bias based on the original sample size of 2895 younger age groups 2070 p 001 those of malay and indian ethnicities 575110 p 001 were more likely to respond to the survey the study was approved by the relevant local ethics committees institutional research review committee and the national healthcare group domain specific review board measures marlowecrowne social desirability scale by crowne and marlowe measures the level of social desirability bias 19 participants were asked to make truefalse responses to 33 items individual item responses range from 1 to 2 however item 1 before voting i thoroughly investigate the qualifications of all the candidates was dropped from the questionnaire after participants expressed concerns that it assessed their political preferences and may be used for other purposes false responses were denoted as a 2 and true responses were given the value 1 the overall internal consistency of 32 items was found to be good the shortform versions were extracted from the original 33item items 12478131617182021242526272931 and 33 were reversed scored higher scores denote a greater bias global physical activity questionnaire developed by the world health organisation measures selfreported levels of physical activity on average at work travelling to and from places during recreational activities on average daily it also records selfreported minutes spent on sedentary activities per day such as sitting or reclining while awake 20 metabolic equivalents are calculated by the ratio of working to resting metabolic rate in minutesweek for each domain an overall global met score was subsequently calculated by the sum of mets in each domain except the sedentary domain which was calculated separately a locally validated diet screener was utilised to record the level of consumption of typical food and beverages in the past one year 21 respondents selfreported the frequency of foodbeverage intake on a 10point scale ranging from neverrarely to 6 or more times per day a dietary approaches to stop hypertension scorea sensitive measure to test against healthrelated outcomes 21 was subsequently calculated by the amount of intake of vegetables nuts or legumes fruit low fat dairy processed or red meat whole grains and sweetened beverages as a whole participants eventually received a score of 1 to 5 on each of the seven categories depending on the quintile level of intake 2223 which were eventually totalled as an overall dash score higher dash scores thus represent a healthier diet a sociodemographic questionnaire comprising of age gender ethnicity personal monthly income highest education level height and weight information were also completed by the participants statistical analysis as the mcsds scale was originally conceptualized in the west it is unclear if the original factorial structure is valid in a multicultural asian setting as factors of social desirability depend heavily on cultural norms that determine what constitutes a desirable response past research showed that the mcsds scale while internally valid and reliable do not have a consistent factorial structure across countries while the original onefactor solution has been supported in the icelandic population 24 various twofactor solutions have gained greater support such as in africa switzerland canada and in malaysia 25 26 27 additionally abbreviated versions of the scale that contain 10 to 20 of the original 33 items 2829 and that were created out of a need to address the lack of factorial fit and lengthiness of the scale have also been widely validated 3031 generally the assumed singledimensionality of alternative forms too have received mixed support 2432 thus prior to the main analyses confirmatory and exploratory factor analyses were conducted to ascertain the factorial fit of mcsds in the local sample confirmatory factor analysis missing data accounted for 233 of all data and were deleted listwise all analyses were conducted based on the final sample size of n 2988 to address the dichotomous truefalse format of the mcsds cfa was performed using unweighted least squares estimator set at a default mode of 1000 iterations and delta parameterization a fixed factor method for factor scaling was used by fixing the model factor variance to 1 and constraints were freed on the first item of each factor 33 model fit was assessed using absolute and relative fit indices ie model chisquare χ 2 root mean square error of approximation comparative fit index and tuckerlewis index this study utilised marsh et al s recommendations for good fit as the model evaluation criteria 34 rmsea 008 cfi 090 tli 090 exploratory factor analysis efa was subsequently performed on one splithalf of the sample to extract the factor structure of mcsds that gave the best fit of data similarly efa was performed using unweighted least square mean and variance with a default setting of oblique geomin rotation the final model derived from efa was tested using cfa on the second splithalf sample and eventually on the overall sample communality coefficients were calculated by the formula 1 estimated residual variances cfa and efa were performed on mplus 83 by muthén and muthén 35 multiple linear regression analyses to address the main aim of the study multiple linear regression analysis was performed on 2895 data points between sociodemographic categorical variables such as age gender ethnicity personal income and education levels and the total continuous scores of the 21item adapted version of the mcsds subsequent hierarchical linear regression analyses using the enter method were performed to ascertain the unique contribution of mcsds in predicting dietary habits physical activity and sedentary behaviours sociodemographic and bmi covariates were entered in the first step to control for confounds followed by the modified mcsds which was added in the second step weights were applied to the survey data for all multiple linear regression analysis for representativeness all missing values were deleted listwise the analyses were conducted on ibm spss statistics software version 230 results goodness of fit of original popular short forms and the modified version after dropping the first item of the scale due to participants concerns cfa was performed on the remaining 32 items and type a b c xx x1 x2 shortform versions to determine the factorial appropriateness of existing popular forms model parameters of all full and abbreviated forms of the mcsds derived from the cfa were unsatisfactory this led the team to conduct efa on the full 32item scale using a splithalf sample the number of factors extracted was determined by an inspection of the scree plot 36 which suggested an optimal extraction of three factors items that had weak rotated factor coefficients were removed this was proceeded by additional efa iterations to eliminate problematic items afterwards it was realised that the third factor could not be identified due to insufficient component saturation and common meaning between its two items leading author wlt to reconsider a twofactor solution the threefactor solution was thus rejected and multiple efas were subsequently performed to eliminate problematic items in the twofactor solution the degree of stability of the final twofactor model was confirmed by performing cfa on the second splithalf of the sample 37 factor coefficients with greater than 040 item loadings were retained resulting in the final retention of 21 items the final 21item twofactor solution was assessed with cfa on the second splithalf and eventually on the full sample parameter estimates of the final 21item twofactor solution showed vast improvements to the model fit and represented the best fit of data the modified 21item version the final adapted mcsds comprised two factors with 21 items the first factorcivil and lawful impressioncentralises on giving an impression of being seen as nonhostile or lawabiding the second factorintegrous image boostingcentralises on presenting oneself with an honest upright or refined image the 21item mcsds is hereafter referred to as the modified mcsds the internal consistency of the modified mcsds was found to be acceptable α 074 the correlation between the full mcsds and the modified version was r 938 with r 2 0890 sociodemographic correlates of the modified mcsds the overall model was significant f 1436 p 001 r 2 0168 multiple linear regression analyses revealed that older age as compared to younger age indian ethnicity as compared to the chinese ethnicity marriage history as compared to singlenever married and having no income as compared to below 2k and 10k and above income brackets were significantly associated with higher social desirability bias gender education levels malay and other ethnicities did not emerge as significant sociodemographic factors of the bias the results of the multiple weighted linear aggression analyses are summarized in table 3 the association between modified mcsds dietary habits and physical activity results from hierarchical linear regression analyses summarized in table 4 revealed that higher social desirability bias was significantly associated with healthier selfreported dietary habits b 0 discussion the main purpose of the study is to ascertain the association between social desirability sociodemographic and selfreported lifestyle factors prior to the main investigation the factor structures of the original 33item mcsds scale 19 and its popular abbreviated versions 2528 were evaluated in the context of a large representative multiethnic nonwestern population a total of nine cfas were conducted and the results showed that the full and shortform versions did not achieve adequate fit of data efa was subsequently conducted and a 21item twofactor solution was ultimately derived additional iterations of cfa on the full and split half samples revealed an excellent fit of data for the modified 21item version as the dimensions of social desirability are uniquely different in singapore as compared to elsewhere it is therefore necessary to discuss its factorial properties in this section overall the results supported a twofactor structure 26 30 31 32 like past studies various items on the full scale had weak rotated factor coefficients implying that not all items of the original scale had adequately captured the factors 24 unique to our investigation item 1 of the scale before voting in an election i thoroughly investigate the qualifications of all the candidates was removed due to significant concerns raised by participants during the survey but not due to weak factor loadings while future research that use this scale may include the first item for scale completeness users need to be aware that participants may feel uncomfortable answering this question facetoface and may have to contend with missing values the present results differed from millhams components of attribution and integrous image boosting appeared to strike a chord with paulhuss two components of the balanced inventory of desirable responding defined as the conscious dissimulation of test responses designed to create a favourable impression and selfdeceptive enhancement defined as any positively biased response that the respondent actually does believe to be true items that load on the cli factor corresponded to a mix of im and sde items whereas the items that load on the iib factor comprised a majority of sde items with a small overlap of im items the highly overlapping constructs of iib and sde factors could imply that they were measuring a highly similar construct an esteem boosting of selfimage whereas the lower degree of overlap between the cli and the im factor could signify a culturally nuanced form of social selfcontrol that is unique to the present population one that represents a form of social selfcontrol against the system or an authority future research could replicate and extend our findings further by investigating the stability and generalizability of the current factor structure in more stigmatizing fields such as mental illness perceptions in singapore 4041 it was discovered that social desirability explained a significant but small proportion of variances of lifestyle factors which corroborated past reports that were based in western communities or unrelated to healthbased research 1242 the small effect of the modified mcsds on lifestyle constructs could be due to the studys emphasis on anonymity and protection of personal data during consent taking despite it being conducted facetoface which could have brought about confidentiality confidence in participants older age groups those of indian ethnicity those who were ever married and those without income had a significantly greater tendency to respond in a way that is socially desired this could be due to unconscious social motivations underlying the need to boost selfimage such as the need for social approval to avoid negative evaluation or to be stereotyped against 19 as the surveys were conducted facetoface it is thus important for future epidemiology research to take into account these minority and or vulnerable groups improving the level of anonymity such as by the use of online selfadministered questionnaires 43 can further mitigate this bias across groups of individuals who have a greater inclination to give socially desirable answers thus leading to underestimation of the true extent of the problem in these communities gender was not a significant predictor of social desirability scores in the present sample which corroborated the majority of fig 1 extracted eigen values from exploratory factor analysis of the marlowecrowne social desirability scale past reports regardless of mcsds item makeup 1927303244 though a small percentage of variance of dietary intake physical activity and sedentary behaviour were attributed to social desirability bias not at all accounting for the bias is discouraged on the contrary such a bias should be measured and accounted for ideally in all healthrelated research that uses the selfreport methodology though facetoface interviewing may contribute to social desirability bias to a greater extent than onlinebased surveys this mode of data collection is essential to engage particularly hardtoreach demographics such as older respondents who may not be as internetsavvy therefore having a mix of online and offline modes of data collection should be encouraged in epidemiological research that requires population representation 4546 strengths and limitations several caveats have to be taken into consideration before conclusions can be made this study uses crosssectional data therefore causal or temporal inferences cannot be made in addition we did not use objective measures to determine the level of deviation from self reported physical activity dietary intake or sedentary behaviours and thus we could not establish the levels of discrepancies in selfreports attributed by the bias while the response rate of approximately 66 is acceptable 47 the results may not be representative of nonresponders as this study uses facetoface surveys social desirability bias may be larger than other surveying modes that provide better levels of anonymity however due to an ageing society facetoface interviews were necessary to engage hardtoreach groups such as older adults this was the first study that investigated social desirability bias in a multicultural asian context results are based on a large cohort sample that is representative of singapores resident population conclusion due to singapores unique cultural makeup preexisting popular abbreviated scales had failed to provide an acceptable factorial fit of local data instead a unique 21item modified scale had produced the best fit additionally certain groups of participants were identified to be more likely to exercise this bias which could be due to unconscious social motivations that interact with facetoface research nonetheless only a small proportion of variance of scores on selfreport lifestyle scores could be explained by social desirability bias which is reassuring as it suggests that participants were not greatly influenced by social expectations to respond in a socially desirable way despite a facetoface survey which has a lower level of anonymity than online surveys in conclusion measuring social desirability bias in healthbased research reliant on selfreport methodology is highly encouraged so as to account for its effects data availability the data that support the findings of this study are available but restrictions apply to the availability of these data which were used under license for the current study and so are not publicly available data are however available from the authors upon reasonable request and with permission data requests can be submitted to list of abbreviations competing interests none

background social desirability bias is one of the oldest forms of response bias studied in social sciences while individuals may feel the need to fake good or bad answers in response to sensitive or intrusive questions it remains unclear how rampant such a bias is in epidemiological research pertaining to selfreported lifestyle indicators in a multicultural asian context the main purpose of the current study is therefore to examine the sociodemographic correlates and impact of social desirability responding on selfreported physical activity and dietary habits at an epidemiological scale in a nonwestern multicultural asian settingprior to the main analyses confirmatory and exploratory factor analyses were conducted to determine the factorial validity of a western derived concept of social desirability multiple regression analyses were conducted on crosssectional data n 2995 extracted from a nationwide survey conducted between 2019 and 2020a unique factor structure of social desirability was found and was therefore used for subsequent analyses multiple regression analyses revealed older age groups the indian ethnic group those with past or present marriages and having no income had a significantly greater tendency to act on the biasthe construct of social desirability bias was fundamentally different in a multicultural context than previously understood only a small proportion of variance of selfreport lifestyle scores was explained by social desirability thus providing support for data integrity

introduction urban greennessor vegetationprovides an array of benefits that may promote health exposure to natural environments appears to stimulate healing and reduce stress 1 2 3 4 additional research in the us and europe indicate that urban greenspaces also provide opportunities for physical activity and social interaction while vegetation reduces exposure to noise 56 air pollution 7 8 9 and extreme heat 1011 recent studies and reviews have found evidence that neighborhood greenness is 2 of 15 associated with higher levels of physical activity better mental health outcomes less cardiovascular disease increased birthweight and decreased mortality 12 13 14 15 previous research also suggests that greenness in urban areas is not evenly distributed studies from australia and germany have found that the availability of greenspace is higher in urban neighborhoods with higher socioeconomic status 1617 in studies of several us cities racialethnic minorities and populations of lower ses were shown to have less neighborhood greenspace 1819 and parks 20 21 22 23 than white and higher ses populations although this is not universally the case 2425 this has led researchers to call for greater attention to social inequalities in access to greenspace and their implications for environmental justice and public health 2627 to our knowledge no studies to date have investigated changes in neighborhood greenness over time in relation to neighborhood demographics to assess whether inequalities in the distribution of greenness are decreasing or increasing racial residential segregation and social inequality are fundamental causes of racialethnic disparities in neighborhood physical and social environments and are crucial to understanding the social drivers of environmental health disparities 28 29 30 in previous work we found that the probability of living in a neighborhood without tree canopy cover and with a majority of its land area covered in impervious surfaces was higher in more racially segregated metropolitan areas compared to less segregated metropolitan areas for all racialethnic groups in the united states 31 another study found that within 1528 us cities residents of color and lowerincome lived in neighborhoods with less vegetation on average than their wealthier white counterparts and these differences were greatest in racially and economically segregated cities 32 these findings suggest that social inequality may play a role in shaping the availability and distribution of urban greenness in us cities one of the consequences of inequity and discrimination in the housing market has been the concentration of poverty in racialethnic minority neighborhoods 33 at the same time while racial residential segregation has declined somewhat in recent decades 3435 economic polarization within cities has grown 3637 this suggests that class or income inequality may be an increasingly important dimension to consider in understanding recent trends in urban landscapes through time herein we investigated the extent to which baseline neighborhood racialethnic demographics and income segregation in 2000 were associated with changes in neighborhood greenness between 2001 and 2011 across metropolitan areas in the contiguous us we use a remotely sensed measure of vegetation to test the hypotheses that neighborhood racialethnic makeup is associated with baseline greenness and also influences the degree of change in greenness over time we also explore the role of residential income concentration in structuring disparities in land cover using the index of concentration at the extremes 38 to measure the concentration of economic privilege and deprivation across census tracts within metropolitan areas we hypothesized that neighborhoods with higher proportions of racialethnic minorities and higher concentrations of economic deprivation would be less green at baseline and would experience a greater loss of greenness over the study period we also hypothesized that the relationship between a neighborhoods racialethnic makeup and the odds of living in a greener census tract would be differential by the level of neighborhood concentrated economic privilege materials and methods data sources data on selfreported racialethnic identity neighborhood poverty rate and housing tenure came from the 2000 decennial us census which we downloaded from the national historical geographic information system for the contiguous us 39 because ndvi data for the analysis spanned 20012011 we standardized all data to 2010 census tract boundaries in order to ensure trends in greenness were based on consistent geographic boundaries 40 census tract boundaries are drawn to reflect similar population sizes usually 2500 to 8000 individuals who share similar socioeconomic characteristics when possible they vary in size based on population density in this study urban census tracts had a median size of 36 km 2 for comparability with prior work 31 and because greenness likely has different qualitative meaning in urban and rural areas we restricted our analysis to census tracts in the contiguous us located in metropolitan areas as defined by the us census bureau with a 2000 population of ≥100000 41 normalized difference vegetation index ndvi is a commonly used measure of vegetative greenness based on remote sensing data and the light absorption characteristics of chlorophyll chlorophyll in plants absorbs visible light for use in photosynthesis while leaves reflect nearinfrared light ndvi calculates the ratio of the difference between nearinfrared light and visible light to the sum of these two measures and ranges from 10 to 10 with larger values indicating higher levels of vegetative density and photosynthetic activity 42 for this study we used ndvi data from the moderateresolution imaging spectroradiometer from the national aeronautics and space administrations terra satellite modis provides composite images every 16 days at a 250 m resolution we considered this level of resolution adequate to summarize greenness of census tracts that generally encompass a much larger area neighborhood ndvi assessed at this spatial resolution has also been previously linked with reductions in mortality 15 for our main analysis we obtained ndvi measures from modis based on images from 12 july 2001 to 2011 because for most parts of the us ndvi reaches its maximum and highest level of geographic variation during the height of summer we used the zonal statistics procedure in esri arcmap 104 to estimate the areaweighted average of the pixels in each census tract to estimate ndvi across the continental us in 2001 and 2011 when the census tract area was smaller than a single ndvi pixel we used the value of the pixel that intersected the census tract centroid we then subtracted the ndvi estimate in 2001 from the ndvi estimate in 2011 to get an estimate of the change in ndvi over this period we also conducted a sensitivity analysis using an annual average ndvi measure constructed by averaging ndvi values from four images for each tract and year raceethnicity we included five racialethnic groups in our analyses derived from 2000 us census counts nonhispanic asians and pacific islanders nonhispanic american indians nonhispanic blacks hispanics of any race and nonhispanic whites for analysis we created percentages of each raceethnic group at the census tract level by dividing the number of individuals in each group by the total census tract population neighborhood socioeconomic context a variety of possible measures of neighborhood socioeconomic context exist such as unemployment or poverty rates or the proportion of adults with at least a high school education 43 we elected to use the percent of renteroccupied housing units and ice for income 38 as measures of arealevel socioeconomic status we selected ice because it can simultaneously measure concentration of poverty and affluence we used a modified version of masseys 38 ice in order to summarize concentration of poverty and affluence at the census tract level whereas prior health studies have used national thresholds to identify gradients of tracts with high proportions of poor and affluent households 4445 we employed metropolitan arealevel specific thresholds to account for regional variability in incomes and the cost of living we calculated the 80th and 20th percentiles of metro area level income using 2000 census householdlevel income data we then defined ice for each census tract as follows ice ij t ij where a ij is the number households in census tract i whose income was ≥the 80thpercentile of income in metropolitan area j during the year 2000 p ij is the number of households in census tract i whose income was ≤the 20thpercentile of income in metro area j during the year 2000 and t ij is the total number of households in census tract i and metro area j during the year 2000 ice ranges from 1 to 1 where 1 indicates all households in the census tract are poor and 1 indicates that all are affluent for our analysis we utilized quintiles of ice where the lowest quintile contains tracts with the highest concentrations of poverty and the highest quintile indicates tracts with the highest concentrations of affluence environmental factors we anticipated that regional patterns of rainfall and ecosystem characteristics would affect local greenness we estimated cumulative rainfall at the county level in the 7 months preceding summertime ndvi satellite imagery in 2001 and 2011 46 the sensitivity analysis with annual average ndvi as the outcome measure utilized annual average cumulative rainfall in 2001 and 2011 we also considered including an estimate of temperature but neither average annual temperature nor the difference in temperature between the average warmest and coolest months provided much explanatory power in our analysis after adjusting for rainfall and were not included in our final models we also characterized census tracts using the level i ecoregions described by omernik 47 ecoregions represent broad regional classifications of ecosystems based on soil type landform major vegetation types and climate ecoregions were assigned based on the location of census tracts centroids because some ecoregions contained only a handful of census tracts we consolidated ecoregion 10 with ecoregion 12 and ecoregion 13 with ecoregion 11 thus we used eight ecoregion classifications 1012 1113 5 6 7 8 9 and 15 in our analysis from the original 59647 census tracts located in a metro area containing ≥100000 people we excluded 55 census tracts with zero population overall or zero population for whom poverty status was determined as well as those tracts without rented or owned housing units lastly census tracts for which 2001 or 2011 ndvi could not be determined were also excluded this yielded 59483 census tracts for analysis in both years statistical analysis the main goals of the analysis were to estimate the association between 2000 census tract level demographic characteristics and lines we also examined the average racialethnic composition of tracts across levels of ndvi this was done by calculating the average composition of tracts within each 001 increment of ndvi as follows c ij x ij t j where x ij is the total number of individuals of raceethnicity i living in a census tract of ndvi level j and t j is the total number of individuals living in a census tract of ndvi level j we then fit two sets of spatial error regression models 48 at the census tract level with ndvi as the dependent variable spatial error models do not assume independent and identically distributed errors but rather allow errors distributed by a spatial autoregressive process this type of model can account for residual spatial autocorrelation when units of observation are located proximally and thus nonindependently in space we defined neighbors as adjacent census tracts located in the four cardinal and four intercardinal directions from each other in the primary analysis we used variancestabilized weights but conducted a sensitivity analysis with rowstandardized weights all models were run using r statistical software 332 and the spdep and superlearner packages 4950 we considered associations statistically significant at the α 005 level first we conducted a crosssectional analysis to evaluate the association between 2000 census tract level racialethnic composition and 2001 ndvi and second a prospective analysis evaluating change in ndvi from 2001 to 2011 the main predictor of interest was percent of individuals of nonhispanic american indian asian black and white and hispanic raceethnicity at the census tract level in 2000 we standardized these continuous variables so that β coefficients were interpreted as the difference in ndvi associated with a standard deviation increase in the predictor variable initially we adjusted models only for a priori identified ecological and climatic variables omernik ecoregion and precipitation included as a continuous variable second we adjusted models for potential census tract level confounding variables also identified a priori population density percent of housing units that were renteroccupied and ice we hypothesized that these factors might confound the relationship between raceethnicity and ndvi because they are related to vegetation and because people of color on average live in more densely populated and less affluent neighborhoods and are less likely to own their own home we evaluated nonlinearity in the association between raceethnicity and ndvi by adding quadratic terms however only for change in ndvi for proportion white individuals did quadratic terms improve model fit as measured by likelihood ratio testing therefore for simplicity we ran linear models in a second analysis we evaluated whether observed relationships between raceethnicity and greenness differed by concentration of neighborhood poverty and affluence because we were concerned about extrapolating to nonexchangeable data in stratified analyses we used machinelearning derived propensity scores to prevent model extrapolation by limiting the stratified ice analysis to exchangeable census tracts 5051 we implemented logistic regression to create propensity scores for either an ndvi ≥ 04 or increased ndvi from 2001 to 2011 we excluded those census tracts with the highest and lowest 1 of the propensity scores by quintile of ice for income from our analysis in the crosssectional analysis we used logistic regression to estimate the odds of living in a green census tract defined as ndvi ≥ 04 by raceethnicity stratified by quintiles of the ice variable in the prospective analysis we estimated the odds of a census tract increasing in greenness defined as a change in ndvi 0 examination of semivariograms indicated that the residuals from these models did not exhibit spatial autocorrelation and thus we ran ordinary logistic regression models results population characteristics our analysis included 59483 urban us census tracts which contained 234071840 individuals in 2000 the average census tract in 2000 was composed of 09 nonhispanic american indians 43 nonhispanic asians 142 nonhispanic blacks 669 nonhispanic whites 132 hispanics and 05 other raceethnicity in 2001 the average level of satellitederived census tract greenness was 058 018 and the northeast appeared the greenest on average compared to 2001 census tracts became less green in 2011 particularly in the southern us we observed positive correlations between the census tract proportion of white individuals and both 2001 ndvi and the change in ndvi between 2001 and 2011 for percent asian black and hispanic individuals we observed bivariate analyses figure 2a illustrates the relationship between average neighborhood racial compositions in the year 2000 by level of 2001 ndvi the average census tract with ndvi 058 in 2001 contained about 07 american indians 4 asians 17 blacks 66 whites and 11 hispanics as 2001 ndvi increased the average percent of whites also increased linearly census tracts with ndvi 090 in 2001 contained on average 94 whites and 12 of other raceethnicities the relationship between 2000 racial composition and change in ndvi between 2001 and 2011 was less linear and more complex census tracts that lost the most greenness were composed on average of 1 american indians 5 asians 24 blacks 54 whites and 16 hispanics the proportion of the census tracts made up of american indians asians hispanics and other raceethnicities was fairly constant across changes in ndvi while census tracts composed of relatively more black residents had larger decreases in ndvi between 2001 and 2011 in bivariate analyses we found that ice was a stronger predictor of greenness than any of the indices of neighborhood socioeconomic context that we sought as potential alternates such as educational attainment and poverty this provided additional rationale for including ice as a confounding variable in our adjusted models multivariate analyses in crosssectional 2001 ndvi models each standard deviation increase in percent american indian asian black and hispanic raceethnicity was associated with a decrease in tractlevel greenness conversely a standard deviation increase in percent white was associated with 0043 higher 2001 ndvi in models only adjusted for climatic variables the relationship between percent raceethnicity and greenness was attenuated but still statistically significant for all raceethnicities in models additionally adjusted for population density ice for income quintiles and percent renteroccupied housing units at the census tract level for example a standard deviation increase in percent white was associated with 0021 units higher 2001 ndvi in the fully adjusted model an increase in the proportion of all other raceethnicities was associated with lower 2001 ndvi in the longitudinal analyses a standard deviation increase in 2000 percent hispanic raceethnicity was associated with a small but statistically significant reduction in ndvi between 2001 and 2011 while a standard deviation increase in 2000 percent white was associated with a 0004 unit increase in ndvi in the fully adjusted model in the sensitivity analysis using the annual average rather than the summertime measure of ndvi we observed qualitatively similar results but smaller effect estimates to those shown in table 2 one exception was that although the partially adjusted model indicated a decrease in baseline annual average 2001 ndvi per sd increase in the percentage of black residents this association attenuated towards the null in the fully adjusted crosssectional model we expected to find smaller effect estimates in the sensitivity analysis because spatial variation in greenness is most evident during the summer when plant growth is at its peak in most of the us given the consistency in the direction of effect estimates using both measures of ndvi and the evidence that summertime ndvi was better able to capture spatial differences in greenness we elected to use the summertime ndvi measure for the remainder of our analysis in a second sensitivity analysis we evaluated the influence of our choice of weights by repeating the main analysis with rowstandardized weights we found little difference multivariate analyses in crosssectional 2001 ndvi models each standard deviation increase in percent american indian asian black and hispanic raceethnicity was associated with a decrease in tractlevel greenness conversely a standard deviation increase in percent white was associated with 0043 higher 2001 ndvi in models only adjusted for climatic variables the relationship between percent raceethnicity and greenness was attenuated but still statistically significant for all raceethnicities in models additionally adjusted for population density ice for income quintiles and percent renteroccupied housing units at the census tract level for example a standard deviation increase in percent white was associated with 0021 units higher 2001 ndvi in the fully adjusted model an increase in the proportion of all other raceethnicities was associated with lower 2001 ndvi in the longitudinal analyses a standard deviation increase in 2000 percent hispanic raceethnicity was associated with a small but statistically significant reduction in ndvi between 2001 and 2011 while a standard deviation increase in 2000 percent white was associated with a 0004 unit increase in ndvi in the fully adjusted model in the sensitivity analysis using the annual average rather than the summertime measure of ndvi we observed qualitatively similar results but smaller effect estimates to those shown in table 2 one exception was that although the partially adjusted model indicated a decrease in baseline annual average 2001 ndvi per sd increase in the percentage of black residents this association attenuated towards the null in the fully adjusted crosssectional model we expected to find smaller effect estimates in the sensitivity analysis because spatial variation in greenness is most evident during the summer when plant growth is at its peak in most of the us given the consistency in the direction of effect estimates using both measures of ndvi and the evidence that summertime ndvi was better able to capture spatial differences in greenness we elected to use the summertime ndvi measure for the remainder of our analysis in a second sensitivity analysis we evaluated the influence of our choice of weights by repeating the main analysis with rowstandardized weights we found little difference raceethnicity and greenspace by quintiles of ice we used propensity scores derived from machine learning to restrict analysis stratified by quintile of ice to exposed and unexposed census tracts with the same probability of being exposed based on the other variables in our models originally each ice quintile contained either 11896 or 11897 census tracts after exclusions the number of census tracts included in analysis ranged from 9211 to 10045 the odds of being a green census tract consistently decreased with a 1sd increase in percent hispanics but the magnitude of the odds ratio became smaller as with increasing concentration of affluence conversely the odds of being a green census tract consistently increased with a 1sd increase in percent whites but again the magnitude of the association became smaller with increasing concentration of affluence an sd increase in percent blacks in the first two quintiles of ice was associated with increased odds of being a green census tract while an sd increase in the percent blacks in the 5th quintile of ice was associated with significantly lower odds of being a green census tract the relationship between the percent of census tracts made up of asian individuals and odds of being a green census tract did not appear to vary by level of ice in the percent whites was associated with increased odds of a census tract becoming greener from 2001 to 2011 and an sd increase in the percent hispanics was associated with reduced odds of a census tract becoming greener from 2001 to 2011 there was no significant association between white or hispanic raceethnicity and odds of a census tract becoming greener from 20012011 in the middle 3 quintiles of ice for an sd increase in either percent black or asian residents the odds of becoming a greener census tract from 2001 to 2011 followed a reversej shape across quintiles of ice in the lowest quintile of ice an sd increase in either percent blacks or asians was associated with increased odds of a census tract becoming greener from 2001 to 2011 however in quintiles 25 the odds generally declined as the percent of black and asian individuals increased discussion to our knowledge this is the first study to examine the relation between crosssectional arealevel measures of racialethnic makeup as well as affluence and poverty concentration and both crosssectional and temporal trends in greenness as measured by normalized difference vegetative index unlike prior environmental justice analyses of disparities in urban greenness our fewer clear patterns emerged from the analysis of change in ndvi between 2001 and 2011 stratified by ice quintile the relationship for an sd increase in percent whites and percent hispanics appeared to inversely mirror one another in the lowest and highest quintiles of ice an sd increase in the percent whites was associated with increased odds of a census tract becoming greener from 2001 to 2011 and an sd increase in the percent hispanics was associated with reduced odds of a census tract becoming greener from 2001 to 2011 there was no significant association between white or hispanic raceethnicity and odds of a census tract becoming greener from 2001 to 2011 in the middle 3 quintiles of ice for an sd increase in either percent black or asian residents the odds of becoming a greener census tract from 2001 to 2011 followed a reversej shape across quintiles of ice in the lowest quintile of ice an sd increase in either percent blacks or asians was associated with increased odds of a census tract becoming greener from 2001 to 2011 however in quintiles 25 the odds generally declined as the percent of black and asian individuals increased discussion to our knowledge this is the first study to examine the relation between crosssectional arealevel measures of racialethnic makeup as well as affluence and poverty concentration and both crosssectional and temporal trends in greenness as measured by normalized difference vegetative index unlike prior environmental justice analyses of disparities in urban greenness our study sought to assess the extent to which baseline racialethnic and socioeconomic composition was associated with changes in greenness from 2001 to 2011 and how that relationship may have varied depending on the degree of poverty concentration within neighborhoods overall in models controlling for ecological and climatic factors population density the proportion of renter occupied units and the concentration of poverty or affluence we found that tracts with a higher proportion of residents of color in 2000 tended to be less green and in the case of hispanics were more likely to experience further decreases in greenness between 2001 and 2011 than tracts with higher proportions of white residents the magnitude of these associations were moderate for example a sd increase in proportion white residents in 2001 was associated with about a 002 increase in ndvi in the health context a 01 increase in ndvi has been associated with a 20 g increase in birth weight 54 and a 12 lower rate of mortality 15 using annual average rather than summertime ndvi as our measure of greenness did not qualitatively change these results crosssectional models stratified by index of concentration at the extremes quintiles showed that racialethnic disparities in 2001 ndvi persisted across levels of affluence although differences between hispanics compared to whites narrowed slightly with increasing concentration of affluence the elevated odds of increased residential greenness for white asian and black residents in communities of concentrated poverty may reflect greening of urban communities related to gentrification of poorer neighborhoods in addition divestments and the foreclosure crisis during the study period may have led to an increase in green space in neighborhoods of concentrated poverty owing to an increase in the number of vacant properties and lack of development interestingly concentrated affluence was associated with an increase in greenness in only neighborhoods with a higher proportion of white individuals in 2000 conversely affluent neighborhoods with higher proportions of hispanic and black individuals had reduced odds of increased greenness this suggests an independent relationship between raceethnicity affluence and greenness stratified models for changes in greenness between 2001 and 2011 yielded mixed results an increase in the percent of white residents was associated with increased odds of tracts becoming greener in the poorest and most affluent tracts only while the opposite pattern was observed for hispanics for blacks and asians increases in the proportion of either group was associated with increased odds of a tract becoming greener at the lowest ice quintile but this association reversed with increasing affluence together these findings suggest a complicated relationship between changes in greenness over time and the spatial concentration of income that varies depending on neighborhood racialethnic makeup our crosssectional results showed racial and economic disparities in exposure to greenness that coincide with other analyses 18 19 20 2332 saporito et al used 2012 ndvi data to assess the distribution of greenness with a focus on differences in exposure between racialethnic groups and economic groups within cities despite differences between our studies in terms of approach in crosssectional analyses we found similar racialethnic disparities in exposure to greenness our study examined a broader range of racialethnic groups used different geographic units of analysis and utilized a different measure of economic segregation or inequality 55 although our study elucidated racialethnic and income disparities in exposures to greenness through time across diverse urban areas in the united states our analysis did not identify the fundamental drivers of these observed disparities moreover ndvi imagery cannot fully capture differences in the quality of vegetation across neighborhoods for example distinguishing between wellmaintained recreation areas and parks versus vacant lots that are overgrown with weeds therefore it is possible that high amounts of greenness or temporal increases in greenness in predominantly poor neighborhoods in cities such as detroit or baltimore for example may be reflective of the increased number of vacant lots due to decades of municipal abandonment and divestment 24 we assessed associations nationwide and did not assess regional or statespecific variability in relationships future research should consider heterogeneity by smaller units that may have resulted from state policy or single city greening efforts our analysis also did not include information on how much time residents spend each day within their neighborhood and the extent to which they interacted with or used greenspace nearby additional analysis is needed to better distinguish the relative accessibility of greenspace in urban and suburban areas for example the use of greenspace by diverse populations is not only determined by its location in a neighborhood but is also influenced by the presence of sidewalks to ensure that residents can safely walk there with young children future investigations should work to elucidate potential disparities in built and social environment attributes such as walkability perceptions of safety and private versus public access rights that affect the use patterns of greenspace across different racialethnic and socioeconomic groups 5657 given significant demographic shifts related to changes in land use housing construction and urban gentrification that is fueling the increased suburbanization of people of color and the poor 58 future analyses should also systematically explore relationships between simultaneous changes in neighborhood demographics and greenness within and between metropolitan regions in the united states to determine whether the suburbanization of poverty may shift sociodemographic patterns of exposure to greenness in the future this analysis has a number of strengths which contribute significantly to the body of literature on disparities in access to greenness first we analyzed data from a large sample including census tracts from all urban areas across the continental us to examine whether baseline demographic factors were associated with neighborhood greenness and changes in greenness over a tenyear period next our analyses were adjusted for socioeconomic ecological and climatic variables as well as population density and housing tenure which reduces the likelihood that observed associations can be explained by confounding finally this analysis incorporated an innovative measure of social inequality through the use of ice unlike other placebased measures of absolute levels of poverty and affluence that would provide the same coefficient if a neighborhood were 100 lowincome or 100 high income ice provides directional tendency toward an extreme and distinguishes between concentrations of very low or very high income at the neighborhood level 59 in addition ice can be applied at the census tract level as opposed to other inequality measures that are more appropriately applied to larger geographic scales such the gini coefficient 60 we also modified the ice measure by incorporating metroarea level income thresholds to reflect regional differences in incomes and cost of living across the us conclusions research has documented the public health benefits and value of parks and vegetation in metropolitan areas however our study builds upon a body of evidence showing that such amenities are often inequitably distributed across diverse communities in urban regions of the united states and that these disparities are not improving city planners and public health practitioners can better integrate urban sustainability health and social equity goals through investment funding allocations and other incentives for greenspace development that promote healthier neighborhoods and living environments in disadvantaged communities author contributions all authors contributed to the conception and design of the study joan a casey conducted statistical analysis created figures and prepared the first draft of the manuscript peter james provided the ndvi data peter james lara cushing bill m jesdale and rachel morellofrosch helped interpret results wrote sections and provided critical revision of the manuscript

background crosssectional studies suggest urban greenness is unequally distributed by neighborhood demographics however the extent to which inequalities in greenness have changed over time remains unknown methods we estimated 2001 and 2011 greenness using moderateresolution imaging spectroradiometer modis satellitederived normalized difference vegetative index ndvi in 59483 urban census tracts in the contiguous us we fit spatial error models to estimate the association between baseline census tract demographic composition in 2000 and 1 2001 greenness and 2 change in greenness between 2001 and 2011 results in models adjusted for population density climatic factors housing tenure and index of concentration at the extremes for income ice an sd increase in percent white residents a 30 increase in 2000 was associated with 0021 95 ci 0018 0023 higher 2001 ndvi we observed a stepwise reduction in 2001 ndvi with increased concentration of poverty tracts with a higher proportion of hispanic residents in 2000 lost a small statistically significant amount of greenness between 2001 and 2011 while tracts with higher proportions of whites experienced a small statistically significant increase in greenness over the same period conclusions census tracts with a higher proportion of racialethnic minorities compared to a higher proportion of white residents had less greenness in 2001 and lost more greenness between 2001 and 2011 policies are needed to increase greenness a healthpromoting neighborhood asset in disadvantaged communities

rate of poverty 10 in northern california black americans had 27 times higher odds of hospitalization after adjustment for demographics comorbidities and income 11 the reasons for differences in covid19 outcomes by raceethnicity are likely multifaceted however an underlying driver is likely the structural racism that influences health disparities seen across diseases 13 14 15 despite extensive evidence about structural racism as a contributor to racial health disparities genetics and biology are discussed frequently as possible explanations for differences 13 this ignores how structural racism influences environmental exposures the biological consequences of those exposures access to information about health and health outcomes themselves 13 14 15 understanding the historical perspective of a region or city through its policies and institutions provides important context and is necessary to appreciate how structural racism or the ways in which societies foster racial discrimination through mutually reinforcing systems of housing education employment earnings benefits credit media health care and criminal justice 15 influences disparities in health outcomes in that city or region 1516 milwaukee wisconsin is a highly segregated minoritymajority city located in the midwest 17 18 19 redlining policies and racially restrictive covenants in the 1930s through the 1970s limited the options of prospective minority homeowners and created residential segregation patterns that continue through today 2021 banks refused loans for homes in predominantly black neighborhoods and denied financial assistance to improve housing in alreadypoor neighborhoods 20 at the same time racerestrictive covenants ensured subsequent owners could not sell lease or convey property to nonwhite individuals 21 the resulting segregation resulted in black americans facing increasingly inadequate housing poorly funded public schools greater proximity to environmental hazards and growing distance from adequate food options and medical services 20 social issues became racialized and led to financial inequalities and reduced opportunities for education and wealth accumulation specifically within minority groups 20 when the covid19 pandemic began underlying segregation and the location of health systems within the region led to concerns that structural factors would lead to disparate outcomes unlike other major metropolitan areas such as new york city which experienced an early and severe wave of cases and deaths wisconsin experienced a slow growth of cases and health care systems were not overloaded this study examines racial ethnic differences in covid19 screening symptom presentation hospitalization and mortality in milwaukee and southeastern wisconsin given the widespread nature of the social factors noted earlier results from this study offer information that is relevant for other urban communities with patterns similar to those seen in milwaukee on the basis of differences in the trajectory of the pandemic compared with other states and the underlying structural racism that has existed in milwaukee and wisconsin for decades we hypothesized there would be significant racialethnic differences in screening rates symptom presentation hospitalization and mortality related to covid19 study data and methods population in this crosssectional analysis data were obtained from the froedtert and the medical college of wisconsin epic medical record the froedtert medical college of wisconsin system has conducted approximately a quarter of all covid19 testing in the state of wisconsin to date the primary hospital for the froedtert medical college of wisconsin system is located in milwaukee county a racially and ethnically diverse county located in southeastern wisconsin 17 compared with the us population milwaukee county has a higher percentage of black americans and a similar percentage of persons of hispanic or latino origin 17 four additional hospitals within the froedtert medical college of wisconsin system are located in surrounding counties that have lower percentages of minority populations compared with milwaukee county but are demographically more diverse than many counties within the state of wisconsin in addition to the five hospitals the health network operates nearly forty health centers and clinics and is the only academic medical center in southeastern wisconsin this analysis included 31549 adults tested within the froedtertmedical college of wisconsin health system who selfreported a race of nonhispanic white nonhispanic black or hispanic all other racesethnicities represented a small sample and were not included in this analysis criteria for testing changed over time on the basis of changes in guidelines from the cdc during the initial phase of the pandemic testing was provided only for individuals presenting with a history of shortness of breath or cough with or without fever the list of symptoms considered for testing expanded over time according to updated cdc guidelines and now includes fever or chills cough shortness of breath fatigue muscle or body aches headache loss of taste or smell sore throat congestion or runny nose nausea or vomiting and diarrhea in addition those eligible for tests expanded over time to include individuals exposed to covid19 and individuals coming to the health care system for other health needs the guidelines for testing in place at the time of submission of this manuscript recommended that the people who should be tested were symptomatic patients patients being admitted to the hospital patients being discharged to a skilled nursing facility patients in ambulatory care settings where clinical decision would change as a result of the test patients being scheduled for a procedure or scheduled for admission to the hospital and health care workers and students suspected of exposure to covid19 tests were not conducted on employees as a requirement for return to work although the racialethnic breakdown across hospitals and clinics within the system differs criteria for covid19 screening and treatment were consistent regardless of location covid19 status covid19 testing was conducted by collecting two swabs from each patienta nasopharyngeal specimen and oropharyngeal specimenusing a minitip and regularsize flocked swab respectively swabs were transported to the laboratory in viral transport media testing was performed using the approved cdc covid19 assay with rna extracted using the biomérieux emag and realtime polymerase chain reaction was performed on abi 7500 fast dx thermal cyclers per the cdc protocol 22 all patients with completed covid19 tests were identified using the medical record patients were considered positive cases if the initial repeat or followup test result was marked detected variables data were abstracted from the medical record using structured query language for all individuals in the sample including demographic information past medical history hospitalization and mortality information individuals without raceethnicity in the electronic medical records or who reported a race other than nonhispanic white nonhispanic black or hispanic were excluded from analyses demographic information included sex age raceethnicity county of residence and primary payor past medical history included tobacco use body mass index and comorbidities comorbidities were defined on the basis of international statistical classification of diseases and related health problems tenth revision codes within the enhanced elixhauser categorization validated by hude quan and colleagues 23 counts using the elixhauser coding structure captured burden of comorbidities by first identifying comorbidities for each individual then a count of comorbidities was created for each individual and categorized into zero one to two three to four and five or more patients with a positive covid19 test were identified as hospitalized or not hospitalized covid19 was not required to be the primary diagnosis in the hospitalization initial symptoms from the hospitalization were collected based on the record within the first twentyfour hours of clinic visit checkin time or hospital arrival time symptoms investigated included cough fever shortness of breath fatigueweakness and muscle pain allcause mortality was based on an indication of deceased in the medical record which is deemed a reliable indicator of inhospital allcause mortality 24 statistical analyses descriptive statistics are presented to summarize sample characteristics three samples within the population of all tested adults were investigated any individual tested which included both negative and positive results any individual with a positive covid19 test result and any individual with a positive covid19 test result who was also hospitalized analysisofvariance chisquare and fishers exact tests were used to calculate differences between demographic and clinical factors by raceethnicity unadjusted and adjusted logistic regression and cox proportional hazard models were run to understand the independent relationship between raceethnicity and covid19related outcomes the first model estimated the odds of having a positive covid19 case by race ethnicity among all adults tested within the health system using a logistic model the second model estimated the odds of hospitalization by raceethnicity among adults with a positive covid19 test using a logistic model the third model estimated the hazard ratio for mortality by raceethnicity among adults with a positive covid19 test using a cox proportional hazard model covariates included sex age geographic location primary payor tobacco use and comorbidity count covariates were selected on the basis of known confounding within the disparities literature or factors found to be statistically significantly different by raceethnicity in preliminary bivariate analyses sas version 94 was used for all analyses twosided tests were conducted and p 005 was considered statistically significant the medical college of wisconsin institutional review board approved the study before data abstraction or statistical procedures were conducted limitations the primary limitation of this study is inclusion of patients from a single center in the midwest us however this is also a strength of the study in that it provides muchneeded information on an understudied part of the nation deeply affected by residential segregation and structural racism and can be generalized to other highly segregated cities second as data were collected from the medical record we could not account for social factors not captured in the record third all data available in the record were used in this analysis with no further investigation for falsepositive results fourth given the sample size risk for mortality may be limited by power fifth starting in may testing guidelines allowed health care workers and students to be tested if they had been exposed to covid19 as part of health system surveillance as they were less likely to have chronic conditions but more likely to have health care exposure this may have influenced the likelihood of covid19 positivity for younger individuals with low comorbidity count finally these data are crosssectional and cannot speak to causality longitudinal followup with individuals is needed to inform the course of disease and longterm outcomes study results covid19 screening overall 2219 of the 31549 individuals screened tested positive for covid19 although 754 percent of those tested were nonhispanic white they made up only 481 percent of the positive cases only 198 percent of those tested were nonhispanic black yet they made up 418 percent of the positive cases just 48 percent of those tested were hispanic ethnicity but they made up 101 percent of the positive cases screen positive rates differed by raceethnicity with 45 percent of nonhispanic white 149 percent of nonhispanic black and 148 percent of hispanic adults screening positive among the total sample of those screened adults who screened positive were more likely to be men minority raceethnicity residing in milwaukee county selfpayuninsured or medicaid have a higher bmi and have type 2 diabetes comorbidity count was significantly associated with screening result with individuals who screened positive more likely to have fewer comorbidities demographic characteristics and symptom presentation among the 2219 adults who screened positive for covid19 there were significant differences by raceethnicity in nearly all demographic and clinical factors in unadjusted analyses these differences included younger age of hispanic adults minorities primarily living in milwaukee county higher medicaid enrollment for nonhispanic blacks and hispanics higher selfpayuninsured in hispanics and more current smokers among nonhispanic blacks nonhispanic black adults also were more likely to have congestive heart failure hypertension chronic pulmonary disease diabetes renal failure fluid and electrolyte disorders and anemia and were more likely to have five or more comorbidities among 489 hospitalized patients with covid19 the only racialethnic differences in symptom presentation were that nonhispanic blacks were more likely to present with cough and hispanics were more likely to have no symptom on record for all five symptoms investigated 25 hospitalization and mortality unadjusted proportions for hospitalization by race were 220 percent overall and 161 percent for nonhispanic white 290 percent for nonhispanic black and 214 percent for hispanic adults unadjusted proportions for an intensive care unit stay during hospitalization by race were 100 percent overall and 78 percent for nonhispanic white 125 percent for nonhispanic black and 103 percent for hispanic adults unadjusted proportions for mortality by race were 54 percent overall and 45 percent for nonhispanic white 63 percent for nonhispanic black and 63 percent for hispanic adults adjusted models for racialethnic differences in outcomes in adjusted analyses nonhispanic black adults were 37 times more likely and hispanic adults were 31 times more likely to have a positive covid19 test compared with nonhispanic whites in addition men were more likely to screen positive than women and selfpayuninsured individuals were more likely to screen positive compared with those with a managed carecommercial payor individuals living in milwaukee county and the counties immediately surrounding it were also were more likely to screen positive compared with those in other counties that have primarily rural white populations among those who had a positive covid19 test minorities were two times more likely to be hospitalized compared with nonhispanic white adults after adjusting for demographics and comorbidities in unadjusted models there was no significant difference in mortality by raceethnicity after adjustment compared with nonhispanic whites hispanics were two times more likely to die and there was a small but statistically nonsignificant difference for nonhispanic blacks discussion in this study from a large health system in milwaukee and southeastern wisconsin nonhispanic blacks and hispanics were statistically significantly more likely to screen positive for covid19 and have higher hospitalization rates among those who tested positive for covid19 when compared with nonhispanic whites differences by raceethnicity were independent of sex age county of residence payor smoking status and comorbidity count limited differences existed in symptom presentation by raceethnicity finally hispanics had higher mortality compared with nonhispanic whites for covid19positive individuals whereas nonhispanic blacks had a small but not statistically significant difference in mortality this study adds to the growing body of literature about racialethnic differences in covid19 by providing results for a highly segregated city in the midwestern us that experienced a slower rate of growth in covid19 cases than elsewhere in the country results showed that racialethnic minorities were more likely to screen positive for covid19 which is consistent with prior studies from other regions of the us 891126 findings are also consistent with national case surveillance reports indicating that nonhispanic black and hispanic adults are disproportionately affected by the covid19 pandemic 27 given the amount of missing data in national surveillance information 27 these findings add to the growing body of literature that uses local data with more complete race ethnicity information 91126 results from this study are also consistent with those from one study in northern california which found that nonhispanic black adults were more than twice as likely to be hospitalized 11 a second study conducted in new orleans found that although nonhispanic black adults made up a higher proportion of confirmed cases once hospitalized race ethnicity was not associated with higher inhospital mortality 9 a recent analysis found a strong relationship between minority race and populationlevel covid19 mortality although these differences varied widely across states 28 our results regarding mortality were similar to the study conducted in new orleans which was also based on data from electronic medical records the mixed results with regard to mortality in our sample were probably a result of the low event rate and because the group predominantly comprised individuals with access to medical care therefore ongoing tracking and monitoring for disparities in mortality across states should continue given the independent associations between raceethnicity and covid19 outcomes some of the social and structural factors not available in our data set are likely important drivers of these findings on the basis of the longstanding history of systemic racism in the milwaukee and southeast wisconsin area that existed before the covid19 pandemic structural racism is one factor that could have contributed to the current findings 12 13 14 15 as previously noted the socioeconomic and political context of a community heavily influences the social position and material circumstances of individuals 29 therefore to comprehensively address disparities that have been magnified by covid19 it is necessary to target policy efforts toward the overarching structural systems that perpetuate health inequities these policies can include influencing the distribution of wealth instituting policies that increase economic empowerment funding programs that enhance neighborhood stability and deploying targeted interventions that address social risk factors 30 a recent communitybased case study conducted in milwaukee identified a new paradigm for addressing health disparities in innercity environments 31 the study suggests that mass incarceration residential segregation statesanctioned violence housing instability food insecurity intergenerational poverty and the limited educational opportunities that characterize the lived experience of innercity african americans create a state of chronic stress which leads to poor health and increased disability and ultimately leads to decreased human capital that study also proposes a new paradigm that posits that innercity challenges are a result of manmade disasters and as such solutions should be based on wellestablished disaster response models and include investments that help individuals meet social needs expand economic and educational opportunities and meet health needs in a way that improves human capital and economic productivity built on feedback from innercity african americans this framework can inform larger policy efforts by combining support for programs that address the most pressing basic and social needs and creating systems that build longterm capacity within the inner city 31 finally future research is needed that incorporates detailed information on social determinants of health that is currently not available in the medical records to allow more robust and detailed examination of pathways and mechanisms as well as helping to inform where best to target policy changes for example emerging evidence suggests that being employed as essential workers and living in multigenerational housing structures may explain the higher covid19 positivity rates in ethnic minorities 4679 but these types of data are not readily available in the electronic medical record and need to be included in future analyses as efforts continue to mitigate the current disparities in covid19 outcomes conclusion this study examined racialethnic differences in covid19 screening symptom presentation hospitalization and mortality minorities were more than three times more likely to screen positive for covid19 and two times more likely to be hospitalized and hispanics were two times more likely to die compared with nonhispanic whites given the longstanding history of structural racism residential segregation and social risk in the us and their role as contributors to poor health efforts to mitigate these disparities should incorporate new frameworks and policies that address structural racism and evaluation of mechanisms and pathways that are not currently available in analyses that use data from electronic medical records health aff author manuscript available in pmc 2021 november 01 supplementary material refer to web version on pubmed central for supplementary material

this study aims to understand racialethnic differences in coronavirus disease 2019 covid19 screening symptom presentation hospitalization and mortality using data from 31549 adults tested for covid19 between march 1 and july 10 2020 in milwaukee and southeast wisconsin racialethnic differences existed in adults screening positive for covid19 45 percent of nonhispanic whites 149 percent of nonhispanic blacks and 148 percent of hispanics after adjusting for demographics and comorbidities minorities were more than three times more likely to screen positive and two times more likely to be hospitalized relative to nonhispanic whites and hispanics were two times more likely to die than nonhispanic whites given the longstanding history of structural racism residential segregation and social risk in the us and their role as contributors to poor health we propose and discuss the part these issues play as explanatory factors for our findings as of september 30 2020 the centers for disease control and prevention cdc reported that the us had had 7129313 total cases of coronavirus disease 2019 covid19 and 204598 deaths 1 demographic and clinical factors such as older age and preexisting conditions including diabetes hypertension and chronic lung disease are associated with higher risk for severe disease and poor outcomes 2 3 4 across the nation the burden of covid19 has been disproportionately borne by some racialethnic minority groups 5 6 7 8 9 10 11 12 nationally black americans and hispanics have covid19 hospitalization rates more than 46 times higher than nonhispanic whites

introduction it has been demonstrated that ethnicity is associated with migration in connection to the notion of social capital referring to the social networks created by the ethnic groups ethnicity is also connected to migration through ethnic capital defined as an externality from ones ethnic environment that contributes to ones human capital accumulation in this paper we use these concepts to conceptualise persisting migration behaviour of an ethnic group for the case of indonesia assessing the relationship between ethnicity and migration in indonesia provides an excellent opportunity to study this issue in the context of a multiethnic country because indonesia is the largest archipelago in the world that hosts about 600 ethnic groups which can be classified into 31 larger ethnic groups 1 in addition as will be elaborated in this paper the relationship between ethnicity and migration in the indonesian context needs to cover the geographical location and historical processes such as the colonial period that have shaped and continue to shape the migration behaviour of ethnic groups the homes of these ethnic groups are some of indonesias largest islands from west to east 2 sumatra batak minangkabau malay and south sumatra 3 java bantenese betawi sundanese cirebonese javanese and madurese bali balinese kalimantan banjarese lombok and its adjacent island sumbawa sasak bima and dompu and sulawesi buginese and makassarese islands outside java were usually referred to as the outer islands one of the rationales for studying ethnicity and migration in indonesia is that intergroup contacts due to migration can lead to various impacts according to bazzi et al interethnic contacts may foster integration and assimilation that can affect social capital and the provision of public goods for instance interethnic groups contacts may result in interethnic marriage ethnic exogamy may lessen ethnic boundaries and thus be a part of an assimilation process that potentially fosters further different group integration on the other hand migration of different ethnic groups to the same location can lead to polarisation that may reduce social capital hamper development and even increase the likelihood of ethnic conflicts these conflicts may be triggered by the fact that despite indonesias decades of rapid economic development inequalities among ethnic groups exist some however attribute inequality in indonesia more to urbanrural differences or regional differences than ethnicity still inequalities exist between migrant and nonmigrant ethnic groups and thus interethnic contacts due to migration may create an antimigrant sentiment and trigger social conflicts violent outbreaks among migrant and nonmigrant or placeoforigin ethnic groups have been recorded in indonesia secondly the relationship between ethnicity and migration is highly relevant for indonesia given its vast ethnic diversity and developing economy the development process is usually accompanied by the growth of population mobility in definite patterned regularities according to the mobility transition hypothesis de haas further expands this hypothesis by the notion that development affects migration through migration capabilitiesvarious capitals that can be mobilised to support migrationand migration aspirationsinclinations to migrate due to undergoing varying stages of regional development and historical and demographic processes different ethnic groups in indonesia may have diverse levels of migration capabilities and aspirations which can lead to heterogenous patterns of mobility at any single point in time it is not clear however to what extent differences in migration behaviour between ethnic groups are related to socioeconomic and demographic differences between these groups or instead are inherent to the ethnic group as such despite its significance studies on the relationship between ethnicity and migration for the case of indonesia are lacking two issues lay at the root of this first of all a cause has been the lack of largescale nationally coverage data on ethnicity starting from the 1961 census for the sake of national unity the recording of ethnicity was restricted by the government of indonesia earlier the results of the 1930 census conducted by the dutch in indonesia demonstrated that the intensity of migration4 differs by ethnicity for a substantial period this census was the only basis to consider that some ethnic groups in indonesia are more likely to migrate than others afterwards studies regarding ethnicity and migration are derived using the birth province information fortunately after the political reformation following the downfall of the suharto regime in 1998 the indonesian populations ethnicity has been rerecorded starting from the 2000 census since then various studies regarding ethnicity have been conducted using the census the indonesia family life survey also started to collect data on ethnicity in 2000 covering some of the largest ethnic groups in indonesia 6 page 4 of 33 the indonesia family life survey also started to collect data on ethnicity in 2000 covering some of the largest ethnic groups in indonesia based on the ifls and 2000 and 2010 censuses auwalin conducted a study on ethnicity and migration he operationalised migration as moving out of ones community 5 between two consecutive ifls waves of 1993 1997 2000 and 2007 auwalin categorised the ethnic groups using the censuses as high or low migrationrate ethnic groups he finds that belonging to a high migrationrate ethnic group is positively related to the probability of migrating however its effect is lessened when this group is the local majority our study adds to this by using ethnicity as the primary explanatory variable instead of classifying ethnicity into having high or low migration rates secondly our insight into the relationship between ethnicity and migration is limited as migration is often assessed as a onetime event for example a recent study using the ifls by pardede mccann and venhorst analysed the effects of individual and location characteristics on migrations that were measured by the change of location between two consecutive waves whether across subdistricts districts or provinces while studies have covered the topic of repeat or return migration migration is rarely assessed across the lifespan although the ifls enables us to study migration across the lifespan and the number of migrations as it records every migration since age 12 we therefore argue that studying what affects the number of migrations across the lifespan among migrants contributes to a better understanding of the differences between migration behaviour of ethnic groups particularly morrison argues that observed population mobility rates are determined by the relative importance of the mobile segment of the population relative to the stable segment of the population furthermore as studies analysing the whole trajectory are still underdeveloped including migration studying migration across the lifespan can contribute to studying the trajectories this study therefore aims to assess how ethnicity measured by selfreported ethnicity affects lifespan internal migration behaviour we measure migration behaviour by first considering whether the individual has ever migrated across the boundary of a village administrative area 6 we then consider the number of migrations across the life trajectory for members of various ethnic groups in indonesia our research question is thus formulated as to what extent does ethnicity affect ever migrating and the number of migrations over and above individual demographic and socioeconomic characteristics this study is the first to do so by fully employing the migration history information in the ifls recorded for participants starting at the age of 12 up to the end of observation ethnicity and migration we derive four general principles from the literature that help shape our thinking on the association between ethnicity and migration and divided them into two parts the first part is related to what ethnicity can represent concerning migration migration as a part of culture that can be viewed as ethnic capital and ethnicity as social capital such as segmented migration networks and labour markets of each ethnic group the second part consists of two principles that are related to the context of indonesia the impact of colonialism in shaping migrations particularly in indonesia and the geographical locations of the ethnic groups whether their home regions are more in the centre of economic administrative demographic activities or the periphery we use these principles to shed light on processes that could be historical cultural or contextual that shape the differences between the mobility of ethnic groups today as will be apparent these principles are to some extent intertwined as a result we cannot identify which of these four causes lays at the root of these results it was demonstrated using the 1930 census that the ethnic groups such as the batak minangkabau banjarese and buginese to have higher migration intensities while ethnic groups such as the malay javanese sundanese madurese makassarese balinese and sasak have lower migration intensities also according to the 2000 and 2010 census three ethnic groups have consistently higher migration rates the batak minangkabau and buginese 7 while changes in the migration rates occurred across these censuses8 our starting hypothesis is that these groups have a higher likelihood of ever migrating and a higher number of migrations than the others in what follows we illustrate the four general principles for these and some of the larger ethnic groups recorded in the ifls 6 page 6 of 33 ethnicity and migration some theoretical explanations migration behaviour as a part of culture and ethnic capital in many cultures migration is an integral part of peoples lives the selectivity of migration may generate a culture of migration that reproduces migration experiences that are made relatively permanent experiences in the life course of members of societal groups which may even be highly valued by people within these groups extending the concept of ethnic capital we presume that ones ethnic environment provides a capital that one can draw upon in the form of skills related to migration behaviour shaped by the ethnic groups migration experiences external to the individuals this form of ethnic capital triggers a higher likelihood of migrating of a particular ethnic group than the other among the minangkabau from westsumatra migration has traditionally been imposed on men because of the weak roles they have in their mothers or their wives households in terms of wealth and inheritance due to their matrilineal culture thus minangkabau males particularly unmarried men tended to move to earn their livelihoods elsewhere although migration of the minangkabau females many as tied migrants also occurred therefore migration has long been established as a part of their culture likewise the buginese from south sulawesi province who have been famous as seafarers travelled as traders and settlers to various parts of indonesia and even to the malay peninsula noted back since the late seventeenth century migration of the buginese is closely linked to their view that pasompe a nameless culturehero is an attribute of their society their society highly values those who have travelled across the sea to seek their fortunes therefore we expect that the members of ethnic groups with migration as a part of culture have a higher likelihood of ever migrating and moving more often than the members of other ethnic groups as they provide ethnic capital that promotes migration ethnically segmented migration networks and labour markets ethnicity is also associated with migration as it is connected to social capital acquired through social relations with others established by each ethnic group such as migration networks and labour markets the networks created by these groups tend to create further migration from those particular groups in indonesia some ethnic groups established themselves in concentrated areas in a wider destination these established networks and social contacts may trigger specialisation in particular occupations of people from a particular area 9 9 migration networks and segmented labour markets may be established in a lowerlevel unit such as a village within a particular ethnic groups home region however the mechanism of creating networks and segmented labour market could be extended to a particular ethnic group as a sense of identity may play a role the buginese migrants from south sulawesi established chain migrations usually by inviting or funding some of their relatives or fellow villagers to come to the destinations and created new homes networks can also be created in the forms of ethnic associations in the destinations such as by the minangkabau the batak usually formed family names associations that can assist new batak migrants also networks can be created by reproducing social systems from the home regions elsewhere for example the balinese who have the lowest intensity of migration according to the 1930 census have very complex longestablished social systems that they use at their home regions to organise their community agriculture and religious affairs by reproducing their unique social systems in particular destinations the balinese may encourage migration of other balinese to these destinations the need to reproduce these systems is perhaps a necessity to organise their community lives in the area of destination given that they are usually ethnic and religious minorities outside their home region as they are mostly hindu while indonesia as a whole is predominantly muslim because of these networks people from particular ethnic groups may have also created segmented labour market opportunities for their ethnic group members in some locations that may trigger migration to those locations therefore the segmented labour market opportunities may represent a specific economic opportunity to an ethnic group in a particular location we presume that people from an ethnic group that tends to occupy jobs that require stable locations will move less often than the others trading for example may require more movement than working as a civil servant those who were famous for moving as traders were the makassarese and buginese the minangkabau and the madurese who were also famous for working as temporary labourers some of these segmented labour markets were notably created during the colonial era through the impact of western education western education in indonesia was earlier introduced as a segregated system limited to the natives after the introduction of ethical policy aimed to improve the conditions of the native population the dutch launched peoples schools at the village level or collaborated with the schools established by christian missionaries it was partly motivated by the need to provide lowerlevel skilled workers for the dutch in indonesia this education system was established alongside islamic education that had been part of muslim lives in indonesia the ethnic groups that to a higher degree embraced western education in the past enjoyed better employment opportunities in more stable higherskilled jobs than those who did not to some extent this historical process may also be related to ethnic capital referring to the average level of skills possessed by the members of an ethnic group the minangkabau and the batak are examples of such ethnic groups therefore we expect that the ethnic groups that had established migration networks and segmented labour markets partly due to the impacts of western education in the past tend to have a higher likelihood of migrating than the others as previously discussed diverse migration flows might have established these networks and segmented labour opportunities some flows were from the lower end of the socioeconomic spectrum such as people with unstable jobs who might have conducted numerous movements out of necessity others were from the higher end of the socioeconomic spectrum such as those impacted by western education ethnicity and migration the context of indonesia the impact of colonialism in shaping migration of indonesians contemporary migration patterns can be understood from their historical backgrounds the indonesian archipelago has a long and complex history of migration and settlement since the prehistoric time that has shaped and formed its populations settlement language and ethnic diversity still western colonisation is considered to largely influence postcolonial mobility patterns in indonesia and developing countries in general hugo maintains that population movement in indonesia during the colonial time was impacted gradually following the increase in the influence and control of the colonial rule from the sixteenth century culminating in the imposition of direct colonial rule by the dutch government in the nineteenth century hugo points out some of the effects on migration brought by this imposition such as revolution in transportation availability and patterns drastic changes in the structure of the economy which created new and different types of job opportunities along with the introduction of wage employment laws to encourage or discourage particular types of movement the existence of forced and semiforced labour schemes the development of urban centres and migration towards them and the introduction of primary and to a lesser extent secondary schools colonialism thus influenced the lives of people who belonged to specific ethnic groups in different ways and was thus shaping their migration behaviour directly or indirectly in a direct sense colonial activities created new migration patterns outside the traditional mobility patterns or accentuated these traditional patterns indirectly migration could also be a reaction to these colonial activities labour was recruited for plantations or mining mainly from the island of java thousands of javanese and sundanese workers were transported from java to sumatra or the outer islands sometimes with some elements of force these economic activities also generated demand for labour from more nearby areas which are the home regions of particular ethnic groups for example some of the batak 10 and also the minangkabau in sumatra 10 according to cunningham batak ethnic group consists of several major subethnic groups which are toba pakpak karo simelungun angkola and mandailing the studies referred here are about tobabatak because most statistics do not differentiate these subgroups or hugo except later such as in jones et al we grouped them as batak responded by moving to the east coast of sumatra for wagelabour or trade opportunities the selection by the colonials of particular locations as the centres of economic activity while other areas lagged created inequalities between different groups and thus also played a role in influencing migrations the creation of urban centres in java such as bataviathe former name of jakarta special region the provincial capital of indonesiasemarang in central java and surabaya in east java triggered migration within java and from the outer islands preferential recruitments also drove the migration of people from the outer islands to java the dutch preferred to recruit the outer islands ethnic groups such as from the eastern part of indonesia who had engaged in western education by the christian missionaries mostly christianised as functionaries such as soldiers police and lowlevel administrative staff in java aside from this the dutch implemented the resettlement policy after they considered java island to be overpopulated in 1905 as a result people were resettled from java to the outer islands the government of indonesia adopted this policy after independence in the programme called transmigration migration could also be a reaction to an act of war by the colonialists for the case of the banjarese from south kalimantan the banjar war with the dutch in the midnineteenth century forced some of the banjarese to flee from their territories primarily to their established migration destinations in sumatra and malaysia according to the 1930 census many of them resided in the eastern part of sumatra riau and jambi provinces in sumatra even abroad such as in malaysia hence the ethnic groups that were most influenced these colonial activities in terms of their likelihood of migrating in the past may have a higher likelihood of migrating than other ethnic groups it may be in the form of chain migration linkages between the areas or return migration thus we expect these ethnic groups to have a higher likelihood of migrating than the others the home region of ethnic groups the second element that may shape ethnic differentials in migration is the home location which is the traditional home region of each ethnic group in indonesia java is the most fertile and was developed more than the rest of indonesia during the colonial era this development has been perpetuated by the government of indonesia after independence consequently java has been the political and economic centre it is the most developed and densely populated island followed by the island of sumatra while the rest of indonesia is lagging the consequence of this extent of unequal development between java and elsewhere within indonesia is that java and the ethnic groups which are dominant there exhibit high intraisland migration on top of attracting migrants from the outer islands on the other hand extractive industries such as mining and plantations in the peripheral locations outside java did attract people to move to the outer islands however these outflows from java were small relative to the inflows as well as java population size as the migrations of the population in java have been concentrated more within java than to the other parts of indonesia the local ethnic groups in java are the majority in their home regions the javanese and the sundanesetwo of the majority ethnic groups in indonesia and the bantenese on the other hand there is an ethnic group in java island the betawi11 from jakarta which is not the majority in their home region only 28 per cent of betawi people lived in jakarta according to the 2010 census their moves however were mainly to the surrounding areas of jakarta it is an intricate task however to determine the effects of the home location of the different ethnic groups in java and outside java on their migration patterns across the lifespan in general pardede et al find that living in java is mostly associated with a lower probability to migrate than living outside java nevertheless migrants from outside of java may tend to move directly to urban centres in java mainly as positive selectivity might play a role in migration from farther away such moves may involve more costly transportation so the migrants tend to move directly rather than repeatedly to reach their intended destination however within java migrants may be able to move in steps to get to their ultimate destinations therefore we expect that the ethnic groups with home regions from outside java are more likely to ever migrate than those from java itself while the ethnic groups from java are more likely to move repeatedly thus have a higher number of migrations than those from outside java other characteristics that determine ever migrating and the number of migrations in this section we distinguish three types of characteristics that are associated with migration across the lifespan the individual characteristics the location of origin characteristics and only in the analysis of the number of migrations the first migration characteristics some individual characteristics that affect migration are birth cohort gender education and parents education as a measure of socioeconomic status birth cohort situates individuals in a particular sociohistorical process as they progress through their lives younger cohorts usually face a higher level of development urbanisation better transportation and communication facilities than the older cohorts in their lifetime thus we expect the younger cohorts to have a higher likelihood of migrating than the older cohorts in the context of repeat migration it is found that males are more mobile than females therefore we also expect more migration across the lifespan for males as education may depict ones tendency to be responsive to opportunities elsewhere and is mostly positively related to repeat migration education and parents education are also expected to be positively related to migration across the lifespan aside from the roles of an ethnic group home region on migration the locations where the members of an ethnic group are born and raised also affect migration a longer distance to the urban centres may necessitate migration while a shorter distance to the urban centres may trigger step migration towards the urban centre therefore the distance of ones place of birth from the capital city can be positively related to ever migrating but negatively related to the number of migrations according to the region at the beginning of migration trajectories we also expect differentials in migration living in java is expected to be negatively associated with ever migrating while positively related to the number of migrations also the degree of urbanity of the area at the beginning of the migration trajectories may affect migration as cities or urban centres are considered the ultimate destination of migration we expect living in rural areas to be negatively related to ever migrating but positively associated with the number of migrations by incorporating these location variables we control that a javanese born further away from the capital city and raised in a rural area outside java may face different economic opportunities and levels of development compared with a javanese born and raised in an urban area on java island we also account for the characteristics of the first migration we presume that the first migration since the start of the observation is a highly consequential transition and may yield a persistent effect on the subsequent migration and thus the number of migrations across the lifespan firstly we use the age of the first migration as age describes a stage in an individuals life the age of the first migration marks the timing of the start of migration behaviour across a migration trajectory first migration at a later age delays the timing of the next migration and thus is negatively associated with the number of migrations as subsequent migration may depend on the reason for the first migration a move for work or education may trigger more moves than a move for marriage or family moving for family reasons or marriage may create more ties to the location of origin consequently we expect those who move for the first time for education or work to have a higher number of migrations than those who move for marriage or familial reasons lastly we also expect the length of stay at the destination after the first migration to be negatively associated with the number of migrations the longer one stays in a location the more locationspecific capital has been formed and the less likely subsequent moves then become additional variables to control for exposure and timing ever migrating abroad to control for the time exposed to the risk of migrating the year of the first migration to control for periodic shock the age at the end of observation and the year of entering the survey will be discussed in the method section data and method the indonesia family life survey 12 was conducted for the first time in 1993 covering 13 provinces in indonesias western and middle parts out of the 27 provinces including timor leste the respondents of the first wave were then followed in 1997 2000 2007 and 2014 selected selected respondents were interviewed for detailed information including migration history and strauss witoelar sikoki overall the ifls covers most of the largest ethnic groups roughly about threequarters of the population targeted respondents were tracked if they still resided in one of these 13 provinces regardless of whether they moved across those provinces consequently our analysis concentrated on the experience of people who reside in these provinces and are more likely to belong to ethnic groups originating from these ifls provinces many smaller ethnic groups particularly those originating from outside the ifls provinces who migrated or the descendants of migrants in the ifls provinces were treated as a residual category for example we grouped a few maluku people surveyed in south sulawesi into the residual category others in contrast others from eastern parts of indonesia such as east nusa tenggara and papua are unavailable the sample for this study was derived by combining all five ifls waves ifls recorded migration history starting from age 12 of targeted adult respondents who were at least 15 years at the time of the survey migration in this survey is defined as moving at least across the village administrative border and staying in the destination for at least six months we used all respondents with migration trajectories from age 12 until at least age 36 furthermore even though moves to and from abroad were recorded we excluded these migrations as we focus on internal migration and continued exposure in indonesia is presumed a respondent who often moves abroad may have fewer migrations across the lifespan than another who only moves internally the analysis was conducted as a twostep procedure the first is an analysis of ever migrating internally across the lifespan using 21427 respondents next we analyse the number of internal migrations using 12161 migrants the dependent variables of our regression models are ever migrating using logistic regression model and the number of migrations across the lifespan using truncated negative binomial regression for count outcomes both models were estimated by clustering the standard errors at the household level at the respondents year of entry to ifls the truncated negative binomial regression models count data the number of events which occurs during a time interval for zerotruncated samples we calculated the exponential value of the estimates to get the expected number of migrations the map depicts mostly the largest ethnic groups these are 33 provinces according to the 2010 census 1 aceh 2 north sumatra 3 west sumatra 4 riau 5 riau islands 6 jambi7 bengkulu8 south sumatra9 bangka belitung10 lampung11 banten12 dki jakarta13 west java14 central java15 di yogyakarta16 east java17 bali18 west nusa tenggara19 east nusa tenggara20 west kalimantan21 central kalimantan22 south kalimantan23 east kalimantan24 north sulawesi25 gorontalo26 central sulawesi27 south sulawesi28 southeast sulawesi29 west sulawesi30 maluku31 north maluku32 west papua33 papua these provinces used to be one province in 1993 province 4 and 5 8 and 9 11 and 13 24 and 25 27 and 29 30 and 31 and 32 and 33 note includes all ethnic groups from this province for example banten includes the bantenese and other ethnic groups in banten province freese 2014 the zero migrations included in model a are truncated from our sample for model b because we only get the first migration characteristics from those who migrated at least once the primary explanatory variable in both regression models is ethnicity we then controlled for individual origin location andonly for the allmigrant sample used in model bfirst migration characteristics the details on how we determined ethnicity from the data can be found in appendix we further categorised the ethnicity based on the number of respondents and geographical proximity the sundanese bantenese and cirebonese were grouped because they used to be in west java province which was split after the 1998 reformation the western part the home of the bantenese is now the province of banten the eastern part with the sundanese majority is still called west java province where the cirebonese also come from the buginese and makassarese were grouped because they are from the province of south sulawesi the sasak bima and dompu were grouped as they are from west nusa tenggara province we treat others as a residual category which is not further analysed the final categories of ethnicity are reported in subsection 41 table 1 13the individual characteristics are birth cohort gender education and socioeconomic status measured by parents years of schooling we account for the geographical aspects by including the distance of the birth province from jakarta the region at age 12 whether in java or outside java and the urbanity of the residential area at age 12 based on the respondents assessment as to whether the area constituted a village small town or big city to differentiate ruralurban areas at the start of the trajectories the first migration characteristics included in model b are the age of the first migration the reason for the first migration the length of stay after the first migration we interacted parents years of schooling with the age of the first migration because the effect of parents years of schooling may differ by the age of the first migration as parents with better economic status tend to keep their children at home longer the reason for the first migration is divided into work education marriage family and others for other timing variables we use broad periods to avoid multicollinearities with cohort and age the length of stay at the destination after the first migration is categorised as up to two years or longer the year of the first migration is included to control for the changes that occurred over time the number of geographical units might have changed as the number of villages has increased after the 1979 law thus those who cross administrative borders recently may have a higher number of migrations than in the past profound political and economic changes also occurred in indonesia in the late 1990s indonesia was hit by the financial crisis in the late 1990s experienced the 1998 political reformation and started the regional autonomy and fiscal decentralisation in 1999 therefore we divide the year of the first migration into before 1980 19801995 and after 1995 finally we included other technical control variables only for model b a control variable ever migrated abroad within the trajectory was added because time spent abroad implies less exposure to the circumstances in the country and less time in observation and at risk to conduct internal migration the second variable is the age at the end of the trajectory divided into four groups 3645 4655 5665 66 or older to control for rightcensoring third we included the year of entry to the ifls controlling for respondents entering the ifls at different waves we estimated seven models for model a and 11 models for model b adding the different controls stepbystep model 1 in each regression table highlights the effects of ethnic groups on migration using only birth cohort accounting for differing shared experiences and the aforementioned technical control variables results descriptive results the descriptive statistics of the respondents are reported in table 1 and2 the highest percentage of evermigrating respondents is for the malay and south sumatra while the lowest is for the madurese the highest mean number of migrations is 275 for the minangkabau while the lowest is 199 for the betawi most of the results regarding individual origin location and the first migration characteristics seem to be in line with the expectations it is necessary to point out that controlling for education and parents education is particularly important as previously mentioned western education impacted each ethnic group differently some ethnic groups embraced it more the batak than the others in the past the madurese it shaped the current levels of education of ethnic groups for some quite strikingly that may affect their contemporary migration patterns the different levels of education among the ethnic groups can also be observed in the ifls data 6 page 16 of 33 table 1 the percentage of evermigrating respondents since age 12 and the summary statistics of the number of migrations by variable source the 19931997200020072014 regression results ethnicity and migration the regression results of ever migrating model a can be seen in tables 34 model a1 which contains our ethnicity classification along with controls for exposure and timing shows that the people belonging to the batak minangkabau malay and south sumatra bantenese sundanese and cirebonese and banjarese are more likely to ever migrate than those belonging to the javanese while the reverse is true for the betawi madurese buginese and makassarese balinese sasak bima and dompu however in the last model which includes all controls the difference between the batak minangkabau malay and south sumatra bantenese sundanese and cirebonese and banjarese with the javanese becomes not significant or even negative for the case of the minangkabau the betawi the madurese the buginese and makassarese the balinese the sasak bima and dompu are consistently less likely to ever migrate for model a1a7 than the javanese for the batak minangkabau malay and south sumatra and banjarese adding original location variables changes the significance and even the direction of the effect thus the higher likelihood of migrating of these ethnic groups in model a1a4 seems to be partly explained by the distance of their birth province to jakarta their region and their type of area at age 12 these results suggest that the geographical location of the ethnic groups shapes their evermigrating tendencies in table 4 we report our analysis of the number of migrations across the lifespan for those who moved only controlling for the timing and exposure variables we find that the batak minangkabau and banjarese have a higher expected number of migrations than the javanese for example the predicted number of migrations is 25 per cent × 100 higher for the minangkabau conversely the sundanese bantenese and cirebonese the betawi the madurese and the balinese have lower migration counts in model b3 after introducing the education variable the higher expected number of migrations of the batak and the lower expected number of migrations of the madurese become statistically not significant thus for some ethnic groups the 19931997200020072014 the 19931997200020072014 table 4 model b truncated negative binomial regression incidencerate ratio of the number of migrations source the 19931997200020072014 the vif values from the multicollinearity tests are all below 10 14 the higher migration count of the banjarese needs to be assessed further hawkins noted that ethnic groups other than banjarese in kalimantan who converted to islam tended to identify themselves as the banjarese this change in selfidentification of ethnicity may partly explain ananta et al finding that only 65 per cent of the banjarese accounted in census 2010 resided in their province of origin while about 20 per cent of them lived in the neighbouring provinces differences reported in model b1 may be attributed to the difference in education level it is also clear that this is not a universal pattern the minangkabau for example exhibit an education level similar to the batak but controlling for education did not substantially alter the finding that the minangkabau are relatively more mobile in model b7b9 we added the first migration and some origin location characteristics for the betawi the lower expected number of migrations found in models b1b6 become not significantly different from the javanese when the reason for the first migration the length of stay after the first migration and the distance of the birth province to jakarta are included after including all other variables in model b11 we find that the minangkabau and the banjarese exhibit a higher expected number of moves than the javanese 14 the lower expected number of migrations of the betawi which is not significantly different from the javanese in model b7b9 becomes significant again at the 10 per cent level after including whether they resided in the village small town or big city we also find consistently negative effects of belonging to the balinese on the number of moves relative to the javanese thus after controlling all characteristics the ethnic groups that have a lower likelihood of ever migrating do not always have a lower expected number of migrations than the javanese and vice versa the balinese and the betawi have a lower likelihood of ever migrating and also a lower expected number of migrations than the javanese the minangkabau even have a combination of a lower likelihood of ever migrating with a higher number of migrations relative to the javanese the ethnic groups that are repeatedly mentioned as highly mobile in various studiesthe batak minangkabau banjarese and buginese do not always have a higher tendency to ever migrate nor higher expected number of migrations in comparison with the javanese in combination the results of models a and b show that the differences between the ethnic groups in the likelihood of ever migrating are smaller for the number of migrations other characteristics and migration some of the findings regarding individual characteristics confirm our expectations males are consistently more likely to ever migrate than females being male also increases the expected number of migrations by 14 per cent × 100 even after controlling for the reason of the first migration this result suggests that this gender gap is not fully explained by the fact that males have a higher tendency to move for work than females as females are more likely to move to more developed areas than males females may move relatively directly to the areas with better economic opportunities instead of moving repeatedly education is positively related to ever migrating and the number of migrations parents years of schooling has a nonlinear effect on the number of migrations through the age of the first migration the effect of age at first migration on migration count becomes less negative at higher levels of parental education in model a7 we do not find evidence for differences in the likelihood of ever migrating between birth cohorts inevitably we have relatively short histories available for the more recent birth cohorts which favours the identification of young and quick migrants making the cohort seem relatively mobile we do not find evidence that the distance from jakarta affected migration however living outside java at age 12 positively affects ever migrating as expected while its effects on the number of migrations are not statistically significant also as expected living in a village or small town at age 12 reduces the likelihood of ever migrating which is in line with earlier research on the contrary starting from the village is related to a lower expected number of migrations than starting from the big city in line with our expectations we find that motives for first migration other than work or education lower the expected number of migrations migrants who stay at the destination of the first migration longer than two years have a lower expected number of migrations lastly we find a negative effect of ever moved abroad as expected moving abroad reduces exposure to domestic moves conclusion and discussion controlling for a rich set of individual characteristics exposure and time we find evidence that ethnicity is related to migration for the case of indonesia the minangkabau betawi madurese buginese and makassarese balinese sasak bima and dompu are less likely to ever migrate than the javanese conversely belonging to the minangkabau or the banjarese is positively related to the number of migrations while the opposite is true for the balinese and the betawi with these findings we show that there are differences between the ethnic groups in the likelihood of ever migrating however we find less differences between the ethnic groups regarding the number of migrations furthermore we find that a lower likelihood of ever migrating does not always correspond with a lower number of migrations our results reflect the four principles identified in this paper as potential drivers of the ethnic differences in migration firstly our results suggest that the effect of ethnicity on ever migrating can be attributed to the effect of the home region being in the centre or periphery and on the impacts of urban centres created since the colonial era we find that the ethnic groups commonly mentioned as highly mobile such as the minangkabau and the buginese have a similar likelihood of ever migrating to the groups commonly considered to have lower intensity of migration such as the balinese and the sasak we find that all these ethnic groups exhibit a lower likelihood of ever migrating than the javanese who are from the central regions the betawi originally from jakarta have a lower likelihood of ever migrating than the javanese and exhibit a lower number of migrations the results are not surprising for the betawi because they tend to move to the surrounding provinces of jakarta the need to move again is perhaps lower because they continue to live near jakarta our results also suggest that ethnicity may play a role as a cultural marker of migration behaviour potentially driven by the average migration skills possessed by an ethnic group regarding the culturally determined differentials of migration by ethnicity in indonesia titus said not so much the cultural differences that are decisive but much more the specific role assigned to the various regions and peoples in the process of peripheral capitalistic development still after including geographical aspects on top of controlling for various personal characteristics we find that ethnicity affects migration across the lifespan our results also suggest relevant roles of ethnically segmented migration networks and labour markets on migration for some ethnic groups aligned with international literature regarding social capital we indeed find that the ethnic groups traditionally more engaged in trade have a higher number of migrations such as the minangkabau and the banjarese the lower expected number of migrations of the balinese may be related to their tendency to move to the locations where previous migrants have established their social system they may not need to move again because living in a destination with an established balinese social system may inhibit more migrations aside from intraethnic social capital however one interesting line of enquiry would be whether interethnic social capital also plays roles in migration especially as interethnic relation is also important in determining migrants socioeconomic status regarding the data limitation we analysed mainly the largest ethnic groups as we focused on the ethnic groups residing in the ifls provinces as previously discussed the smaller ethnic groups were also captured among those are the migrants and their descendants from the nonifls provinces as these groups are small in size our results as a whole were not affected that much still it would be worth investigating other ethnic groups migration behaviour particularly in the middle and eastern parts of indonesia we also note that cultural identities such as ethnicity are fluid and not fixed in space and time thus the ethnicity defined in the data should be assessed further mainly on how it affects migration for example the members of other ethnic groups in kalimantan identified themselves as banjarese when they converted to islam might have influenced the banjarese migration rates another issue that needs to be mentioned is that we included various time elements in the analysis hence we have partly isolated the changes across the age period and cohort such as the stages of development and changes through the trajectories still the members of specific ethnic groups may have experienced changes in migration behaviour over time as the migration assessed is the lifespan migration since age 12 and also covers different cohorts therefore further analysis is needed to address the issue of changes in migration behaviour following de haas migration aspirations and capabilities may change and need further assessment this paper also adds to earlier studies on migration as a onetime event phenomenon by distinguishing between the likelihood of ever migrating and the number of migrations across the lifespan and how the effect of ethnicity on migration differs for these two measures doing so provides a point of departure to understand the phenomena of repeat migrations and migration trajectories in general in multiethnic countries in developed countries with issues regarding ethnicity and international migrations and in indonesia in particular data availability the datasets generated andor analysed during the current study are available in the rand repository rand org wellbeing socialandbehav ioralpolicy data fls ifls html

this paper is the first to examine to what extent ethnicity affects ever migrating and the number of migrations across the lifespan for the case of internal migration in indonesia we use all five waves of the indonesia family life survey ifls to study migration behaviour of respondents belonging to some of the largest ethnic groups in indonesia our logistic regression results show that the minangkabau betawi madurese balinese buginese and makassarese and sasak bima and dompu are less likely to ever migrate than the javanese using only migrants and controlling for the first migration and other characteristics truncated negative binomial regression results show that in comparison with the javanese the minangkabau and banjarese have a higher expected number of migrations while the numbers are lower for the betawi and balinese thus ethnicity contributes to ever migrating as well as the number of migrations but we find that the differences between the ethnic groups diminish for the latter these results also point out that a higher likelihood of ever migrating does not always correspond with a higher number of migrations highlighting the importance of studying migration count to complement the study of migration as a onetime event

introduction recent social economic and environmental problems are believed to be primarily related to rapid increases in population family planning is considered a development tool at the individual and global levels it allows individuals to gain more control over their lives ensures a greater balance between population increases and preservation of natural resources upon which some rural families are dependent and helps improve the global economy with china being the worlds most populous country population pressure has captured the attention of scientists and the chinese government since the 1970s the country has pursued what is termed chinas family planning policy which promotes a onechildpercouple policy late marriage and the postponement of childbirth advocating that these policies will result in conceiving and rearing healthier children efforts are targeted at controlling population growth improving population quality increasing household welfare and alleviating social economic and environmental problems in 2002 the population and family planning law touted cfpp as a basic national policy and citizens duty under this policy only people belonging to small and endangered ethnic groups in remote regions were allowed to have two or more children but they were not provided with welfare support for these children cfpp has remarkably controlled population as indicated by the substantial decline in fertility levels and the reduction of average family size perceived environmental and social risks of overpopulation have prompted the chinese government to not only reduce fertility but also change urban families attitudes toward children influencing the latters preference for a smaller family china is believed to have completed the transition to low fertility but many couples still have strong cultural beliefs that children increase the income of parents they still prefer having more children especially in rural areas where the notion of a distinguished family with several generations living together is pursued and families with only one child are rare in rural china births are underreported and many families have not adhered to cfpp raising more than two children the situation contradicts the governments notion of resolving chinas issues concerning agriculture the countryside and farmers through rural population control cfpp was indeed a controversial social decision that sparked discussions among many scholars in china and the rest of the world fong argued that urban daughters have benefited from chinas onechild policy and have become more capable of supporting their parents in old age attane zhang and goza assessed the impact of cfpp on reproductive behavior and discussed potential demographic problems such as aging disagreement over cfpp has long persisted in academic circles with some scholars believing that cfpp should be continued in china for example wu argued that chinese citizens should be vigilant regarding the countrys population yang and meng proposed that a stabilized low fertility level is a precondition for the construction of a harmonious population conversely some scholars have not entirely approved of cffp chen suggested revising the cfpp to permit bearing a second child and increasing the birth rate in china considering that population growth is now under control he likewise noted that the termination of the onechild policy was inevitable in avoiding the risks of having onechild families yi claimed that cfpp has shaped an inverted pyramid population structure and that the government should abolish cfpp to improve population quality chinas current population is approximately 13 0713 billion of whom are registered as rural residents hence rural population development continues to face severe challenges because cfpp is not very popular among rural families population and fertility rates should be reduced further in rural china urbanization is clearly a part of the development process and ruralcity mobility is viewed as a means to reduce rural population and resolve chinas issues concerning agriculture the countryside and farmers this study does not propose focusing on ruralurban mobility alone because this equates to draining a pool but neglecting the stream pouring into the pool on the one hand we recommend facilitating the movement of rural households toward the urban on the other hand we advocate reducing the fertility rate or family size in rural areas chinese society has stressed the vital role played by children in the lives of their elderly parents particularly adult children who are considered important sources of emotional physical and financial support for the latter chinese culture encourages having more children as conveyed in the popular adage more children mean more happiness for a traditional family in china are larger families easier to urbanize will having more children bring more happiness several studies have focused on the association between wellbeing and family size among chinese families but these studies have not employed econometric methods moreover no study has tested the association between ruralurban mobility and family size preference the primary goal of this study is to analyze the arguments by examining whether larger families are easier to move toward urbanization permanently and whether having more children provides increased benefits to rural families in china and by explaining rural families preference for more children additionally this study aims to discover alternative means for controlling rural population besides cfpp because no society has lowered its birth rate using a single method of family planning this study presents two main developments the first pertains to the sample used in this study which includes households that have resided in urban areas for the past 3 years and rural families the data and the results will help in gaining a comprehensive understanding of the migration of rural households the second development explores the possibility of ruralurban mobility when assessing family benefits given the major changes in socioeconomic structure generated by chinas economic institutional reform since 1978 living and working conditions have improved more in urban than in rural areas and the number of surplus agricultural laborers migrating to cities and towns has increased we believe that the movement of rural households to an urban area or town benefits such families and represents a development process for a country the rest of this study is organized as follows section 2 provides the theoretical framework the data source is introduced in sect 3 and the estimation results are presented in sect 4 section 5 offers conclusions and suggestions theoretical framework the objectives of this study are to examine the effects of family size preference on the possibility of ruralurban mobility among rural families satisfaction with life and income in rural families in china and to explore the reasons behind rural family size preferences the results of this study should contribute to the discovery of ways to decrease the rural population and to smooth the urbanization process in china this study stresses that the household is the basic unit for conducting policy families decisions to have more children are based on a comparison between the expected returns and costs and their family size preferences have impacts on benefits at the individual level and urbanize process at the country level we would expect on average higher levels of benefit to be associated with the following the possibility of ruralurban mobility which can impact the urbanization process at the country level higher family income and life satisfaction thus this study analyzes real benefit in terms of these three aspects first since 1978 an increasing number of families have moved into cities or urban areas this change can be attributed not only to urban agglomeration economies but also to the gaps between the living and working conditions of rural areas and cities in china given that the quality of life is better in cities than in rural areas we employ the probability of moving into urban areas to describe the real benefits for rural families second a familys gross income is a common index for measuring family benefits but it does not clearly reveal the levels and the ability of each family member to create wealth because population size and structure differ across chinas rural families in addition to gross family income the influence of household demographic characteristics on family members average incomes and annual income per labor force participant are discussed these three income indicators comprise the family income evaluation system adopted in this study because these indicators complement each other and measure family income from different perspectives third the tradition of saving and retaining money over long periods of time is common among chinese families therefore an income indicator is insufficient to reveal the true benefits for highincome families life satisfaction is frequently used when evaluating subjective benefit a number of recent studies have focused on life satisfaction in measuring the level of wellbeing among families life satisfaction is defined as the overall assessment of an individuals quality of life according to hisher personal judgment and criteria studies on the relationship between family size preferences and life satisfaction that have primarily focused on the association between childlessness and psychological benefit have yielded mixed findings for example lowenstein et al found that filial norms are negatively related to life satisfaction in older people whereas hansen et al indicated that childless women report significantly lower life satisfaction compared with mothers with residential children and emptynest mothers however among men parental status is unrelated to any of the aspects of psychological benefit we evaluate the relationship between family members life satisfaction and family population characteristics in rural china the definition of family size is another important aspect that requires explanation having more children generally results in a larger population for a traditional rural family in china this study focuses on family population and certain issues are addressed first gender differences are ignored given cfpp and the chinese preference for sons we can speculate that the first child in families with more than one child is more likely to be a girl and that the second or the third child is a boy in onechild families the child is more likely to be a boy second intergenerational relationships are not considered in discussing children in this study traditional chinese rural families generally have several generations living in one house therefore differentiating a father from a son is not necessary in the dynamic perspective third to reflect family population and its structure three variables are selected namely family size number of family members in the labor force and number of minor children different combinations of these variables can reveal different population preferences and other population characteristics among families a logit regression model is employed to evaluate how having an additional member influences the possibility of ruralcity mobility in rural families and family members life satisfaction the model is expressed as follows probðy j i ¼ 1þ ¼ e b 0 x i 1 þ e b 0 xi ð1þ where y 1 and y 2 denote two independent models and j is coded either as 1 or 2 in these models the model is used to estimate the influence on the probability of ruralcity mobility of a rural family when j is 1 and the dependent variable y 1 takes a value of 1 when the family has resided in an urban area otherwise y 1 is 0 the model likewise estimates the influence on family members life satisfaction when j is 2 with y 2 as the dependent variable of satisfaction when family members feel satisfied ie their expected benefit exceeds costs then y 2 takes a value of 1 otherwise y 2 is 0 equation can be transformed into the following equation l j i ¼ ln p j i 1 à p j i ¼ b 0 x i ð2þ generally eq is termed the linear expression of the parameters a linear equation facilitates the explanation of estimated parameters a sample expression of b 1 is provided in eq oz ox 1 ¼ b 1 ð3þ where z ¼ ln p j i 1àp j i by taking the antilogarithm of the estimated coefficient we obtain the odds ratio or the change in the ratio of the probability of a particular event to the probability of a reference event for a unit increase in an independent variable while holding other variables constant this study estimates eq then explains parameters using eq maximum likelihood estimation is employed to calculate the parameters for the binary logit model using sas 92 software a linear equation is employed to study the influence of family size and structure on a rural households income including annual family income annual average income of each family member and annual average income of labor force participants the model is expressed as follows ln y j i ¼ a þ b 0 x i þ u i ð4þ the superscript j is used to designate the independent models j 1 2 3 respectively the regressands y 1 y 2 and y 3 represent annual family income average income of each family member and annual income per labor force participant respectively these three variables are used in their logarithmic forms in the regression analysis the vector x is a column of factors that influence family income including variables regarding the vocation of labor force participants local regional information and those expressing family population characteristics which is a main theme of this study the parameter b is a column vector whereas u is the residual error for i 1…n individuals this study adopts an ordinary least squares method in estimating the parameters using sas 92 software multicollinearity is a common issue especially in crosssectional data although it is simple to diagnose no satisfactory solutions for this issue are currently available principal component analysis and elimination of variables with low tolerances are commonly used methods this study eliminates variables with tolerances that are lower than 071 based on the multicollinearity diagnosis conceptual models of decisionmaking in related literature tend to view households as unified social units and empirical tests of these models often regard the views of one person as the view of the entire household similarly this study is based on a rational family hypothesis that considers livelihood pattern as the decision of all family members in pursuit of utility maximization for the whole family therefore we treat the family as the research unit wherein every family member understands the familys decisions and holds a similar characterization of their family situation and life hence the respondent can always provide accurate information in a survey data from the china ruralcity mobility questionnaire survey conducted in august 2010 was employed in this study the questionnaire consisted of items gathering data on family characteristics and vocational information population average age and educational level of the main labor force participants family income and any change in residence comprised the former whereas information regarding changes in workplace departments and so on comprised the latter respondents provided family background information whereas regional information consisting of figures issued by local statistics departments was obtained by researchers based on the locations provided this survey was conducted among 4000 rural households and 4000 urban households with response rates of 67 and 592 respectively for the survey is conducted at random and only 138 urban households are new ones from rural areas in 3 recent years we extracted these 138 questionnaires from 2368 urban questionnaires unlike in related literatures this study combines 2680 questionnaires of rural families with 138 questionnaires from urban families data consistency was checked by comparing the household income some observations with extreme income were excluded and those with missing values also were deleted the final sample size was 1552 the samples not only met the criteria for a large sample but also covered the 30 counties in shaanxi and henan provinces in china the definitions and statistical descriptions of the variables considered are presented in table 1 the average values of variables are similar to the summary statistics reported in china statistics yearbook the results revealed and that urbanization is a result of rural populations pursuing their own interests in addition to having a relatively higher family income a city resident can also enjoy the social benefit of using communal facilities the greater the probability of ruralurban mobility is the more likely rural families are to enjoy urban benefits in developed countries urbanization is inversely related to family size decline however the nature of this relationship is not well understood at the rural family level in china we use eq to estimate the impact of family size and instruction on the probability of ruralurban mobility for a rural family table 2 which only contains the variables concerning the subject of this study shows the estimated results of how household characteristics affect the probability of ruralurban mobility we can find that only the variable labf has a weak statistic significance at the 10 level among the core variables and the estimated parameter is 03232 suggesting that the population characteristics in a rural household dont have an effect on the probability of ruralurban mobility or have a weak effect suggesting that the probability of ruralurban mobility will decrease when the number of laborers in a rural family increases chen and zheng suggested that the preference for local work of certain farmers is based on rational decisions instead of traditional sentiments for their hometown this study agrees with said argument and proposes two reasons why a family composed of more laborers may choose not to migrate first a rural family may experience difficulty in availing of the benefits offered to urban residents given the stringent limitations in chinas household registration system second families composed of more laborers have sufficient local social capital and produce higher gross earnings thus preventing them from qualifying for these benefits the parameter for the yoch variable is statistically insignificant suggesting that the number of minor children has no significant influence on the probability of ruralurban mobility some scholars consider childrens education as a factor for urbanization which is worthy of further examination in the abovementioned results childrens education may not have sufficiently driven the rural families to move to urban areas moreover family size which is in fact negative has no significant effects on migration ability we can also find that two noncore variables educ and inco are statistically significant at 1 level their parameters are 01169 and 03397 respectively these are interesting results and seem to suggest that rural families with better educated economically active members have a greater likelihood of ruralurban mobility and rural families with greater financial resources are more inclined to migrate to urban areas this is possibly because they have greater prospects of getting paid employment the impact of rural families demographic characteristics on family income this study uses eq to estimate the separate influences of family income average income of each family member and average annual income of main labor force participants the results are shown in table 3 in which each column describes an estimated result and all three regressands have been transformed by the natural logarithm the results indicate that increasing the number of laborers in a family can efficiently improve family income model 1 suggests that the number of labor force participants in a family is statistically significant and that family income increases by 20 when another member of the family joins the labor force holding other variables constant in a general case of a family with two workers family income will increase by 50 when another member joins the labor force holding income per worker constant however the marginal income for this additional worker is lower in this model at approximately 20 based on the results having more than five laborers is considered ideal for a rural family model 3 suggests that the annual income per laborer will decrease if the number of laborers grows which is the microeconomic embodiment of the involution of agricultural labor inputs only two of the parameters for the variable yoch are weakly significant at the 10 level we can think that the number of minor children has not or has low possibility to influence on family income if it has the number of minor children is expected to positively influence family income and average income per family member both parameters approximately measuring 4 which is relatively low a possible explanation is that the consumption of minor children is lower than that of the elderly or that minor children can participate in family work as semiskilled laborers different combinations of the three family demographic indicators reveal different rural family structures for example keeping the family population and labor force size constant the family is considered a young family when the number of minor children increases otherwise it is an old family when the number of minor children and the number of laborers remain constant increasing the family size indicates that there are more elderly nonworking members in a given family estimation results show that the parameters for the variable pfam are significantly negative in the three models which indicates that increasing the number of nonworking elderly members will reduce family income average income per family member and laborers average incomes thus workers not only support the elderly financially but also provide more effort in caring for them this finding proves the revenue utility and insurance utility of adult children in rural families rural families are not entitled to receive insurance from the government or from society in rural china hence older people have to depend on their adult children for support insurance utility can be considered a reason for rural families preference for more children or a larger family in this case in reviewing sect 41 we infer that rural households preference for housing more generations and workers is a logical reaction to the lack of a rural insurance system variables mage and mage 2 are both significant at the 5 level and we can find by calculation that the dependent variables will be largest in three models when the average age of main labor forces is about 40 suggesting that keeping the average age of main labour forces in a rural family be 40 years old can make a rural family get more total income average income per family member and average income per labor force and that may be the reason why giving birth to a baby earlier is a preference for most rural families in china the parameters of variable educ in three models are all significant at the 1 level and they are 0235 0244 and 0232 respectively these parameters suggest that family income will improve about 24 if the average education year of familys main labor forces increases one year the impact of rural familys demographic characteristics on satisfaction with life considering the universality of utility maximization rural families pursue both pecuniary income and nonpecuniary effects and life satisfaction is used in this study to measure their overall benefits although computing nonpecuniary benefits and costs is difficult family members are deemed subjectively satisfied when their expected returns exceed expected expenditures the questionnaire measures satisfaction on a scale of 15 with scores representing quite dissatisfied relatively dissatisfied satisfied relatively satisfied and quite satisfied respectively this study reclassifies these five levels into dissatisfied when the value is less than 3 and satisfied above this value the influence of a rural familys demographic characteristics on family members life satisfaction is estimated using eq and the results are presented in table 4 among the demographic characteristics none of the core demographic variables was significant at the standard 5 level suggesting that the popular saying in china the more children the more blessings is not necessarily the case even though the variable yoch the number of minor children is significant at the weak level of 01 with a positive parameter family members are lower likely to be satisfied when the number of minor children grows reflecting the utility effects of childrens consumption however this effectiveness fades as children grow older in other words a flourishing population cannot ultimately provide satisfaction to rural parents conclusions and suggestions the chinese notion that more children bring more benefits is considered oldfashioned whereas prior research has focused on the link between income and fertility and the effects of childlessness on the psychological wellbeing of the elderly the current paper investigates the effects of having more children on family income life satisfaction and the probability of urbanization of rural families in china in summary a rural familys willingness and ability to migrate would decline if the family were to gain more workers this study posits that rural families with more workers have more social capital are powerful in the local area and can easily find work locally by contrast a rural family composed of fewer workers must leave the rural area because of limited work opportunities compared with families with more workers families with few working members always fails in competing for local work opportunities such families have lower income and experience difficulty in migrating to an urban area permanently workers in these families must move from rural to urban areas seasonally therefore the mobility of rural families to urban areas is impeded by rural families larger size and is regarded as a lowefficiency process in china we also find that increasing the size of a family does not effectively increase a rural family income even if the number of workers increases evidence confirms diminishing marginal returns population characteristics variables have few effects on the life satisfaction for a rural family although variable yoch affects the life satisfaction of family members at a significant level of 10 as feng and ren noted fertility is a diseconomy in chinas rural areas and rearing children is similar to investing in durable consumer goods along with discussions on the influence of family income in part 4 this study mainly concludes that more children will not lead to an improved welfare but finds the evidence of supporting the idea of rearing a son for elderly care and that birth earlier for a couple is better strategy in a rural family indicating that having more adult children increases the likelihood of an elderly receiving support such evidence explains why many families especially those in rural areas prefer having more children the pursuit of more children is a corresponding response to the current structure of rural life where insurance for aged care is lacking as another popular chinese adage preaches a son is insurance for old peopleelderly persons living with household members are happier than those living alone however family size preferences have diminishing marginal effects on increasing familys income and a negative effect on ruralurban mobility chinas government has determined basic strategies for ruralurban integration realizing the permanent migration of surplus rural labor these strategies have been developed to encourage rural families with more members to decrease their fertility or permanently migrate to urban areas based on all of the studies cited above some suggestions are made first the rural endowment insurance system requires the active promotion of reforms to convince rural parents that their later livelihood will be guaranteed thereby eliminating the concept of rearing sons to care for them in old age we argue that social insurance can effectively replace family insurance because elderly persons living in nursing homes express higher levels of life satisfaction than those living in households mostly with their children the second suggestion involves removing obstacles to the migration of rural families thus facilitating their migration and promoting stable lives urbanization is a development process it not only promotes the wellbeing of rural families but also reduces fertility this phenomenon can be explained by the fact that an urban resident is entitled to social insurance for elderly care in china which replaces the need for family insurance third the construction of town systems in affluent areas with surplus rural laborers must be strengthened to create more local offfarm employment opportunities many chinese cities are overly populated because of economic imbalance among regions and the present infrastructure will be incapable of coping with the demand a balance in economic and employment opportunities among regions is sought policies should encourage enterprises to locate in small towns or developing regions to allow citizens from less powerful rural families to easily find work ultimately leading seasonally mobile families to return to their hometowns and achieve permanent migration on the one hand big cities would be relieved of population pressures on the other hand the economies of smaller towns would be developed thereby achieving parallel development among big cities and small towns a few limitations are noted observational studies are rarely based on purely random samples intentionally or unintentionally but the results of this study are largely dependent on the survey data employed a deterministic theory can be invalidated by a single contradictory observation further investigation is necessary to validate the accuracy of the results of this research

employing data from the china ruralurban mobility survey conducted in 2010 this study investigates the influence of family demographic characteristics on the income life satisfaction and potential for ruralurban mobility at the rural household level of two provinces of china shaanxi and henan a larger labor force in a rural household was found to reduce a familys ability or inclination to move to a city the findings reveal that family size negatively affects the average income per family member and reduces the marginal income of the labor force and that minor children can improve the life satisfaction of family members we conclude that a larger family size does not translate to more benefits for a rural household family size preference is found to be a reflection of parents concerns about elderly care and is deemed to be unfavorable for urbanization in p r china

introduction population development policies in the context of national and regional development need to be strengthened both in concept and implementation at the policy level population development must be able to integrate national and regional population issues so as to give birth to the concept of populationoriented development the synergy of populationoriented policies with the quality of human resources requires the quality of the population as a systemic vehicle in producing people who have life skills personal skills that include selfawareness and thinking skills as well as social skills academic skills and vocational skills the main problem is the high population growth and the unbalanced distribution and age structure at the implementation level the population development policy is expected to be able to raise the standard of living of the population so that they become more advanced independent happy and prosperous where population development must really be able to take advantage of demographic bonus opportunities to trigger economic growth and improve peoples welfare n for this reason this research is expected to provide a scientific foothold on the facts of the ongoing population phenomenon as well as to bridge it in the handling of this phenomenon through a population policy that is more prosociety methods the type of research used is normative juridical research in the form of regulatory research that focuses on the study of theoretical aspects in the form of principles norms or policy regulation rules while the method used is 1 observation 2 documentation 3 fgd the analysis that will be used is secondary data analysis and document review residents are peopleresidents who live in an area and settle or intend to stay longer policies these five aspects are known as the 5 pillars of population development in 2019 the contribution of womens income in the boalemo district could reach 2921 percent even higher than the average income contribution of women in the province of gorontalo results and discussion a research results boalemo

population development policies related to national and regional development need to be strengthened both conceptually and practically at the policy level population development must be able to integrate national and regional population issues to create the concept of populationoriented development the purpose of this study is to describe population development policies in boalemo regency related to policy implementation policy concept and the situation and conditions of population development the method used is observation documentation and fgd with the support of secondary data analysis and document review the results of the study indicate that generally the implementation of population development policies in the boalemo district has been carried out optimally but still needs to be improved especially in

introduction nurses play an essential role in ensuring the continuity of healthcare systems globally and improving healthcare practices they work on the frontline in fighting against covid19 infection 1 covid19 is defined as an infectious disease caused by a new type of coronavirus associated with severe acute respiratory syndrome 2 the major symcovid19 patients experienced fears of being contaminated at work and of becoming sick and dying the same authors further indicated that some nurses reported that the infection or death of other nurses exacerbated their fear creating serious anxiety and stress gordon et al 7 stated that in addition to the fear of being infected themselves nurses also expressed concerns about transmitting the infection to others including their family members a study conducted on the covid19 pandemic 1 has revealed that nurses who are directly in contact with a potentially fatal virus have increased concerns about their personal health which tends to make them feel stressed about continuing to provide care khatatbeh et al 5 added that many physical problems have been reported by nurses caring for covid19 patients because they worked for long hours and were mentally occupied caring for patients diagnosed with covid19 infection can cause a wide range of psychosocial and physical impacts on nurses because they serve under extraordinary stress due to the high risk of infection stigmatization understaffing and uncertainty 5 the stigmatisation faced by nurses caring for covid19 patients in their social lives has led to limitations in areas of their personal freedom 8 stigma is defined as a mark of disgrace that sets a person apart from others 9 ardebili et al 10 stated that feelings of helplessness hopelessness and becoming powerless are prevalent among nurses caring for covid19 patients a study 11 revealed nurses to be both sad and stressed due to the morbidity and mortality of the covid19 pandemic lulgjuraj et al 12 reported that despite the experiences and stress faced by nurses many were proud to be on the frontline and they saw themselves as being in a position to help when care seemed out of their control as a result nurses were proud of the lives that were saved it is imperative that research be undertaken to determine what nurses are experiencing physically and emotionally to help nurses today and in the future 3 methods study design this study used a qualitative descriptive phenomenological and contextual design to explore and describe the live experiences of nurses caring for patients diagnosed with covid19 infection in the north west province study setting the study was conducted at four selected public hospitals caring for patients diagnosed with covid19 infection in the north west province population and sampling the study population comprised nurses caring for patients diagnosed with covid19 infection in the nwp including registered professional nurses enrolled nurses and enrolled nursing auxiliary the target population was nurses who have been registered with the south african nursing council and currently employed in covid19 sites in nwp with more than one month of experience in caring for patients diagnosed with covid19 infection in nwp a nonprobability sampling technique was used to obtain a sample for the study data collection data were collected through semistructured virtual focus group discussions via google meet where an interview guide was used data collection techniques included the use of a voice recorder and field notes a broad question was asked to all participants what are your experiences in caring for patients diagnosed with covid19 infection and this was followed by probing questions based on the responses data were collected until data saturation was reached at the fourth focus group discussion the names of nurses were not used data were collected from nurses caring for patients diagnosed with covid19 infection in four public hospitals of north west province from each public hospitals covid19 ward 4 nurses caring for 21 covid19 patients were selected for focus group discussion the interviews took a total of 45 minutes ethical approval was obtained from the northwest university health research ethics committee with approval number nwu0030921a1 data analysis data were analysed using descriptive phenomenological data analysis 13 data were transcribed verbatim from the collected data an independent cocoder was involved and consensus was reached for themes and categories measures to ensure trustworthiness credibility dependability confirmability transferability and authenticity were determined in this study to ensure the trustworthiness of the study 14 credibility was ensured through prolonged engagement with nurses and by collecting data using virtual focus group discussion purposive sampling and data saturation were used to enhance transferability 15 results data saturation was achieved with a sample of four focus group discussions a total of 26 nurses participated in the study the fgds of nurses consisted of professional nurses enrolled nurses and enrolled nursing auxiliary the themes and categories of the live experiences of nurses caring for patients diagnosed with covid19 infection are presented in table 1 below theme 1 nurses knowledge of covid19 nurses conceptualisation of covid19 the study has identified that nurses seem to have an understanding of what covid19 is and also the symptoms of covid19 the following quotes substantiated this finding participant 3 said covid19 is a large family of viruses that cause illnesses ranging from common cold to more severe diseases like pneumonia sars and mers participant 4 said the signs and symptoms that are associated with the virus are fever cough body aches and sometimes you also have headache the virus when advances to stages it happens to have signs of diarrhoea and loss of appetite as well as loss of sense of smell participant 3 stated covid19 is an airborne disease that can spread from one person to another and it affects your lungs and the upper respiratory system in most cases some of the patients will struggle with insufficient oxygen to the lungs and to the brain that is when they get hypoxia theme 2 nurses experiences of caring for patients diagnosed with covid19 infection the findings of the study revealed that nurses have different experiences in caring for covid19 patients the nurses alluded that they have physical psychological and social experiences of caring for covid19 patients the nurses further indicated their positive experiences and their experiences of coping when caring for patients with covid19 the following categories detail the experiences of nurses caring for covid19 patients nurses physical experiences of caring for patients diagnosed with covid19 infection nurses verbalized that as the result of caring for patients diagnosed with covid19 they ended up having physical problems and some of the nurses indicated that they ended up having covid19 infection nurses psychological experiences of caring for patients diagnosed with covid19 infection the study revealed nurses to experience fear when caring for covid19 patients nurses reported being afraid of infection with covid19 and they felt that they would also die of covid19 their fears and feelings are supported by the following quotes participant 6 stated it stresses to go in there you have to go inside there you dont have a choice you have to go inside and try to save somebody there you might be infected you might die with the very same person that you are going inside to try to save participant 3 said when we lost colleagues i felt that we were all going down that was the feeling i felt like we are all gonna die participant 1 reported i am caring for patients with covid19 psychologically it affected me in this way because of seeing patients fighting for their lives every now and then and people are dying now and then in our hands i have been diagnosed with depression so i was depressed and had been taking medications for depression nurses social experiences of caring for patients diagnosed with covid19 infection the findings of the study further revealed that nurses were stigmatised and socially isolated because they were seen as carriers of covid19 infection nurses reported that people including their colleagues working in noncovidwards and managers did not want to be closer to them because they thought that they would infect them with covid19 participant 5 stated even with us we were affected because you know when you go to the passage they know that you are working in covid ward you are like an alien people would run away from you the night supervisor would just say put the report there by the entrance that is the reality that is how we worked management was not even coming they were afraid of us just to come and say how are you feeling participant 6 reportedand you felt as sometimes isolated when you get amongst other people and they just say you are a nurse people just want to be scattered they do not want to be next to you because you are a nurse and you might be having the infection you might be infectious and you might kill them because it was a disease that was drastic a drastic disease that is causing death when they see you they just say this one is going to kill us participant 4 added the management did not want to enter our ward they feared for their lives so they would be standing at the door and calling you even some of the colleagues knowing that we are working in covid19 ward they would be standing at the door it is not nice for us it was very very bad it was emotional to be neglected by management and colleagues from other wards nurses positive experiences of caring for patients diagnosed with covid19 infection the study also revealed some nurses to have shown compassionate care to covid19 patients nurses used their phones to video call patients families because they were not allowed to visit during covid19 in addition they reassured patients and prayed for them and they further used their money to buy things that they thought could assist the patients in recovering from covid19 participant 2 said sometimes i was buying for the patients the lemons ginger and garlic so that we can prepare for the patients we even boiled them hot water every day when i was on duty so that they could drink hot water from the jars not cold water we mix that with the gingers and garlics so that they can all drink participant 7 stated when the patient is about to demise when the condition changes and maybe the saturation level goes down and you can see that the patient is dying and we have tried everything you know sometimes when they would speak you can see that they are scared they long for that family member so on my side what i would do is that i would video call the family members so that they can just say their last words and see the patient for the last time and say whatever that they need to say i think because what a lot of family members say on its own brought a lot of closure because they can at least see that my father my mother or my sister is suffering they can see that heshe is fighting but chances are that they are not gonna make it so that on its own brings closure participant 6 added we were just standing next to the bed holding their hands reassuring them even when you know the prognosis is not good you reassure them to say that she is going to be okay a lot of time we were just standing and praying for them nurses experiences of coping when caring for patients diagnosed with covid19 infection nurses alluded that they had to accept continue to be committed and care for covid19 patients the following are the quotes from the participants participant 1 said but i remembered that i said i solemnly…you see the nurses pledge i said okay i am going to care for the patients let me just be strong and do what i said i want to participant 5 but it is okay but at least we did our best only god knows because it is not only about money it is about caring and reassuring the patients we have played our part participant 3 it is a matter of saying okay i am going to work i dont know what i am gonna come across today but god help me discussion the findings of this study revealed nurses to be physically psychologically and socially affected when caring for patients diagnosed with covid19 infection nurses reported to have developed comorbidities such as hypertension since they started caring for covid19 patients these findings are supported by the study conducted by gholami et al 16 who reported hypertension to be a prevalent comorbidity among nurses caring for covid19 patients khatatbeh et al 5 added that nurses complained of having headaches and muscle pain so they started using analgesics furthermore it was reported that nurses caring for covid19 patients had a fear of being infected and infecting others with covid19 the results of this study indicated that nurses were not sure whether they were the carriers of the covid19 virus and it was not easy for them to go home because of the fear of transmitting covid19 infection to others nurses reported that it was so difficult to go home because they were not sure whether they were taking the virus home in a study conducted by galehdar et al 17 nurses experience showed that they could not have close contact with their family members because of the risk of being a potential carrier the same authors are of the impression that nurses have always had fear and anxiety about being a carrier and because of this they may not be able to see their family members for several days in the study conducted by galehdar et al 17 one of the causes of stress in nurses was the fear of being infected with covid19 hu et al 18 added that nurses suffered from the fear of spreading the infection to their loved ones these findings were also supported by who reported that nurses were fearful that their contact with covid19 patients would result in the unintended infection of others especially their own family the findings of this study also revealed nurses to have a fear of dying the nurses mentioned that when they saw their colleagues dying they thought they were also going to die nurses verbalized that they felt powerless helpless and hopeless they even thought to be failures because they could not save patients lives these results concur with the findings of ardebili et al 10 who stated the feeling of helplessness hopelessness and becoming powerless to be prevalent among nurses caring for covid19 patients the findings of this study showed nurses experienced trauma to be related to sudden and multiple deaths of covid19 patients these responses are in line with the findings presented earlier 20 which revealed that patient death is often interpreted as a traumatic experience for nurses contributing to stress and other psychiatric symptoms the study has also shown some of the nurses to no longer be the same people as they used to be they reported to have developed longterm emotional effects such as anger the present study showed that nurses were stigmatised and isolated by their colleagues working in noncovidwards managers families and the community because they thought the nurses to be carriers of covid19 these results are congruent with those of muz and erdogan 1 who stated that the isolation and stigma towards nurses by some members of the society continue they further reported that such reactions of the society cause nurses to feel guilty and prefer a life that increases social isolation and restricts contact with the outside world in a study conducted 11 nurses reported that they had moved away from social environments because of the risks of being stigmatised by society and of transmitting the disease hence they felt isolated and lonely in this study the findings revealed that covid19 has helped nurses to learn about some other equipment that they did not know about before such as ventilation machines the results of this study indicated nurses to have shown acts of kindness and care to covid19 patients as shown by video calling the relatives to connect the patients with their families kellogg et al 20 stated that nurses had additional responsibilities to use technology during covid19 such as smartphones or tablets to allow patients to see their loved ones provide updates to family or facilitate goodbyes as patients came close to the end of life the same authors further stated that nurses use of technology was the link between patients and their families during the covid19 pandemic effective coping strategies promoted positive psychological health outcomes among nurses 21 chow et al 22 pointed out the importance of spirituality as a coping skill in the maintenance of psychological wellbeing for nurses during covid19 pandemic the same authors maintained that positive religious coping remains a significant coping mechanism to boost mental health commonly via prayers attending religious services reading scriptures or meditation the authors 22 also stated that spirituality was found to aid nurses in coping with stress encourage recovery resilience and reduction in burnout and reduce fear sorrow and anxiety in relation to the covid19 pandemic and consequent social isolation the findings of this study revealed nurses to have thoughts of resigning because of the trauma that they experienced when caring for covid19 patients nurses felt like they were in danger and many left their jobs and resigned because of covid19 kackin et al 11 confirmed these results that nurses caring for covid19 patients had felt an extreme desire to resign and they may also exhibit avoidance behaviour in a study conducted by lulgjuraj et al 12 nurses reported that they have thought about leaving bedside nursing since experiencing the peak of the covid19 pandemic strengths and limitations of the study the study was conducted in the four hospitals of the north west province caring for patients diagnosed with covid19 due to the fact that this study was conducted only on nurses working in north west province the results of this study can only be generalized to the individuals included in the study this makes it difficult to compare the experiences of nurses based on their culture with other provinces and other countries taking into consideration the fact that the covid19 pandemic is not limited to a single province or country a global integrated comparative study is required that takes into account the experiences of nurses working in other countries implications of the findings the study findings confirm the nurses caring for covid19 patients to experience physical psychological and social problems in this regard providing them with the necessary support will encourage them to provide quality patient care conclusion this study reveals important aspects of nurses experiences in caring for patients diagnosed with covid19 nurses have experienced fears of being infected with covid19 and they also have had fears of transmitting covid19 infection to their loved ones the findings of this study can provide guidance for understanding the problems of nurses as frontline healthcare workers during covid19 and provide solutions for healthcare institutions to respond effectively to similar pandemics in the future authors contribution jmd initially drafted the manuscript mmm and las assisted in the review of the manuscript and all the authors agreed to publish the final version of this manuscript list of abbreviations ethics approval and consent to participate the study includes human participants and the ethical approval of the study was obtained from the northwest university health research ethics committee with the number nwu0030921a1 human and animal rights no animals were used for studies that are the basis of this research all the human procedures used were in accordance with the ethical standards of the committee responsible for human experimentation and with the helsinki declaration of 1975 as revised in 2013 consent for publication the participants were made aware of the data for publication and an informed consent has been obtained from them their participation was thus voluntary standards of reporting coreq guidelines were followed availability of data and materials the derived data used to support the findings of the study are available from the corresponding author jd on request conflict of interest the authors declare no conflict of interest

nurses are the frontline healthcare workers and continue to play a vital role in caring for patients diagnosed with covid19 infection exploring and describing the experiences of nurses caring for covid19 patients are significant to determine what nurses are experiencing physically psychologically and socially in order to help them in improving the quality of patient care

introduction in the process of implementing the rural revitalization strategy rural social work plays an irreplaceable role and the construction of its talent team is an important part of guaranteeing the realization of chinas rural revitalization strategy and an important support for comprehensively promoting the development of rural social undertakings with the continuous advancement of new rural construction and new urbanization the development of rural social undertakings is being placed in a new development environment facing new development problems and is in urgent need of a highquality social work team to provide specialized and personalized services at present chinas rural social work talent team construction in the process of development there are a series of problems such as insufficient number of talents low quality poor treatment and so on this paper focuses on the problems existing in the construction of rural social work talent team in accordance with the current situation problems causes solutions to the logic of the exposition to develop through the design of the rural social service system to the construction of rural social work talent team mainly in the logic of the construction of rural social work service system focusing on the construction of the talent team problem of the comprehensive study aims to the construction of rural social work talent team to analyze and solve the problems existing in the construction of rural social work talent team it aims to analyze and solve the problems existing in the construction of rural social work talent team and accelerate the construction and quality improvement of rural social work talent team by optimizing the talent system and improving the treatment of talents and other measures current status of rural social workforce development chinas rural social work talent team construction is in an initial exploration stage although the development of rural social work has made some progress in recent years but compared with urban areas there is still a large gap between the scale and quality of the rural social work team and even more a lack of professionalism and vocational empowerment the proposed strategy of rural revitalization provides an opportunity and policy support for the development of rural social work the number of social work professionals in the country has risen dramatically national development has entered a new era and the great changes over the past decade have been landmarks in the history of social construction and development the number of people holding professional qualification certificates for social workers nationwide totaled 929000 1 uneven and inadequate development of rural social work compared to urban social work at present the development of rural social work is unbalanced and inadequate in comparison with that of urban social work there are many professional and vocational social work talents in the urban construction team who have set up a number of social service organizations as well as social service sites for the different needs of urban community residents playing an important role in the urban community governance system and public services and enhancing the sense of wellbeing of community residents 2 on the other hand the development of the construction of the social work talent team in rural areas is relatively slow and compared with the cities rural areas are allocated fewer resources including human resources material resources and financial support this leads to a large gap in rural social work in terms of staffing program development and service quality as the economy of rural areas is relatively backward and less attractive many social work professionals prefer to choose employment in urban areas resulting in an inadequate staffing structure and lack of professional support for rural social work teams in addition infrastructure development and social service facilities in rural areas including education health care and culture lag behind those in urban areas making it difficult for rural social work to provide services and support rural revitalization provides a policy basis for building a rural social work workforce the issue of agriculture rural areas and farmers is a fundamental issue related to the national economy and peoples livelihood and it is necessary to always take the solution of the three rural issues as the top priority of the national work and implement the strategy of rural revitalization rural social work needs to closely focus on the key tasks of the rural revitalization strategy with the indepth promotion of the rural revitalization strategy rural social work has gradually become an important part of rural revitalization and the task of rural social work has more clarity and the first prerequisite for the development of rural social work is the construction of rural social work personnel but the construction of rural social work personnel has always been a relatively weak link 2021 february the state general office of the state office of the state council issued the opinions on accelerating the promotion of rural talent revitalization proposed to accelerate the development of rural social work opinions on rural talent revitalization issued by the state general office proposed to actively introduce social workers in rural revitalization accelerate the construction of the rural workforce and help the comprehensive revitalization of the countryside with rural talent revitalization the strategic plan for rural revitalization issued by the relevant state departments clearly proposes to build a new type of rural governance system and strengthen the construction of the rural social security system in the rural revitalization strategy these policies provide a policy basis and direction for the development of rural social work problems in building a rural social work workforce social work cannot be separated from the talent team and the construction of the rural social work talent team has already had a certain embryonic form and has made certain progress and achieved certain results in the process of construction but still faces many challenges and problems these problems have seriously constrained the development of rural social work teams and have become bottlenecks in the process of building rural social work teams insufficient number of rural social workers the differences in economic and cultural conditions in rural areas in china have led to an imbalance in the development of social work in rural areas resulting in the phenomenon of hot in the cities but cold in the countryside the demand for social work in some developed cities is saturated while there is a serious shortage of manpower in the construction of rural talent teams few graduates of social work programs return to their hometowns each year to take up social work positions exacerbating the problem of the shortage of rural social work personnel most of the social workers in the existing rural social work team have switched jobs because of factors such as the shortage of resources in rural areas a difficult environment poor welfare benefits and limited room for advancement and even many rural social workers have left the countryside for urban development the loss of rural social work talent has greatly weakened the scale of rural social work talent building lack of professionalism and practical capacity of rural social work teams according to a survey of the real situation the construction of rural social work personnel is lagging behind and the structure of the entire team is complex with varying professional qualities among the existing rural social workers some are promoted from village streets while others are recruited from official websites in addition the level of education varies greatly with some having a secondary school education some a college education and some a bachelors degree or above most of the personnel engaged in social work services are nonsocial work majors and most of them deal with the problems encountered in rural social work with their personal experience the number of licensed personnel is relatively small they lack professional theoretical knowledge and skills and professional education and training the services they provide are not very much different from those of general volunteer services and they cant well highlight their professionalism let alone be good at solving professional problems the rural population is large and concentrated and since the main targets of rural social work are the elderly women children the disabled and other vulnerable groups in rural areas the problems of these vulnerable groups are often difficult and complex and there are organizations or groups of different sizes and natures in rural communities which are both differentiated and connected and these differences and connections often create an antagonistic or conflicting relationship 3 if rural social work lacks attention to and research on these factors it will easily lead to the failure of rural social work services in the face of such a complex rural situation the number of social workers is small experienced social workers lack theoretical knowledge and social workers with rich theoretical knowledge lack practical experience then the problems caused by the barrel effect are very serious 4 rural social work continues to face a more difficult professional environment compared with cities rural areas have a less favorable natural environment infrastructure and working environment our rural social work professionals working in rural areas need to face more pressures and difficulties than in cities such as inconvenient transportation 24hour oncall usually temporary latenight meetings no holidays and weekends heavy workloads low pay few benefits and lack of corresponding promotion paths etc and these difficulties and pressures sometimes discourage some potential social workers the small number of rural social work recruitment positions has made it difficult for social work professionals to choose a career and the number of people staying at home is high there is also the problem of an unreasonable appraisal system while social workers are working in order to ensure the quality of social work services and the sound development of social organizations it is common for social organizations to adopt an appraisal system 5 however the appraisal system of rural social work lacks scientificity and flexibility resulting in many staff members only being able to complete their work tasks in a mechanical way making it difficult for them to utilize their potential and making their work inefficient low recognition of social work in rural areas when rural social workers carry out social work in rural communities the functional positioning of rural social workers is vague and the role of social workers is more generalized and the majority of rural residents knowledge of social work remains at a superficial level believing that they are no different from community volunteers and volunteers rural residents usually seek help from their acquaintances when they are in trouble according to their inherent thinking and they feel that social workers do not have enough ability to help them deal with their problems and they are skeptical of their efficiency and even if they finally seek help from the social workers they are unable to actively cooperate with the work of social workers in rural areas the professional authority of social workers has not been established and some rural residents consider rural social workers to be fulltime nannies who call on them at will leading to an awkward situation for rural social workers most rural residents even think that the services provided by social workers are similar to those provided by village committees and neighborhood committees ignoring the scientific and professional nature of social work 6 causes of problems in building a rural social workforce problems in the construction of rural social work personnel are constrained by a number of factors and there are four main causes of these problems first the factors of the social work personnel themselves second the lack of a professional training mechanism third the imperfection of the personnel security system and fourth the small publicity efforts and the lack of attention paid by the relevant departments to the construction of the personnel team brain drain in rural social work the underrepresentation of rural social work is caused by the social work brain drain first most students are not aware of the social work profession at the university stage the specialty of social work is not well known and many students do not know that there is such a specialty nor are they interested enough in these specialties and many college students do not choose this specialty which leads to a lack of the number of social work talents secondly social work students think that there is no employment prospect for the social work profession and it is difficult for them to take the public examination and most of them tend to go to graduate school for further study or work in other industries third the respect needs and selfrealization needs of social work talents are not satisfied rural residents do not have enough trust and respect for rural social workers which leads to the frustration of rural social workers and makes it difficult for them to identify themselves with the profession in addition in the existing social workers most of the social workers think that the degree of selfrealization of value is low which creates an imbalance and they choose to give up social work after becoming dissatisfied with social work lack of professional training mechanisms for rural social workers rural problems are intricate and complex and rural social workers need to be professionally trained and educated applying specialized knowledge and skills including knowledge of social work theory social policy and social work methodology to carry out services that take into account the needs of rural residents in practice most of the social workers in the rural social work talent team have not received professional training and education and deal with problems based on personal life experience only mainly because of the lack of professional training mechanisms the lack of professional training mechanism leads to the fact that social workers are unable to learn knowledge and master skills systematically at the same time the lack of professional training mechanism also leads to the lack of practical ability of rural social workers although some social workers have undergone professional technical training they are often unable to apply the theoretical knowledge they have learned to their practical work due to the lack of practical opportunities and guidance this has resulted in a lack of practical skills in solving rural problems and an inability to effectively meet the needs of rural residents inadequate rural social work personnel security system the difficult professional environment of rural social work is mainly due to the imperfection of its talent protection system which is mainly reflected in the following firstly the lack of incentive system which leads to the poor remuneration of rural social work talents this makes the enthusiasm and creativity of rural social work talents limited and makes it difficult to attract and retain excellent talents second the career development channel is not smooth the career development channels of rural social work talents are relatively narrow with limited space for promotion and opportunities for selfimprovement which makes rural social workers stay in the same position for a long time and lack motivation for career development thirdly there is a lack of scientific and reasonable evaluation system in rural social work there is a lack of scientific and reasonable evaluation system to comprehensively and accurately assess the performance and contribution of rural social work talents this makes the efforts of outstanding talents not properly recognized and rewarded affecting their work motivation fourthly the support mechanism is not sound rural social work talents face greater pressure and difficulties in their work but there is a lack of effective support mechanisms in the face of complex rural social problems they often feel powerless and uneasy with insufficient help and support leading to a decline in the quality of their work low publicity for rural social work and insufficient attention paid by the relevant authorities to the building of a talent pool in rural areas rural residents generally have a low level of literacy and lack proper knowledge and understanding of social work they do not understand the content of social work services let alone the role and advantages of social work in solving problems in rural communities the low recognition of social work in rural areas is to a large extent due to the fact that the relevant departments in the construction of rural social work personnel do not pay enough attention to rural social work most of the relevant departments at the rural grassroots level do not pay attention to the development of community services and lack of accurate positioning of the function of rural social workers resulting in social work professionals in rural work is difficult to play their own advantages and the construction of townships and townships of social work talent team is stranded countermeasures for building a rural social work workforce in order to promote the construction of the rural social work talent team improve the professional quality and working ability of the overall social work talent team and better provide specialized and efficient services for the development of rural social work this paper puts forward the following four countermeasures increasing the attractiveness of policies for social work professionals an open communication atmosphere allows social workers to freely express their thoughts and feelings thus more effectively improving their experience of selfrealization of the value of feelings therefore leaders should try to establish an open and transparent communication environment to encourage social workers to share their work experience and express their ideas and suggestions freely establishment of professional training mechanisms in the process of building a social work talent team it is necessary to strengthen the professional training and education of rural social workers and to establish a specialized training mechanism first of all personalized training programs are formulated for different types of rural social workers and professional knowledge training in the form of courses seminars conferences readings and other forms can be carried out for social workers on a regular basis to make them adapt to the requirements of their work as soon as possible to improve their communication skills and the level of their professional services so that they can cope with all kinds of problems in their actual work to alleviate their psychological pressure to increase their recognition of the job itself to help them establish a professional and occupational image among rural residents and to enhance their prestige this work will increase their sense of identity and help them to establish a professional and occupational image among rural residents and enhance their prestige and respect secondly colleges and universities are encouraged to actively carry out professional internships for students in social work so as to improve their practical ability and adaptability and enrich their practical experience improvement of the rural social work personnel security system optimizing the workplace environment for rural social work requires the establishment of a sound system to safeguard rural social work talents and the system needs to be improved in the following ways first a sound incentive mechanism should be established including measures such as reasonably adjusting wages optimizing benefits strengthening training and implementing a vocational assessment system so as to enable staff members to receive better career development and life care so that they can devote themselves to their work in a more active manner secondly the government should strengthen its support for rural social work and provide better protection and support for rural social workers by formulating relevant regulations and policies these regulations and policies should include job arrangements professional training salaries and wages working environment and other aspects so as to provide an allround guarantee for the development of rural social workers third the appraisal system should be flexibly adjusted the appraisal content and standards should be set scientifically and reasonably and diversified appraisal methods should be adopted to improve the staffs work enthusiasm and motivation fourthly psychological support and assistance mechanisms should be established to pay attention to the psychological health of rural social work talents and provide necessary psychological counseling and support psychological counseling activities can be organized to help them reduce work pressure and anxiety at the same time regular peertopeer exchange meetings or seminars can be organized to share work experience and insights and to jointly solve problems encountered in social work increased rural awarenessraising efforts and increased attention to rural social work by the relevant authorities rural social workers need to actively enter villages to publicize the concept of social work make use of the internet and multimedia platforms to widely publicize the concept of social work and write about the deeds of outstanding social workers so as to raise the level of rural residents awareness and understanding of social work and increase their trust in social workers rural social workers are engaged in work very close to rural residents to strengthen the communication and contact between rural social workers and rural residents to establish a good working relationship to understand the actual needs and wishes of the residents to provide a full range of highquality services and at the same time actively develop rural volunteer services the development of rural voluntary services can effectively integrate rural resources mobilize the enthusiasm and initiative of rural residents to participate in rural governance enhance the awareness and ability of rural residents to participate improve the quality of life of residents and improve the credibility of rural social workers in rural governance and the peoples recognition of social work in the new situation the relevant departments should recognize the important goal of rural social work talent team building and local economic and social development village development therefore the relevant departments should pay attention to the relationship between rural social work talent team building and local economic and social development and balance the development of these two aspects only through the mutual promotion of talent team building and local economic and social development can we realize the sustainable development of rural areas at the same time the relevant departments should also focus on establishing a good service concept rural development and construction must put the needs and interests of rural residents in the first place and constantly improve the quality of services to meet the diversified needs of residents and this requires the relevant departments to pay attention to the construction of rural social work professionals and to improve the service consciousness and service level of the overall social work talent team only by doing so can the core competitiveness of rural workers be enhanced in addition the relevant departments also need to improve their management capacity strengthen the construction and management of the team and realize highquality rural development conclusions rural revitalization and rural social work interact with each other the implementation of rural revitalization strategy promotes the development of social work and the development of social work contributes to rural revitalization starting from the perspective of status quo analysis and policy interpretation this paper researches and analyzes the existing problems in the construction of rural social work talent team sorts out the intrinsic causes and finally puts forward four realistic solutions although rural social work has achieved certain results the construction of rural social work talent team is still facing a series of problems and challenges and by adopting corresponding solutions the service capacity and quality of the rural social work team can be effectively improved so as to make greater contributions to the social development of rural areas community work is a noble cause dedicated to serving the people aiming to improve the quality of life of community residents and promote the development and prosperity of the community and social work is of great significance to the social stability and sustainable development of rural areas however in the climbing stage after the start of the 14th fiveyear plan rural social work still needs to be invested in more vigorous construction

the construction of rural social work personnel is an important part of guaranteeing the realization of chinas rural revitalization strategy and is an important support for comprehensively promoting the development of rural social undertakings with the development of economy and society chinas rural areas are being placed in a new development environment and facing new development problems and rural residents have higher and higher requirements for the quality of life and after satisfying the basic material needs they begin to pursue spiritual cultural and psychological needs rural social work with its professional social and service characteristics has become the resource guarantee and social security foundation for the implementation of the rural revitalization strategy however in practice the construction of rural social work talent team still has a series of problems such as insufficient number of talents insufficient development of talent quality and low recognition of social workers which seriously restricts the development of rural social undertakings and the cause of rural revitalization strengthening the attention paid to social work and the training of rural social workers plays an important role in promoting rural revitalization facilitating the development of rural economy and society improving peoples livelihoods and safeguarding the public interest from a practical point of view it is necessary to build rural social work teams to revitalize the countryside by establishing a sound system of talent protection and optimizing the work remuneration of social work talent so as to attract talent to reside in the countryside

those living in initial asylum accommodation are at increased risk of vaccinepreventable disease yet confidence in vaccination may be low we aimed to understand vaccine confidence and decisionmaking among those going through the uk asylum system from a sociological perspective indepth semistructured interviews were done on views and experiences around vaccination with asylum seekers or those recently granted asylum interviews were conducted remotely audiorecorded transcribed and analysed through reflexive thematic analysis in nvivo 12 25 participants were interviewed of whom 13 were living in asylum accommodation at the time of interview preliminary analysis has indicated candidate themes relating to trauma social isolation agency and precarity running through discussions around vaccination decisions past trauma such as discrimination at healthcare facilities or feeling forced to receive vaccinations in asylum accommodation often directly impact trust and decisions to reject future vaccination participants described how their struggle for basic necessities social isolation and precarious living situations imposed by the asylum system left them with other priorities than vaccination participants who perceived they have been well cared for in the healthcare system or who described feeling empowered to make their own decision about vaccination often suggested they would be likely to accept vaccination if offered asylum seekers and refugees have often experienced substantial trauma precarity and have a lack of agency directly imposed on them by the asylum system which are likely to impact trust and decisionmaking around healthcare formative experiences in the uk are key to establishing trust a traumainformed approach should be central in developing vaccination interventions for these groups particularly in asylum accommodation key messages trauma precarity and lack of agency imposed by asylum systems are likely to impact trust and decisionmaking around healthcare a traumainformed approach should be central in developing vaccination interventions for asylum seeking and refugee groups particularly in initial accommodation settings 7c workshop health for all policies the cobenefits of intersectoral action abstract citation id ckad160444 organised by european observatory on health systems and policies chair persons matthias wismar contact the objective of this roundtable discussion will be to provide the arguments and evidence for increased intersectoral action to achieve the sustainable development goals sdgs

the covid19 pandemic showed that health denialism and conspiracy beliefs may influence adherence to preventive measures many variables have been considered as determinants of conspiracist attitudes this study aims to assess the determinants of conspiracy beliefs related to vaccination vaccine conspiracy beliefs score vcbs in polish society during the covid19 pandemicthe analysis was based on data from the online survey conducted in november 2021 in a representative sample of adult internet users uni ulr and multivariable linear regression mlr models were developed for vcbs the relationships of health literacy hl ehealth literacy ehl future anxiety fa internet iu and social media use smu selfassessed health status sahs and prevalence of chronic disease cd with vcbs were assessed after adjusting for sociodemographic variables and political sympathies b coefficient b and 95 confidential intervals 95 ci are reported here for mlrthe study sample of 2189 comprised 512 of women and 261 of persons with a university education the mean age standard deviation sd of respondents was 441 1525 years vcbs 377 152 ehl score 2891 1063 and fa score 475 127 mlr revealed that vcbs was significantly associated with hl but not ehl vcbs was higher in persons with inadequate hl than those with sufficient hl b 95 ci 066 036 095 greater fa was also associated with higher vcbs 008 003 013 interestingly less duration of iu the lowest vs the highest use 047 008 085 but more intense smu frequent vs infrequent use 031 011 051 predicted higher levels of vcbs finally sahs and cd were not significant predictorshealth literacy remains a key modifiable determinant of the prevalence of conspiracy beliefs related to vaccination effective measures counteracting conspiracy beliefs should be considered in future public health challengesdeveloping adequate health literacy may be an efficient measure counteracting unfavorable impact of conspiracist thinking on the acceptance of vaccinations health denialism manifesting with conspiracy beliefs should be treated as a target for public health interventions during pandemics

the quality of life problem is particularly relevant for young people today in relation to youth insecurity in transitions from education to employment it is also relevant for older people with regard to the everincreasing retirement age and the need for active inclusion of older people in the labour market and in society as well as the need for continuing education and lifelong learning it is also relevant for different professional groups in relation to the different opportunities that the profession and related income career environment development opportunities create for the unfolding of objective and subjective dimensions of quality of life in personal and community terms it is also relevant in terms of the issue of gender equality and the specificity this creates for the quality of life of women and men the problem of quality of life is also particularly relevant in relation to the recent increase in natural and technological disasters and catastrophes which present affected communities with severe challenges to their future and current quality of life all of these and much other quality of life issues are addressed in the articles in this issue of postmodernism problems two of the articles are devoted to the particularly topical issue of the quality of life of the elderly albena nakovas article examines the social inclusion of the elderly in bulgaria as an indicator of their quality of life rumiana zhelevas article examines the quality of life of the elderly negative impact of two catastrophic events that occurred in bulgaria an earthquake and a flood on the quality of life of local communities in economic financial and material terms as well as in terms of the physical and mental health of the affected individuals and communities while highlighting that in terms of social connectivity and cohesion disasters can also have a positive impact by acting as a catalyst for social relations creating greater closeness and support between people on the one hand and on the other building new cultural memory and places of remembrance

the thematic focus of this issue of postmodernism problems is the dynamics and transformations in the quality of life of social communities in bulgaria and romania the publications in it are the result of the implementation of a joint research project under the interacademic cooperation between the bulgarian and romanian academies and more specifically between the institute of philosophy and sociology at the bulgarian academy of sciences and the research institute for quality of life at the romanian academy on the topic transformations in the quality of life of social communities in the conditions of globalization challenges and perspectives 2022 2023 this project aims to continue and expand the already established cooperation between the institute of philosophy and sociology at the bulgarian academy of sciences with the research institutes of the romanian academy and to develop this cooperation to a new stage and in a new thematic area through the realization of new interdisciplinary research focusing on current societal issues of both countries the question of quality of life as a research problem arises in connection with the transition from the modern industrial to the postmodern postindustrial postmaterialist society and as an alternative to the concept of primary material and economic growth with the idea of the emancipation of man from the excessive dominance of material values but today this question is becoming increasingly relevant in connection with the global crisis caused by the pandemic of covid19 and the war in ukraine and the deteriorated living conditions including economic

introduction the social media milieu in which we are enmeshed has substantive impacts on our beliefs actions and reactions to information and thus is a relevant arena for understanding public health digital media helps shape cultural beliefs and practices 1 in particular social media is a major factor in the exposure to information and the structuring of socialcultural landscapes in the contemporary world 2 as humans receive socialcultural information we create mental representations and neural connections developing ideas understandings and beliefs that become neurobiological social and psychological processes influencing how we see and experience the world with particularly popular socially pervasive and central cultural figuresconcepts having disproportionate influence 3 4 5 social media exposure and engagement influences the tone tenor and content of public perceptions and action in a variety of arenas and there is substantive evidence that social media is intricately involved with health 7 there is widespread agreement that due to its influence extensive use and the frequency and ease of access by the general public social media can and should be used for beneficial dissemination of public health information especially in the context of the covid19 pandemic 89 there is also evidence that world leaders social media use especially twitter has been substantive and influential during the covid19 pandemic 10 as rufai and bunce 11 note twitter may represent a powerful tool for world leaders to rapidly communicate public health information with citizens however they urge general caution when using twitter for health information with a preference for tweets containing official governmentbased information sources our analyses reveal the dominance of a few individual accounts as central actors in the networks of tens of thousands of tweets on the topic these few individual accounts and the content of their tweets mentions and retweets are thus substantially overrepresented in terms of public exposure to understanding of and reaction to critical elements of public health information during the pandemic 12 most concerning is the outcome we report here the prominent presence of realdonaldtrump as one of the central structuring figures in the global twitter discourse related to the covid19 pandemic in 2020 there is good evidence that donald trump intentionally used twitter in a manner so as to structure the power and content of presidential talk into a new mode of control and influence 1314 a recent study demonstrated that donald trump specifically exploited twitter as a tool to divertdirect the attention of mainstream media in relation to his personal goals rather than public good 15 there is also substantial evidence documenting donald trumps antagonism towards scientific data and public health assessmentsrecommendations and the officialsresearchers who generated them 16 and that such antagonism has had deleterious impacts on public health and health systems in the usa 17 there is also evidence of the negative and harmful impact donald trump had as a twitter user resulting in his being suspended permanently from the social media platform on january 8 th 2021 finally there is also supporting evidence that donald trumps activity on twitter significantly affected content and patterns of discourse on social media writ large such as a 73 decline in online misinformation about election fraud in the week after twitter permanently suspended realdonaldtrump 19 we contend that realdonaldtrump played a particularly prominent and harmful role in damaging public health efforts in the usa during the covid19 pandemic of 2020 via the twitter platform here we offer an analysis supporting this contention and suggest reasons why reconciling with this potential for information bias is critically important for future public health crises our goal here is to offer a retrospective look at the potential impact of a single potentially malicious individual twitter account on public health discourse as fodder for future considerations of the management and structuring of social media content in public health crises materials and methods from may to july 2020 our research group conducted a preliminary examination of six mainstream news media websites multiple state public health websites and articlesessays by six prominent science writers as initial research for a larger project to examine communication of scientific and public health information during the covid19 pandemic drawing on the preliminary data from may through july we identified seven keywords to sample narratives about the covid19 pandemic on twitter 1 coronavirus origin 2 coronavirus vaccine 3 covid19 4 fauci 5 mask 6 open and 7 social distancing from july 25 th 2020 to november 15 th 2020 using nodexl pro we made weekly collections of tweets that include these individual keywords nodexl pro software accesses the application programming interface of twitter to compile tweets within specified parameters we instructed nodexl to pull relevant tweets for each of our keywords separately allowing us to compile unique keyword twitter networks for each topic because this sampling method does not include every tweet using each keyword our subsequent network analysis involves partial networks each of our keyword networks contains a maximum of 10000 tweets to keep network download times and file sizes manageable while also collecting a representative sample of tweets using the identified keywords the period of july 25 th to november 15 th was selected so that the twitter project data coincided with concurrent elements of the larger project on tracking covid19 information we also used nodexl pro software for social network construction and analysis for each keyword network we calculated the total nodes edges and mean geodesic distance we further assessed indegree and betweenness centrality measures for every node in each network indegree centrality in the twitter network is measured by mentions replies tweets retweets and mentions in retweets registered to an account in the given network high indegree centrality for a given twitter account indicates that a high number of twitter users engaged with it in the respective keyword network betweenness centrality in the twitter network is the number of times a given node appears on the shortest path between two other nodes therefore high betweenness centrality for a given twitter account indicates that they are a crucial node for information transmission between other twitter users we then identified the top ten twitter accounts in each weekly keyword network for both centrality measures the accounts appearing in the top ten for indegree and betweenness centrality in three or more weekly networks for each keyword network series were identified as key contributors to the twitter discourse surrounding those topics we calculated the mean centrality of each account across all weeks they appeared in a keyword networks top ten indegree and betweenness centrality values we then calculated a metric to assess the relative impact of each account across keyword network series by multiplying their mean indegree and betweenness centrality by the ratio of weeks they appear in that keyword networks top ten accounts per total number of networks in that keyword series we call this measure the adjusted influence centrality this metric is important given that in large participant pools some individuals may miss some events as such comparing the mean centrality measures of each individual for the events at which they are present is insufficient as one should scale those means to reflect the relative frequency of each nodes presence at the successive events thus the aic is a useful metric for determining which nodes sustain influence over successive partial networks when the participant pool may vary in this analysis the aic allows us to measure which twitter accounts have a sustained influence over twitter keyword networks across the 17 weeks of data collection for instance an account with a moderate average centrality measurement after appearing in 11 of the 17 weekly networks may have a greater influence on the keyword topic discourse overall than an account appearing in only three of the 17 weekly networks even if that latter account peaks to the highest recorded centrality for that keyword network series in one of those weeks therefore the aic assesses consistency of impact for specific twitter accounts across multiple keyword networks in a series our research was conducted under the permission from the princeton university institutional review board protocol irb 13070 approved 17 july 2020 and following the internet research ethical guidelines 30 from the association of internet researchers the data set used for the analysis we present here is openly available on dryad results and discussion while we found a number of different twitter accounts scored high in one or more of our network measures in different weeks across the entire survey period realdonaldtrump was the top or in the top two in indegree and betweenness centrality and aic across the entire data collection period for the following four keywords fauci mask open and social distancing with one exception also realdonaldtrump made more appearances per week in the top ten accounts based on centrality for these networks than any other single twitter account in each of these keyword networks across the entire data collection period between july 25 and november 15 2020 realdonaldtrump received a combination of more mentions replies tweets retweets and mentions in retweets in two of the four keywords than any other account the specific pattern of which varied depending on the keyword network with the highest betweenness centralities across the entire dataset realdonaldtrump was the peak common node for information transmission between other twitter users for these four keywords finally realdonaldtrump had the highest aic measure in every case except for the mask keyword network series indegree centrality aic this one exception to top rank was due to the massive surge of joebiden in the mask keyword network between october 10 th and november 1 st 2020 otherwise realdonaldtrump was between one and fourteen times higher in aic value than the nearest other twitter individual across the four categories meaning that the consistency of impact of realdonaldtrump across multiple keyword networks in a series was substantially dominant realdonaldtrump was the central node in the twitter landscape of fauci mask open and social distancing between july 25 and november 15 2020 in that time period the usa went from 65000 infections per day to 136000 infections per day and from 147000 deaths to 246000 deaths from covid19 20 there is no debate that donald trumps use of twitter was both highly influential and filled with misinformation in an eightyear study of trumps twitter content pain and chen 21 found that his tweets reach americans directly and give him an enviable method of talking directly to the people thus they could be a boon of deliberative dialogue our analysis shows the opposite his tweets perpetuate division misinformation and lies and lack any semblance of deliberative discourse he does not use evidence to support points which could further his deliberative reach and instead he attacks in a manner that leads to greater divisiveness and rancor as noted earlier there is robust documentation of donald trumps antagonism towards healthscience research and officials 16 his use of twitter to divert media focus 1314 and the central role of twitter in the potential for disinformation regarding covid19 9 it would appear from both established longterm general patterns and from specific tweet content 1622 that realdonaldtrump tweeted disinformation and harmful information regarding covid19 thus given that he had over 88 million followers receiving his tweets we can argue with reasonably certainty that tweeting from realdonaldtrump potentially harmed public health understanding and engagement with covid19 but that is not the only context in which realdonaldtrump influenced twitter discourse on this topic given the structure of our data collection and analyses we are measuring not only content originated or retweeted by realdonaldtrump but also content generated by those tweeting for or against him andor criticizing him andor mentioning him andor retweeting him in these contexts even those of rebuttal or critique the presence of realdonaldtrump as a central node structuring the twitter discourse guarantees broadscale exposure of the content from realdonaldtrump and those who intentionally support it these data and analyses support the assertions that between july 25 and november 15 2020 a substantive component of the public social informational milieu of the covid19 pandemic was shaped and amplified via realdonaldtrump given this documented overall central role in twitter networks what might the dominance of realdonaldtrump in twitter discourse surrounding the terms fauci mask open and social distancing mean for the publics understanding of and actions towards specific and serious public health issues related the covid19 pandemic three of these four terms are directly linked to public health actions clearly and consistently stated and reinforced by a majority of state public health departments by the centers for disease control and the white house coronavirus task force the recognized need for masks and social distancing as key prevention measures was ubiquitous across the entirety of the covid19 research and public health landscape by april 2020 as of july 27 2020 mask mandates were officially required by a majority of us states and emphatically emphasized by the cdc 23 by september 2020 the white house coronavirus task force and nearly all states had and supported mask mandates yet a large percentage of the usa population resisted wearing masks increasing transmission risk across the time period of our data collection activity by realdonaldtrump and public statements and actions by donald trump were largely negative on mask wearing realdonaldtrump did tweet one significant positive mask statement along with an image of wearing a mask on july 20 th 2020 but shortly thereafter returned to the pattern of negative mask contents while the data are only correlational we argue that the central presence of realdonaldtrump in appearances of the term mask on twitter is likely to have influenced public perception of their use the risk of not using them and of actions by the public this assertion is supported via the recent finding that selfreported maskwearing increased separately from government mask mandates suggesting that supplemental public health interventions are needed to maximize adoption and help to curb the ongoing epidemic 24 one final bit of support for the pattern we propose is that nearly all states and all federal health agencies recommended if not required masks by september 2020 yet mask use in the usa dropped slightly from 70 to 65 between the end of july 2020 and early october 2020 when it began to rise to the level of 75 interestingly this time frame for the rise in mask usage maps to the period from early october when donald trump contracted covid19 and to that of between october 10 and november 1 st when joebiden replaced realdonaldtrump as the most prominent twitter user in indegree centrality for the term mask the case with social distancing is similar however public patterns and changes in social distancing behavior are more difficult than that of mask wearing to effectively assess in direct connection to pattern of realdonaldtrump tweets the case for open is also similar to mask in that realdonaldtrump consistently tweeted against restrictions on gatherings hospitality school closures and related issues and the open controversy remained prominent as a public health concern in the usa during our data collection period regardless of whether or not the twitter users were supportive of the tweets and retweets of realdonaldtrump arguing against them or not responding directly to them many of the tens of millions of individuals who saw tweets with these keywords in them were exposed to the structuring of the conversation around activity by realdonaldtrump finally the result of realdonaldtrump being so dominant on twitter networks involving the keyword fauci is centrally concerning as dr faucis views most often reflected the up to date scientific and public health information this pattern implies that the context in which most individuals who engage with twitter saw tweets associated with the term fauci were likely influenced or shaped by the tweetsretweets of realdonaldtrump we suggest that this pattern as with the other three key terms created a mode of influence on the public that corresponded with continued highrisk behavior derision of valid scientific and public health information and subsequent growing infection rates setting the stage for the massive increases in infections of november and december of 2020 and january of 2021 conclusion our assessment of twitter patterns related to the covid19 pandemic offers a cautionary tale for public health the lancet commission on public policy and health in the trump era clearly document the specific damage done to usa public health policy and public health itself by the trump administration 17 the report lays out a number of specific executive and legislative actions to remediate such harms but does not address social media we along with many others 9 10 11 12 13 14 suggest adding increased analytic and scientific attention to social media as a platform and process for the structuring of public health outcomes we recognize that the data set provided here is only correlational but given the numerous research findings regarding the use of social media by donald trump and his administrations well documented negative impact on public health 17 we argue that our data and analyses offer support to the assertion of a substantive influence of realdonaldtrump in negatively shaping public health perceptions and thus outcomes we add our voice to the contention that there should be careful analyses and monitoring of public health disinformation and harmful assertions on social media 8926 twitters removal of realdonaldtrump following the violent mob attack on the usa capitol building january 6 th 2021 is an extreme example but one might also note that the actions of realdonaldtrump between july 25 and november 15 in regard to the covid19 pandemic may have been as dangerous and intentionally misleading but much more lethal than the lead up to the january 6 th mob event this fundamental centrality of realdonaldtrump in public health related discourse on twitter begs the question of why many analyses of public health activity both positive and negative occurred during the pandemic in 2020 without mentioning and directly confronting the activity of realdonaldtrump while there have been some such assessments 121626 much of the twitter analyses research has focused on the veracity of information being distributed on twitter 2728 recent social science investigation has focused in on the role of political actors on twitter 11152930 but this area of study has yet to develop explicit linkages with public health related behavior and outcomes this may be due to current approaches viewing the patterns on twitter as a phenomenon primarily about information dissemination and not yet making the links to the effects on specific patterns of public healthrelated behavior influenced by information consumption of twitter users one reason for this absence of linkage may be that there has been little in the way of responseschallenges to these patterns on twitter by the medicalpublic health community given the increasing evidence that social influence is a significant force in shaping individuals responses to pandemic contexts 31 and the centrality of integrative social scientific approaches to public health in this and future pandemics 32 our results lead us to ask the question can the activities of individual social media accounts be seen as analogous to the patterns of infectious biological or noxious environmental agents in the assessment and management of public health threats we think they might but do not have sufficient data to accurately assess the possibility at present our data do support the assertion that investigating social media social network processes as they influence public health related behavior and outcomes might offer insight into public perception and reaction in the face of pandemic and other health crises overall we suggest that public health research and assessments can benefit from expanding engagement with realtime social media structures and activities that may act like biological agents to influence and likely shape the perceptions concepts beliefs and actions of the broader public the data underlying this study are available on dryad data curation

the social media milieu in which we are enmeshed has substantive impacts on our beliefs and perceptions recent work has established that this can play a role in influencing understanding of and reactions to public health information twitter in particular appears to play a substantive role in the public health information ecosystem from july 25 th 2020 to november 15 th 2020 we collected weekly tweets related to covid19 keywords and assessed their networks patterns and properties our analyses revealed the dominance of a handful of individual accounts as central structuring agents in the networks of tens of thousands of tweets and retweets and thus millions of views related to specific covid19 keywords these few individual accounts and the content of their tweets mentions and retweets are substantially overrepresented in terms of public exposure to and thus interaction with critical elements of public health information in the pandemic here we report on one particularly striking aspect of our dataset the prominent position of realdonaldtrump in twitter networks related to four key terms of the covid19 pandemic in 2020

background there is growing evidence demonstrating the public health benefits of promoting participation in cycling 1 2 3 this is because cycling for recreation and transport are positively related to overall physical activity 4 5 6 7 8 and improving participation in cycling has the potential to significantly increase the proportion of the population that accumulate health enhancing levels of physical activity 910 however available data shows that less than 3 of total trips made by adults are by bicycle in the united states australia canada ireland and united kingdom and less than 6 in france austria and switzerland 11 accordingly the world health organisation suggests that more evidencedbased strategies and interventions to stimulate cycling participation are required 12 to guide the development of such strategies and interventions it is important to understand the effect of multiple socioecological factors and the interactions that may exist between these factors 13 socioecological models recognise that physical activity is a complex and multifaceted behaviour that may be influenced by multiple factors from various levels of influence 1314 socioecological models also suggest that synergistic relationships may exist between factors from different levels of influence 1516 and that a change at one level of influence is likely to have a reciprocal effect on other levels 17 therefore socioecological models posits the effect of factors from multiple levels of influence on behaviour is likely to be greater than the summation of each individual factor 15 factors from the ecological model that may influence cycling include the built environment and social norms which are the normal and accepted behaviours within a group of individuals 18 there has been some research albeit limited reporting the interactive effects of the built environment and social environment on general recreational physical activity walking for recreation and walking for transport in adults 19 20 21 22 23 two studies reported a synergistic interaction between the built environment and social support where a supportive built environment and positive social climate reinforce each other to facilitate recreational walking 20 and transport walking 21 in contrast two studies suggest that the built and social environments interact in a way where a supportive built environment can compensate for a negative social environment for general recreational physical activity 22 and recreational walking 19 additionally one study found no interaction between social norms or social support and walkability on adults transport or recreational walking 23 despite the independent influence of social norms and the built environment on cycling that has been reported previously 24 25 26 to the authors knowledge the interactive effect of the built environment and social norms on cycling participation in adults is yet to be reported to our knowledge the only studies to investigate the interactive effects of the built and social environment on cycling have been conducted on children and adolescents between the ages of 9 and 16 2728 a study involving belgian children reported an interactive effect between support from friends and neighbourhood walkability on cycling in leisure time 27 the study showed that friend support moderated the relationship between walkability and cycling in leisure time however the effect size of this interaction was small the same study showed that there was no interactive effect between social norms or support from parents and neighbourhood walkability on cycling in leisure time additionally two studies found that there was no interactive effect between perceived social support and the built environment on childrens and adolescents active commuting behaviours 2728 inconsistent findings between different age groups and types of physical activity suggests the interactive effects of the built and social environments are likely to be behaviourally and contextually specific 29 30 31 therefore further research is needed into specific physical activity behaviours such as cycling for recreation and transport the aim of the present study is to explore the interactive effects of the built environment and perceived social norms on adults participation in cycling for recreation and transport methods study design crosssectional data was collected between july and august 2017 using a selfadministered online questionnaire participants included 228 adult office workers aged between 22 and 70 years from metropolitan melbourne australia participants were recruited from metropolitan melbourne due to the availability of geographic information system data and because there is a variability in cycling environments between neighbourhoods 32 to recruit participants an email introducing the study with a hyperlink to the questionnaire was sent to a convenience sample of organisations and workplace bicycle user groups in metropolitan melbourne bicycle user groups were identified from a publically accessible database 33 and researchers directly contacted several large organisations known to them organisations that chose to be involved in the study were prompted to distribute the questionnaire hyperlink to employees using internal communication channels due to the nature of the recruitment process response rates could not be calculated however several strategies were used to increase the response rate of both cyclists and noncyclists namely the questionnaire length was kept short which was highlighted in the recruitment email 34 and the study introductory email emphasised that employees were eligible to complete the questionnaire regardless of whether they cycle or not additionally to encourage participation in this study participants who completed the questionnaire were eligible to go into the draw to win one of five 50 department store gift cards prior to the main study the questionnaire was piloted by a convenience sample of six adults with similar characteristics of the study population based on their feedback slight modifications were made to the wording of some questions to meet australian vernacular and the layout of some questions was changed to improve questionnaire flow measures sociodemographic characteristics sociodemographic variables measured were gender age education level number of cars in participants household whether the participant had regular access to a bicycle distance participants lived from their workplace suburb of residency and suburb of workplace cycling participation cycling for transport was measured using an item from the international physical activity questionnaire long form selfadministered format 35 the ipaqlf has good testretest reliability 35 and has been used widely to measure cycling for transport 3637 participants were asked during the last 7 days on how many days did you cycle for at least 10 minutes to go from place to place participants were also asked how many minutes did you usually spend on one of these days to cycle from place to place participants were instructed to only include cycling to get from placetoplace such as work shops and public transport this wording was slightly modified from the original ipaqlf to more accurately reflect the australian cycling context in the present study the distribution of time cycling for transport in the last week was skewed and a decision was made to dichotomise the variable the dichotomous categories were cycled for transport in the last week and did not cycle for transport in the last week cycling for recreation was measured using an item derived from the ipaqlf 35 similar to a previous study 38 the question was adapted to only measure cycling for recreation participants were asked during the last 7 days on how many days did you bicycle for at least 10 minutes in your leisure time participants were also asked how many minutes did you usually spend on one of these days bicycling for recreation sport exercise or leisure participants were instructed to only include cycling that was solely for sport exercise or leisure and not to include any cycling that they had already reported the distribution of time cycling for recreation in the last week was skewed so it was decided to dichotomise the variable the dichotomous categories were cycled for recreation in the last week and did not cycle for recreation in the last week perceived neighbourhood built environment perceptions of the built environment were measured using nine items from the instrument for assessing levels of physical activity and fitness environmental questionnaire 39 similar to the process used by a number of other authors 384041 the items included in the questionnaire were selected based on their applicability to cycling for recreation and transport two items were used to measure perceived cycling infrastructure there are special lanes routes or paths for cycling in my neighbourhood and there are cycling routes in my neighbourhood that are separated from traffic perceived maintenance of bicycle infrastructure was measured with the one item the cycle paths in my neighbourhood are well maintained three items were used to measure perceived neighbourhood pleasantness and aesthetic my local neighbourhood is a pleasant environment for cycling there is litter or graffiti in the streets of my neighbourhood and in my neighbourhood there are badly maintained unoccupied or ugly buildings finally three items were used to measure perceived network and connectivity cycling is quicker than driving in my neighbourhood during the day there are many road junctions in my neighbourhood and there are many different routes for cycling from place to place in my neighbourhood so i dont have to go the same way every time each item was measured on a fourpoint likert scale and a mean score was used in analyses previous studies using the alpha environmental questionnaire have shown interclass correlation coefficients for individual items used range from 054 to 082 indicating moderate to good testretest reliability 42 additionally as suggested by van dyck deforche cardon and de bourdeaudhuij 43 the definition of the participants neighbourhood was modified to the area you could cycle to in under 15 minutes rather than walk in 15 min this increase in buffer size was necessary to account for the increased mobility of cycling 44 perceived workplace built environment perceived workplace built environment was measured using four items developed by handy and xing 45 participants were asked how true the following statements are about their workplace i have access to a shower within a 5minute walk of my workplace the streets near my workplace are dangerous for cycling there is good transit service near my workplace and it is easy to find a secure rackpost to lock my bike at work each of these items were measured on a fourpoint likert scale and a mean score was calculated for the analyses objective residential density street connectivity and landuse mix an objective assessment of landuse mix residential density and street connectivity was determined using walk score™ the walk score measures access to amenities within walking distance population density block length and intersection density for all points in a city to give a combined total score between 0 and 100 with a higher score indicating greater walkability 46 walk score provides a ranking for each suburb by calculating the walk score for latitudinal and longitudinal grid points approximately 150 m apart across an entire suburb and providing an average walk score weighted by population density for the suburb 46 walk score has been validated previously exhibiting strong and significant correlations with objectively measured street connectivity residential density and landuse mix 4748 the suburb ranking for the suburb in which participants lived was used as the objective measure of landuse mix residential density and street connectivity for cycling for recreation since both the home and work neighbourhood environments are associated with active transport 49 a composite ranking of the suburb of which participants lived and the suburb in which they worked was used as the objective measure of the landuse mix residential density and street connectivity for cycling for transport perceived descriptive norms perceived descriptive norms were measured using three items 50 participants were asked to what extent they agree that the following three referent groups cycle their closest friends their familypartner and their work colleagues each of these items were measured on a fivepoint likert scale and a mean score was calculated for analysis perceived injunctive norms perceived injunctive norms were measured using three items 50 participants were asked to what extent they agree that the following three referent groups accept them cycling their closest friends their familypartner and their work colleagues each of these items were answered on a fivepoint likert and a mean score was calculated for analysis perceived group norm it has been found that descriptive norms are more influential on health behaviours when coupled with an injunctive message 1851 so a group norm for each participant was calculated consistent with other authors group norms were operationalized as a combination of descriptive and injunctive norms 3352 therefore perceived group norm was calculated by summing the mean score of participants perceived injunctive norm and descriptive norm data analysis overall 3 of the 228 completed cases had some missing data with the level of missing data for these cases ranging from 3 to 7 as suggested by tabachnick and fidell 53 the expectation maximization method 54 was used to impute missing data descriptive statistics were calculated presenting the mean and standard deviation of scores for each variable for the study population multiple binary logistic regression analyses were conducted to explore the interactive effect of the built environment and social norms on the cycling participation each model included cycling for recreation or cycling for transport as the dependent variable and a single built environment variable a single social norm variable and the product term of those two variables as the independent variables all statistically significant odds ratio for product terms could be interpreted as the multiplicative factor of the built environment variable given a 1standard deviation increase in the social norm variable 55 to account for the lower power of interactions and similar to previous studies 2728 all interactive effects will be considered significant at p 010 and plotted using the excel spreadsheet which automates the steps in plotting interaction effects in logistic regression 56 further because of the exploratory nature of the study no adjustments were made for multiple hypothesis testing prior to running the models as suggested by menard 57 to make each of the models easier to interpret social norm and built environment variables were standardized to have a mean of 0 and a standard deviation of 1 each model was adjusted for sociodemographic variables that had a significant association with the outcome variable where transport cycling was the outcome models were adjusted for gender number of cars in participants household whether participant had regular access to a bicycle and distance lived from workplace models with recreational cycling as the outcome were adjusted for whether participant had regular access to a bicycle all data analysis was conducted using spss version 24 results descriptive statistics in total 833 of the sample had completed a bachelor degree or higher 776 lived more than 6kms from their workplace 86 had regular access to a bicycle and on average participants had 134 cars in their household additionally 539 of participants cycled for transport in the last week and 254 cycled for recreation in the last week descriptive statistics for each of the independent variables for the sample are presented in table 1 built environment and social norm interactions twelve models were run to examine the interactive effects of the built environment and perceived social norms with transport cycling as the outcome the interaction between perceived group norm and perceived workplace built environment was significant the nature of this interaction indicated that positive perceptions of the workplace built environment can somewhat mitigate the negative influence of unfavourable group norm perceptions a line graph plotted at 1sd and 1sd group norms illustrates this interaction ten models were run to examine the interactive effects of the built environment and perceived social norms with recreation cycling as the outcome none of the interactions tested were significant discussion this study was the first to the authors knowledge to examine the interactive effects of the built environment and perceived social norms on adults participation in cycling for recreation and transport results indicated that there was a significant interactive effect between perceived workplace built environment and perceived group norm on transport cycling there were no significant interactive effects between the neighborhood built environment and social norms on transport or recreational cycling these findings provide limited support to the proposition of ecological models that multiple levels of influence interact to influence physical activity behaviours 1315 the positive influence of cycling facilities at the workplace such as showers changing facilities and secure bike parking on cycling for transport have been reported previously 5859 the interactive effect found in this study suggests that the association between the workplace built environment and transport cycling is stronger among adults with less supportive group norms therefore workplace cycling facilities can somewhat mitigate the negative effect of an unsupportive group norm towards cycling and decrease the influence of group norms on individuals decision to cycle for transport the findings from this study showed that there was no significant interactive effect between perceived and objective measures of the neighbourhood built environment and social norms on transport cycling these findings are similar to a two previous studies that found no significant interactive effect between walkability and social norms on transport walking behaviours in adults 23 or active transport behaviours of children 27 a possible explanation for lack of interactive effects on cycling for transport in this study is because on average participants in this study lived in very walkable neighbourhoods this means that destinations in many participants neighbourhoods were easily accessible by walking which may make cycling to destinations in their neighbourhood superfluous if not inconvenient 60 in addition to living in very walkable neighbourhoods the vast majority of the participants travelled into the central business district or inner suburbs of melbourne for work meaning that there was a notable lack of variability in attributes of the built environment between participants also over threequarters of participants reported living more than 6kms from their workplace therefore it is possible that a large portion of the area that participants cycled for transport was between the neighbourhood they live and work which was not captured in this study this study also showed that there were no significant interactive effects between perceived or objective measures of the neighbourhood built environment and perceived social norms on recreational cycling this finding is akin to the findings of a study on children that found no significant interaction between social norms from participants parents and walkability on cycling in leisure time 27 similarly another study found that there was no interactive effect between social norms and walkability on walking for recreation in adults 23 interestingly a number of studies have found significant interactive effects between the built environment and social support two studies reported and interactive effect that shows that a supportive built environment can somewhat negate the negative effects of a lack of social support on recreational physical activity 1922 other studies found an interaction between social support and the neighbourhood built environment whereby social support and the built environment reinforced each other to encourage recreational physical activity 2027 these findings further demonstrate that social norms and social support interact differently with the built environment to influence recreational physical activity the difference in findings between studies supports the proposition of ecological models that the influence of variables are very behavioural and context specific 29 strengths and limitations a major strength of the current study was the use of validated and conceptually relevant measures of the built environment and cycling participation another strength of this study was that a composite ranking of the home fig 1 interactive effect of perceived workplace built environment and perceived group norm on probability of cycling for transport and work neighbourhood built environment were included in transport cycling models additionally both subjective and objective measures of the built environment were used however the current study also had some limitations that should be considered when interpreting the results first despite being validated walk score remains a novel method for measuring the built environment and does not measure cycling specific components of the built environment additionally measures used in this study did not capture the objective built environment between the neighbourhoods that the participants lived and worked which may have influenced participants decision to cycle for transport this could partly explain the absence of interactive effects between the objective built environments and social norms in this study second the crosssectional study design means that conclusions from this study can only infer association rather than causation third this study relied upon selfreported measures of cycling which may be influenced by recall bias and social desirability 61 fourth there were some limitations associated with the sample although the sample size was appropriate for the type of data analysis conducted 62 the relatively small sample size may have increased the likelihood of type ii errors also participants in this study were recruited from a convenience sample which may beget selection bias evident by cycling rates in this study being greater than the national average for australia and limit the generalisability of the results finally this was an exploratory study so no adjustments were made for multiple hypothesis tests conclusion the present study provides limited support for the interactive effects between the built environment and social norms on cycling participation only the interactive effect between the workplace built environment and group norm was significant the nature of this interaction suggests that positive perceptions of the workplace built environments may somewhat compensate for the effects of negative group norm perceptions given the potential health enhancing benefits of increased cycling participation further research into how other socioecological factors interact to influence cycling participation warrants further attention findings could guide the development of interventions to increase cycling participation in the future additional file additional file 1 online questionnaire abbreviations alpha assessing levels of physical activity and fitness questionnaire ipaqlf international physical activity questionnaire long form authors contributions mb th and mc contributed to the conceptualization of the study mb designed the study and collected the data statistical analysis was conducted by mb under the supervision of th and mc the initial draft of this manuscript was prepared by mb and was critically proofed and revised by th and mc all authors have read and approved the final manuscript competing interests the authors declare that they have no competing interests

background there is growing evidence of the public health benefits of promoting cycling the ways that the built environment and perceived social norms independently influence cycling participation is well established however whether these factors interact to influence cycling participation has not been examined such research is important because understanding the effect of multiple socioecological factors and the interactions between them is needed to guide the development of interventions and strategies to increase cycling participation therefore the aim of this study is to explore the interactive effects of the built environment and perceived social norms on transport and recreational cycling methods data was collected using a selfadministered online questionnaire from 228 office workers in metropolitan melbourne australia measures used in previous research were employed to assess selfreported transport and recreation cycling in the last week perceptions of neighbourhood built environment perceived social norms towards cycling and objective landuse mix residential density and street connectivity of the suburbs in which participants lived and work multiple binary logistic regression analyses were conducted to explore the interactive effects of the built environment and perceived social norms on transport and recreation cycling all interactive effects were considered significant at p 010 results there was a significant interactive effect between the workplace built environment and perceived group norm on transport cycling p 006 there were no other significant interactive effects observed between components of the built environment and perceived social norms on transport or recreational cycling conclusions the interactive effect found in this study provides some evidence that the workplace built environment interacts with perceived group norms to influence cycling for transport positive perceptions of the workplace built environment such as showers and secure bike racks can somewhat compensate for the negative influence of when cycling is considered less of a norm among family friend or colleagues however the findings of this study did not support that the neighbourhood built environment and perceived social norms interact to influence cycling for recreation or transport these findings contribute to the knowledge of how multiple factors may reciprocate to influence individuals decision to cycle more research into the interactive effects of socioecological factors is warranted

intersection it will be argued that when common meaningmaking and individual identities collide with shared experiences that demand integrative explanations what emerges is not religion per se but religionmaking in other words this paper explores answers to the question of whether it is simply that some voicehearersas they prefer to be calledmake sense of their experiences in religious terms or whether it is the case that the process of making sense of their experiences is itself religious such circumstances may not always lead to a search for supernatural agency to be sure but they may lead to a search for new social territory within the sociocultural landscape and therefore rely on certain mechanisms for legitimation following sociologist hans mol this essay refers to that social territory as identity and to its bid for legitimacy as sacralization a process of religionmaking in which myths rituals and emotional commitments reinforce and sustain validation thus meaning thus identity the hvm offers a uniquely manageable and clear example of this sort of intentional meaningmaking with identityconstruction as an integral correlate of that process applying religionmaking or sacralization as our theoretical framework then intensifies our focus further illuminating some of the subtleties at work as this sociopolitical movement grows and provides its members with salient identities indeed as the following analysis shows the discordant experiences which receive meaning and sacralization for members of the hvm extend beyond the obvious troubling phenomena associated with auditory verbal hallucinations and into postmodern concerns such as the decolonization of the body as well as the validation of biographical experiences by those who resist the interpellation of identity by the dominant discourses of power in this particular case for example voicehearers are not simply those who in fact experience relatively inexplicable auditory phenomena but rather are those whose sense of identity comes from the agentive and empowering act of embracing those same discordant experiences and in so doing decrying the pathologizing tendencies of the mental health field whilst benefitting from a sense of selfnarration for this reason the hvm perhaps represents a form of postmodern religionmaking in that its myths rituals embodied experiences et cetera receive a particular interpretation by those involved one in which the major concerns relate to notions of power and perspective these focithe hvm postmodern anxieties sacralization and the religious identity of the voicehearerstructure our discussion after introducing the hvm and briefly discussing our understanding of postmodernitys dual concern with power and perspective we then summarize mols concept of sacralization before weaving it all together in an exploration of the hvm as religionmaking along the way and on an admittedly meta level we demonstrate that mols theoretical ideas can be harmonized with notions of secularity and postmodernism in addition to suggesting that religious categories are useful for illuminating some instances of the complex interplay of identity meaningmaking nonordinary experiences and postmodernism hvm it is important then to introduce our illustrative case for it is in the details of the hvms origins and collective contours that one encounters a striking example of identity intertwined with a meaningsystem in such a way that both reinforce one another expressed differently the hvm seems to fit mols formula of the religious process as the sacralization of identity very well but at least a basic familiarity with the movement is necessary to make such a suggestion indeed it is noteworthy from the outset that the hvm is a sociopolitical movement as much as it is a selfhelp group as much a specific narrative as it is a repertoire or framework for constructing individual narratives perhaps even as much a psychotherapeutic approach as it is a collection of formal international organizations although the movement is arguably representative of the sort of religiouslyinflected meaningmaking processes with which this paper is concerned to say so is not to claim that the hvm is simple or easily reduced to a few individuals with shared experiences in fact the hvm is comprised of approximately 20000 members in 28 countries with 180 affiliated groups just in the united kingdom the website intervoiceonlineorg is a primary internet resource for the movement as is hearingvoicesorg which among other things directs voicehearers to those local groups across britain of course the hvm also organizes and hosts national and international conferences the first ever national conference was organized in maastricht netherlands in 1987a sort of launching point for the movement twentytwo years later the first world hearing voices congress was also held in maastricht and subsequently there have been seven more of these international events in england italy wales australia greece spain and france these large conferences certainly underscore the growth and influence of the hvm since 1987 but the local gatherings are of perhaps greater significance for the movement as it is on this smaller scale that voicehearers tend to make their first connections with its characteristic claims about the reality and relative normality of hearing voices as well as the backstory to the movement itself it is that history of the movement which informs the identity of the voicehearer imbuing it with a certain social and political force this is because the hvm was born from the paradigmshifting encounter of dutch psychiatrist marius romme with a single patient patsy hage in the mid1980s from 1984 to 1987 romme met frequently with hage using various methods to attempt treatment of her persistent voices eventually it became apparent that hages voice hearing intensified twice a year coinciding with the dates of traumatic events of her past also around this time hage read julian jaynes 1976 the origin of consciousness in the breakdown of the bicameral mind a work of creative historical linguistic and psychological musings which posits a preconscious period in human history during which thoughts and inner speech were perceived to be from external voicesoften the gods one of the notable implications of jaynes book was that hearing voices was once commonplace even inspiring struck by this notion and willing to connect her past trauma with her present voices hage convinced romme to take her voices seriously to begin seeking recovery rather eradication for his part romme was not so much interested in the validity of jaynes thesis but in the effect that it had on hages experiences instead of treating the voices as symptoms of psychosis most likely schizophrenia romme was challenged to address the voices as significant phenomena in and of themselves perhaps he and his patient began to think these voices were reflecting something about or for hage they began to discuss the content frequency nature and timing of the voices by 1987 the evidence or something like it was there hages voices ceased to bother her and she got married shortly after participating in a television programme alongside romme and the journalpsychologist sandra escher which initiated that first ever hearing voices conference anthropologist tanya luhrmann summarizes the situation well what romme noticed was that attributing meaning to voices had made a difference to someone who was hearing them he also noticed that there were hundreds of other voicehearers in the netherlands alone who could potentially benefit from this approach together with escher who later became his wife romme was made the de facto leader of a movement more importantly his story of that first patient began in the words of medical humanities scholar angela woods to function as a foundation myth told and retold in multiple contexts and on multiple occasions those who heard voices but were discontent with standard psychiatric practices and prevailing discourses had found a spokesman a narrative resource andas will become cleara more resonant identity the postmodern power and perspective locating that new identity in the shared embodied experience of voicehearing however also means that the hvm firmly situates itselfwhether consciously or notin postmodern preoccupations with empowerment and alternative viewpoints indeed amending and appropriating sociologist andrew dawsons definition of modernity for present purposes we take postmodernism to consist of at least in part a reflexive awareness ofand insistence onmore than one point of view combined with a concern for the power dynamics operative between individuals and both the macrolevel social structures and middlerange institutions with which they find themselves engaged this is not to deny the overlap of postmodernity with sixteenth century protestant ideals of personhood seventeenth century philosophies of individual liberty or any of the myriad other influences on contemporary thought and culture at the same time charles taylors notion of the present era as an age of authenticity in which everyone feels pressure to locate create and embrace a socalled authentic identity seems aptespecially if his observation is supplemented by a related comment on the active agency now takenforgranted as individuals seek selfdefinition 2007 with regards to the hvm the dual focus on power and perspective may be seen in the groups conscious scepticism of onesizefitsall mental health diagnoses as well as in a general and unashamed claim of individual empowerment in the face of both the disturbing voices and the sometimes demeaning psychiatric establishment indeed it is worth noting that voicehearer as an identity is useful for members of the movement in part because it represents agency 1 consider for comparisons sake religious communities of the past that came to embrace monikers related to a single aspect of their ritual and spiritual liveseg quakers shakers or the more recent hare krishnas each of those groups received such names from outsiders who simply chose to highlight the most conspicuously unique trait and who in most cases sought to disparage the new religious movement by exposing eccentricities for the hvm voicehearer is a selfdesignationindeed it seems to be an attempt to legitimate their conspicuously unique trait and to validate associated experiences and emotions to achieve these ends the hvm empowers the voicehearer in at least three overlapping ways 1 by providing meaning and explanations with which to seize power over the voices themselves 2 by offering a collectivelylegitimated identity based on an inversion of sociopolitical power structures and 3 by reclaiming for voicehearers the authority opportunity and psychosocial devices needed to compose their own narratives these three factors are of considerable import for our understanding of the religionmaking process but they are expressed in a strikingly postmodern manner as journalist adam james notes of the movements origins it was the postmodern era and its notion of cultural relativity which … cradled the hvm it is important to consider briefly how this is so power embodiment and political charge it is difficultartificial evento separate the element of power over the person from an analysis of discursive or political power at work in the hvm after all efforts to make sense of voice hearing involve not only the hearers but also psychiatrists psychologists and greater societyto say nothing of friends family and the voices themselves what is more the desire to construct an authentic unifying identity seems particularly fraught when ones sense of self is almost literally fragmented by subjective psychological experiences characterized by a lack of material rootedness this is movingly expressed by john robinson a voicehearer who recounts his involvement with the hvm fondly now that i have something valuable in my life the voices have faded away a sense of self has only begun to emerge in the past five or so years before that i was just fragments as will be shown later mols concept of identity entails stable order pitted against potentially destabilizing influences in an interminable balancing act for voicehearers the challenge then is to erect and reinforce a stable identity in the face of two potentially deleterious threats the voices and the field of psychiatry it is not surprising then that lucy holt and anna tickles study of the methods used by eight voicehearers to make sense of their experiences revealed both that perceptions of the voices as being powerful … seemed to restrict the search for meaning and that most participants actively rejected theories that were imposed upon them by other people the latter observation is followed by a discussion of the loss of agency experienced by voicehearers as they take on the dominant discourses of pathology mental illness and western cultural assumptions of autonomy indeed some participants actively rejected misunderstood or experienced an increased sense of hopelessness when an implicit biological framework was used by professionals this rejection of psychiatric or biological explanation is quite clearly more than an intellectual disagreement although the hvm is held together somewhat loosely by its postulation of an alternative interpretation of auditory verbal hallucinations wherein the voices are linked to traumatic histories and are accordingly communicating something of importance to the heareran approach that encourages interaction between the hearer and his or her voices and denies the universal efficacy of pharmaceutical solutionsit also views itself as a sort of necessary disruptor of power structures the mental health patient so the narrative goes is marginalized stigmatized and subjugated by the predominant psychiatric models which tend to insist on physical genetic causes of phenomena like auditory verbal hallucinations from the voicehearers perspective this approach is clinical and dehumanizing replete with technical jargon and one might suggest unpalatable in its ostensible reductionism as one voicehearer expressed it receiving the diagnosis of schizophrenia was disempowering another notable voicehearer ron coleman whom we will revisit later applauded the hvm and its influence on his own recovery by asserting that the voices no longer belonged to doctors … the voices belonged to me here we see the critical energy as woods puts it offered by the movement to its members as they subvert mental health authorities and claim the title of experts by experience luhrmann stresses this same element in noting that the hvm repeats mental health facts such as the presence of some form of voice hearing among a significant minority of the population but then takes this fact and turns it into an attitude as has been mentioned the focus of that attitude is directed at both the hallucinations themselves which romme and others suggest often weakens the abusiveness of the voices to such a point that they can be ignored or may even disappear as well as at psychiatric modes of thought that the hvm is explicitly opposed to psychiatrys existing order and that such a struggle is very much an issue of power is recognized by journalists and scholars alikeincluding psychiatrists who oppose the movement 2 ian parker and his colleagues go so far as to claim that the hvm is an instantiation of postmodernisms deconstructing enterprise its focus as a collective and its message for individuals is bound up with challenging the status quo problematizing the category of expert and engendering the very social legitimation needed to sustain the newly pioneered social territory of the voicehearer expressed somewhat differently because hearing voices is an unavoidably bodybound experience and a potentially injurious experience the hvm must offer something more than yet another alternative therapy it must offer a salient identity built onrather than in opposition tothose same experiences which has as its generative stimulus the quintessentially postmodern program of decolonization in this case however the agenda is more accurately to depathologize the experience of voice hearing thus dismantling the cultural and intellectual classifications used to identify the mentally ill and rerouting the lifecourses of those who would have previously fallen into that category this leads woods to note that the identity offered by the hvm is politically charged which becomes clear in relation to its excavation of such previously takenforgranted assumptions of mental health and aberrant behaviour in a sense the hvm by virtue of its insistence on sociocultural acceptance of voice hearing outside of existing mental health schemas actively unearths what hegel calls the sittlichkeit or bourdieu calls doxa these are the subterranean currents of morality sociality and belief that do not receive widespread reflection until they are exposed by seismic forces of course for bourdieu doxa is suddenly forced to justify itself in the face of imminent challenge one might frame this in terms of plausibility whereby the new identity of the voicehearer threatens the status quo by seemingly offering individuals a higher sense of meaning or a more effective interpretation of reality in this way the hvm not only forces psychiatry and society at large to face their presuppositions concerning for instance the normality of hearing voices but it also involves its own members in the hermeneutical storytelling necessary to sustain that political energy narrating the self indeed woods is justified in claiming that storytelling is central to the paradigmshifting business of the hvm as it reframes debates over schizophrenia auditory verbal hallucinations and the validity or acceptability of voicehearers among us of course insiders recognize this as well the motto for the 2016 world hearing voices congress betrays this selfunderstanding making history owning our stories as might be expected those within the movement emphasize the life story not so much as an opportunity for creative bricolage but as the fitting substrate for the imperative psychological mining necessary to identify the past events connected with the origin and continued significance of their voices this is captured well by what luhrmann calls a manifesto which appeared on the intervoice website as of 2009 hearing voices is related to problems in the life history to recover from the distress the person has to learn to cope with their voice and the original problems that lay at their roots in that single sentence one encounters both the fundamental beliefs of the hvm and its reliance on a sort of conversion process as will be discussed more fully later the collective narrative of the hvmin which shared values and beliefs are embeddedand the individual life stories of its members echo something like william james religion of the sick soul or other notions of religious conversion in relation to the postmodern aspect of the movement however we need only underscore the interplay of selfnarration meaningmaking and power for the voicehearers wilma boevink one such voicehearer who shared her story at a voice hearing conference in 1996 expresses this web of elements quite clearly for a long time there has been only one version of my life story according to this version i had a psychiatric disorder which had landed me in an institution i had received treatment there and although i was never cured i was able to live with the remnants this is not my story i do not believe in it and it is of no use to me another voicehearer maxwell steer believes that most people have voices of creativity and insight but do not recognize them as such because society doesnt echo that interpretation back to them again with both boevink and steer we witness the postmodern notion of more than one perspective receiving due the hearing voices movement as postmodern religionmaking 115 © equinox publishing ltd 2018 attention although boevink wants to denounce the psychiatric perspective steer offers a unique vantage in which hearing voices is a matter of collective interpretation in this view there would be many more voicehearers if our societies validated the experiences most people are having in a different way this is significant for the identity of the voicehearer does not simply highlight their belonging to a wider social network it also draws its viability from that collective legitimation this can be seen in holt and tickles study in which shared sensemaking was effected through the use of peer support groups just as is made explicit in the summary declaration of the 2014 world hearing voices congress our voices have value and acquire meaning when they encounter other voices even more poignantly the more than 100 postcards collected during the 2016 international conference on which respondents wrote what the hvm means to them include numerous references to hope and in keeping with our postmodern thesis empowerment but one card humbly encapsulates the transition from abstract notions of power and politics to the immediate marriage of meaning and sociality by stating that the hvm means moving from me to every one of us as the voicehearer seizes power over his or her own meaningmaking processes identity is both suggested and extended to others as those who share similar experiences invoke the same label identity is reinforced yet the lone voicehearer and the collective voicehearers enjoy the fruits of meaningmaking alsonecessarily soin relation to both the mental health establishment and greater society insomuch as voicehearer is an assertion of agency and emancipation from the prescribed interpretations of societys experts it is only a salient identity to the degree that it mobilizes fellow voicehearers and purports to alter conventional wisdom concerning hallucinatory experiences this is because meaning is not autogenous even if personal experience and the subsequent drive for explanation are at times the propellants of the sociocultural processes by which collectives and individuals negotiate values truths and even identities sacralization thus far of course our analysis has not required or introduced religious frameworks to make sense of the hvm its values and truths however with this turn to the relationship of the overtly social to the agentive search for meaning we may now enter the arena of the sacred indeed our attempt to elucidate some of the concrete mechanisms and processes utilized by members of the hvm to make sense of their lived experiences will benefit from a familiarity with mols aforementioned definition of religion and its associated concepts of sacralization and identity for mol the self can be made sacred through a particular form of meaningmaking in which identity is supported by the fourfold scaffolding of myth commitment ritual and objectification 1976 in this process of sacralization meaning receives religious inflection religious meaning making in his article religious meaning making positioning identities through stories psychologist joseph schwab implements the positioning theory of rom harré and colleagues to execute a discursive analysis of the ways in which people make sense of their lives through religious or spiritual narratives the study focuses on talkininteraction as the primary means through which identities are performed coconstructed and contextually defined most importantly for the present study schwab connects religious narrative with identityconstruction and meaningmaking by referencing the midtwentieth century work of developmental psychologist erik erikson the result is schwabs persuasive claim that autobiographical narratives answer the who am i question by making sense of past experiences through a navigation of overarching dilemmas … which include … continuitychange samenessdifference and agencynonagency in other words personal histories are sometimes given a religious narrative structure in the process of ones active attempt to navigate between sets of binary identity dilemmas similar notions of identity as a sort of zerosum game have been posited by others including an implicit awareness of the link between loss of agency and loss of meaningidentity in the study of voicehearers conducted by holt and tickle cited earlier that being said schwabs account of religious identityconstruction bears an even more striking resemblance to mols general theory of religion itself partly based on eriksons pioneering work on identity sacralization and identity a process even so it is important to begin our summary of mols theoretical framework by highlighting one instance of significant disagreement between mol and schwab the latter takes religion to be a sort of static a priori retained by individuals and only subsequently made meaningful as they explain it to others whilst such a view rightfully forefronts the social nature of religion and deftly navigates the pitfalls of both substantive and functional definitions of religion it only manages these virtues by avoiding critical analysis of the category altogether simply assuming that religion is a personal possession which predates the process of religious narration for mol religion essentially is religious narration in his terms religion is the sacralization of identity and is therefore a dynamic process or activity rather than a static cultural object this is crucial to our own conception of the hvm as postmodern religionmaking for we take mols theory to be instructive in any analysis of the overlap between religion and meaningmaking due to its emphasis on the incessant nature of religious meaningmaking as individuals and groups face those identity dilemmas noted by schwab indeed the relationship of meaningmaking to what one might call nonordinary experiences is precisely the same as the relationship of mols sacralization to identity meaningmaking is perhaps the more general term for human attempts to make sense of and derive purpose and order from uniquely human experiences the more specific process of sacralization then is the process of safeguarding and reinforcing a complex of orderly interpretations of reality rules and legitimations by attaching myths commitments and rituals in such a way that the systems of meaning and motivation are wrapped in dont touch sentiments when existential changebe it social differentiation or auditory hallucinationthreatens to deplete or destroy ones sense of self sacralization seeks to integrate such forces into a meaningful system thus bolstering identity and ensuring a more robust defence against future threats in mols words if the human muddle and mess can be related to order then the muddle and mess are relativized for this reason mol prefers to sketch his identity theory in terms of a dialectic between order and change or between identity and differentiation he suggests that order is bound up with security and thus identity is understood as a stable niche that man occupies in a potentially chaotic environment which he is therefore prepared vigorously to defend it is in this sense that we argue that the identity of the voicehearer is essentially the claiming of new social territory such territory will be defended as long as the identity remains relevant and useful and sacralizing the identity goes some way toward ensuring just that to summarize then identity is a sense of stable order whichby being reinforced through mechanisms such as myths rituals and emotional commitmentscomes to be sacred to the individual andor group yet as mol is keen to argue sacralization functions not so much to remove identity from harms way but to strengthen identity by absorbing and making sense of harm sacralization is so to speak the balancing act between the stagnation of too much order and the anomie or social displacement of too much change strikingly as a balancing act sacralization is a reimagining of religion as a process of course much more could be said of that process as of mols theoretical system more generallyparticularly of his fourth sacralizing mechanism objectification however we must continue on to our final section exploring the ways in which the hvm combines postmodern concerns with elements of mols sacralization in an arguably unique form of religionmaking the voicehearers power place and religious meaning recall that by religionmaking we intend something like meaningmaking achieved by the construction and implementation of sacred apparatuses such as myth and ritual as voicehearers seek an explanation of and integrative meaning for their voices they necessarily reject existing systems whilst formulating new ones earlier the sociocultural space available for such competing narratives was attributed to a general postmodern concern for the equal validity of multiple perspectives here we wish to bring that observation in line with mols concept of sacralizationall in an attempt to illuminate some particular details of the hvm this is relatively easily done for sacralization contains an inherent sense of opposition as it uncovers doxa and reinforces identity in relation to alternatives all whilst circumscribing legitimate territory of the new identity on the one hand mols dialectic obviously relies on conflict between stable identity and external disruptive forces however on the other hand as it relates specifically to voicehearers the effort to establish a sacred sphere around voice hearing necessitates both positive and negative selfdefinitions positively these individuals are rooted in a new mental health paradigm with noticeable growth in both actual membership and in terms of societal attention directed toward the movement negatively the voicehearer is one who has made claims about what he or she is notpointing to biological models of psychiatry as well as to hollywood depictions of schizophrenia and other cultural stereotypes to underscore a personal and collective past that has been discarded in favour of something more profound at times firsthand accounts affirm these and other aspects of mols theoretical ideas quite directly as in voicehearer debra lampshire from new zealand who echoes mols definition of identity in her account of involvement with the hvm i have found my niche … i have found where i belong similarly voicehearer jacqui dillon describes the various selfhelp practices that she has used since encountering the hvm as giving her a sense of order and structure in what often felt like a chaotic environment together these two statements repeat mols definition of identity almost verbatim what is more they juxtapose the present identity of voicehearer with some less satisfying previous life or worldview anthropologist douglas davies refers to this as superplausibility a common feature of religions as they pinpoint the flaws in the human condition and posit modes of redress the old defective thoughts and ways of being are superseded by the more plausible meaning system on offer this again corresponds well with mol who speaks of the transition from an old identity to a new identity as conversion undoubtedly influenced by william james discussion of the religion of the sick soul or the twice born as a religious orientation demanding salvation and conversion from the wicked ways of the past mol argues that conversion is the means by which a new perspective becomes emotionally anchored in the personality … the convert … strengthens his or her new assumptive world by repeating over and over again how evil or disconsolate or inadequate he or she was before the conversion took place of course myths offer convenient and efficient means for sanctioning such transitions and repeating such notions and the hvm appears not to have eschewed this useful element of religionmaking myth and testimony in discussing the junction of psychotherapeutic paradigm shifting identity conversions and myth construction we should not forget that claude lévistraussin structural anthropologyexplicitly connects psychoanalytic treatment with conversions in which an individual having been deemed a patient emerges as one cured he goes further as well suggesting that this conversion process is no different than the shamans magical healings because in both instances the value of the system is no longer … based upon real cures from which certain individuals can benefit but on the sense of security that the group receives from the myth underlying the cure and from the popular system upon which the groups universe is reconstructed this is directly relevant to the hvm in that lévistrauss insightfully illuminates the connection between myth and meaning by recognizing that ones successful conversion to a new identity relies less on the possibility of an empiricallyvalidated solution and more on the collectivelyvalidated articulation of the problem to revisit the words of walter benjamin with which this essay began the answers offered by a religion are less important than the worries anguish and disquiet given pride of place in their myths in some sense it would seem that myths tell of identity conversions and those conversions reinforce myths for the hvm and its members this is manifest in a number of ways for example it is somewhat remarkable in the light of lévistrauss comparison of psychoanalysis and shamans that one journalist actually compares the hvm to the indigenous healers of africa asia and south america who were vilified by colonial europeans the implication of this being that voicehearers represent an oppressed minority who offer alternative explanations and methods of recovery perhaps in some sense the movement is postmodern and quite literally postcolonial even more to the point however is woods earlier remark about patsy hages biography functioning as a foundation myth for the group as myth hages story need not correspond with some empirical reality it need only offer a meaningful system in which values and life orientations may be embedded and transferred added to and borrowed from at the most basic level hages story provides historical rootedness for the hvm it began with the inspired mettle of this single individual in the mid1980s who read jaynes book and challenged her psychiatrist to view auditory verbal hallucinations in a different light as a living component of the movement however the myth of patsy hage communicates specific values such as a general disapproval of biological psychiatric explanations of voice hearing and a rejection of the stigma associated with pathology additionally the myth offers and perpetuates a conversion formula in which one enters as a frightened and voiceless mental health patient and leaves an empowered voicehearer eleanor longden who now gives frequent public talks on her experiences of voice hearing describes her recovery as a transition from schizophrenic to voicehearer likewise voicehearer peter reynolds says i dont class myself as a schizophrenici class myself as a voice hearer even one scathing review of rommes prohvm book living with voices laments how the book presents people as voice hearersan engulfing the hearing voices movement as postmodern religionmaking 121 © equinox publishing ltd 2018 role which undermines the identity that many strive to recover of course for those who faithfully narrate themselves into the myth there is little interest in striving to recover the old identity indeed hages story seems to be quite useful in that it not only intimates a conversion formula but also includes a sort of exemplar in the person of marius romme as the representative psychiatric expert in the narrative romme is the first convert he emerges as a near pauline figure who sees the light albeit in a metaphorical sense and goes on to serve as learned leader of the movement coolheaded but convinced romme takes the message of the hvm to those within the psychiatric establishmenta hebrew of the hebrews so to speak ron coleman a nearly largerthanlife figure within the hvm also illustrates the way in which the hage myth engenders resolute faith in its message and potential conversions which voicehearers would not want to reverse coleman heard voices for eight years and used a number of medications to try to stop them as he tells it one day he then just woke up and thought that is enough i do not want to take medicine anymore it was a revelatory experience for coleman who now reports having fully recovered from the voices if romme is the first convert a sort of religious virtuoso in this narrative coleman is the later charismatic evangelist who spreads the myth near and far with passion and conviction he sells books and videos and gives public talks promoting the accepting voices approach coleman does much of the work of emotionally anchoring the myth in the lives of his audience of course the voices themselves actively participate in reinforcing the religious tone of the experiences as the voicehearer sacralizes their newfound sense of meaning ami rohnitz initially interpreted her voices as spiritual experiences that were stimulating to her when the voices ceased to inspire and began to be more troubling rohnitz attended a public lecture on the hvm which set in motion a series of events that led to the end of her voices however even the final voice she ever hears calls to mind western notions of the divine as it said to her in a deep tone you have heard enough although this is likely a simple result of limited cultural expressions religious terminology is also sometimes used by voicehearers to describe the hvm itself gavin young for example says that the hvm gave him the keys to the kingdom and that it helped him develop a set of coping tools which he believes to be his salvation in the midst of highlighting these conversions and their seeming connections to the myth of the hvm all as a function of meaningmaking for those who hear voices it is important to comment on the rest of hages biography shortly after appearing on television to discuss her experience and to invite other dutch voicehearers to contact romme hage nearly disappeared her absence from the nascent stages of the hvm likely augmented the myth with a useful sense of mystery and thus broad application but that was not the end of her story unfortunately after 16 years the voices returned yet the movement was underway with a mass of believers and the momentum produced by their collective engagement once again the empirical strength of the myths solution proved much less significant to the sacralizing of the identity it conferred than the manner in which it framed the problem hages relapse if we may use the term did not derail the hvm the myth was already in place the identity of voicehearer was therefore already being validated made sacred by the recurrent narration of the story and the collective legitimation that that tends to accompany ritual and emotional commitment in keeping with mols notion of sacralization one would also expect to see ritual activity and any number of emotional commitments being reiterated by those rites this seems to be precisely the case with the telling and retelling of not only that origin myth but also of the personal histories of the converts as woods contends sharing stories is a ritual feature both of local hearing voices groups and larger international congresses the exchange of narratives functioning variously as a form of testimony healing empowerment and the forging of individual and group identity indeed the local meetings which often meet multiple times per month and the nearannual international congresses seem to serve as both calendrical ritesin catherin bells sense of rituals that give socially meaningful definitions to the passage of time as well as sacred spaces as markers of time the gatherings permit voicehearers to plot out their own timelines from the point of conversion to the present an everwidening gap that hopefully correlates with everdiminishing disturbances from the voices as sacred spaces these ritual meetings offer a fitting environment within which the values and myths of the movement may be regularly verbalized and enacted for mol of course ritual is the repetitive enactment of human systems of meaning in which nonrational commitments have anchored the hearing voices movement as postmodern religionmaking 123 © equinox publishing ltd 2018 the emotions thus it is also in this repetitive social gathering and collectivelylegitimating swapping of testimonies that voicehearers are afforded the opportunity emotionally to seek and find hope and meaning two of the most common responses listed on the aforementioned postcards about what the hvm means to its members as voicehearers engage in active meaningmaking practices the sacredness of identity comes as these emotions and ritualized activities combine with a powerful myth and a sense of reclaimed authority to conceive of the subjective experience of voice hearing as central to the unity of self rather than as the single greatest impediment to that same end conclusion all in all it could be argued that the hvm is quite successful in its ability to challenge predominant psychiatric discourses surrounding schizophrenia whilst conferring a meaningful identity on its members because it has these inbuilt mechanisms bailey for his part believes that the concept of implicit religion can be taken to be implying a secular kind of religion and may be a useful tool for finding religious aspects of the secular for as modern society evolves into postmodern culture religiosity in its historical forms becomes an increasingly restricted tool for understanding human behaviour baileys view seems to concur with and in at least a basic sense informs the preceding exploration of the hvm as an instance of religionmaking however it is our contention that mols theory of religious identity offers a more fruitful lens for locating and analysing socalled secular religiousness a notion first suggested in a 1999 issue of the journal implicit religion indeed whilst we cannot go so far as to agree with mol that any sacralized ideology is a religion at least not in the terms he lays out his concept of sacralization does seem quite useful for explorations of postmodern movements because those movements are so selfconsciously in the business of identity construction and conferraleven if they are less selfconsciously religious than the more traditional communities on which mol sharpened his theoretical scalpel in the light of mols ideas we see the hvm mobilizing voicehearers around a shared set of valuesexperiences and buttressing their identities against past present and future threats by shrouding them in a sense of sacred place and purpose accordingly qualitative interviews suggest that the means by which this is achieved entails at least in part the construction and perpetual ritual vivification of a myth which simultaneously

over the past 40 or 50 years scholars of religion have frequently attempted to use the tools of social science to analyse describe and explain the relevance and persistence of religion in the modern world with the bold predictions of the secularization thesis as their stimuli many sociologists and anthropologists preferred to focus on the underexplored marginalized or otherwise unexpected expressions of religion within those ostensibly secularizing contexts such studies have led to an abundance of theories and accompanying terms implicit religion vernacular religion vicarious religion lived religion popular religion and folk religion without choosing any one of these but owing much to their sharedarguably postmodernthemes of commonplace sacrality and personal empowerment this paper seeks to explore the possibility of the hearing voices movement hvm as an example of religionmaking hvm is a growing force of voicehearers from at least 28 countries who have formed userled networks for activism and mental health recovery more importantly it is argued that hvm blends meaningmaking postmodern notions of identity in relation to power structures and ritual embodiment resulting in a striking example of sociologist hans mols notion of religion as a sacralizing process in 1921 german philosopher walter benjamin stated one can see in capitalism a religion that is to say capitalism essentially serves to satisfy the same worries anguish and disquiet formerly answered by socalled religions 2005 259 although influenced by both marx and nietzsche and accordingly given to underestimating the enduring significance of traditional religions benjamins observation helped establish something of a precedent whereby cultural critics and socialscientists identify and 106 adam powell © equinox publishing ltd 2018 elucidate trends movements and ideologies that resemble socalled religions within a given society as the twentieth century progressed similar notions received evergreater attention consider the tomes produced by sociologists anthropologists and others within religious studies on topics quite frequently neologisms coined for this very purpose related to the discovery of the sacred where one ought to find the secular initially delivered by the swirling currents of the 1960s and 1970s counterculture poststructuralism secularization theories cult research and a widespread denial of functionalist understandings of religion these efforts offered the academic study of religion fresh concepts such as civil religion bellah 1967 folk religion mensching 1964bock 1966 popular religion isambert 1982 vernacular religion primiano 1995 bowman 2012 lived religion hall 1997mcguire 2008 and vicarious religion davie 2007 perhaps one of the most recognizable a few decades later is implicit religion in his original essay on the subject one in which he argues for the actuality of a set of sociocultural phenomenaexperiences which constitute humanitys expressions of implicit religion edward bailey concedes that his chosen term may more accurately be said to correspond with instances of meaningmaking that are religious rather than instances that together form religion 1990 485 this calls to mind georg simmels distinction between religiosity and religion the former linked to a sort of primordial social impulse and the latter corresponding with those formal institutions that sometimes follow indeed for both thinkers the emphasis is on the nexus of sociality humanitys drive for meaning and the behaviours and experiences that may be deemed sacred spiritual or religious in some sense the following pages combine benjamins implicit awareness of both the strikingly religious appearance of some presumably secular movements and the complex web of connections between emotions existential instabilities and religious systems with simmel and baileys astute recognition of religiousness as one possible signpost at the crossroads of meaningmaking experience and the social person utilizing both secondary sources and qualitative data gathered by psychiatrist marius romme and his colleagues as well as by members of durham universitys wellcome trustfunded project hearing the voice we introduce and consider the hearing voices movement hvm a userled recovery and activism network for individuals who hear voices but either have not required or intentionally reject psychiatric treatment as one such ostensibly secular the hearing voices movement as postmodern religionmaking

introduction in highincome countries children from lower socioeconomic backgrounds are more likely to be overweight or obese compared with children with greater social and economic resources 1 in australia 33 of children living in the most disadvantaged areas are overweight or obese compared with 19 of children living in the least disadvantaged neighbourhoods 2 dietary behaviours follow similar socioeconomic gradients among children and adolescents higher socioeconomic position is associated with healthier dietary patterns 34 and better diet quality 5 in particular children with higher sep are more likely to consume and achieve recommended intakes of fruit and vegetables 6 7 8 9 10 11 discretionary food and drinks can be defined as food and drinks containing added fat sugar andor salt and are considered not necessary for a healthy diet 12 despite recommendations to limit consumption 12 they have been found to contribute up to 40 of australian childrens total daily energy intake 213 children with lower sep are more likely to consume discretionary food and drinks such as sugarsweetened beverages 610111314 fruit juice 7 snack foods 11 and fast food 1015 this is concerning because poor diet quality including consumption of sweet drinks and unhealthy snack foods in childhood is considered a key risk factor for overweight and obesity 16 17 18 whilst many aspects of diet are important given their lack of nutritional value and high contribution to childrens daily energy intake discretionary food and drinks are an important policy target whilst there is evidence of socioeconomic differences both in childrens weight and diet quality there has been no formal examination of the mediating role of discretionary food and beverages in the development of socioeconomic inequalities in childrens weight from birth identifying the mechanisms by which socioeconomic inequalities in weight gain develop across the life course can highlight leverage points for intervention that are both effective and equitable this is critical as inequalities in weight translate into inequalities in health 19 using data from the longitudinal study of australian children this study explored the mediating role of cumulative discretionary food drink consumption during childhood on the development of socioeconomic inequalities in weight gain from birth to age 1011 years methods ethics the lsac study protocol was approved by the australian institute of family studies ethics committee written consent was provided for each participant study design and sample lsac is a nationally representative prospective study following two cohorts of australian children since 2004 20 our study comprised participants from the b cohort of lsac into which 5107 participants were recruited our eligible sample included the 3764 children in the b key messages • weight gain among children in australia follows a socioeconomic gradient whereby those with lower socioeconomic position have higher bmi zscores at age 1011 years compared with children with higher sep • socioeconomic differences in the consumption of discretionary food and drinks emerge at a young age and persist throughout childhood • discretionary food and drink consumption from the first year of life appears to contribute to the development of inequalities in excess weight among australian children cohort present at wave 6 we excluded participants with missing data for sep at wave 1 bmi zscore at wave 6 dietary variables of interest at waves 1 2 3 4 or 5 and relevant confounding variables resulting in a final analytical sample of 3190 participants the proportion of participants with missing data was less than 10 for variables included in our analysis data collection data were collected via structured interviews conducted by trained professionals and written questionnaires completed by the childs primary caregiver socioeconomic position a composite measure of sep was generated for the lsac cohort to provide a continuous relative sep score the score comprised measures of parents annual income years of education of each parent and the occupational status of each parent accounting for the number of parents in the home 21 to capture sep around the time when discretionary food and drinks are first introduced we used the sep score generated at the first wave of data collection to create deciles of sep which were used as a continuous measure of sep in our mediation analysis from the composite sep score we also generated tertiles of sep which were used to describe population characteristics according to higher middle and lower sep anthropometry trained professionals measured childrens weight to the nearest 50 grams and height to the nearest 01 centimetre from this bmi was calculated and converted into continuous ageand sexspecific bmi zscores 22 overweight and obesity were classified according to international obesity taskforce cutoffs 23 diet in facetoface interviews parents were asked about their childs consumption of specific food items in the previous 24hour period the interviewer asked in the last 24 hours how often did child have and response options were not at all once more than once questions on consumption of sweet drinks were asked from wave 1 onwards and questions about discretionary foods were asked from wave 2 onwards our analysis examined all available discretionary food and drink variables that we grouped into four categories sweet drinks discretionary hot food savoury snacks and sweet snacks for our descriptive analysis participants were identified as nonconsumers or consumers for consumption in the past 24 hours of any of the food or drink items listed within each discretionary food and drink category for each survey wave for mediation analyses these dichotomous responses were summed across each survey wave for each discretionary food and drink category so that each participant was classified as an overall high consumer or low consumer covariates covariates were identified based on prior evidence of their influence on the relationships examined in our analyses at the first survey wave parents reported their childs sex weight at birth and age in months parents reported their childs preference for active or inactive use of free time at each survey wave from age 23 years onwards by responding to the question what does child usually do when she he has a choice about how to spend free time usually chooses inactive pastimes like tv computer drawing or reading just as likely to choose active as inactive pastimes usually chooses active pastimes like bike riding dancing games or sports mothers age in years was selfreported parents reported whether their child was of aboriginal or torres strait islander origin mothers main language was determined by the question does mother speak a language other than english at home descriptive analysis descriptive statistics examined key demographic and behavioural characteristics of our analytical population according to tertile of sep logistic regression models were fitted to examine socioeconomic differences in the prevalence of overweight and obesity at wave 6 adjusted for childs age sex birthweight mothers age english as main language and atsi origin longitudinal mediation analysis to determine the mediating effect of cumulative discretionary food and drink consumption throughout childhood on the relationship between sep and bmi zscore at age 1011 years we fitted a series of regression models in accordance with the product of coefficients mediation method a mediator must be associated with sep and be associated with bmi zscore at age 1011 years independently of each other mediator sep and potential confounders the proportion mediated was determined by dividing the indirect effect by the total effect coefficients we used a bootstrap with 5000 replications to obtain 95 confidence intervals for all coefficients and mediated proportions all models were adjusted for wave 1 covariates including childs age sex birth weight mothers age english as main language atsi origin and childs preference for active or inactive pastimes at waves 25 a heuristic model of the longitudinal mediation analysis is depicted in figure 1 sensitivity analysis we tested whether our analyses were sensitive to nonresponse and attrition by applying lsac sample weights to our descriptive analyses and regression models 24 we also tested sensitivity of our exposure and outcome indicators in separate models using mothers education at wave 1 and sep at wave 6 as exposures and overweight and obesity at wave 6 as the outcome all analyses were conducted using stata version 14 25 results descriptive analysis socioeconomic patterning was observed for a number of key characteristics weight at birth birthweight zscore and maternal age increased with increasing sep the proportion of atsi children and childs bmi zscore at age 1011 years decreased as sep increased the proportion of families with mothers who spoke a language other than english was higher among those in the low and high sep tertiles the proportion of overweight and obesity was lower for each increase in tertile of sep at each study wave the consumption of sweet drinks discretionary hot food and savoury snacks was greater among children with lower sep across all study waves longitudinal mediation analysis of the four potential mediating categories of discretionary food and drinks examined in our study sweet drinks and discretionary hot food were associated with both exposure and outcome consumption of sweet drinks from age 01 to 89 years mediated 59 of the relationship between sep and bmi zscore at age 1011 years and consumption of discretionary hot food between ages 23 and 89 years mediated 54 of the relationship between sep and bmi zscore at age 1011 years collectively the intake of these discretionary items across childhood mediated 1131 of the socioeconomic differences in bmi zscore at age 1011 years sensitivity analysis the relationships between sep and all mediators and between mediators and bmi zscore did not appreciably differ after applying lsac sample weights using mothers education and sep at wave 6 as the exposures and overweight and obesity as the outcome results were not appreciably different to the primary analysis discussion this is the first study to our knowledge to estimate the mediating effect of specific discretionary food and drink items on the development of socioeconomic inequalities in childrens weight using a contemporary sample of australian children followed up every 2 years between birth and age 1011 years we found distinct socioeconomic differences in the development of overweight and obesity which increased as sep decreased similar socioeconomic differences in the consumption of discretionary food and drinks emerged at a young age and persisted throughout childhood childhood consumption of sweet drinks and discretionary hot food was associated with a greater gain in bmi zscore from birth to age 1011 years cumulative consumption of sweet drinks from age 01 year and discretionary hot food from age 23 years mediated just over 11 of the longitudinal relationship between sep and bmi zscore from birth to age 1011 years our analysis found that sep was positively associated with birthweight zscores but this association shifted to an inverse association by age 23 years which remained throughout childhood other research has also identified this shift in socioeconomic patterning from a positive sepweight relationship at birth to an inverse relationship in later childhood commonly reported to occur around the ages of 57 years 2426 our findings of socioeconomic differences in adiposity among children are comparable to the observed socioeconomic differences in weight among children in lsacs kindergarten cohort 27 similar socioeconomic inequalities in childrens weight have been reported in a number of highincome countries in recent years 2829 consumption of discretionary foods appears to begin at an early age with sweet drink consumption evident among almost half of 0to 1yearold children in the lowest tertile of sep in our sample we identified socioeconomic gradients in the cumulative intake of discretionary food and drink items including sweet drinks discretionary hot food and savoury snacks throughout childhood similar socioeconomic patterning in the consumption of sweet drinks and highsugar highfat foods has been observed among children in a number of other highincome countries 3031 we observed a positive association between childhood consumption of sweet drinks and bmi zscore at age 1011 years this is consistent with international findings from crosssectional and longitudinal research indicating that consumption of sweet drinks including fruit juice in early childhood is associated with excess weight gain 32 33 34 we also observed associations between consumption of discretionary hot food across childhood and higher bmi zscore but found no association between consumption of sweet and savoury snacks and bmi zscore the lack of association between consumption of sweet snacks and bmi zscore may be due to the limited variability in consumption with high prevalence observed among all children for savoury snacks the lack of association with bmi zscore may be due to differential reporting bias according to childrens weight status the relatively crude manner in which these items were reported with little detail regarding quantities consumed or a true lack of effect our findings showed that cumulative consumption of sweet drinks and discretionary hot foods throughout childhood mediates around 11 of the socioeconomic differences in childrens bmi zscore at age 1011 years sweet drinks and discretionary hot foods were related to both a coefficient adjusted for all confounders b coefficient adjusted for all confounders the exposure and all other mediating variables childrens weight gain and to inequalities in the development of bmi from birth to age 1011 years thus interventions that reduce intake of these items may contribute to the dual outcome of reduced population weight for children and reduced inequalities in excess weight gain across childhood whilst sweet snacks was not identified as a mediator it was consumed in high quantities by all children regardless of sep and should be considered a target in interventions to improve childrens diets across the socioeconomic gradient our analysis also highlights the critical need to identify and target additional determinants of inequalities in weight gain across childhood additional determinants that may contribute to the development of socioeconomic inequalities in childrens bmi zscores include perinatal factors including maternal weight and diet during pregnancy commencement and duration of breastfeeding and complementary feeding 35 behavioural factors in childhood such as overall diet and total energy intake physical activity sedentary behaviour and sleep and more upstream determinants including neighbourhood environments 36 and social and cultural norms 3738 a reduction in childrens consumption of discretionary food and drinks is therefore an important target for preventive health policy alongside complementary actions to address the range of determinants of socioeconomic inequalities in childrens weight strengths of this study include six waves of data collected over 10 years allowing examination of the role of cumulative discretionary food intake on socioeconomic inequalities in weight gain from birth to age 1011 our study utilized a robust measure of sep measured at wave 1 which tracked across study waves with 70 of participants remaining in the same sep tertile at wave 6 our study was further strengthened by objectively measured anthropometric data the study also has a number of limitations to note first whereas the initial study population was representative of australian children nonresponse across lsac waves was higher for children whose parents were lowincome earners of atsi origin or spoke a language other than english as the main language at home however sensitivity analyses accounting for lsac nonresponse yielded similar results second discretionary food intake was selfreported selfreported dietary data can be imprecise and susceptible to underreporting 39 the extent of differential underreporting according to sep eg due to social desirability bias is unclear third information for many discretionary food and drink items were not captured and of those that were we had information on frequency of consumption only ideally dietary data would be obtained using datacollection methods validated for use in children 40 and provide greater detail on total dietary intake including quantities consumed fourth whilst the data used in our study were the most contemporary data available for this age group earlier waves of data were collected prior to the mounting public awareness of the harms of ssbs and may not fully reflect current perceptions or consumption of sweet drinks finally the measure of physical activity in lsac is relatively crude reporting childrens preferences for time spent in active or inactive pastimes the differential attrition selfreported dietary data and limited dietary detail may mean that the results in this study are underestimates of the true effect of impact of discretionary food and drink consumption on the development of inequalities in childrens weight our findings demonstrate that intake of discretionary hot foods and sweet drinks throughout childhood contributes to the development of socioeconomic differences in childhood weight gain these findings may be generalizable across highincome countries where similar socioeconomic gradients in overweight and obesity are evident reducing inequalities in discretionary food and drink consumption among children in highincome countries will require a combination of interventions which act across the gradient of socioeconomic disadvantage this will likely include interventions that change the structural drivers of unhealthy food and drink intake and a combination of population level and targeted interventions towards more socioeconomically disadvantaged groups 4142 evaluation of interventions and ongoing population health monitoring will be critical to our understanding of the impacts of population level and targeted interventions across the socioeconomic gradient further research is also required to improve understanding of the role of other important modifiable obesityrelated risk factors on socioeconomic differences in childrens weight conflict of interest none declared

background in highincome countries children with a lower socioeconomic position sep are more likely to gain excess weight compared with children with a higher sep the extent to which childrens consumption of discretionary food and drinks contributes to the development of these inequalities over childhood has not been examined methods the study sample comprised 3190 children from the nationally representative longitudinal study of australian children linear and logistic regression models were fitted in accordance with the product of coefficients mediation method to determine the contribution of cumulative consumption of sweet drinks discretionary hot foods savoury snacks and sweet snacks from the first year of life over a period of 10 years on the relationship between sep and childrens body mass index bmi zscore at age 1011 years results at age 1011 mean bmi zscore was 017 in the highest sep tertile 033 in the middle and 047 in the lowest tertile corresponding values for overweight and obesity prevalence were 166 257 and 327 respectively eleven per cent 95 confidence interval ci 477 1984 of the observed difference in bmi zscore at age 1011 years was mediated by socioeconomic differences in consumption of sweet drinks and discretionary hot foods including pies and hot chips throughout childhood conclusions findings indicate that consumption of sweet drinks and discretionary hot food from the first year of life is likely to contribute to the development of inequalities in excess weight among children poor dietary intake is a key risk factor for excess weight gain among children and a reduction in discretionary food and drinks is likely to contribute to the dual goal of improving overall weight and reducing socioeconomic inequalities in weight gain across childhood to maximally reduce inequalities in weight gain across childhood additional determinants must also be identified and targeted

einstein 20211916 antes da pandemia de coronavírus 2019 e excesso de peso apresentaram maior risco de impacto no nível de atividade física o aumento do tempo sentado foi associado a indivíduos mais velhos inatividade doença crônica maior número de dias no isolamento social e níveis de escolaridade mais altos conclusão nossos resultados demonstraram que a idade a presença de doenças crônicas e a inatividade física antes do isolamento social tiveram maior risco de impacto na redução do nível de atividade física e maior tempo sentado durante a pandemia de coronavírus 2019 descritores coronavírus infecções por coronavírus covid19 quarentena sedentarismo comportamento sedentário inatividade física ❚ introduction the novel coronavirus disease 2019 pandemic is one of the most colossal and farreaching public health problems in human history up to september 10 2020 almost 27 million cases and approximately 899 thousand deaths had been reported worldwide stay at home orders and social distancing are some of the few strategies available to contain the spread of covid19 billions of people are in social isolation around the world which may lead to unhealthy behaviors such as decreased physical activity and time spent using electronic devices such as televisions computers and smartphones the tactics utilized in combating the covid19 pandemic have varied from country to country the strategies have depended on contrasting cultures political views social isolation and available resources among other factors brazil has recently become the new epicenter of the covid19 pandemic and the consequences of social isolation on physical activity and sedentary behavior have been poorly addressed ❚ objective to investigate the impact of the coronavirus 2019 pandemic on physical activity levels and sedentary behavior among brazilians residents aged ≥18 years ❚ methods sample and ethics this survey was conducted in brazil between may 5 and 17 2020 participants were invited through social media to answer a structured questionnaire this study was approved by the ethics committee of the universidade nove de julho before data collection participants were anonymous all procedures follow the national legislation and the declaration of helsinki inclusion criteria were age ≥18 years and to answer all questions procedures after approval by the ethics committee a questionnaire in google forms was presented to participants as 70 questions distributed in seven sections personal information covid19 personal care physical activity eating behavior habits contributing to health risks mental health and overall health the format was developed for senior researchers who have phd degree in various subjects to analyze and draw conclusions the following includes questions used in the present analysis after filling in the questionnaire the entire form was redirected to a spreadsheet generated by google in microsoft excel format for further analysis for the purpose of the present study only personal information physical activity health risk habits and overall health domains were analyzed the details of these domains are described below instrument concerning personal information information about sex date of birth type of residence educational level and days of social isolation were obtained to assess physical activity habits participants were asked how often do you exercise a week how long do you exercise how long have you been engaged in a certain physical activity how intense is the physical activity what type of exercise do you practice based on these responses time spent during each exercise session throughout the study was multiplied by the number of days spent exercising each week those that reached 150 minutes or more of moderate to vigorous physical activity were considered physically active while those who fell below this threshold were classified as inactive additionally there were questions related to the impact of covid19 on physical activity and sedentary behavior how much has the covid19 pandemic interfered with your daily physical activity habits for analysis purposes none and a little were considered as no and a lot as yes those who responded i do not exercise were excluded from this analysis the section about health risk habits included information regarding health care related to social habits such as smoking drinking alcohol screen time on a smartphone computer or television and the time the participant spent sitting the question for this section was due to social isolation have you spent more time seated the section about overall health assesses the presence of diagnosed diseases from the list of diseases the participant could mark all that apply for research purposes if the participant marked any of these options they were considered as yes for chronic diseases if none of them were marked the participant was considered as no for chronic disease in this section it was also asked what is your weight and what is your height as well as what is your body mass index this was calculated by dividing body weight by squared height overweight was defined as a bmi ≥250kgm 2 statistical analysis all statistical analyses were made in the spsspredictive analytics software version 20 frequency and mean were used for descriptive analysis multiple logistic regressions were conducted to identify predictors of impact on physical activity levels and increased sitting time during the covid19 pandemic furthermore stepwise regression techniques were employed to enter the covariates into the model using only variables with p 020 in the bivariate analyses in the regressions only variables with p 005 remained in the final model the hosmerlemeshow test was used to assess the models goodnessoffit and suitability to the set of observations the significance level was set at p 005 for all analyses ❚ results out of the 1895 individuals who were enrolled in the present study three did not inform their sex and 11 did not report their age therefore the final sample comprised 1881 individuals table 1 shows general characteristics physical activity levels an sedentary behavior of the sample table 2 shows comparisons of the impact of the covid19 pandemic on physical activity and sitting time participants who changed their physical activity levels during the covid19 pandemic were younger more overweight and less active before the pandemic participants who increased their sitting time during the covid19 pandemic were younger with more days of social isolation higher prevalence of undergraduate and graduate educational levels more overweight and less active before the pandemic table 3 shows the predictors of impact on physical activity levels and increased sitting time due to the covid19 pandemic adjusted analysis shows adults who were older inactive overweight and suffering from chronic diseases had a greater impact on physical activity levels due to covid19 increased sitting time was associated with older inactive presence of chronic diseases more days in social isolation and high schooling level ❚ discussion the results of this study indicated that social isolation imposed by the covid19 pandemic led to a reduction in physical activity levels and an increase in sedentary behavior in brazilian adults age presence of chronic disease physical inactivity and excessive weight before the covid19 pandemic induce greater risk of impact on physical activity levels increased sitting time is associated with age previous physical inactivity presence of chronic diseases more days in social isolation and higher schooling levels in this study more than 50 of men and women reported that the covid19 pandemic reduced their physical activity levels interestingly these alterations occurred similarly in all age groups these results are consistent with the reports of a wearable physical activity tracking device used by more than 30 million people worldwide it identified a 7 to 38 reduction in step count during the week of march 15 2020 when compared with the same period in the previous year this data raises concern since both physical inactivity and longer sitting time are independent predictors of allcause and cardiovascular mortality the adverse effects of the variables physical inactivity and sedentary behavior are multiple and directly related to sarcopenia increased falls in elderly people hypertension insulin resistance and type ii diabetes obesity cancer and ultimately higher mortality rate physical inactivity is the fourth leading cause of death worldwide and it is also associated with reduced life expectancy and quality of life of note physical inactivity relatedcosts such as health expenses and productivity losses exceeded us 675 billion dollars in 2013 the deterioration of wellbeing and quality of life caused by inactivity and increased sedentary behavior emphasizes the fundamental importance of physical activity in the life of every individual increasing physical activity such as the number of steps significantly improves health and it has been inversely associated with developing chronic diseases guidelines for increase physical activity are crucial in preserving muscle mass and neuromuscular function cardiorespiratory fitness and glucose metabolism especially when unexpected circumstances cause a strong restriction of daily movement in comparison to normal life of particular importance individuals who were older had chronic diseases or were inactive before the pandemic showed an even greater decrease in physical activity levels and an increase in sitting time interestingly we demonstrated that older adults who have some chronic disease and were already inactive were those who suffered more during the pandemic increasing sitting time and reducing physical activity levels they also should probably be the last to leave social isolation these people are precisely those who most need physical activity especially during personal isolation our findings prompt the need to implement preventative public health measures to support the practice of physical activities at home during the pandemic this is especially imperative because the termination of these arduous circumstances is still unknown several studies have suggested that homebased training during the pandemic can be effective although more evidence is needed to determine long term health benefits and consequences use of social media or other online resources specifically geared toward physical activity may be a viable method in helping increase the practice of regular physical activities at home this study has limitations that are worth highlighting the crosssectional design of this study is an evident limitation because no causality can be inferred additionally online surveys are susceptible to information and social biases especially without direct measures of physical activity and sedentary behavior on the other hand the large sample size and its timely assessment of health behaviors make our findings important and quite relevant ❚ conclusion our study clearly demonstrated that age chronic disease and physical inactivity before social isolation had an immense impact on physical activity levels as well as a detrimental influence on increased sedentary behavior during the coronavirus disease 2019 pandemic ❚ authors information botero jp farah bq correia ma lofranoprado mc cucato gg shumate g rittidias rm prado wl

objective to investigate the impact of the coronavirus 2019 pandemic on physical activity levels and sedentary behavior among brazilians residents aged ≥18 years methods an online survey was distributed through a social media platform between may 5 and 17 2020 participants completed a structured questionnaire in google forms which assessed the physical activity level and sedentary behavior of adults in brazil during the pandemic results age or 098 95 ci 097099 chronic disease or 129 95 ci 103163 physical inactivity before the coronavirus 2019 pandemic or 220 95 ci 178272 and overweight or 134 95 ci 109165 showed higher risk of impact on physical activity levels increased sitting time was associated with older individuals or 097 95 ci 096098 inactivity or 151 95 ci 116196 chronic disease or 165 95 ci 123222 higher number of days in social isolation or 101 95 ci 100102 and higher schooling levels or 187 95 ci 126278 conclusion our results demonstrated that advanced age chronic disease and physical inactivity before social isolation had a greater risk of impact on reduced physical activity levels and increased sitting time during the coronavirus 2019 disease pandemic

introduction the term multimorbidity is generally defined as the presence of two or more chronic health conditions in the same individual 12 in the conception of multimorbidity none of the diseases is understood as the main one believing in the comprehensive management of all health problems that the individual presents 3 the complexity of assisting patients with multiple chronic diseases brings multimorbidity as a major challenge especially since health guidelines are usually based on treating isolated conditions 4 5 6 7 8 9 epidemiological studies on multimorbidity have shown great methodological differences which makes it difficult to compare them 810 even so there is a consensus that multimorbidity has a high prevalence in both highincome countries and developing countries such as brazil burdening health systems 1115 in the adult population multimorbidity reaches about 20 in most studies affecting more women and those with unfavorable socioeconomic conditions 1112 15 16 17 18 19 20 21 among the elderly it affects the majority reaching up to 98 of this group 10131522 in southern brazil a populationbased study carried out with adults and the elderly observed an overall prevalence of multimorbidity of almost 30 while in the female population the prevalence was over 35 12 individuals with multimorbidity have a lower quality of life lower functional capacity reduced life expectancy and a higher risk of mortality than those with isolated conditions 1215 23 24 25 these individuals use health services more and receive complex and multiple treatments which makes adherence to treatment difficult and increases the risk of adverse effects 192627 in this context it is important to identify the factors associated with multimorbidity so that preventive measures may be applied effectively it is already established that lifestyle factors such as smoking unhealthy eating alcohol consumption physical inactivity and being overweight are associated with the occurrence of many chronic diseases when they are assessed individually 28 regarding multimorbidity studies have shown that presenting with a combination of lifestyle factors that is considered unhealthy increases the chances of multimorbidity 2930 but when evaluated separately the literature is not consistent about the association of these behavioral characteristics with multimorbidity with regard to the above this study aimed to identify the prevalence of multimorbidity and its associated factors in women in southern brazil methods we conducted a crosssectional populationbased study with a representative sample of women living in urban areas in the city of são leopoldo rs this research is part of a larger project entitled living conditions and health of adult women populationbased study in the rio dos sinos valley evaluation after 10 years carried out in 2015 this study employs multiplestage sampling methods details of the methodology used have already been published 31 the sample size was calculated based on the outcomes of interest we chose the one that required a larger sample size the total sample of 1128 women made it possible to estimate the prevalence of multimorbidity with a margin of error of 3 points for associations the chosen sample size allowed the detection of prevalence ratios of ≥14 with a power of 80 using 95 confidence intervals women who were residents of the urban area of são leopoldo residents of the sectors and households drawn and aged between 20 and 69 years were eligible for inclusion in the study population those who may have been in the household drawn at the time of the study but were not residents of that household and pregnant women were excluded a standardized and pretested questionnaire was administered to each participant in a pilot study data quality control was carried out using a shorter questionnaire which was applied to 10 of the participants the outcome multimorbidity was assessed from the identification classification and usage of drugs prescribed by a doctor that the participant reported through the question are you currently using any medication prescribed by a doctor to correctly register each medication it was requested the presentation of the prescription packaging or package insert when possible to determine the health condition for which each medication was used the following were taken into account 1 main therapeutic indication of the medication 2 the indication of use referred by the participant and 3 other medications used and their therapeutic indication rev bras epidemiol 2022 25 e220007 when necessary other auxiliary information was used such as age and the selfreporting questionnaire score 33 the latter being used to confirm the presence of common mental disorders the drugs in use that were referred to for acute health conditions or occasional use were not included those who presented two or more chronic conditions were considered multimorbid 2 the independent variables were classified as demographic socioeconomic and lifestyle variables and nutritional status the demographic variables were age selfreported skin color and marital status socioeconomic variables were education household income per capita in quartiles economic class 34 and occupation lifestyle variables assessed were smoking alcohol consumption physical activity and consumption of fruits and vegetables alcohol consumption was established based on the frequency type of drink and quantity ingested 35 and was classified as excessive when consumption was ≥15 g of ethanolday 36 only 60 women were in the excessive consumption category and only 2 of these were multimorbid for this reason this category was incorporated into the category of moderate consumption in the multivariate analysis participants were considered physically active when they reached at least 150 min of weekly physical activity verified by the international physical activity questionnaire ipaq 37 the consumption of fruits and vegetables was considered adequate when ≥5 timesday 2938 nutritional status was defined by the body mass index which is given by the measurement of weight in kilograms divided by the square of the height in meters and classified according to criteria from the who as follows 185 kgm 2 low weight ≥185 and ≤249 kgm 2 eutrophy ≥250 and ≤299 kgm 2 overweight and ≥300 kgm 2 obesity 39 weight and height measurements were recorded by trained interviewers weight was measured with a portable analog scale with the participant wearing light clothes and no shoes and distributing their body weight equally between their feet height was measured with a portable stadiometer on the wall with the interviewee in an upright posture and arms loose along the body both measurements were performed in duplicate and the respective mean values were considered only 20 women in the study were classified as underweight and none of them had multimorbidity thus this category was incorporated into the eutrophic category for the multivariate analysis rev bras epidemiol 2022 25 e220007 statistical analysis of the data was performed using stata version 120 statistical software to verify the association of the exposures of interest with the presence of multimorbidity a poisson regression analysis with robust variance was performed 40 according to the multivariable model of analysis 41 according to the model the first level includes distal variables which can determine the intermediate variables these in turn are interrelated and can determine the thirdlevel variable which proximally determines the outcome all variables were adjusted to those at the same level and higher levels considering a pvalue 020 variables with pvalue 005 were considered to be associated with the outcome the project was approved by the ethics and research committee of the university of vale do rio dos sinos all participants signed the informed consent form results the prevalence of multimorbidity was 217 among the 1128 women interviewed 95 had two chronic conditions 67 had three chronic conditions and 55 had four or more chronic conditions table 1 shows the 26 chronic conditions found in the study population with the most prevalent being hypertension followed by cmd which included anxiety and depression disorders regarding sociodemographic characteristics as seen in table 2 there was a homogeneous distribution between the age categories and the average age was 434 years most women reported being white living with a partner having 8 or more years of education belonging to economic class c and being employed a quarter of the study population reported family income per capita up to r 52530 and the average family income per capita was r 1295 the prevalence of multimorbidity increased with increasing age with 592 of women between 60 and 69 years of age being multimorbid multimorbidity showed an inverse association with educational level occurring in 382 of the population with less than 5 years of education and was also found in 358 of women who were unemployed no statistically significant differences were found in the prevalence of multimorbidity according to skin color marital status economic class and family income per capita in the context of lifestyle variables most women reported an inadequate consumption of fruits and vegetables were inactive had a moderate consumption of alcohol and did not smoke regarding nutritional status 332 of women were overweight and 329 were obese the prevalence of multimorbidity was higher among those who had an adequate consumption of fruits and vegetables those who did not consume alcohol and those who were exsmokers the prevalence also increased with an increase in bmi levels there were no statistically significant differences in the prevalence of multimorbidity according to physical activity table 3 shows that after adjusting for potential confounding factors age and income showed a direct linear association with multimorbidity those who aged 6069 years were rev bras epidemiol 2022 25 e220007 discussion we identified that onefifth of the adult and elderly women had two or more chronic conditions whereas when the category of elderly women was evaluated separately individuals with multimorbidity represented the majority twentysix chronic conditions were identified the most prevalent being hypertension and cmd the occurrence of multimorbidity was strongly associated with socioeconomic characteristics such as fewer years of schooling higher income and not having an occupation for the characteristics related to lifestyle the study corroborated the association of multimorbidity with excess weight and found that alcohol consumption had a protective effect our studys reported prevalence of multimorbidity was lower than that in the national health survey which evaluated a nationally representative sample and found multimorbidity in 261 of brazilian women considering 22 preestablished chronic conditions 42 and was also lower than the prevalence found among brazilian women in the amazon region northern brazil where multimorbidity reached 358 considering 12 preestablished chronic conditions 43 these differences can be related to the method of identifying chronic conditions since the two studies above used selfreported information regarding the presence of chronic conditions from a preestablished list our study adopted the use of medicines as a proxy for detecting multimorbidity and therefore newly diagnosed women without pharmacological treatment were not included thus it can be assumed that the prevalence of multimorbidity in this population may be even higher the positive association between advancing age and multimorbidity has already been demonstrated in other studies 1415194445 however our data highlight the fact that between 40 and 49 years old the prevalence of multimorbidity was 163 while at 5059 years it became 39 even considering that women consult the doctor more as they age and are therefore more likely to be diagnosed with health problems 31 it is observed that middle age has a significant impact on the occurrence of multimorbidity which thus indicates an important avenue for prevention although it was not evaluated in our study the hypothesis that our findings are related to the menopausal status of these women cannot be ruled out rev bras epidemiol 2022 25 e220007 since the postmenopause phase is associated with multimorbidity 16 nevertheless it is also biologically plausible that the association between age and multimorbidity is related to an accumulation of stressors throughout life that favor illness and consequently the increase in the number of diseases 46 in alignment with literature 1447 an inverse linear association between schooling and the occurrence of multimorbidity was observed this is relevant because studies have shown that in hypertensive patients low education is associated with limited knowledge about the disease which can negatively affect its control and also contribute to the development of other diseases 4849 besides our finding also shows how exposure to a marker of a socioeconomic level that is difficult to reverse impacts the development of multimorbidity increasing the need for public health measures aimed at reducing social inequalities on evaluating social inequality indicators an association was observed between lowincome or lower socioeconomic status and multimorbidity 1921444550 however similar to our findings data from the pns 2013 showed that the southern states of brazil which are more developed in terms of both income and education showed an increase in the occurrence of multimorbidity possibly related to an increase in the life expectancy in these states in comparison with the others states 42 additionally it is known that higher income is associated with greater access to health care services 31 which may be related to a higher number of diagnoses and therefore a higher percentage of multimorbidity we found association between women who were unemployed and multimorbidity pns 2013 data also showed that unemployed adults were almost 20 more likely to have multimorbidity than those who were employed 51 the authors stated that it should be taken into account that primary health care services are only offered during weekdays and daytime hours in the brazilian public health system impairing the access of those who work thereby impacting the diagnosis of multimorbidity which should be considered when interpreting our results however we cannot rule out the possibility of reverse causality since the presence of chronic diseases increases the chances of the individual not being able to work precisely because of poor health 52 according to a national sample of american adults as the level of multimorbidity increased the chances of the individual not working significantly increased 53 the association between alcohol consumption and multimorbidity still remains controversial while some studies have shown no association between these variables 2930 a brazilian study conducted with individuals who aged 50 years or older found that those who did not consume alcohol had a higher prevalence of multimorbidity 46 along the same lines we found alcohol consumption to be a protective factor for multimorbidity other evidence has also identified moderate alcohol consumption as a protective factor for chronic conditions 5455 however it is possible that women with multimorbidity stopped consuming alcoholic beverages after diagnosis of chronic diseases and for this reason the temporality of this association should be investigated in longitudinal studies finally our investigation pointed out a significant doseresponse relationship between bmi categories and the prevalence of multimorbidity this association is consistent with findings from several studies that have assessed the relationship between nutritional status and multimorbidity 16304445 in this context it is known that the prevalence of excess weight has been increasing over the years 56 therefore one can speculate as to the negative impact this will have on the incidence of multimorbidity in the future as it is also a chronic condition some studies on multimorbidity have used the presence of obesity as part of the construction of the outcome instead of as an exposure 1150 however given its established role as a risk factor for chronic noncommunicable diseases 28 we chose to assess the presence of excess weight as a risk factor for multimorbidity thereby highlighting the importance of public policies in combating this pandemic this study has some limitations the crosssectional design did not allow us to establish a temporal relationship between the exposure and outcome although it appears that the hierarchical model accounted for those variables with possible reverse causality in relation to the external validity this is a populationbased study carried out in a city in southern brazil and for this reason it is possible that the findings cannot be extrapolated to populations with characteristics different from this study population the lifestyle variables assessed were selfreported therefore it is possible that behaviors that are recognized as negative by the general population may have been underreported and as a result would be higher than those presented in the study for the assessment of nutritional status gauging weight and measuring height circumvented the possibility of this bias one of the criticisms made of the concept of multimorbidity is that it often does not take into account the severity of the health conditions 57 however polypharmacy is common in multimorbidity and is associated with the occurrence of adverse effects due to drugs 27 additionally the initial conduct during the management of some chronic conditions is the adoption of healthy habits associated or not with pharmacological treatment thus when we include women already using medication it can be assumed that nonpharmacological management as an isolated therapy was not effective and therefore due to the requirement of medication the disease being treated is likely to be severe to the best of our knowledge this is the first populationbased study conducted among women in southern brazil where medication usage was employed to detect chronic conditions enabling the identification of a wide range of diseases and pointing out its severity as per our understanding the strategy used to classify morbidity by reporting the name of the drug contributed to better data quality since the current use of medicines was considered these were classified according to their main therapeutic indication and confirmed by the selfreport of the individuals interviewed the evaluation of medication use also allowed an unlimited number of health conditions to be considered without restricting it to a specific number of preestablished diseases as observed in most available studies 14305051 furthermore the use of atc classification has already been considered as an uptodate mapping approach to identify patients with chronic diseases using pharmacy data 58 and other studies investigating multimorbidity have also used this methodology 12265960 however due to the absence of a validated instrument for screening the variety of chronic conditions addressed in studies on multimorbidity the use of various methods limits the comparability of results among the available studies rev bras epidemiol 2022 25 e220007 conclusion this study showed that the prevalence of multimorbidity in women increases significantly with increasing age and is not restricted only to the elderly population given the aging of the population multimorbidity should be treated as a public health problem that is a cause for worry especially since the prevention and management of multiple health conditions is a task of great complexity for health systems our study identified a range of factors associated with increased multimorbidity such as fewer years of education higher income and not having an occupation regarding nutritional status and lifestyle characteristics excess weight was observed to be an independent risk factor for multimorbidity while alcohol consumption displayed a protective effect it is vital to understand the risk factors that must be addressed by both clinical guidelines and public health policies so that the strategies to be proposed address the challenge of preventing and managing multimorbidity ethical approval the project was submitted to and approved by the ethics and research committee of the university of vale do rio dos sinos and has been performed in accordance with the ethical standards as laid down in the 1964 declaration of helsinki and its later amendments or comparable ethical standards

objective this study aimed to identify the prevalence of multimorbidity and its associated factors in women in southern brazil methods we conducted a crosssectional populationbased study with a sample of 1128 women age 2069 years living in são leopoldo southern brazil multimorbidity was defined as two or more chronic conditions measured using the therapeutic and chemical anatomical classification of continuous use medications prescribed by a physician poisson regression model with robust variance was used to assess the association between sociodemographic and lifestyle variables and multimorbidity results the prevalence of multimorbidity was 217 95 ci 193242 and 26 chronic conditions were identified a direct linear association was observed with age and income and an inverse association with education being unemployed was a risk factor for multimorbidity pr 195 95 ci 151252 alcohol consumption moderate or excessive had a protective effect overweight and obese women were 53 pr 153 95 ci 109215 and 76 pr 176 95 ci 127245 more likely to have multimorbidity than eutrophic women conclusion over 20 of the adult women had multimorbidity and its occurrence was strongly associated with socioeconomic characteristics such as fewer years of schooling higher income and not having an occupation the results regarding alcohol consumption are still insufficient to propose a public policy for the prevention of multimorbidity excess weight was an independent risk factor and should be addressed in public health policies for the prevention and management of multimorbidity

introduction smoking continues to be an unacceptable burden on the health of canadians mortality caused by tobaccorelated disease accounts for approximately 37000 annual deaths in this country 1 tobacco use is thus the leading cause of preventable premature mortality 2 this is of particular concern among young adults who have the highest prevalence of smoking of all age groups in 2012 prevalence in the 2024 year and 2534 year age groups was 179 and 185 respectively compared to a prevalence of 146 in the general population 2 young adults not only have the highest prevalence but they also experience significant changes in smoking behavior both in terms of initiation and quit attempts 3 4 5 empirical studies provide evidence of significant smoking uptake in this age group finding that as many as 25 of youth who took up smoking did so before age 24 but after high school age 3467 moreover the number of young adult smoking initiates appears to be surpassing that of adolescents as suggested in a systematic review of smoking initiation in the united states and canada 8 these trends call for attention because young adulthood is recognized as a key transitional period in terms of health behaviors and risk factors not only by public health organizations 9 but also by the tobacco industry who identifies it as an important window to market tobacco products 10 nonetheless this age group is frequently overlooked in tobacco control efforts 4 and underutilize evidencebased cessation treatments 11 this in spite of studies suggesting that successful prevention of smoking initiation during young adulthood increases the likelihood of never becoming a regular smoker 5 similar to other health outcomes there are significant placebased inequalities in smoking 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 for example on the island of montreal smoking rates differ significantly across place of residence in 20072010 they ranged from 156 to 360 across the regions health and social services administrative units 29 these studies highlight the potential role of neighborhoodlevel factors as enablers and barriers to health above and beyond individuallevel sociodemographic characteristics such as age sex and education well known correlates of smoking 30 differences in health behaviors and outcomes at the neighborhood level are thought to arise in part due to differential distributions of resources available to their residents 31 as well as their differential capability to access them 32 these resources may be healthpromoting 33 or healthdeterring 34 acknowledging the importance of understanding the potential role of neighborhood exposures in shaping smoking behavior there is a significant body of research devoted to the examination of associations between neighborhoodlevel exposures and smoking among an array of environmental exposures potentially associated with smoking outcomes proximity and density of tobacco retail stores and presence of smoking accommodation facilities are thought to be relevant a considerable amount of research has explored associations between smoking outcomes and proximity and density of tobacco retail stores in adult populations a greater density of tobacco outlets around address of residence has been found to be associated with a higher likelihood of smoking 1435 and a lower likelihood of smoking cessation 3637 among adolescents proximity and a greater density of tobacco outlets around schools and homes have been found to be associated with higher experimental smoking rates 38 the number of cigarettes smoked daily 1439 and likelihood of smoking 40 however while associations between exposure to tobacco retail and smoking outcomes have been explored in adolescents and adult populations very few studies have examined the potential impact of proximity and density of tobacco retail stores on smoking outcomes in young adults a recent study found a positive association between density of tobacco outlets and smoking initiation in individuals aged 1834 years 41 another recent study included both residential neighborhoods and activity spaces as areas of exposure to density of tobacco outlets results showed a higher likelihood of smoking in young adults exposed to greater numbers of tobacco retail stores both around residential neighborhoods and activity spaces 42 moreover limited research has been conducted to examine associations between the presence of smoking accommodation facilities and smoking outcomes either in relationship to the implementation of smoking bans in public spaces or without such relationships following a national ban on indoor smoking in hospitality venues a french study found that while indoor smoking decreased significantly the offer of outdoor smoking spaces increased this resulted in reported rates of outdoor smoking increasing from 336 at baseline to 759 at followup suggesting that although overall individual prevalence declined in many cases smoking simply moved outdoors 43 interestingly a recent study examining associations between exposure to patio smoking and smoking cessation found that smokers who were exposed to smoking in patios were less likely to have attempted to cease smoking and more likely to relapse after having made a quit attempt 44 these studies highlight the relevance of outdoor smoking accommodation facilities as a potential hurdle to smoking cessation although it is also possible that these spaces play a role in facilitating smoking initiation to date no empirical studies have examined associations between exposure to smoking accommodation facilities and smoking initiation moreover as with proximity and density of tobacco retail stores very few studies have examined associations between the presence of smoking accommodation facilities and smoking outcomes in young adults among a number of conceptual and methodological challenges that must be addressed in order to better understand associations between neighborhood exposures and health outcomes one important consideration is the definition of appropriate spatial scales among the set of challenges related to the analysis of spatial data 45 this issue is central to studies of neighborhoods and health given that processes underlying associations between neighborhoodlevel exposures and health outcomes are likely to operate at different scales depending on specific exposureoutcome pairs for example the geographic scale at which social networks and distance to retail outlets respectively impact smoking behavior may not be the same moreover the potential impact of these two exposures may operate at different scales in the context of other health outcomes such as depression or cardiovascular disease therefore the operationalization of spatial units must be specific to the associations under study 46 47 48 nonetheless although some scholars have conducted studies to better understand the impact of using different spatial scale definitions in studies of neighborhoods and health 49 50 51 52 to our knowledge few studies of neighborhoods and smoking have examined the potential role of spatial scales in shaping research findings importantly the choice of a spatial scale that does not correspond to the geographical level at which a specific exposure is hypothesized to influence smoking outcomes may translate into an inappropriate operationalization of geographical boundaries which in turn may result in significant measurement error 53 this issue is widely recognized in the literature as the modifiable area unit problem 54 in the presence of maup estimates of betweenarea variation may depend on how boundaries are defined 5255 and may potentially result in two types of error the first usually called the scale effect may arise when different statistical results are obtained depending on the scale at which data are aggregated the second usually called the zoning effect may occur when different statistical results are obtained depending on how boundaries of a territory are defined 5253 some scholars have called for the use of theories linking spatial scales mediating processes and health outcomes prior to the analysis of neighborhood effects 4856 although it would be ideal to define spatial units based on theory exploratory empirical analyses can allow for initial exploration of spatial issues in the absence of strong theory 57 in keeping with this notion the majority of studies of neighborhoods and smoking have used empirical approaches in order to examine associations between exposures and smoking outcomes rather than identifying theorybased spatial unit definitions in general terms two broad types of spatial units have been used in the literature the first is a proximal unit type that seeks to capture the more immediate neighborhood environment either by the use of administrative areas such as census tracts and municipal subdivisions or by the creation of buffer zones with different radii the second is a community unit type that captures environments relevant to health processes that likely operate at a larger scale such as social norms and community practices another important issue for research on neighborhoods and smoking is the study of associations between exposures and changes in smoking behavior or lack thereof research in this area has typically focused on static smoking variables as their outcome of interest for example all of the studies on smoking included in a recent systematic review of healthrisk behaviors and neighborhood deprivation examined current smoking status as their outcome 58 this was also the case for a vast array of studies of different neighborhood exposures and smoking behaviors including current smoking status smoking initiation and smoking cessation although it is certainly important to examine associations between neighborhood exposures and smoking outcomes using crosssectional designs this approach cannot provide information regarding the potential role of neighborhood exposures in influencing changes in smoking status such as becoming a new smoker becoming a new nonsmoker or lack of change in any direction this is particularly important among young adults because this age group experiences significant changes in smoking status hammond proposes that contrary to hypotheses postulating that smoking behavior becomes largely fixed after high school age young adults display variable smoking patterns with significant smoking uptake taking place after high school age in many cases shifting repeatedly between daily and occasional smoking 60 therefore regular smoking habits may only develop later in life 61 moreover in comparison to older adults young adults are more likely to attempt to quit smoking 11 this variability in smoking behavior in young adults was portrayed in the results of a 2004 study of changes in smoking behavior over a fouryear period among a cohort of college students within this timeframe 13 of daily smokers at baseline ceased to smoke and 28 changed their status from daily to occasional smokers 14 of occasional smokers at baseline became daily smokers while 51 ceased to smoke and 11 of nonsmokers at baseline initiated occasional smoking additionally 87 of smokers at baseline and 50 of occasional smokers at baseline continued to smoke after four years 62 given the significant differences in smoking behavior between collegeeducated and noncollegeeducated young adults in the united states 63 these results may not generalize beyond collegeeducated young adults nonetheless they illustrate the instability of smoking status in this age group to date the bulk of research on neighborhoods and smoking has mainly focused on how neighborhood exposures are associated with static smoking outcomes such as smoking rates or cessation rates at a specific point in time moreover the vast majority of these studies has devoted their efforts to adolescent and adult populations while little attention has been paid to young adults therefore it is crucial to understand the role of neighborhoodlevel exposures in shaping the smoking trajectories in this population additionally in spite of calls for explicit consideration of spatial scales more specific to the exposures and outcomes under examination there is a paucity of studies exploring the variability of associations between neighborhood exposures and smoking across spatial scales hence empirical research in this area can contribute to improving knowledge of associations between neighborhoodlevel exposures and the smoking trajectories in young adults the objective of this study was to examine associations between the presence of tobacco retail stores the presence of smoking accommodation facilities and selfreported smoking trajectory among young adults across two nested spatial units in montreal canada one specific question was asked for what categories of smoking trajectory and at what spatial scales are these associations statistically significant we hypothesized that individuals living in neighborhoods with a greater presence of tobacco retail outlets andor a greater presence of smoking accommodation facilities would be more likely to change their status from nonsmoker to smoker over two years or to maintain their smoker status during this twoyear period and less likely to change their smoking status from smoker to nonsmoker over two years or to maintain their nonsmoker status during this twoyear period methods study sample this study was conducted in the context of the interdisciplinary study of inequalities in smoking a cohort study with the objective of better understanding the joint role of individual and neighborhood factors in producing social inequalities in smoking in montreal among young adults 64 analyses were based on the isis baseline sample from 2011 to 2012 this sample was composed of noninstitutionalized individuals aged 1825 years proficient in either english or french who had been living at their current address for at least one year at time of first contact an initial random sample of 6020 individuals obtained from quebecs provincial health insurance program was contacted through a nominalized letter between november 2011 and august 2012 at the end of the recruitment period 349 individuals refused to participate 458 were declared ineligible and 3111 could not be reached resulting in a final sample of 2093 participants the response rate was 376 while relatively low these rates are not uncommon in observational studies and could be attributed to unreported moves inaccurate mailing addresses or to a lack of interest in participating in the study participants had similar characteristics to those of participants in the canadian community health survey a statistics canada survey designed to gather healthrelated data at the health region level 65 they were however in slightly less good physical and mental health and included a lower proportion of daily smokers and a higher proportion of nonsmokers full details on sampling and survey procedures are available elsewhere 64 description of neighborhood spatial scales to examine the potential role of different spatial scales in shaping findings regarding associations between neighborhood exposures and smoking trajectory over 2 years among young adults we used two empirical spatial unit definitions the first health and social services catchment areas called centres de santé et de services sociaux may capture processes operating at a larger scale cssss created in 2004 are administrativelydefined geographic service units comprising a local network of health and social services territories typically include several partners notably general practitioners pharmacies community organizations private organizations specialized health and social services organizations and multisectoral partners 66 the second definition sociological neighborhoods may capture processes operating within the more immediate neighborhood environment in contrast to csss territories sns are communitydefined spatial units based both on administrative boundaries and shared perceptions of their residents regarding their history sense of belonging infrastructure and services and population characteristics these territories were created in 2008 by the direction de santé publique de montréal in partnership with local organizations to better capture the subjective sense of neighborhood experienced by residents the 111 sns on the island of montreal are nested within the 12 cssss and respect statistics canadas census tract and dissemination area boundaries these spatial units are fairly homogeneous in terms of socioeconomic characteristics and are recognized as relevant spatial divisions for local development initiatives 67 maps of the territories used for planning and delivery of health and social services on the island of montreal can be found elsewhere 6869 measures of neighborhood exposure two exposure measures were used in this study the first was presence of tobacco retail stores at each spatial unit to construct this measure data regarding retail outlets legally selling tobacco products were extracted from the 2011 dmti enhanced points of interest database 70 this database is a collection of geocoded address points covering a comprehensive range of land uses including tobacco retail stores this data source was validated using the 2010 database version for convenience stores and supermarkets data were found to be adequately representative with sensitivity values of 059 and 075 and positive predictive values of 073 and 100 for convenience stores and supermarkets respectively 71 to operationalize the presence of tobacco retail stores the first step was to compute the number of retail outlets selling tobacco products for each dissemination area where at least one cohort participant resided das are the smallest geographic census areas in canada composed of one or more adjacent dissemination blocks with a population of 400 to 700 persons there are 3175 das on the island of montreal with a mean area of 016 km 2 a total of 1399 of the 3175 das were aggregated to create this exposure given that more than half of the das had no presence of tobacco retail stores and most of those having presence of tobacco retail stores had only one outlet the values obtained at the da level were categorized as a dichotomous indicator of presence of at least one retail outlet selling tobacco products in the da a similar approach has been used in previous studies alternative approaches to the operationalization of this exposure were explored including density of tobacco retail outlets per 10000 inhabitants and density of tobacco retail outlets per km 2 analyses revealed relatively low densities per 10000 population compared to those reported in a recent british study 72 96 of the measured das had a density of 496 per 10000 inhabitants or lower the lowest reported value in this study since no locally validated standard measures of density of tobacco retail stores that account for population density were available we chose to use a dichotomous indicator of presence of at least one retail outlet selling tobacco products in the da second dalevel values were aggregated at each of the two spatial scales cssss and sns and mean values of presence of tobacco retail stores were computed finally in order to contrast neighborhoods with greater presence of this exposure against all other neighborhoods these values were recoded into a dichotomous indicator spatial units at which the highest means were observed were coded 1 to reflect greater presence whereas all other areas were coded 0 reflecting lesser presence of tobacco retail the second exposure measure was presence of smoking accommodation facilities data used to construct this indicator were extracted from the isis observational database observational data were collected between june and september 2012 using a validated observation grid 73 to develop this grid a theoretical framework 32 conceptualizing the nature of neighborhoods and their potential role in the generation of health inequalities was used based on this framework 86 indicators were constructed operationalizing a range of neighborhood environmental exposures these indicators were evaluated by trained raters who filled out a paper form the instruments interrater reliability and temporal stability were assessed through a generalizability study showing that 75 of the indicators in the observation grid were measured with acceptable to excellent reliability 73 a random sample of street segments within montreals 35 local community service territories was selected clsc territories are administrative units based on the provision of health and social services created by the ministry of health and social services to operationalize the presence of smoking accommodation facilities street sections having at least one smokingaccommodating feature were coded 1 to indicate presence of such facilities whereas street sections with no smoking accommodation facilities were coded 0 indicating no presence the majority of the das had no smoking accommodation facilities dalevel values were aggregated at each of the two spatial scales cssss and sns and mean values of presence of tobacco retail stores were computed lastly in order to contrast neighborhoods with greater presence of this exposure against all other neighborhoods these values were recoded into a dichotomous indicator of smoking accommodation facilities spatial units at which the highest means were observed were coded 1 to reflect greater presence whereas all other areas were coded 0 reflecting lesser presence outcome measures the dependent variable for this study was selfreported smoking trajectory to measure this variable the study population was classified into four categories these categories were constructed based on selfreported smoking behavior at baseline measured in 2011 and selfreported previous smoking behavior over a 2year period the cutoff point used to construct the categories of smoking trajectory was based on empirical studies of milestones of nicotine dependence and smoking cessation 74 75 76 77 the following baseline isis individual survey questions were used in this study currently do you smoke cigarettes every day occasionally or never have you ever smoked an entire cigarette how old were you when you smoked an entire cigarette for the first time when was the last time you smoked a cigarette based on responses to these questions each participant was allocated to one of four nominal categories participants who either never smoked an entire cigarette or reported a nonsmoker status at baseline and smoking a cigarette for the last time 2 years ago or longer were categorized as nonsmokers for 2 years or longer participants who reported an occasional or regular smoker status at baseline and smoking an entire cigarette for the first time 2 years ago or longer were categorized as smokers for 2 years or longer participants who reported an occasional or regular smoker status at baseline and smoking an entire cigarette for the first time less than 2 years ago were categorized as smokers for fewer than 2 years finally participants who reported a nonsmoker status at baseline and smoking a cigarette for the last time less than 2 years ago were categorized as nonsmokers for fewer than 2 years covariates three individuallevel covariates were used for this study age sex and educational attainment all variables were dichotomized participants aged 1821 years were coded 0 while those aged 2225 years were coded 1 male participants were coded 0 whereas female participants were coded 1 finally participants who completed high school or lower and were not enrolled in postsecondary studies at the time of survey were coded 0 and those who attained at least a postsecondary degree or were enrolled in postsecondary studies at the time of survey were coded 1 fullyadjusted models included a neighborhood socioeconomic position variable to examine potential confounding of associations neighborhood sep was operationalized using pampalons material deprivation index quartiles 78 this index is composed of three indicators education work status and income which are widely used as measures of sep statistical analyses associations between neighborhood exposures and smoking trajectory were examined using threelevel multinomial models level1 individuals level2 sns level3 cssss multilevel models are widely used in studies of neighborhood effects among other reasons due to their ability to account for correlated or clustered observations and to describe the variability and heterogeneity in the population above and beyond average relationships 79 models were built using hlm v7 software following a stepup approach in which multilevel models are progressively specified hlm is a statistical software designed to fit a variety of linear and nonlinear models using hierarchicallystructured data allowing for continuous count ordinal and nominal outcome variables 80 first to explore the variance in smoking trajectory at each spatial unit threelevel interceptsonly models were built second level1 models were built to explain withinneighborhood variability adding three sociodemographic covariates age sex and educational attainment third level2 and level3 models with no level1 variables were constructed for each measure of exposure at both spatial levels finally randomintercept level2 and level3 models including predictors at all levels were built results a total of 1183 female and 910 male young adults participated in the study approximately 51 of them were aged 18 to 21 years the majority of participants completed or were pursuing postsecondary studies information regarding education was missing for 10 participants the smoking status of the majority of young adults did not change over the twoyear period most participants were nonsmokers for two years or longer while almost onefifth were smokers for two years or longer 320 participants reported a change in their smoking status over a twoyear period 252 participants were nonsmokers for fewer than two years while 68 participants were smokers for fewer than two years information regarding smoking trajectory was missing for 13 participants since missing data were not imputed all analyses were conducted based on a subsample of 2070 participants reflecting missing data for a total of 23 ya at the sn level 26 sns had a greater presence of tobacco retail outlets while 27 sns had a greater presence of smoking accommodation facilities at the csss level three cssss had a greater presence of both exposures details appear in table 1 interceptsonly models revealed significant betweenarea variance in smoking trajectory at the larger spatial unit definition conversely no statistically significant betweenarea variance was observed at the smaller spatial units threelevel models with individual sociodemographic covariates as predictors showed a significant association between age and smoking trajectory the likelihood of being a smoker for two years or longer was higher among participants aged 2225 years vs 1821 years the likelihood of being a smoker for fewer than two years was significantly lower among participants aged 2225 years associations between sex and smoking trajectory showed that female young adults had a lower likelihood of being a smoker for two years or longer in comparison to male young adults associations between educational attainment and smoking trajectory were not statistically significant details appear in table 2 below multilevel models with snlevel exposure variables as predictors showed a statistically significant association between a greater presence of tobacco retail stores and the likelihood of being a smoker for two years or longer individuals residing in sociological neighborhoods with greater presence of tobacco retail stores had a greater likelihood of being a smoker for two years or longer associations between a greater presence of smoking accommodation facilities at the sn level and smoking trajectory were not statistically significant different from models with snlevel exposures as predictors models with cssslevel exposures as predictors showed a significantly higher likelihood of being a smoker for two years or longer for individuals living in cssss with a greater presence of smoking accommodation facilities in contrast associations between a greater presence of tobacco retail stores at the csss level and smoking trajectory were not statistically significant results of models predicting smoking trajectory from snlevel exposures and cssslevel exposures appear in tables 3 and4 respectively given the statistically significant associations between snlevel greater presence of tobacco retail stores cssslevel greater presence of smoking accommodation facilities and the likelihood of being a smoker for two years or longer a first fullyadjusted model model 1 using these two exposures as well as age and sex as individual sociodemographic predictors was tested in this model associations between age sex and the likelihood of being a smoker for two years or longer remained statistically significant interestingly while the association between cssslevel greater presence of smoking accommodation facilities and smoking trajectory over two years also remained statistically significant this was not the case for snlevel greater presence of tobacco retail stores to examine whether the association between the presence of smoking accommodation facilities and smoking trajectory was confounded by neighborhood socioeconomic position a second fullyadjusted model model 2 using neighborhoodlevel material deprivation was tested after adjusting for material deprivation cssslevel presence of smoking accommodation facilities remained statistically significant therefore suggesting no confounding of this association by neighborhood sep results for these two models appear in table 5 discussion this study examined associations between the presence of tobacco retail stores the presence of smoking accommodation facilities and selfreported smoking trajectory over two years among young adults across two nested spatial units in montreal canada results showed that the likelihood of being a smoker for two years or longer was higher among adults living in cssss where there was a greater presence of smoking accommodation facilities conversely this association was not statistically significant at the sn level in contrast the likelihood of being a smoker for two years or longer was significantly higher among residents of neighborhoods with a greater tobacco retail presence at the smaller spatial unit but this association was not statistically significant in fullyadjusted models these results indicate that greater cssslevel presence of smoking accommodation facilities is associated with being a persistent smoker over a twoyear period above and beyond individual sociodemographic characteristics additional analyses revealed that this association was not confounded by neighborhoodlevel socioeconomic position one mechanism that could explain the association between cssslevel presence of smoking accommodation facilities and the greater likelihood of being a smoker for two years or longer is an increase in access and opportunities to smoke in hospitality venues and public places 4381 evidence regarding smokefree policies suggests that removing these environmental features contributes to curbing smoking prevalence by reducing smoking opportunities and by denormalizing smoking 82 another potential mechanism underlying associations between the presence of smoking accommodation facilities and persistent smoking in young adults is the exposure to social visual and olfactory cues these cues have been found to be associated with a lower intent to quit and a higher risk of relapse 83 84 85 86 to date most tobacco control interventions targeting this exposure have resorted to indoor smoking bans in public places while outdoor smoking restrictions are frequently less stringent allowing smoking in places such as outdoor patios and terraces moreover these bans for the most part appear to have protected nonsmokers from being exposed to secondhand smoke studies have shown that smokers tend to more frequently visit outdoor smoking venues 44 and report smoking more cigarettes in these places in particular among younger individuals 87 therefore future interventions may want to consider an extension of such bans to include outdoor public places such as hospitality venues the importance of extending smoking bans to outdoor spaces has been recognized by the government of quebec who recently passed a bill prohibiting smoking in a variety of outdoor spaces including patios and terraces 88 no significant associations between the two neighborhood exposures and other categories of smoking trajectory over two years were found in the case of changes leading to a nonsmoker status at baseline a lack of significant associations with a greater presence of tobacco retail outlets and a greater presence of smoking accommodation facilities appears to be a reasonable expectation this is notable because these exposures were operationalized to detect associations with the greatest levels of exposure the reverse may have resulted in findings of significant associations between the lowest levels of exposure and the likelihood of being a nonsmoker at baseline a greater presence of tobacco retail outlets is likely to increase accessibility to tobacco products 89 and exposure to pointofsale marketing 90 91 92 while as discussed above it could be hypothesized that a greater presence of smoking accommodation facilities increases not only opportunities to smoke in public venues but also social acceptance and exposure to social visual and olfactory stimuli all of which can trigger smoking therefore it is more likely that greater levels of these exposures are associated with changes leading to a smoking status at baseline rather than the reverse while it is possible for a greater presence of tobacco retail outlets and smoking accommodation facilities to be associated with the likelihood of being a smoker for less than two years the lack of statistically significant associations with this category of smoking trajectory over two years may suggest that these exposures are not sufficient to contribute to smoking initiation a similar absence of statistically significant associations was found in a recent study of incidence and determinants of smoking initiation among young adults that examined three neighborhoodlevel exposures likely to operate through mechanisms similar to those thought to underlie associations between the presence of tobacco retail outlets smoking accommodation facilities and smoking trajectory over two years among young adults 4 another potential explanation for the absence of statistically significant associations in three of the four categories examined in this study is the instability of smoking status in this age group young adulthood is increasingly recognized as a crucial developmental period during which a number of important changes take place including those related to health behaviors 9 since young adults may experience frequent changes from smoking to nonsmoking and vice versa it is possible that measurement at baseline captured one of these changes albeit not with enough time for them to become more solidly established behaviors repeated measures designs may be helpful in addressing this issue the results of this study echo theoretical propositions regarding the specificity of scales at which healthrelated processes take place as diezroux proposes it is very plausible that areas of different size could be relevant for different processes and different health outcomes 57 therefore as suggested by gauvin et al the use of an exposurespecific and outcomespecific spatial scale approach is likely to be best suited to the study of neighborhood effects on health 93 the significant association between a greater presence of tobacco retail at the sn level and the likelihood of being a smoker for two years or longer suggests that geographic proximity may play an important role in facilitating access to tobacco products this is in line with findings in the literature 36379495 however evidence of mechanisms underlying the association of presence of smoking accommodation facilities at the csss level rather than at the sn level are currently lacking future studies are warranted to explore this issue further in sum two important issues regarding neighborhoodlevel exposures and smoking in young adults are highlighted in this study first differences in associations between neighborhoodlevel exposures and the likelihood of being a smoker for two years or longer suggest that additional knowledge regarding smoking outcomes in young adults can be gained by examining not only smoking prevalence but also how this population goes through different stages of smoking behavior specific to this study results suggest that variability in smoking trajectory over two years among young adults is explained at least in part by a greater cssslevel presence of smoking accommodation facilities second as evidenced by the differences in magnitude of associations between the specific exposures examined in this study and smoking trajectory over two years depending on the geographic scale of analysis these results suggest that there is a need to consider spatial unit definitions appropriate to the specific exposureoutcome associations under analysis doing so is likely to contribute to the reduction of measurement error due to an inadequate operationalization of spatial scales this study also has a number of limitations first given the crosssectional nature of its design it was not possible to establish causal links between a greater cssslevel presence of smoking accommodation facilities and the likelihood of being a smoker for two years or longer second there is potential for selection bias given the relatively low response rate to the individual questionnaire of note nonresponders were more likely to be male and to reside in mostdeprived areas than responders third even though the data source used to measure presence of tobacco retail outlets was validated and found to be adequately representative misclassification bias cannot be ruled out fourth given that data regarding presence of smoking accommodation facilities were collected at the dissemination area level there is potential for understatement of this exposure in neighborhoods for which a more limited number of observations were conducted a larger sample could help examine this issue more thoroughly finally neighborhood exposures were measured only once and in consequence any changes that may have occurred were not taken into account given that changes in neighborhoodlevel exposures may be associated with the smoking trajectory future studies could focus on the examination of changes in exposures across time conclusions our findings highlight the importance of studying not only static smoking outcome measures such as smoking prevalence at a specific timepoint but also the smoking trajectory over two years this is particularly important in young adults who experience repeated changes in smoking behavior throughout this life stage additionally in line with calls for greater specificity in neighborhood effects studies 46 47 48 96 our results point to the relevance of spatial scale considerations in the studies of neighborhoods and smoking scaledependent differences in associations between the two exposures examined in this study and smoking trajectory over two years above and beyond individual sociodemographic characteristics suggest that processes related to smoking in young adults take place at different scales and differ as a function of the specific exposures and outcomes being examined further research on specific neighborhood exposures and smoking trajectories in young adults is warranted author contributions adrian e ghenadenik conceptualized this study analyzed and interpreted the results and wrote the manuscript katherine l frohlich and lise gauvin contributed to the conceptualization of the study the interpretation of the findings and the revision of the manuscript

young adults have the highest prevalence of smoking amongst all age groups significant uptake occurs after high school age although neighborhood exposures have been found to be associated with smoking behavior research on neighborhood exposures and the smoking trajectories among young adults and on the role of geographic scale in shaping findings is scarce we examined associations between neighborhood exposures across two nested increasingly large spatial units and smoking trajectory over two years among young adults living in montreal canada a sample of 2093 participants aged 1825 years from the interdisciplinary study of inequalities in smoking isis was surveyed the dependent variable was selfreported smoking trajectory over the course of two years residential addresses data on presence of tobacco retail outlets and the presence of smoking accommodation facilities were coded and linked to spatial units threelevel multinomial models were used to examine associations the likelihood of being a smoker for 2 years was significantly greater among those living in larger spatial unit neighborhoods that had a greater presence of smoking accommodation this association was not statistically significant at the smaller spatial units our findings highlight the importance of studying young adults smoking trajectories in addition to static smoking outcomes and point to the relevance of considering spatial scale in studies of neighborhoods and smoking

introduction the advancement of industrialization and urbanization in china has caused the migration of rural laborers to the city to seek jobs or start businesses in 2017 there were 28652 million migrant workers from rural areas in china due to poor economic conditions most of their children were left in rural hometowns under the supervision of one of their parents grandparents relatives or neighbors more than three consecutive months these children are called leftbehind rural children ie leftbehind children the ministry of education of the peoples republic of china reported that there were 2019 million lbc in the stage of compulsory education in 2015 accounting for 1442 of children nationwide leftbehind children show poor psychological adjustment due to longterm parentchild separation which has recently attracted increasing concern psychological adjustment refers to the phenomenon that an individual will maintain good mental health despite changes in his or her environment it is often measured using different indexes such as depression happiness and other emotional indicators previous studies have shown that compared with those children living in nonmigrant families ie nonleftbehind children lbc exhibit more negative emotions such as loneliness and depression but less positive emotions such as selfesteem and happiness hence lbc are generally inferior to nlbc in terms of psychological development based on the above results loneliness depression selfesteem and happiness were used as indicators of psychological adjustment in this study according to the theory of developmental assets lbcs poor psychological adjustment may be related to their insufficient assets the assets in this study refer to the factors that effectively promote the growth of adolescents including 20 external assets such as family support and 20 internal assets such as resistance skills each of which can positively affect an individuals adjustment the individuals developmental needs and psychological adjustment will be impeded if such assets are absent leffert et al further emphasized that the assets do not work in isolation but they may function as a precursor to other assets or increasedecrease the efficiency of other assets the longterm parentchild separation may result in insufficient care lack of support assets some unsatisfied basic psychological needs in lbc and consequently low psychological adjustment however some lbc with poor assets show surprisingly good adjustment in daily life in this case does social support have a vital influence on the psychological adjustment of lbc if so does it function through the mediating effect of basic psychological need satisfaction in addition does resilience buffer the adverse effects of deficient support assets on bpns and psychological adjustment tda provides a theoretical basis for this study in exploring these research questions relation between social support and psychological adjustment sarason et al defined social support as the existence or availability of people on whom we can rely people who let us know that they care about value and love us the main effect model of social support suggests that social support will improve individuals psychological health regardless of their current level of stress and support there are four sources of social support for lbc in their daily life first migrant father andor mother communicates regularly with lbc via phone or social media to learn about their childrens development situation and provide guidance meanwhile the actual guardians may fulfill the parenting and supervision obligations second lbc usually have their own circle of friends to help them when they feel sad third teachers in the schools typically care for lbc in terms of life emotions and academics fourth the direct relatives such as grandparents or uncles of lbc and social workers may be willing to provide help in their life and studies totally family members friends teachers and significant others all can give them necessary help if lbc need previous studies have demonstrated that the parentchild cohesion and friend companionship negatively predict depression and loneliness of lbc but positively predict their life satisfaction in addition the teacherstudent relationship has a positive effect on lbcs selfesteem and a negative impact on lbcs depression moreover support from significant people is also crucial to lbcs emotional and social development finally social support is negatively associated with the mental health problems of lbc in general all the four sources of social support have an important impact on lbcs psychological adjustment however these discrete results make it difficult to reveal the overall relation between social support and psychological adjustment the ecological systems theory proposed that the relationship between individual and certain microsystem may influence the relationships between individual and other microsystems as predicted by this theory parentchild separation affects not only family support but also other sources of social support which can be proved through the strong positive correlations between them in both lbc and nlbc therefore this study aimed to use the covariance structural equation model to show the full picture of the social support of children in leftbehind situation based on above results hypothesis 1 was proposed social support positively affect lbcs psychological adjustment mediating effect of bpns selfdetermination theory proposes that individuals have three bpns namely need for autonomy need for relatedness and need for competence these three bpns are important to individuals development and satisfying these needs contributes to their wellbeing furthermore the process of need satisfaction does not occur automatically but through interactions between the individuals with their environment indeed the perception of respect care help and love that children gain through interactions with others not only satisfies their bpns but also further promotes their psychological adjustment as an analogy chen et al found that bpns mediates the relationship between perceived need support from physical education teachers and adolescents healthrelated outcomes in addition shao et al demonstrated that the parentchild cohesion has a negative impact on lbcs depression and loneliness through the partial mediation of bpns these results indicate that the support of teachers and family members has an effect on adolescents psychological adjustment in daily life lbc may also interact with their friends frequently and if necessary seek support from significant others such as relatives and caring people apart from interaction with their schoolteachers and migrant parents according to the main effect model of social support the support from different sources has a positive effect on childrens psychological adjustment furthermore in sdt all the above effects should be achieved through bpns therefore different sources of social support may positively affect lbcs psychological adjustment through the mediation of bpns which is the hypothesis 2 in this study moderating effect of resilience resilience is a very broad term that encompasses different essentials in different domains in developmental studies masten defined resilience as the capacity of a dynamic system to adapt successfully to disturbances that threaten system function viability or development resilience is interiorly similar to resistance skills a social competency that resists dangerous situations in view of tda and belongs to internal assets therefore both resilience and social support are protective factors for the development of an adolescent the protectiveprotective model suggests that two interaction modes exist when several protective factors jointly act on the development outcome that is one protective factor may enhance or weaken the impact of another factor on the outcome variables the former is called promotion hypothesis and the latter is called exclusion hypothesis wang et al found that resilience strengthened the influence of social support on the mental health of junior high school students which supported the promotion hypothesis other studies have suggested that resilience weakened the predictive effect of social support on lbcs loneliness and migrant childrens depression and loneliness and they supported the exclusion hypothesis however the insignificant moderating effect of psychological resilience on the relation between social support and subjective wellbeing of the ant tribe group could not be explained by any hypothesis hence the moderating mode of resilience on the direct relation between social support and psychological adjustment remains unclear basic psychological need satisfaction is not only the antecedent variable of psychological adjustment but also the outcome variable of environmental factors limited evidence is available on the moderating role of resilience in the relation between social support and bpns however previous studies have demonstrated that individuals with high resilience have additional positive qualities such as selfconfidence and decisiveness good emotional stability and high agreeableness strong cognitive ability in interpersonal relationships and implicit tendency to consider themselves capable these traits are conducive to individuals with highlevel resilience to obtain the social support assets achieve behavioral autonomy establish and maintain intimate relationships with others and realize the development goals of their ability as a result their bpns are fully satisfied under this circumstance the impact of inadequate external social support from family members friends teachers and significant others on their bpns should be limited due to their abundant internal assets by contrast lowresilience individuals have poor psychological assets and their cognitive responses to adversity are slow so that they are more likely to assess the influence of adversity to be more persistent such adversities may easily fixate their attention and become difficult to overcome and external support may be crucial in their bpns in this case accordingly resilience may likely reduce the impact of social support on bpns in the same sample the two moderating effects of resilience on the impact of social support on psychological adjustment and bpns are simultaneously carried out however to the best of our knowledge limited studies have examined these effects as far as lbc are concerned they have been living in a situation with absent support assets for a long time for one thing the difficulty in meeting some of their bpns affects their subsequent adjustment and for another the effect of individual differences in resilience on adjustment has emerged that is compared to those with lower resilience children with higher resilience show less loneliness and better mental health it is to be determined whether the moderating effects of resilience on the direct and indirect relationships between social support and psychological adjustment result in lbcs differentiated development or not bronfenbrenner emphasized that the interaction between environmental factors and individual factors has a great impact on individuals development and this interaction may have different strengths and forms in different scenarios to be specific lbc with different individual characteristics may treat environmental factors in different ways through daily interviews with lbc in dilemma fan found that an old chinese proverb very aptly summed up the plight of these children jin shang tian hua yi xue zhong song tan nan which means icing on the cake is ordinary but offering fuel in the snowy weather is scarce specifically for those resilient lbc external support only makes their good adjustment even better so they do not pay much attention to it however for those with poor resilience they are more eager for external support and cherish this hardwon support more so the impact of social support on their bpns and adjustment is likely to be greater based on the above viewpoints hypothesis 3 is proposed resilience diminish the direct and indirect relations between social support and psychological adjustment in lbc current study studies have proven the significant impacts of family socioeconomic status and gender on the psychological adjustment of children however whether school age has significant impact on lbcs adjustment remains unclear therefore the current study uses ses gender and school age as the candidates of covariables to control their effects on the psychological adjustment of lbc in addition chang and zhang summarized that development assets have different influence patterns and degrees on adolescents development due to their different developmental context and history similarly masten argued that how in summary after controlling for the effects of ses and gender the current study investigates the following issues the impact of social support on lbcs psychological adjustment the mediating role of bpns in the relation between social support and psychological adjustment and the moderating role of resilience in the direct and indirect relationships between social support and psychological adjustment figure 1 shows the overall study model materials and methods measures social support social support was measured with a 16item chinese revised version of the multidimensional scale of perceived social support this scale consists of four dimensions with four items in each dimension the participants rated each item on a fivepoint likert scale from 1 to 5 the average score of each dimension was calculated to create an indicator for the latent variable social support with higher values representing higher levels of support basic psychological need satisfaction basic psychological need satisfaction was measured using a simplified version of the need satisfaction scale this scale consists of nine items in three dimensions with three items in each dimension the responses were provided on a sevenpoint likert scale ranging from 1 to 7 the mean score of each dimension was calculated to create an indicator for the latent variable bpns with higher values indicating higher level of need satisfaction resilience block and kremens 14item resilience scale was used to measure the childrens resilience the responses ranged from 1 to 4 the mean scores were calculated with higher values indicating higher level of resilience depression the revised chinese version of radloff s center for epidemiologic studies depression scale was used to assess depression symptoms in 20 items during the past week the responses ranged from 1 to 4 the average scores were calculated after the answers of affirmative statements were reversed with higher scores representing higher level of depressive mood loneliness loneliness was obtained using the 21item adolescents loneliness scale which consists of four dimensions the participants rated each item on a fourpoint likert scale ranging from 1 to 4 the mean scores were calculated after the affirmative expressions were reversed with higher scores representing a stronger sense of loneliness selfesteem selfesteem was measured with the nineitem chinese revised version of rosenbergs selfesteem scale the responses ranged from 1 to 4 the mean scores were calculated after the positive statements were reversed with higher scores representing higher level of selfesteem happiness according to shen happiness was measured with the following item overall do you feel that you have lived a happy life in the past year the responses ranged from 0 to 10 with higher values indicating higher level of happiness socioeconomic status socioeconomic status was calculated from parents educational level parents occupation and family income following the five steps specified in pisa 2003 technical report and fang et al first all variables were assigned parents educational level was scored according to the years of schooling and occupations were scored in the range of 16 to 90 according to the international socioeconomic index given that most children may have limited knowledge about their family income it was indirectly measured by evaluating family resources including computers televisions and 10 other daily facilities in their homes each item counted as 1 with a total score from 0 to 12 second the above assigned variables were filtered or converted the parent with higher years of schooling or higher score in occupational classification represented the parents educational level and occupation third item response theory was used to estimate the family resources and subsequently obtain the parameter estimation index fourth the missing values in each variable were processed the samples with two or more missing values were eliminated in the sample with only one missing value the two other variables were regressed the regression value then replaced the missing value finally educational level occupation and family resources were converted into standard z scores for the following principal component analysis ses was then calculated by using the following formula ses ε f where β 1 β 2 and β 3 are factor loadings and ε f is the characteristic root of the first factor higher scores indicated higher level of family ses collection and analysis of data ninetyeight undergraduates were recruited as research assistants from a university in hunan province china this study used a snowball sampling scheme to recruit rural children in the rural villages during a week of winter vacation in 2014 the research assistants conducted some household surveys in the village where their families were located the study was approved by the research ethical committee of the university and written informed consent was obtained from all participants and their caregivers during the survey the research assistants read the items for primary school students to help them understand and encourage their responses at any time the junior high school students finished the questionnaire by themselves after the experimenters introduced the requirements after completing the survey participants were rewarded with stationery including notebooks and pens spss 220 and amos 220 were used for data cleaning and screening preliminary analyses and model verification data cleaning and screening included missing value outliers and normality analysis of the data a total of 1012 rural children participated in the study with 16 of them being excluded because of missing more than one third of questionnaires and 40 of them were excluded on account of missing one or more of the dependent variables according to wen and lin multiple imputation method was used to insert missing data in the independent variables there were no multivariate outliers test of normality demonstrated that variables follow a weak skewed distribution and bootstrap maximum likelihood method was used for followup analyses to correct the bias caused by nonnormality the preliminary analyses included manova test and pearson correlation analyses for the study variables in lbc and nlbc model verification included tests for measurement model among all latent variables main effect mediating effect and moderated mediating effect models for lbc and nlbc then invariant models were used to conduct model comparisons between the two groups resilience and all the dimensions of social support were centered and then multiplied to obtain four product items as the interactive indexes of resilience and social support when testing moderating effect results preliminary analysis comparisons of study variables among the three categories of children table 2 presents the scores of study variables in slbc dlbc and nlbc the children type was set as the grouping variable and all study variables were used as outcome variables for manova analysis in terms of overall study variables the main effect of children type was significant further univariate anova analysis showed that slbc and dlbc had significantly higher depression and loneliness but lower selfesteem and happiness compared to nlbc in addition the levels of the social support from family friends and significant others all dimensions of bpns and resilience of dlbc were all significantly lower than those of nlbc correlation analysis among the variables pearson productmoment correlation analysis was conducted among all study variables and covariates ses gender and school fas family support frs friend support ts teacher support sos significant other support bpna basic psychological need for autonomy bpnc basic psychological need for competence bpnr basic psychological need for relatedness ses of skewness and kurtosis for all variables were 008 and 016 respectively age in slbc and dlbc after each correlation coefficient r was converted into fisher z r z tests were performed to evaluate the difference of z r between the two groups the results demonstrated no significant difference existed in their pairs of z r accordingly slbc and dlbc were merged into one group for further analyses table 3 lists the pearson correlations among the variables in lbc and nlbc table 3 shows that the correlational patterns of the study variables of lbc and nlbc are highly consistent positive pairwise correlations existed among all the dimensions of social support all the dimensions of bpns and resilience in both groups and these variables negatively correlated with depression and loneliness but positively correlated with selfesteem and happiness the majority of these correlations were significant at the level of 0001 moreover both gender and ses were significantly correlated with depression loneliness and selfesteem in lbc however there was no significant correlation between school age and these three indicators on the basis of these correlations ses and gender were set as the covariates for subsequent analyses model verification measurement model among all latent variables as mentioned earlier the latent variable social support included four sources of different support bpns was constructed by three kinds of needs satisfaction and psychological adjustment was represented by the four indicators of depression loneliness selfesteem and happiness on the basis of these constructs a measurement model including these three latent variables was built as shown in figure 2 according to the criterion of goodnessofindices in amos the model fitted the data well for lbc and nlbc χ 2 df 488205 normed fit index 093093 relative fit index 091091 incremental fit index 095096 tuckerlewis index 093095 comparative fit index 095096 and root mean square error of approximation 00750063 and all factor loadings were higher than 045 main effect of social support on psychological adjustment structural equation model was used to investigate the direct effect of social support on psychological adjustment the results demonstrated that the overall model fitted the data well for the two groups in addition social support had a positive impact on psychological adjustment in lbc and nlbc and thus the higher the social support the better the psychological adjustment good fit in the two groups social support had a significant effect on bpns which in turn had a significant effect on psychological adjustment whereas the direct impact of social support on psychological adjustment was not significant the bootstrap tests demonstrated that the mediating effect of bpns was 029 and 028 in lbc and nlbc which accounted for 836 and 766 of the total effect respectively their corresponding 95 confidence intervals were and at p 0001 which indicated that bpns completely mediated the relationship between social support and psychological adjustment in both groups of children mediating effect of bpns between social support and psychological adjustment moderating effect of resilience on social support→bpns and psychological adjustment as shown in figure 4 four paths of resilience and social support × resilience→bpns and psychological adjustment were added on the basis of the mediation model the results showed the model fitting indexes in lbc and nlbc were acceptable the interaction of social support and resilience had a significant effect on bpns in both groups whereas the effect of social support × resilience on psychological adjustment was only significant in nlbc second simple effect analyses were carried out to detect the interaction effects lbc and nlbc were ranked from lowest to highest using their z scores in resilience the children with z score less thanequal to 1 and greater thanequal to 1 were grouped into lowand highresilience groups respectively while the rest belonged to the medium group we used sem to verify the mediation model in the three groups of lbc and nlbc table 4 shows that in the three lbc groups the direct effects of social support on psychological adjustment were insignificant and the mediating effects were all significant at the 001 level which indicated social support promoted lbcs psychological adjustment through bpns regardless of the level of resilience notably the higher mediating effect values of low and medium groups than those of the high group demonstrated a generally decreasing trend of mediating ability of bpns which reduced significantly in the highresilience group table 4 also shows that the direct effect of social support on adjustment was only nearly significant in the medium group of nlbc in addition the main effect of social support on bpns and the mediating effect of bpns declined with the increasing level of resilience and both became insignificant at a high level of resilience this finding suggests that the increasing level of resilience reduced the mediating ability of bpns in turn and social support had no effect on adjustment in the highresilience group third a series of consistency tests were conducted to detect the difference of the path coefficients either in the moderated mediation model between lbc and nlbc or in the mediation model among the lowmediumhighresilience groups of lbc and nlbc invariant models were used to reduce the risk of familywise errors results of nested model comparison showed that moderated mediation model and mediation model in mediumresilience group both demonstrated an overall significant change 260 nfi 0003 ifi 0003 rfi 0000 and tli 0000 p 001 when assuming model measurement weights and intercepts to be correct further comparison showed that mediation model only demonstrated a significant change in mediumresilience group 335 nfi 0007 ifi 0008 rfi 0002 and tli 0002 p 001 the results of pairwise comparisons showed that the path coefficient of social support → bpns in lbc was larger than that of nlbc but this difference was only demonstrated in the mediumresilience groups with the influence being stronger in lbc than that in the corresponding nlbc group in addition the weaker coefficient of resilience → bpns in lbc than that in nlbc indicated that resilience had a stronger impact on the bpns of nlbc discussion on the basis of the tda framework social support bpns and psychological resilience denoted predictor mediator and moderator respectively we investigated their joint influences on psychological adjustment in lbc and obtained significant results the findings of this study will provide a theoretical basis on the mental health intervention of lbc comparison of lbc and nlbc scores in the study variables compared with nlbc lbc exhibited lower selfesteem and happiness but higher loneliness and depression hence lbc showed poor psychological adjustment which is consistent with the results in previous studies in addition lbc exhibited decreased support from family friends and significant others and lower resilience indicating that they had poor external support and internal resistance assets from the perspective of tda the insufficiency of assets may induce poor psychological adjustment the growth environment in lbc has been changed since their parents migration due to employment lbc may experience not only decreased parental care but also high social discrimination and peer bullying some social help activities might also strengthen their feelings of being treated differently as a result lbc generally perceived a decreased sense of effective social support according to the conservation of resources theory the shortage in resource will put a certain pressure on individuals to alleviate the disadvantages brought by life pressure lbc must use their limited assets for resistance however such a small investment will unlikely make ends meet the continuous depletion of their antiadversity ability will likely cause the loss of assets in lbc hence their resilience will increasingly decrease moreover lbc exhibited significantly lower bpns than nlbc which is consistent with the results of shao et al childhood and adolescence are of great importance for the physical and mental development of individuals and the children in these two stages are highly dependent on their families and parents although lbc have additional opportunities to make seemingly autonomous decisions such autonomy without parental guidance will likely confuse them and result in the poor satisfaction of the need for autonomy in addition the absence of parental care in lbc cannot be compensated by other people and the children often face a considerable amount of pressure in life and have lower levels of selfconfidence and enterprising spirit than nlbc thus it is difficult for lbc to fulfill their needs for relatedness and competence independent prediction effect of social support on psychological adjustment of lbc in line with our hypothesis 1 social support had a positive impact on lbcs psychological adjustment this result is consistent with the proposition of the main effect model in which social support generally has a positive effect on the physical and mental health of individuals this finding is also congruent with tdas assumption of horizontal pileup effect which indicates that the additional support assets from different contexts improve the adaptive outcome effective care help love and respect from family members teachers friends and significant others are extremely vital in lbc who are desperate for love at this time this assistance not only broadens their social space and makes them feel safe supported and competent but also protects them from life pressure in the pursuit of maintaining good mental health the number of bootstrap samples was 1500 in all the groups mediating effect of bpns on the relation between social support and psychological adjustment in lbc in line with our hypothesis 2 bpns fully mediated the effect of social support on lbcs psychological adjustment in other word the positive effect of social support on psychological adjustment was completely realized through bpns this finding can be explained from the viewpoint of sdt deci and ryan proposed that bpns are of universal importance in the psychological adjustment of adolescents and the degree of satisfaction in these needs depends on the adequacy of support assets in their living environment specifically if the support provided by a certain environment cannot meet an individuals basic needs they will look for it in another environment if the other environments cannot provide sufficient support either they will fall into a dilemma of maladjustment as far as lbc are concerned the support they receive from grandparents and migrating parents in family life is extremely limited and the effective help from friends and teachers in school life is also inadequate moreover in their social life the substantial assistance from volunteers such as social workers is often unsustainable therefore the lack of support assets makes it difficult to satisfy their bpns and hinders their psychological adjustment moderating effect of resilience on the relation between social support to lbcs bnps and psychological adjustment in line with our hypothesis 3 the results showed that the interaction of social support and resilience had a negative effect on bpns with the increasing level of resilience the power of social support to predict bpns weakens which changes from offering fuel in the snowy weather to icing on the cake thus leading to the reduction in the mediating ability of bpns this finding supported the exclusion hypothesis of ppm the findings further indicated that resilience reduced the mediation between social support bpns and psychological adjustment in other words social support influence on psychological adjustment was less likely to occur through bpns among lbc who had a higher level of resilience implying resilience may have a stronger impact on psychological adjustment compared to the mediation pathway to roughly examine our inference we added the path resilience → psychological adjustment to conduct the aforementioned consistency tests in the invariant mediation model among the lowmediumhighresilience groups of lbc results showed that with the increasing level of resilience the mediating ability of bpns reduced and the direct effect of resilience on psychological adjustment increased which is consistent with our inference therefore high level of resilience directly enables lbc to have a high level of adjustment without relying solely on bpns to play a mediating role the analysis in nlbc demonstrated that resilience had a simultaneously significant moderating effect on the association of social support with bpns and psychological adjustment with the increasing level of resilience the mediating ability of bpns reduced and social support no longer had an effect on psychological adjustment in the highresilience group the declining trend of this mediating effect in nlbc was nearly consistent with that in lbc but the decline rate of the former was clearly greater than the latter these patterns indicate that the moderating model of resilience is applicable to both groups but the moderating ability in nlbc is generally better than that in lbc these conclusions support the tdas viewpoint wherein the effects of development assets on adaptive outcomes vary with the context of adolescents masten emphasized that if children were exposed to adversity in their early development especially in the critical period when individual differences in personality and selfregulation were formed their vulnerability to stress would increase and thus form malignant response patterns to stress and poor selfregulation skills as far as lbc are concerned they have been living with the dilemma of insufficient support resources for a long time consequently many of lbc will become sensitive and selfabased excessively caring about how others judge them with their extreme lack of selfconfidence these personality traits might increase their vulnerability to leftbehind dilemmas and hinder the development of resilience by contrast nlbc possessed a better growth environment more adequate support assets and more developed resilience therefore the moderating effect in nlbc is more evident than that in lbc moreover it is worth noting that unlike lbc no increasing trend of effect of resilience on adjustment was found when conducting the abovementioned consistency tests for nlbc this suggests that compared with nlbc although the leftbehind dilemma weaken the moderating function of lbcs resilience it may make lbc grow from another perspective that is make their resilience play a more direct role furthermore crossgroup comparisons showed that the impact of social support on bpns was significantly greater in lbc than that in nlbc the reason is that lbc have fewer available support assets and more life stress to cope with so they will likely place more importance on their existing support than nlbc consequently changes in support resources will produce improved satisfaction when support increases but demonstrate greater loss when support decreases in addition the smaller influence of resilience on bpns in lbc than that in nlbc can be elucidated by the different functions of resilience in the two groups as mentioned above compared with nlbc the effect of psychological resilience in lbc is more reflected in directly improving their psychological adjustment rather than only affecting the paths related to bpns significance implications and limitations this study explored the influence mechanism of social support on psychological adjustment in lbc and nlbc and tested the viewpoint of the assets model of human positive development compared with previous studies that only demonstrated the mediating effect of resilience the current study found that resilience can alleviate the impact of adverse situations on lbc which is of more practical significance on the basis of the results we now provide a form of intervention on the psychological adjustment of lbc first a sound social support system should be cultivated for lbc specifically we should provide targeted guidance and training in the parentchild communication skills for migrating parents and make efforts to create a fair and harmonious atmosphere in the campus and community for example a community family activity room in sichuan province of china enhanced lbcs sense of social support by mobilizing the internal strength of rural communities and giving lbc a place to learn entertain and exercise meanwhile we should coordinate and guide all kinds of social care activities that lbc accept willingly second we should focus on improving the psychological resilience level of lbc scales and leffert proposed several measures such as increasing childrens participation in social activities that promote social and psychological development enhancing their selfefficacy experience and implementing adult supervision responsibilities to build supportive adult networks that promote the resilience development of children the abovementioned views can be used and combined with the specific plight of lbc to carry out resilience intervention which could not only enhance their immunity against life pressure but also alleviate the adverse impact of poor support assets on psychological adjustment in line with abovementioned assumptive measure guan and deng provided us a good example by implementing a communitybased childrens companion mother program which benefit lbc in many aspects including their resilience the major limitations of this study were as follows first the data in this study were collected via selfreport questionnaires making it difficult to eliminate the influence of social desirability in addition tian summarized the chinese version of rosenbergs selfesteem scales shortcoming that related to cultural difference such as item 8 had a different meaning from that of western version which lead to the relatively low reliability in selfesteem measure both in the current study and other chinese studies subsequent research could be improved by combining selfreport questionnaires with otherreport methods and adopting more indigenized scales with higher reliability second this investigation used a crosssectional design which could only demonstrate the correlation pattern between variables statistically followup longitudinal studies are needed to verify these findings at the causal level third snowball sampling conducted in the current study is a nonprobability sampling and the data were collected from hunan province rather than the whole country of china which may lead to the possible selection bias and limited generalizability of studys conclusion future studies could randomly sample over a larger sampling range fourth some additional variables related to the leftbehind phenomenon were not considered studies have shown that the age at which children are separated from their parents state of communication with migrating parents and duration of separation from parents may have a main or interacting effect on their psychological adjustment the internal validity of a followup study will be improved if the above factors can be controlled conclusion first compared with nlbc lbc exhibited lower level of social support bnps resilience and psychological adjustment second the higher the level of social support the higher the lbcs psychological adjustment third social support affected lbcs psychological adjustment completely through bpns fourth with the increasing level of resilience the indirect effect of social support on lbcs psychological adjustment was gradually weakened university written informed consent to participate in this study was provided by the participants legal guardiannext of kin 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 research ethical committee of hunan normal 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

there are tens of millions of children left behind by one or both ruraltourban migrant parents leftbehind children lbc in rural china compared to nonleftbehind children nlbc lbc are disadvantaged in psychological adjustment research has shown social support can help lbc grow up healthily but the plausible mechanisms linking support to adjustment remain unclear the present study investigated the mediating role of basic psychological need satisfaction bpns in the above relationship as well as whether the predictive pathways of support on adjustment and bpns were moderated by resilience in a sample of 692 lbc and 264 nlbc structural equation modeling indicated social support positively predicted lbcs psychological adjustment which was completely mediated by bpns in addition the mediating effect was weaker for lbc with higher levels of resilience which indicated resilience was a necessary asset for lbcs growth amid the adversity of low social support

voronova 1 the troubled histories of nations are built from the bones of a million damaged children but what about the nations and children who are stuck in the periphery between troubled and happy between damaged and healthy these are the settings that anthropology can thrive in nations that have both suffered and benefited from colonialism oppressed groups discriminating against others and other ambiguous cultural dynamics in this paper i want to focus on finland as a specific nation that serves as a good example of how collective trauma and ambiguous histories can be contested these contestations are most commonly expressed through minute inequalities between the two main cultural groups in finland finnish and swedishspeaking finns modern inequalities between different cultural and linguistic groups in and around finland are expressed through stereotypes and expressions of identity these stereotypes and identities are often mixed with ambivalent feelings especially in regard to finns relationship with sweden the state and people both historically and in the present these relationships are based on the hegemonic and nonhegemonic views that finnish speakers fennoswedes and swedes hold of each other hegemonically quiet admiration and casual disapproval are common hence the ambiguity nonhegemonically extreme emotions and fixations are commonly perceived as strange and distasteful everything must be just right or lagom in swedish in this paper i focus the discussion on finnish issues of cultural and linguistic identity while keeping their relationship with the swedish state and people in mind hence my goal is to answer these questions how has discrimination shaped finnish identities has it shaped finnishspeaking versus swedishspeaking finnish identities differently how does a collective memory of oppression affect finnish peoples perceptions of others however what i ultimately background context in order to answer the questions of discussion most effectively it is important to provide some context on the issue finland is a northern european nation located on the baltic sea it borders sweden in the west russia in the east norway in the north and estonia in the south currently there are two official languages in finland finnish and swedish both of which are associated with their own unique cultural identities rooted in history finnishspeaking finns comprise the majority of people within finland while swedishspeaking finns make up around 52 of the population the remaining 5 are comprised of other minority languages such as russian sami and romani historically swedishspeaking finns have been a privileged minority group while finnishspeaking finns comprised the disadvantaged majority this was due to finlands long history as a province ruled by the kingdom of sweden from around 1249 to 1809 ad before swedish rule various finnish and sami tribes populated finland the former of which were eventually consolidated into the swedish state this consolidation was done through three legendary crusades between the 12th and 14th centuries as well as colonialization which translated to waves of swedish settlement on the southern and western finnish coasts these are some of the ancestors of modern swedishspeaking finns some of whom became noblemen in control of finland while others remained peasants during swedish rule finland was socially and economically underdeveloped but that changed when russia annexed finland in 1809 and granted it autonomy finnish nationalism began to arise and be expressed through the fennoman and svecoman movements which identities on the periphery emphasized finnish and swedish cultural values respectively while the fennoman movement used historical revisionism to serve a victimhood narrative the svecoman movement was famous for utilizing the pseudoscience of biological racism to justify their values biological racism emphasized white supremacy and in the svecomans case the superiority of swedes and other germanic peoples over the mongoloid finns and sami in 1917 finland gained independence from russia survived a devastating civil war and was involved in three wars during wwii all of which have led to todays modern issues while swedish and finnish speakers were historically divided by class the sociolinguistic inequalities have greatly decreased in recent years however the remains of this class distinction can still be seen today through subtle inequalities such as stereotypes and regional healthrelated inequalities in addition there is a continuous debate over the roles of finnish and swedish in modern finnish society and culture the primary point of contention concerns the teaching of swedish in finnishspeaking schools a debate commonly referred to as pakkoruotsi finnish and swedishspeaking children are taught the other national language through mandatory classes lasting from grades six to nine mandatory swedish was introduced to finnish classes in the 1960s as part of a greater educational reform aimed at modernization there are two main schools of thought on the reasoning for swedish classes culturalhistorical preservation and geopolitics in terms of preservation finland has had a long and involved history with the swedish state and language finland was a swedish territory for around 600 years and swedish voronova speaking finns were at the foreground of creating finnish national identity some would even argue that sweden created the finnish state which is not wholly inaccurate in terms of geopolitics it is important to note that mandatory swedish was instituted in the 1960s during the cold war finland was a neutral country at the center of the iron curtain stuck between appeasing the united states and the soviet union when mandatory swedish language was implemented the finnish governments aim was to emphasize their countrys western connections through increased nordic cooperation while some argue that mandatory swedish has furthered nordic cooperation others assert that it has furthered antiswedish sentiments methods and data the sources used for this paper are divided into two categorizations primary and secondary sources in an academic context primary sources include any and all relevant firsthand accounts of personal experiences historical events and original thinking this type of source is particularly useful in historical and anthropological contexts the former for an accurate telling of the past the latter for ethnographic data as well as the individuallevel social science specialized in anthropology conversely secondary sources essentially interpret primary sources they are the professional retellings analyses interpretations and evaluations of primary sources which produce easily digestible syntheses of information both primary and secondary sources each serve their own function to answer the questions laid out in the introduction the primary sources used include reddit historical documents and primary news articles secondary sources include any and all materials that interpret analyze or synthesize primary data such as history books or anthropological analyses in regard to the usage of primary sources their primary goal in this paper is to showcase how discussions of finnish issues identities on the periphery histories and identities manifest among ordinary people in everyday life conversely the papers goal of using secondary sources is to gain professional peerreviewed and ready to access information and analyses on data that already exists nevertheless no matter the type of sources used in a paper it is vitally important to contextualize how they are used to control for divergent views and false data one of the most prevalent primary sources in need of proper data control is reddit a social news aggregator site that combines link distribution and discussion platforms many have claimed reddit to be a toxic community and an unreliable source however i object to these opinions for several reasons 1 reddit is one of the worlds mostused websites currently with around 430 million monthly users and 22 million subreddits thus to claim that reddit is toxic is a gross oversimplification of a large website 2 the claim of reddit toxicity is more an accurate statement attributed to socially oriented websites than reddit alone 3 in the last few years the moderators of reddit have begun to enforce stricter measures in order to curb toxicity this involved new guidelines policies and the permanent banning of certain toxic subreddits like rthedonald and rincels to name a few in terms of source reliability reddit has several advantages as well as disadvantages which i have outlined and summarized on table 1 page 28 4 finally i use reddit as a primary source due to its popularity among nordic people as well as its balance between anonymity social reinforcement and communal specificity which reflect facetoface communication since the goal of this paper is to showcase how ordinary people feel about modern finnish issues and identities it is important to distinguish which subreddits are appropriate to use in terms of subreddit selection i chose to stay clear of those known to harbour and promote farright extremism or radicalism these subreddits include but are not limited to rconspiracy voronova rconservative and rscandinavia most englishspeaking nordiccentered communities are now relatively stable in their politics and thus will be used as the basis for data subreddits chosen for the collection of data are rfinland rnordiccountries rnordichistorymemes reurope and raskeurope these subreddits were chosen based on the prevalence of regular everyday interaction between finns fennoswedes and swedes which showcase the effects of historic discrimination on finnish identities the time range for selected data was restricted to a maximum of the last five years to ensure the accuracy of modern viewpoints theoretical framework when deciding on a theory for the topic of discussion i narrowed down my options to three distinct theories social representations theory postcolonial theory and theories of macrolevel versus microlevel sources of conflict during the decision process i asked myself two key questions how is this theory applicable to the topic of finnish identity and how can it be used to explain the history and origins of finnish identity and discrimination i think of selecting a theory like picking out filtered lenses a filter can highlight important details or obscure them in favour of others using this analogy i tried on many filtered lenses which i have outlined below theory selection process the first filtered lens that i examined was that of postcolonial theory this theory highlighted issues of ethnic discrimination but obscured the identities of independent and privileged finns it is useful in a modern context where cultures have been systematically oppressed however this level of oppression does not reflect most finns today who enjoy the privilege of wealth and independence additionally the application of postcolonial theory in this identities on the periphery context obscures other equally important factors that contribute to inequality such as genetics and regional politics the lens offered by various theories of macrolevel and microlevel sources of conflict filtered out too much important information since while good at explaining conflict they did not explain how finnish identities have developed these filtered lenses focused in on intergroup violence however physical violence between finns fennoswedes and swedes have always been far and few between finally when i tried on the filtered lens of social representations theory they fit my topic perfectly social representations explain the processes that go into creating finnish identity the ways in which different identities interact with and form each other and how they can turn into negative generalizations which encourage discrimination thus i decided on the lens of social representations theory to examine my topic in 1961 a social psychologist by the name of serge moscovici championed the concept now known as social representations theory simply put it is defined as a culmination of various systems of values beliefs and shared experiences that enforce community and social order it exists as both a theory and a concept in which the systems of values and beliefs are created through collective memories and are continually reinforced through social representations and cultural activities connected to those memories these social representations have varying levels of acceptance in a given culture or community and can either be hegemonic or nonhegemonic nonhegemonic views can be further split into emancipated or polemic representations the former being partially accepted as an alternative view but not the norm and the latter being wholly unaccepted and not the norm while hegemonic and emancipated views are opposing representations they are both frequently practiced and voronova reinforced by dominant and accepted cultures while polemic views are often practiced by marginalized groups in academia social representations theory exists dually as a concept and theory resulting in its widespread acceptance and criticism within the social sciences sometimes referred to as a common sense theory social representations theory has been both praised and criticized for its relative lack of abstraction its proponents argue that this aspect makes the theory universal and widely applicable while critics of the theory argue that its common sense is too simplistic to be used as a social theory and can be more accurately described as a concept or set of guidelines rather than an abstract framework in addition some critics emphasize that what is now considered common sense has not always been this way the ways in which we think of and interact with the world are constantly in flux but i would argue that this only serves as further proof of the universality of social representations theory cultures thoughts and ways of knowing are constantly being reinforced through the memories and cultural activities that we as groups and individuals choose to reinforce how that looks in modern western culture will be drastically different from how it was in for example ancient china there are several components deemed essential to forming social representations one of these is cultural memory which as defined by jan assmann is one of the three main components of levelled memory that aid in creating social representations maintaining social order and predicting our thoughts and actions these three components of memory are individual communicative and cultural memory which are themselves split by assmanns divisions of inner social and cultural levels of time memory and identity that form our individual and collective thoughts actions and ways of life for example inner identities on the periphery memory works with our inner private identities and personal sense of time to form how we think and act as individuals conversely communicative memory works with combining the social self as a person responsible for creating following and enforcing social norms with social experiences of time here we focus on cultural memory which works by combining memory with cultural identity present in ones identified group nationality or ethnicity as well as the historical cultural or mythical sense of time a key factor in understanding social representation is knowing how it builds culture this process is called sociogenesis and it works as a repeating cycle which is outlined in figure 2 the cycle of sociogenesis begins when a new event or phenomenon is introduced to a group which is often deemed threatening or traumatic as a means of coping with the event the culture in question will engage in mass collective discourse wherein the event is anchored or given a name and is interpreted and expressed through preexisting cultural symbols and materials the event could be rationalized or mythologized by the culture which could be expressed with preexisting symbolic culture in various representations such as objects art or metaphors eventually this discourse becomes enculturated and a matter of common sense for the culture which finally fits perfectly into the giant jigsaw puzzle that is a cultures social identity with these new pieces the cultural jigsaw puzzle works together to create more culture thus a new social representation is born and the cycle begins anew this jigsaw of social representations is crucial to the state which is at the forefront of this papers research according to michel bouchard the anthropological concept of the state relies heavily on benedict andersons book imagined communities in it anderson states that the states concept is socially constructed and reinforced in all levels of society specifically voronova by the people who identify themselves as belonging to that nationstate however we must distinguish between state and nation a state is simply a sovereign territory with its own laws regulations and borders a nation is a community of people who live within the borders of a territory and are connected by history language culture or any other commonality suffice to say a state is a sovereign and bordered land a nation is a community of likeminded people living in proximity and a nationstate is a sovereign and bordered land in which likeminded people live thus it can be argued that any state in which social representations are reinforced can also be a nation and subsequently a nationstate however how can a state securely exist if its existence is not continuously reinforced i could argue that a state can indeed be a nationstate and even the most internally disconnected states are communally bound whether that be from shared experiences dissatisfactions or sense of duty in fact i would argue that for any state to securely exist they must have populations that share a collective history language or culture that builds solidarity and connection in other words a state can only survive if it becomes a nationstate in my papers case finland has an emotionally strong but in practice insecure feeling of nationhood this is due to its prolonged history of being controlled by other nations and its supposed centuriesold national identity in this upcoming section we will dissect this idea history of finland when finland was first given a name it was the newly colonized province of the swedish kingdom dated to around 1249 ad before that finland was not a consolidated society but rather a collection of various iron age protofinnish and sami tribes as a note when discussing the modern territory of the swedish state during swedish rule over finland i will refer to sweden as the mainland and the swedish kingdom as identities on the periphery the full territory which included modernday finland this is because finland while an integral part of the swedish kingdom was culturally and politically distinct from the rest of the kingdom despite their own identification as swedes finns had legal rights equal to swedes and identified themselves through a combination of their swedish nationality and regional place of residence likely a remnant of iron age tribal divisions however one must remember that equality in law does not translate to equality in practice finland was often underdeveloped compared to sweden as a result of many factors like geography culture and climate finland has also always been situated in a geographically compromised position sandwiched between sweden and russia this meant that finns often bore the brunt of russian attacks and occupations which was a large factor in the development of finnish identities finns and swedes were frequently conscripted into swedish wars which took its toll over centuries this issue reached its peak during the great northern war when the russian empire occupied finland and issued a scorched earth policy involving the systemic torture murder and rape of local people in addition finland was struck by widespread famine an outbreak of the bubonic plague and received no fundamental support from the swedish government adding to mass devastation this occupation lasted from around 1714 1721 and was consequently dubbed the isoviha contemporary scholars argue that russias scorched earth policy in finland was so destructive that it kickstarted collective finnish identity as a defensive response to the trauma and feelings of betrayal stemming from swedens lack of support essentially the isoviha gave rise in finland to the question of how if at all sweden could protect finland from the growing russian empire voronova as the russian empire grew the sociopolitical situation within the swedish kingdom worsened finns were becoming more aware of their unique finnish identity and russia began utilizing propaganda and psychological warfare as a means of separating finland from the swedish kingdom such propaganda included claims that the swedish king was planning to trade finland for norway and that sweden and its king have never had finlands interests in mind these tactics eventually worked as finland was easily annexed by the russian empire in 1809 ad signifying the birth of the finnish state finland received extensive autonomy under the title of a grand duchy which allowed finland to retain its swedish laws and language as a means of coping with separation both sweden and russiagoverned finland launched their own historical revisionism campaigns essentially erasing one another from history swedish historical revisionism practically erased finland from history while finnish revisionism heavily exaggerated narratives of swedish oppression going so far as to blame sweden for finnish suffering and hailing russia as a saviour from swedish tyranny the latter views were intricately related to the rising fennoman and svecoman movements in finland both of which acted as direct responses to russian rule and emerging finnish identities when finland was first incorporated into sweden it was continually settled by swedish farmers fishermen and nobility these continuous waves of settlement to finland throughout swedish rule consequently resulted in the swedishspeaking finns or fennoswedes one of the most influential cultural groups within finland this group distinct today by their linguistic and cultural proximity to sweden was responsible for much of finlands upperclass culture and society this was due to factors such as inherited wealth swedish connections and social factors of language and culture that benefited them in finland hence it is a safe bet identities on the periphery to say that any powerful or influential finn born between the 12th and 19th century was most likely a fennoswede this influential group was also central to the development of finnish identity by way of the fennoman and svecoman movements initiated by elias lönnrot and johan vilhelm snellman the fennoman movement was a reactionary response of finnish nationalism in opposition to russian rule the movement can be summarized by a quote credited to adolf ivar arwidsson one of the initiators of finnish nationalism swedes we are no longer russians we do not want to become therefore let us be finns eventually the fennoman movement turned into a question of language and more specifically the role of the finnish language in finnish identities the swedishspeaking intelligentsia switched their everyday languages to finnish and many even changed their names to reflect a finnish background this caused a reactionary response amongst other swedishspeaking finns who in turn emphasized the swedish language and culture this led to the finnish language strife a drawnout culture war over the control of finland the svecoman movement in particular was influenced by the rising pseudoscientific field of biological racism invented by carl linnaeus he initially classified people into four categories but later split them further into subcategories such as swedes finns and sami swedes were classified as the most racially superior of the three with finns being inferior to swedes but superior to the sami finland eventually declared independence from russia following the russian revolution in 1917 the official and final birth of the finnish state still affected by the conflicts of the language strife finlands contested identity was challenged in a devastating civil war that claimed over 25000 lives in 191825000 lives in following the civil war finland faced two soviet invasions in 1939 and 19401944 ad followed by an invasion by nazi germany in 19441945ad finland managed to retain its independence throughout wwii but it came at the price of war reparations and trauma all of which took a heavy toll on finlands people economy and foreign relations over time finlands people and economy recovered and the country now enjoys its rich and privileged status as a modern and highly developed nordic country however modern countries have modern problems which is where our discussion of history ends and the one of modern issues begin voronova contemporary issues in finland if one were to ask random swedes and finns of both languages what they thought about one another the results would be highly varied swedish views can range from positive finlands cause is ours to neutral i dont think about finland to negative finns have no culture conversely finnish views about swedes have the same range of positive sweden created finland sweden is our big brother to neutral swedes are people to negative swedes are pretentious colonizers this is a direct reflection of finlands longstanding history as a land with an ambiguous history and ambivalent relationship with sweden on average these dynamics are often referred to among contemporary swedes and finns as that of a big brother little brother relationship this analogy is meant to represent how finns and swedes view one another as siblings there is frequent fighting banter comparisons but at the end of the day there is a deep familial love and connection that keeps these groups close however being familiar with finnish social history i can say that much of this big brother little brother dynamic is a great oversimplification of a far more complex dynamic alas most people are not aware of their countries histories so these contemporary groups have social dynamics that most often emerge in the form of jokes and various generalizations there is a great variety of jokes and stereotypes identities on the periphery to choose from all with varying levels of offensiveness these can range anywhere from innocent pop culture references and banter such as finns sound like moomintrolls and swedes are fashionable to offensive generalizations like finns are alcoholics with no culture and sweden is a kingdom stuck in the past with a short eye for the future generalizations of the latter are less common than those of the former however these examples represent only two sides of a complex issue generalizations between swedish and finnishspeaking finns also exist however contemporary discourse amongst ordinary people is often tamer than those between finns and swedes stereotypes of fennoswedes can range from being seen as happy and sophisticated to rich snobs who demand swedish service to colonialist svecomans who control the finnish state conversely fennoswedes stereotypes of finnish speakers can range anywhere from being seen as quiet and melancholy to knifewielding loners living in the forest to violent alcoholics who hate everything associated with swedes these generalizations are also congruent with the issue of mandatory swedish or pakkoruotsi there are countless arguments both for and against mandatory swedish language many proswedish arguments revolve around cultural and geopolitical preservation of national heritage while antiswedish arguments typically center in on the practical usage of swedish in everyday adult life more divergent arguments from each side use the ambiguous nature of finnish history and its complex relationship with the swedish state to their advantage in this case proswedish views emphasize the need for gratitude from finns as well as cultural and historical connections between finland and sweden conversely many divergent antiswedish views emphasize the voronova narrative of fennoswedish and swedish control over finland claiming that these groups maintain colonial control arguments against mandatory swedish language include that it takes up class time that could be used for other classes or languages that it is a useless language and that there is little to no motivation amongst finnishspeaking teenagers to learn swedish conversely many proswedish arguments emphasize swedish connections cultural and linguistic preservation job opportunities and the argument that the more languages a child learns the better off they will be while few can agree to a consensus decision there has been increasing thought on using english between the two groups as a sort of lingua franca as a common and bridging language however this is deemed by some fennoswedes as yet another threat to their language as is illustrated in image in figure 3 these contentions over the swedish language are a major source of linguistic tension between these two linguistic groups swedishspeaking finns argue that their language and culture are being oppressed while finnishspeaking finns retort that their own historically oppressed group is bearing the brunt of modern discrimination some swedishspeaking finns feel like they are foreigners in their own home while others say that they are just finns who happen to speak swedish there have been records of occasional public conflict between the two groups that have mostly revolved around language use one such incident involved two people ordering tickets to turku in swedish when the bus driver did not answer the customers asked for two tickets again which was met with this response shall we agree that in finland we speak finnish translation by google charlotta one of the customers said what irritates me the most is the attitude but also the idea that it would not have been as easy for the children to handle a identities on the periphery similar situation… in addition it was clear that this was not the first time that the bus driver in question drove with the same attitude the reluctance to even try to serve in swedish feels strange translation by google discussion if one examines finnish identities from the outside looking in patterns of ethnic discrimination are difficult to see finns fennoswedes and swedes tend to be similar in appearance values culture and patterns of behaviour yet when one examines these cultures with a filtered lens one can easily point out the small remnants of ethnic discrimination in a way these remnants are like pebbles in a shoe when you walk sometimes a pebble will roll under your foot and make you wince but then that pebble will roll away and you will forget it ever existed until another one rolls in ethnic discrimination between finns fennoswedes and swedes is small but it can have big if momentary impact take generalizations and stereotypes as an example while they are generally frowned upon generalizations in our case studys dynamic lie on a spectrum of acceptability between the messenger and receiver wherein generalizations are selectively picked to generate identity for example a common joke from finns about swedes is that swedes are gay this can either be accepted by the swedish recipient thats our thing… finns are sad alcoholics… and we are amazing at being gay or rejected grow up… dont use homophobic jokes conversely a common joke from swedes about finns most often used online is that finland is eastern sweden as with the previous joke this one can either be accepted how are you going to do that with the majority of your army on the opposing side though or rejected most finns find that offensive if one considers the histories and cultural memories of the two countries a clear image of deeply established views appears from a finnish perspective finns have more often emphasized masculinity and grit in their culture which combines with the cultural memories of war swedish abandonment and finlands long history as a periphery to produce jokes and generalizations that associate swedish men with various homophobic stereotypes conversely swedish perspectives have typically associated their nation with imperial might progressive thinking and modernity all while associating finns with poverty violence lower classes and alcoholism this set of generalizations about the self and others creates a recipe for feelings of superiority and control of countries no longer under swedish control and are the results of centuries of social representations reinforced via sociogenesis if jokes about finland as eastern sweden are not common jokes about finnish alcoholism are these are the negative generalizations that are both surprisingly accepted and rejected within swedish circles a reflection of swedes contradictory views of self of others and of finns in regard to this swedish view of finns conflicting characterizations of finnish people have been commonplace since at least the 18th century at that time finns were often labelled as savage violent and prone to alcoholism however finns were also labelled as loyal mysterious and brave warriors whose sacrifices during wartime were highly honoured in the 19th century following the loss of finland to russia and the erasure of finland from swedish history finns were placed into an even more romanticized space where they were savage inferior mongoloid and violent but also wise philosophical brave and loyal this ambivalent characterization is best described as a noble savage archetype wherein a dominant group exotifies a marginalized culture as primitive undesirable but admirable and exemplary at the same time essentially the archetype of the noble savage between familiar identities on the periphery groups can be described as love at a distance a description readily applicable to swedish views of finnish identities all of these views form a social dynamic of distant love reinforced over centuries of sociogenesis the aforementioned significant year of 1809 when russia annexed finland from sweden proved to be a momentous change for both countries to cope with the new event finnish and swedish cultural groups anchored it in their own familiar terms by giving the event a name and expressing it in familiar terms such as poetry biological racism and propaganda eventually these were objectified and internalized in the cultures identities through metaphors artistic expressions and collective memories which created new social representations that are used to create and reinforce newer ones today thus the issues of linguistic debate generalizations and history feed off of each other in a vicious cycle of falling dominoes as we inch closer to the truth newer questions appear which issues came first and which ones were the first dominoes that knocked over all the others conclusion twenty pages are not enough to fully explore such a complex and fascinating topic but this does not mean that this paper is fruitless any number of pages that can reveal the truth about how identities social representations came to be is a worthy pursuit thus as we conclude this paper i can attest that ethnic discrimination has affected finnish and fennoswedish identities however i did not expect to find that a cultures historical usage of ethnic discrimination could turn around on itself as it did with swedish cultures expressions of finnish generalizations in addition i found that differences in identity between finnish and swedishspeaking finns were most prominent in the past however even though cultural and ethnic differences between the two groups have decreased they have not been wholly erased whether that is for bad or good is something that finns and fennoswedes must decide the cultural histories and memories of ethnic discrimination have shaped finnish and fennoswedish identities in different directions however with the rise of globalization and various issues more pressing than that of language finnish and fennoswedish identities and cultures have begun to shape back incongruent directions to answer my fundamental question on the existence of finnish ethnic discrimination i can say that yes there is discrimination but not to the claimed extent finns did indeed suffer from discrimination based on ethnic markers however the extent to which some claim a victimizing narrative is simply a reflection of finnish historical revisionism funded by the 19thcentury russian state now someone reading this may be asking the question of why studying this is important after all finnish discrimination was not as widespread as some make it out to be but that is just the point this paper is important because we need studies that examine the ways in which discrimination historical revisionism and cultural memory play in changing and forming identities if we as scholars can identify how reactionary identities are formed we can use papers like this to help minimize the spread of misinformation these complex and ambiguous cultural dynamics are where anthropology thrives anthropology allows us as scholars to contribute to modern complex issues by analyzing them with a culturally holistic view one that permeates nearly every facet of human life one can even say that anthropology is the glue that holds the social sciences and humanities together it should be up to us as anthropologists historians and other researchers to uncover how our pasts affect our present selves so that we may improve helping ourselves and others in the process tables and figures voronova

identities on the periphery want to answer is what is the source of finlands ambiguous historical identity were finns victims of ethnic discrimination or is this a narrative produced by historical revisionism to answer these questions the paper is divided into several sections that will explore the roles of discrimination and cultural memory on finnish identities the sections consist of background context methods and data theory historical issues modern issues discussion and a conclusion in the methods and data section i outline the methods used to collect and use the sources presented as evidence in the paper these include primary and secondary news reddit historical documents academic papers and analyses of primary material the theory forms the lens through which to examine the topic of discussion which is why i employ social representations theory this framework is based on the idea of collective memories reinforced by cultural representations which was championed by sergei moscovici in 1961 these representations can be either hegemonic meaning mainstream and accepted or nonhegemonic meaning unconventional and unaccepted sakki and hakoköngäs 2020 after outlining my theoretical framework i give an overview of finnish historical issues which act as evidential sources for the ambiguous finnish identities and relationships seen today modern issues are expressed through stereotypes and debates over language in everyday spaces many issues of the modern world are direct responses to ones from the past and examining them together through a theoretical lens is the central issue in the discussion conclusively i argue that both finnish and swedishspeaking finns have been negatively affected by discrimination reinforced over centuries and these effects are especially prevalent in finnishspeaking finns collective memories of oppression have substantially influenced finnish identities which results in the fear and lack of trust of foreigners these are important questions to answer not only for anthropology but all social sciences regardless of the case study anthropology is the glue that voronova 3 holds the social sciences together and it is our responsibility to uncover the sources of discrimination so that we may know how to prevent it

money as a factor in respect for people planning expenses money as a means of achieving freedom and power as well as sociopsychological attitudes in the field of motivations and needs conclusions the obtained results can be used in designing training and motivational programs for women in the system of staterun commercial and public organizations key words personal styles womens behavior attitude to money monetary attitudes sociopsychological attitudes transactional analysis 1 « » « » « » « » « » « » « » 99 організаційна психологія економічна психологія № 4 2023 « » « » « » « » « » « » « » « » « » « » « » « » « » « « » « » 100 організаційна психологія економічна психологія № 4 2023 « » « » « » « » « » « » « » « » « » r0 « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » 104 організаційна психологія економічна психологія № 4 2023 « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » 105 організаційна психологія економічна психологія № 4 2023 « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « »

aim to analyze the relationship between womens personal behavioral styles and the types of money beliefs and behavior money attitudes and sociopsychological attitudes in the field of motivations and needsresults there are positive and negative statistically significant relationships between personal styles parentcontroller parenteducator functional adult adaptive child natural child and types of money beliefs and behavior money obsession power economy inappropriate behavior with money monetary attitudes money as a good money as an evil money as a means of achieving success

introduction in 2008 an estimated 334 million people in the world were living with hivaids and 27 million people were newly infected 1 ninetyfour percent of cases were working age adults who will become sick and die within 10 years with no access to treatment and care unfortunately roughly 80 live in low and middleincome countries where access to the treatment and care remains limited and they remain unaware of their hiv infection status 2 this has led to major crises with consequences for human social and economic progress unless access to treatment and care particularly arv is addressed for hiv infected individuals to receive necessary treatment and care they need to know their hiv infection status through hiv testing hiv testing provided on a voluntary basis should be accompanied by preand posttest counseling this has major public health benefits by not only linking infected individuals to treatment and care but also in reducing further hiv transmission 3 quality vct has been demonstrated to reduce hiv risk behaviors 4 unaids and who have supported expanding vct to cover as many individuals as possible by encouraging countries to established national policies 3 andissued their hiv testing policy statement in june 2004 5 and guidance on providerinitiated vct in health facilities in 2007 6 promoting universal access at the xvii international aids conference in mexico city cannot be attained without encouraging people to seek vct however expanding vct had been a challenge in lowandmiddle income countries this manuscript describes the implementation of community mobilization to promote vct services using mobile voluntary counseling and testing units in the intervention communities of nimh project accept thailand site and presents the results there were some challenges to our approach and we tested modifications to increase our success a detailed description of the nimh project accept intervention can be found in the project accept protocol and manuals at 7 and in khumalosakutukwa et al 8 in brief nimh project accept is the first international multisite study of a phase iii communitylevel randomized controlled trial conducted in 34 communities at 5 sites in 4 countries to determine the efficacy of a multilevel hiv prevention intervention where community hiv incidence and stigma reduction are the study end points communities were paired within site and randomized to be either control or intervention communities the control communities received standard vct which for thailand site was clinicbased vct provided at district hospitals the intervention communities received the project intervention in addition to standard vct the project intervention has three components1 cmmobilizing the community stimulating interest and participation education stigma reduction and enhancing vct uptake 2 mvctincreasing access to vct by offering free and same day hiv test results directly in the community hopefully increasing testing rates and changing hiv testing norms and 3 posttest support services to build support and improve the quality of life for hiv positive individuals reduce social harms create a support system as well as assist hiv negative individuals to remain negative standard principles were followed in conducting the intervention according to the research protocol by all sites an intervention working group was established with representatives from the intervention core of each site to address sitespecific issues and development of intervention standard operating procedures however modifications were made to the intervention according to site situations and cultures the overall utilization out come of the project accept trial in three countries presented by sweat et al 9 shows that cbvct captured more first time hiv test cases significantly and four time higher to detect hiv cases than svct across site project accept thailand was conducted in partnership with johns hopkins university research institute for health sciences chiang mai university and chiang mai public health office thai ministry of public health the intervention was launched in january 2006 the operation and data described here are from field notes on conducting the intervention in the intervention communities which was completed up to march 2009 a total of 39 months experience in the field during which the site made local modifications to fit with thai culture and the local context in this paper we present our project cm and mvct operations overtime and the uptakes in the seven intervention communities as well as the clients characteristics and comparing between thai lowland and ethnic minorities methods study setting and community selection fourteen communities in six districts of northern chiang mai province were selected to be the research communities the region is mountainous rural and home to lowland thais and ethnic minorities including lahu karen hmong lisu yao and burmese immigrant groups who vary in geographic area of origin and language two communities were selected from each district except fang where four were selected paired within each district for randomization to intervention or control for a total of seven pairs at the thailand site each community wascomprised of 823 villages from 1 to 2 subdistricts using baseline data the estimated community size ranged from 5000 to 9200 ethnic minorities made up 40 of residents in the 14 communities 10 these 14 communities are similar in term of communities resident way of life where most of them are famers or being hired for daily working in agriculture farms each district has a district hospital to provide health care for the district residents and others the hospitals provide clinicbased vct and have opts out vct policy for pregnant women very few if any of an organization other than our project provided mobile vct in these communities community preparedness and involvement community preparedness and involvement is a main component of nimh project accept the protocol required sites to undertake a rigorous program of community preparedness and involvement and required establishment of community working groups which included community leaders and stakeholders the thai site introduced the project to the communities by first meeting with community stakeholders including the district governors district hospital directors and vct unit nurses district public health chiefs and key personnel and subdistrict leaders in these meetings we introduced the project concepts and procedures and asked for their opinions and support the purpose of these meetings was to gain entry to the communities with acceptance from the top down after this meeting the cwg in each community was formed comprised of village leaders village health volunteers persons infected with hivaids housewife leaders and youth leaders meetings with cwgs were conducted several weeks before each research activity was conducted in the community the meetings were mostly led by the local pi and accompanied by at least one representative from the cmpho the primary aim was to inform the cwgs about the activities that were going to occur and to ask for their suggestions on conducting project activities and to seek their assistance the intervention protocol required establishing communitybased outreach volunteers in the intervention communities cbovs were community members who had the potential to volunteer to work with the project staff to disseminate project information conduct outreach to community members for hivaids information and encourage local participation cbovs were trained using a standardized project curriculum religious figures are influential local leaders and earn much respect from community members they were invited to join the project in each research community the team worked with respected monks who were actively working with hiv aids issues in the province to organize hivaids education for local monks in turn these monks assisted the study similar to cbovs once understanding the project and local hiv aids issues these religious figures could clearly explain the goal of the project to community members and effectively respond to their questions staff composition with an estimated 40 ethnic minorities residing in the project communities we recruited cm staff who did outreach for community mobilization and hivaids education who could speak lowland thai and at least one ethnic minority language seven ethnic minorities of 11 cm staff were successfully recruited and later more were added qualified nurses were recruited and trained to be hiv vct counselors and phlebotomists using a scripted risk reduction counseling curriculum 1015 in number over the intervention period nurses from the 6 district hospitals were also trained as counselors to provide standard vct for the project these nurses joined the mvct team occasionally almost all cm staff was trained to be vct counselors after the first round when we realized the need and importance of counseling in the ethnic minorities languages for those who had limited thai language capacity ptss personnel were comprised of core and local staff as well as staff from the community health centers who were ministry of public health employees working parttime for the project in the evenings and weekends conducting the intervention pathai launched the intervention in the seven intervention communities beginning in january 2006 cm and mvct were conducted by round this intervention round defined as the conduct of cm and mvct activities sequentially in all seven communities before starting the next round each round took about 36 months to complete and by march 2009 we had completed the intervention in the seven intervention communities for a total of seven rounds weekly meetings to discuss outcomes difficulties and strategies were held with the project director and senior staff with more lengthy meetings following each completed round to address major changes for the next round of intervention monthly pi and senior staff meetings were held to discuss issues raised and to problemsolve as needed to adapt the intervention for the first three rounds of intervention pathai followed the conventional strategies of delivering services to the communities the cm teams entered the scheduled villages first followed by mvct teams 35 days later to deliver vct in order to gradually introduce the project hivaids education and mobile vct to community members the cm strategies used were going doortodoor and holding small group meetings with village members during the day to educate community members about hiv and to alert them to the upcoming availability of mvct testing during the scheduled time period in their community problems encountered included too few people being at home during the day many of whom had difficulty understanding thai cm staff tried joining community leader organized meetings that were already planned for the purpose of discussing village issues during these meetings important community members were in attendance since these meetings had their own lengthy agendas hiv education and mobilization activities occurred only at the end of very long meetings with members demonstrating fatigue and lack of interest meeting attendees also did not seem motivated to disseminate information to their community daytime cm organized meetings remained the cm strategy as a result occasionally incentivized by small gifts for participation adjustments were made to include setting cm activities according to the dates and times suggested by community leaders providing mvct services during evening hours and splitting staff into smaller teams in order to stay at each service venue for a longer period of time however the overall number of people who utilized the mvct service showed a decreasing trend in rounds 2 and 3 in the middle of the third round of the intervention in november 2006 a special cwg meeting with the chai prakan intervention community leaders was organized the community was selected because they experienced the greatest decrease in mvct utilization at the meeting there was agreement that the community and pathai project would cohost a large community event called pathai concert for world aids day on the evening of november 25 2006 the activities included entertainment shows by well known local singers and artists traditional shows by community youth a pathai hiv knowledge booth donations for the community aids fund world aids day awareness activities and the sale of lottery tickets for prizes the event was a major success in raising hivaids awareness as well as increasing peoples recognition of the pathai project thousands of villagers joined the activities that night and many asked for hiv vct lessons learned from the pathai concert world aids day is that offering vct at events can attract large numbers of people to participate the pathai team decided to adopt similar approaches for cm and vct strategies for the upcoming fourth round starting in february 2007 but on a reduced scale providing events and services during evening hours using a strategy referred to as edutainment all mvct and cm staff was combined into one team to work together at the same venue for edutainment activities the edutainment events were divided into several tents with activities including vct hiv education sessions blood pressure checkup karaoke movie projection sport games and prize givealways for active participants villagers could choose to join activities voluntarily in no particular order there are three main cm activities which included hiv aids related games in order to raise hiv transmission awareness interactive group hiv aids education include vct and interactive group education about hiv prevention and condom use to encourage participation in the three cm activities a card was given to individual participants and a check mark was added when she participated in each activity participants who attended all three cm activities were eligible for lottery ticket drawing prizes included a small carton of pasteurized milk cooking oil soap detergent a bag of snacks etc typically the facilities were set up and ready by 5 pm and activities were finished around 1011 pm loudspeaker announcement vans and doortodoor strategies just before the event were still used as needed after three rounds of edutainment in round seven the team attempted to enroll community members who have not yet opted to receive services and a semi optout strategy was adapted in addition to edutainment village health volunteers and cbovs joined forces for the optout strategy these people went from house to house to collect lists of people interested in getting vct and to give them an appointment date and time to schedule vct services on the scheduled date volunteers reminded villagers again about the services the volunteers were given a tshirt or a jacket for their participation in the program according to the success of their recruitment the voluntary nature of vct was enforced during pretest counseling community public venues including schools churches temples and community centers were used as venues to set up mvct units and the edutainment events mvct process after setting up vct at a selected venue cards with unique numbers were given to individuals who desired vct each individual client was assigned to a counselor for pretest counseling after consent for vct and pretest counseling were completed the counselor led the client for a finger prick for rapid hiv testing two hiv rapid test kits were used in parallel bioline hiv12 and determine hiv12 when both test kits gave the same result the hiv infection status of the client was judged according to the results if the results were discordant a third kit or clearview hiv12 statpak was used as a confirmation clients were asked to keep hisher card while waiting for test results while waiting many vct participants joined cm activities the result was usually available within 30 min and the same counselor provided the client with posttest counseling an anonymous vct and client centered risk reduction counseling approach was used for project accept only the unique number on the card was recorded on data collection forms and counseling chart notes the counselor kept the card after completing posttest counseling with this approach it was not possible to identify the client clients were provided a certificate of test results if requested or were referred for additional medical attention and support as needed data collection management and analysis preand posttest counseling chart notes were created for the purpose of counseling individuals as well as collecting data which include demographic characteristics history of prior vct and hiv risk behaviors the data were entered into an excel spreadsheet and exported for data management and analysis in sas 91 and stata 9 as each intervention community received the same intervention strategy in each round and is similar in term of the residents characteristics and vct access thus the seven communities are combined for data analysis frequency tabulation percentage and χ 2 test are used for data presentation and analysis meeting and field notes were also used ethical review pathai underwent ethical review at each of the three institutions involved the johns hopkins bloomberg school of public health chiang mai university research institute for health sciences and ministry of public health results from jan 6th 2006 to march 25th 2009 we completed seven rounds of cm and mvct activities in the seven intervention communities with 574 days of field activities a total of 57007 community residents aged 16 years or older participated in cm activities of whom 31813 were female persons could attend cm activities repeatedly during the first three rounds using conventional strategies mostly doortodoor outreach and group discussion without setting up mvct concurrently in the same day were conducted in round 4 we shifted to the edutainment strategy where mvct concurrently setting up near by the numbers of clients reached increased with the change in strategy as well as numbers of days spent each round when calculating number of cm participants10 staff hours invested theses are 53 39 and 18 persons respectively10 staff hour for doortodoor outreach group discussion without mvct concurrently setting up near by in the same day and edutainment with mvct setting up concurrently near by in cm activities which were conducted at night persons aged younger than 16 years attended the edutainment sessions many more than persons aged 16 years and older there were 17785 persons aged 16 years and over who participated in vct services 8503 men and 9282 women of the participants 7093 reported a history of prior hiv testing and 632 declined to have an hiv test from the project median age of clients was 36 years old with same day results higher proportions of clients received their test results the numbers of vct clients show a decreasing trend in the second to third round which led to the shift of cm and mvct approaches to edutainment from the 4th round onward the numbers of mvct clients then increased through the 7th round the trends of mvct clients are reflect in both absolute numbers but also by clientsday and clientscounselor hours available in each round counselor hours available were rarely oversubscribed at each mvct event so few clients were turned away due to lack of counselors the average number of clients per day between 13rd and 46th rounds were significantly different p 00001 the average age of clients were younger in 46th compared to 13 rd round with the medians of 35 and 38 respectively the seventh round is not considered as the semi optout strategy was used along with other strategies the percentages of repeat testers also increased over time as forecasted comparisons of characteristics of the 17153 who decided to get an hiv test for thai lowlanders and ethnic minorities are shown in table 2 as of december 2009 there were 44477 persons aged 16 years and over in the intervention communities 19054 ethnic minorities and 25423 thai lowlanders of the population age 16 and over 8786 cases of lowland thai and 8386 cases of the ethnic minorities came for hiv test with the project p 0000 when compared to thai lowlanders ethnic minorities had a higher proportion of persons aged 30 years or younger p 0000 had no formal education p 0000 had a higher proportion being first time testers p 0000 and had a higherproportion with a history of drug use p 0004 injecting drug users was similar among the two ethnic groups p 0901 approximately 6 of these two populations had more than one sexual partner in the prior 6 months of the 17153 who decided to get an hiv test with project accept 164 were hiv antibody positive similar for thai lowlanders and ethnic minorities overall 161 of the hiv positive cases received their test result 136 were newly detected cases more commonly among ethnic minorities compared to thais the majority 109 had no signs and symptoms of aids and were healthy ethnic minorities were more often seen to have signs and symptoms of aids as compared to thai lowlanders including among those new detected cases these comparisons are not statistically significant discussion of the team experiences in conducting cm mvct and ptss in the field for over 3 years we have adapted cm strategies to better support promoting vct uptake we did not encounter major problems in the initial community approach to mvct stake holders raised some concerned that community members would not come forward to get hiv tested because hivaids has stigmatization issues associated with it they thought that the openness of the vct operations in public venues would scare people away and that community members may be afraid of being labeled as hiv positive or having risk behaviors if they came forward for the test we have demonstrated that with more knowledge and understanding of the subjects mobile communitybased vct is a successful avenue to promote vct kawichai et al 12 and morin et al 11 provided surprising results that demonstrate minimal hiv testing stigma and that stigma is not a factor influencing whether people come forward for hiv testing at mobile vct units the cm strategy of doortodoor solicitation had limited reach as most of the target population was usually at work few people attended the initial group sessions many left during the sessions and many made excuses to leave to return to their daytime activities or household chores even though more persons could be reached with the same staff effort compared to daytime cm organized meeting and edutainment the effort did not yield as many persons daytime cm organized meetings include joining community leader established meetings could increase the numberssession compared to doortodoor canvassing with most attendees being adults joining organized meetings created a sense of formality and required taking time from daily work to participate the nighttime edutainment required greater staff hours eligible participants for vct this is expected as running the event required more staff for activities and at least six staff members for each of the three tents for hivaids education prevention and awareness games the activities also lasted longer than the prior approach we found that the edutainment approach to cm was more attractive to younger people and generated more attendeessession most often more than a hundred sometime reaching 300 if we included those younger than 16 years this was viewed as a benefit for educating teens and youngsters who may soon be at risk young adults also came forward more often for vct using the edutainment approach concurrently providing hivaids knowledge along with availability of vct assists decisionmaking for clients often the project young adults vct clients gave reasons for receiving vct such as the following quotes i came to cheer on my friend for the karaoke contest but i am early my other friends are not here yet so i am decided to get vct while waiting or my intention for coming here is not for vct at first but to play the games and get a prize however i am here anyway and it is free so i decided to get it these quotes suggest that these young adults may use of being early for cm or have nothing to do while waiting for playing game be a reasons for getting vct to avoid being stigmatized such as labeled to have hiv risk among the ethnic minority communities particularly those in very remote areas movies that were related to hivaids education in their own language were an effective means to educate them about hivaids thevillagers would ask for movies almost every time we visited the villages although the same movie was often repeated discussion would follow after the movies to respond to questions and concerns we assessed participants knowledge of hivaids after the movie and found that their understanding of the issues were generally correct and accurately demonstrated hiv awareness however movies were less attractive to lowland thais who had easy access to modern technology however karaoke singing contests were attractive to them lottery tickets for prizes after completing the three core cm activities was also an effective method to encourage individuals to learn about hiv aids and vct in all ethnic groups mobile vct was effective for outreach and promoting vct among hard to reach populations 91112 when accompanied with appropriate cm strategies those who lag behind can also be encouraged in 574 vct field days we tested 17153 cases and identified 136 new infected cases of whom 95 were had no signs or symptoms of aids this case finding has implications not only for infected individuals but also for the community at large all identified new cases received comprehensive posttest risk reduction counseling and were offered referral to care and support early detection of infection status will help to limit the spread of hiv by those otherwise unaware of their hiv infection having large numbers of people in the community going through risk reduction counseling and learning their hiv status may also help to limit the spread of the virus particularly among these loweducation communities in our case almost 50 of our vct clients were ethnic minorities of whom 54 had no formal education a common scenario for young adultsfrom remote areas is to migrate to big cities to seek work becoming at risk for hiv infection knowledge will empower them to prevent themselves from infection which should lead to reducing the further spread of the virus there are some limitations to the study our results may not generalize to other populations first the study was conducted in northern thailand rural areas and participants voluntarily came forward for vct these individuals could be biased to be either the worried well or to be at higher risk for hiv infection however the information came from a sizable sample where the bias from both groups could be balanced second the data are based on selfreports which are subjected to some bias participants may tend to report socially desirable data to the counselors risk behaviors may be underreported and some lowrisk behaviors may be overreported by participants in conclusion this study suggests that vct can be successfully promoted in populations with appropriate strategies that fit the local context entertainment is of human interest and can be a useful tool for drawing attention to public health issues integrated entertainment with hivaids community mobilization is one strategy recommended to increase hiv aids knowledge in populations which lead to vct promotion and ultimately to stigma reduction in conducting this research and all study participants for their contributions we also thank study staff and volunteers at all participating institutions for their work and dedication study setting appendix

project accept is a rct designed to test the efficacy of community mobilization cm mobile voluntary counseling and testing mvct and posttest support services ptss in reducing hiv incidence in three african countries and thailand the intervention started in rural areas northern thailand in january 2006 cm initially included doortodoor visits during the daytime small group discussions and joining organized meetings and followed by mvct in february 2007 cm strategy using hivaids edutainment education and entertainment during evening hours was introduced after edutainment was initiated the number of participants increased substantially vct uptake increased from 18 to 28 personsday on average t test t 787 p 00001 edutainment especially motivated younger people as the median age of vct clients decreased from 38 to 35 years old median test z 674 p 00001 providing free mvct in community settings along with edutainment during evening hours increased vct uptake and was particularly attractive to younger adults

introduction criminology criminology is a study of a crime the criminal behavior and the criminal justice system associated with it criminology is the scientific study of the causes correction and prevention of crime and those who commit it feminist criminologyfeminist criminology focuses on women offenders women victims and women in the criminal justice system in order to understand the causes trends and results of female criminality it includes the role of sex and sexism in sentencing and imprisonment the role of victimization in womens lives and the increase in the number of incarcerated women despite declining crime rates feminist criminology developed as a school in criminology because the major criminology theories were for men it is a study mainly that focuses on women offenders women victims and the impact of female criminality in societyfeminist criminology includes how women are ignored and stereotyped in criminology women committing murder robbery theft and dacoity are easily escaped by the laws protecting themwomen committing the crime are generally stereotyped as mentally unstableclaire m renzetti is the first person who brought the concept of feminist criminology where the author mentions the development of criminology and examines the diversity of feminism generally crimes committed by women differ from male criminality the difference can be seen in the nature of the crime and its consequences combined with the method crime weapon and choice of victim it is difficult to overlook the fact that crimes committed by women have a more emotional characteristic than those committed by men objective of the study • to find out the causes of female criminality • to know socioeconomic and other factors of female criminality • to prescribe solutions to curb female criminality reasons and causes for criminality amongst women womens participation in crime has been majorly associated with a large amount of indifference compared to men in criminologymotivation of criminality among women is mostly because of the social conditions that they face there are possibilities that the criminality can be installed in a womens mind genetically the character of a criminal is put in a womens brain by social exposure right from a young age which also results in behaviour development most of the families do not provide a woman with support respect or acceptance in the decisions where she chooses to be selfdependent such scenarios are leading women to rebel by giving them a platform where they are more likely to deviate or commit a crime the social environment contributes a lot to the making of women criminals especially in a patriarchal society despite a guarantee from the constitution of india of equal rights and privileges a womans fate cannot be changed even after equal involvement and excellent performance in her education and her workplace she does not get the credit and respect she deservesthe problem manifolds when despite being capable enough she has to obey the orders of a man of lesser ability her own opinion is brutally crushed and overheard she is subjected to victimization just because she is a woman phoolan devi the bandit queen is a classic example of how a victim turns into a victimizer further the marital status of a woman might have a significant role in making the decision to be a part of criminal activity unmarried women tend to get more regular work as compared to the married ones corporations often consciously decide to employ married men over married women as they want to cut the burden of paid maternity leave thereby contributing to the everpresent discrimination against women in workplacesthis discrimination in a twisted fashion provides women an opportunity to get involved in crime as they are already being discriminated against at the workplace further acknowledging the presence of commercial sex in indian society it is not explicitly illegal as there are no laws that punish a sex worker however some activities related to commercial sex such as soliciting running brothels trafficking and pimping are punishable under the immoral traffic act due to lack of awareness women lack basic legal rights healthcare and support from the government and society they end up being victimised and their safety goes for a tosseventually the women who have been forced into it do not get a way out once they survive and climb up the ladder they act as brothel owners or drug peddlers and get involved in other illegal activities due to the frustration from emotional mental and physical abuse these women tend to supress others in order to protect themselves from being supressed and hence end up victimising others battered women syndrome is another state of affairs which not recognized under the indian judicial system it is a psychological condition that can develop when a person experiences abuse for a long time in a relationship abuse can be sexual physical or psychological aggression in nature due to the repeated abuse women start suffering from learned helplessness threat to further violence also stops them to share their concerns to someone else this concept of battered women syndrome has not been placed in indian judiciary to explain the reasonableness of a womans actions in selfdefence against the abuser society provides close supervision and social restrictions on girls girls are trained to be passive domesticated nonviolent gentle and are made to learn more of nurturerelated jobs than getting involved in fighting or using a weapon on a contrary boys are nurtured to be aggressive and involved in activities that project masculinity hence when girls grow up they do not get involved in combats where they have to get involved in physical fights or in crimes where they have to threaten someone with their physical strength they get more involved in petty thefts poisoning or the crime which take less of masculine work freda adler has attributed prostitution drug addiction and female juvenile delinquents to the liberation movement of women and a way how women project assertiveness she contends that educated girls and women are more willing than ever to challenge the traditional restrictions and social roles bajpai and bajpai talk about the frustration and helplessness a woman experiences due to the lack of support and discrimination she has to face every day in her life in this fight for their rights the clash is unavoidable conclusion in conclusion what needs to be analysed in the social environment of a woman who is in conflict with law is their upbringing sexual socialisation their roles in their respective families their personal relations with their inlaws and their career preferences society plays a major part in a womans life span whether or not a woman turns into an offender highly depends on what kind of life she is living and what options does she have if she wants to change it the irony here is that these options are very often not of her own choice but are presented by the society finally both sexes are equally responsible for criminal activity criminals motivations will always be a mystery but it seems sense that they would be different for males and girls this is because the majority of published works focus on males before being adapted to females but this is not always the case since men and women engage in criminal activity at various times and in different ways they should have distinct motivations for breaking the law women have a lower recidivism rate than men suggesting that this is due to either a desire to maintain a certain lifestyle or the fear of having their children taken away and placed in foster care thus criminologists deduce that there must be a substantial difference between the motivations of males and females for criminal behaviour

in almost every part of the world women are considered as care givers women manage their homes family and childrenwomen are homemakers and more uninvolvedthe belief that women can inflict atrocities was beyond the imagination of criminologists and most areas of criminal science banished women from its examinationsover the years in every religious society women have always been considered asphysically and mentally inferior and unproductive to men this trend might havereduced in the early 21st century due to the advent of media women commissionsngos human rights organizations etc but we find reports of widespread violence against thecreators of life particularly in the backward and developing nations this paper focuses on the situation of female criminality in the recent times it is designed to highlight the causes and consequences of criminality amongst women and potential solutions to prevent such acts

introduction most of the studies on alcohol dependence are concentrated on its individual and social consequences and on early recovery phases less is known about the maintenance stage of recovery among both treated and nontreated subjects moreover the definitional boundaries of recovery remain blurred since professionalsaddiction treatment researchers and policy makers have not yet reached a consensus on the definition of recovery that would meet the criteria of precision inclusiveness exclusiveness measurability acceptability and simplicity there is also a gap between theoretical discussions on the meaning of recovery and operational criteria used by researchers who tend to define recovery as rather short periods consequently less is known about the longterm processes involved in maintaining recoveryrelated changes and about the impact of time on the stabilization of the recovery process only some authors suggest that the maintenance stage can be divided into phases klingemann identified the sequence of phases during the maintenance stage of recovery tricks and a renewed selfconfidence protecting the achievement a new life and peace of mind and reconciliation with others the last phase can be characterized by the internalization of new social roles and by the successful completion of a search for meaning in ones life similarly in a mohatt et al study the last phase named the life as it is meant to be lived follows the active coping phase from an outer perspective maintenance studies are focused on the measurement and observation of factors covarying with successful recovery prior studies have shown that receiving social support from family members and friends or having significant others goes along with individuals wellbeing and thereby seems to enhance their motivation and selfconfidence to maintain the change of addictive behaviour blomqvist emphasizes gender bias in his study men significantly more often than women cited the role of the partner as an important maintenance factor lack of family resources is often compensated by spiritual or religious involvement and support received from a religious community in blomqvists study women were more inclined than men to report esoteric or spiritual experiences as important part of their recovery in addition to family resources the work and financial resources are considered to be the most important ingredients of stable recovery maintenance studies show also an intervening effects of maintenance factors such as improved health and feelings of well being selfconfidence selfcontrol and willpower factors sense of pride about what has been accomplished and a more profound sense of life these findings point out that the meaning and individuals importance attributed to these factors may considerably differ and consequently determine different outcomes antonovskys salutogenic model accommodates this perspective suggesting that maybe the question which and how many resources are available to the individual in the process of recovery is after all not very relevant but the ability to use them flexibly in coping situations comes to the foreground also marlatt and gordons pathogenic model of relapse focuses on the role of low selfefficacy and lack of effective coping skills as risk factors for relapse indeed in previous studies of treated and untreated individuals fewer personal resources such as lack of selfefficacy and coping skills have been associated with relapse qualitative studies focusing on the inner perspective shed more light on maintenance strategies and the interplay and actual use of structural resources during recovery from addiction most remitters are conscious strategists however for some these coping strategies are only needed in the initial phase of recovery whereas others continue to use them on a daily basis for years this refers to respondents commitments to reinvest in themselves and their longstanding values and interests becoming more involved in or renewing their involvement in meaningful work nonsubstancerelated activities volunteer work or artistic and creative endeavours some remitters engage in new improved or more meaningful interpersonal relationships or a spiritual life workrelated changes changes in general lifestyle or in living arrangements as well as the resumption of leisure time activities are strategies often mentioned in maintenance studies some strategies serve the practical task of avoiding temptations or former company and providing alternative rewards to those obtained from alcohol use other strategies include strengthening the right attitude remembering of negative consequences of alcohol use positive thinking and future orientation and rewarding oneself former alcohol dependants are attempting their reintegration into society by socializing with nonor social drinkers and focusing on their own responsibilities and societys role expectations engagement in volunteer work may provide a framework for selfforgiveness and since helping is much better regarded in our society than being helped it may also improve the status of recovered individual for those who have recovered by the use of professional treatment or selfhelp group further participation in alcoholics anonymous as an ongoing reminder in conjunction with observable examples of recovery may also serve as a maintenance strategy studies on the maintenance of alcohol addiction recovery conducted among naturally recovered individuals help to overcome the institutional bias created by treatment studies even though treatment samples still represent the lions share of research moreover differences between treated and untreated samples are deduced mainly indirectly because comparisons of those groups within one study are the exceptionals in a blomqvist study selfremitters reports were mainly concentrated on the role of the partner or family members and on internal emotional andor cognitive changes whereas the reports of treated remitters were more evenly distributed across a greater number of factors including changes in living circumstances and various habits as well as various forms of formal assistance selfhelp group members continued their involvement in aa activity whereas natural recovery group members were absorbed by their families and leisure activities bischof et al compared naturally recovered individuals with subjects who remitted with the aid of extensive selfhelp group participation they identified no group differences in terms of coherence satisfaction with life domains temptation to drink and selfefficacy in remaining abstinent the groups did not differ on supportive life domains except that selfhelp group subjects specified friends family and religion more and health less as maintenance factors moreover selfchange investigated on grounds of longitudinal data showed high stability the study presented here explores issues related to maintenance of recovery from alcohol dependence in poland among a sample of individuals who have recovered by means of selfchange selfhelp group participation or specialized outpatient and inpatient therapy for alcohol dependents the article explores dependence as a social rather than biological state defined socially and embedded in social acts that condition it specific resources or recovery strategies are not equally distributed within societies and their recovery potential may differ in different cultures the analysis presented here provides an indepth qualitative understanding of what maintains recovery with a focus on the broader social context of change of addictive behaviour and including the impact of time on the recovery process results of the addiction recovery studies show that subjective accounts of addiction and recovery differ the article discusses recovery as a subjective process linking it with a conceptual framework of the meaning of recovery in poland no previous systematic research has to the authors knowledge addressed these issues methods sample the study is based on extensive interview data from 24 men and 5 women all participants had previously been alcohol dependent according to icd10 diagnostic criteria all participants had to have at least a 2year period of recovery meaning no symptoms of dependence or harmful use of alcohol or other drugs complete abstinence was not a criterion for inclusion in the study however the majority of respondents were abstainers others were moderate drinkers their alcohol consumption did not exceed 163 gday data collection lack of predictive power with quantitative statistical data may result from an insufficient knowledge of the variance in meanings attributed to the same terms used in structured questions by the respondents qualitative research shed light on the subjective variance of meaning this qualitative study was conducted in poland between october 2006 and june 2007 using media recruitment to establish the sample respondents were not remunerated for their participation in order to ensure data reliability and validity source triangulation and methodological triangulation procedures were applied more specifically to ensure synchronic reliability different methods were used to collect data from the respondents and to ensure diachronic reliability respondents were contacted several times in severalweek intervals and some of the questions were repeated two sociologists each of whom was trained in qualitative methods of data collection conducted the interviews each possessed previous research experience with substance users from different cultural backgrounds interviewers followed the interview guidelines of asking questions in a flexible manner in order to merge with and facilitate the narrative flow consequently the interviews were structured by interviewees not by the guidelines ad hoc questions were asked only if certain topics were left out by the interviewees to secure comparability of the data and completeness of topical areas two trained students of social sciences meticulously transcribed the interviews recordings transcripts include information on nonverbal communications such as laughter crying silence interview interruptions as well as comments from the person transcribing the interviews facilitating the interpretation in order to check the validity of the data information was gathered both from the respondents themselves and from collaterals however to avoid biasing the sample in favour of subjects with intact social networks nomination of collateral informants was not a criterion for eligibility information gathered from collateral informants was used to validate respondents addiction history and helpseeking status no inconsistencies were found analysis data were collected and analysed according to the problemcentred interview methodology using atlasti software the concept of a pci borrows largely from the theorygenerating procedure of grounded theory however the insight gained through data analysis is organized as an inductivedeductive mutual relationship the deductiveinductive scheme allows utilization of theoretical concepts and findings from previous research without lowering the chances for serendipity this implies a twostep coding procedure initially the transcripts were inductively coded sentence by sentence the applied opencoding procedure captures the meaning of data and sentence by sentence procedure guarantees that no data are left out afterwards the inductive codes were linked with the more general categories derived from the interview guidelines that second step linked the interview data with the deductive theoretical categories finally the codes and quotations were compared within each category and new categories were created if needed in order to identify and deduce inductively typologies the constant comparative method was applieddifferent types of data as well as the categories codes and finally the cases were compared and similarities and differences identified and interpreted ethics consent was treated as a continuous processrespondents were advised at every stage of data collection that they could terminate the interview at any point and that they could also refuse to give answers to certain questions if they felt they could become distressed while answering them after the phone interview respondents received an information sheet describing in detail the research objectives contact information assurance of confidentiality of the data and information about the benefits and risks of participation written informed consent was obtained from all respondents no respondent who volunteered to participate in the interviews refused to discuss any of the predetermined topics identified by the interviewers results the analysis of the respondents helpseeking history led to the identification of five subgroups adopting different paths of overcoming dependence selfchangers consumers aa outpatients and inpatients the group assignment was the result of the analysis and interpretation of addiction history narratives not only the contacts with addiction treatment were taken into consideration but also its subjective meaning the paths differ due to the type of support used to overcome dependence and served as baselinebackground for assessingrelated maintenance strategies sc used exclusively lay support and lay strategies those respondents have not been in touch with any therapeutic help during their recovery period cr used some amount of professional help however these individuals were not treated in the classical sensethey included rather some proactive elements of professional assistance in their lay recovery programs they treated treatment and therapeutic messages instrumentally and selectively and they had full control over the quantity intensity and costs involved they also mainly used services offered by the private sector aa recovery is based exclusively on participation in aa meetings and the aa traditions and steps op participated in individual or group therapy offered by op clinics for alcoholdependent people ip participated in several weeks of individual and group therapy offered by specialized residential therapy centres both op and ip after having completed their therapy often attended aa meetings which they treated as a form of aftercare the individual change process is embedded in a changing socioculturalhistorical context the context of dependency treatment has changed several times over the last few decades and so have treatment methods the legal background and treatment availability most of the respondents overcame their dependence after the last health system reform in poland however some respondents had already recovered in the 1980s and early 1990s ie during the systemic transformation and dynamic increase of selfhelp groups and the combination of psychoeducation and aversive therapy as the principle method of treatment treatment availability could have been an important determinant of this classification however a closer look shows that all respondents were aware of at least one form of treatment at the time they were considering the change of addictive behaviour no significant demographic differences were found between those groups no differences between groups were found with respect to severity of dependence although sc and cr experienced fewer alcoholrelated problems four out of six respondents who reduced or stopped drinking at the very first attempt were sc sc and cr have also slightly longer recovery period compared with the treated groups and aa although all groups can be said to be stably recovered a detailed description of the study sample is provided some respondents have managed to maintain a balanced life throughout dependence despite the turmoil in their lives their friends and family stood by them and they themselves had managed to keep their jobs and hence avoid financial and housing instability others described the process of hitting the bottom and bouncing back their history of dependence was full of dramatic events and serious problems and their recovery was more of a struggle than a smooth change of addictive behaviour following the methodological procedure outlined earlier a broad range of maintenance strategies and resources were reported by the interviewees figure 1 maps all identified codes related to the maintenance strategies and resources which can be grouped into five analytical categories becoming a new better person adopting new values and goals experiencing a new quality of social relationships pursuing new meaningful activities and changes in their environment even though respondents differed considerably with regard to their choice of how to overcome their addiction striking similarities appeared when their way of how to maintain change was taken into consideration consequently the results of the analysis are presented for all groups by specific theme not by type of recovery multidimensionality of change after identifying the range of specific aspects of change the joint appearance or the linking of these aspects in the narratives was highlighted in a second step of the analysis combining a multitude of change elements emerged as an important theme from the respondents accounts which was perceived as helpful in their decision to stop drinking 19 respondents referred to all five analytical categories describing their maintenance efforts and another quarter of them referred to four categories a closer look shows that not only the pattern of drinking changed but also the respondents whole life changed practically symbolically and often spiritually some respondents took advantage of the opportunity to make a new living in a new environment without the burdening consequences of dependence change of house new job completely new people who did not know about the problem this was more than just quitting drinking quite by accident everything whole my life began anew symbols in parentheses gender age type of recovery strategy present alcohol consumption pattern multidimensional change of environment helped respondents to maintain their recovery a new place of residence new job new friendsall that helped to start a new life the system transformation in 1989 … the wholesome change of functioning and quitting alcohol … maybe i am wrong but it seems to me that in some way the history of my country has influenced my personal history at some point i have changed my environment place of living work … change sometimes was connected to a birth 11 55 52 49 52 52 years of addiction m addiction 12 9 15 9 18 13 8 15 9 10 9 11 number present consumption pattern a 7 3 3 5 6 2 4 m 2 1 1 1 0 5 m male f female a abstinence m moderation sc selfchanger cr consumer aa aa participant op outpatient ip inpatient of a child or grandchild my granddaughter was born and i was taking care of her while my daughterinlaw was at work i saw it as a chance to have somebody who trust me who does not think bad of me and sometimes to a new relationship im 52 and am still going to enjoy life my wife came back to me we plan to marry again improved relations with partners and children are very important in maintaining recovery some respondentsin order to stop or to cut down on their drinkingsignificantly changed their life situation their living and working arrangements circle of friends however they did not intentionally and consciously go through any identity transformationfor them it was rather the return to previous life and normal social roles the return to normality i used to be punctual responsiblewhen i gave my word i kept my word now again i can make plans and promises and i can be trusted others emphasized the spiritual nature of their changes at some point i have stopped attending therapeutic meetings but i started to spend more time in my religious community more i was praying to god more i received from him overcoming dependence was also connected to personal growth leading to internal transformation selfwork that was the hardest part you have to make a great effort to change you have to become somebody to be sober when i started therapy i have noticed that my life is not empty anymore i even felt better then other normal people who spend their lives watching soapoperas because i am doing something with myself coping with stress and cravings respondents from all groups reported the change in coping with everyday life problems they try not let the problems to accumulate everybody has problems i am just not letting them to accumulate anymore they perceive them as easier to overcome and they feel more confident in coping with them one can say a sober person has small problem but a drunk person perceives it as enormous and impossible to solve cravings tend to appear in relatively early stages of the maintenance phase twice i dreamt that i got drunk i cried through my dream i was so sorry and i could not understand why i did that i woke up all sweated it was after two or three years of abstinence strategies used in such situations include weighing pros and cons of drinking and recollecting the negative consequences of dependence to recall the problemsmy memories of unpleasant physical effects are completely blurred but my psychological condition that i do remember its hard to let yourself be pushed back into something like that once again it was terrible indescribable … i felt completely stripped of selfrespect … the thought of being in such a position once again definitely motivates you not to drink you could easily mess everything up again the older you are the less time you have to pull yourself back up i am fully aware of the danger also contact with people who need support helps respondents to remember about the problems they have already overcome impact of time on consolidation of life changes the changes once introduced in respondents lives stressful and turbulent at the beginning become an inseparable part of the new life style time certainly every year sort of accumulates … bit by bit thoughts about what youve lost becoming reconciled with your losses stabilization organizing your life anew respondents perceive their recovery as complex process requiring strength balance and patience the life situation gradually stabilizes the experience of dependency is often reframed and is no longer perceived as a source of weakness there is this saying if it doesnt break you it will make you and thats very true as far as im concerned im much calmer now than i used to be when i drank more balanced i think that ive crossed a threshold and learned something i needed this fragment of my life to teach me something it has strengthened me discussion the article addresses the subjective experience of the maintenance stage of recovery from alcohol dependence within a broader sociocultural context findings of the first polish study of available paths to recovery including selfchange are presented a triangulation procedure was adopted in order to ensure reliability of the data and validity of the data analysis although people change for a wide variety of reasons they share a more similar repertoire of techniques to maintain the change our findings support the assumption that independent from helpseeking status more commonalities than differences exist within successful recoveries from alcohol dependence the aftercare treatment services and support of selfhelp groups can be perceived as additional resources in reaching a stable recovery especially if similar resources in the daily life context of an individual are missing however recovered subjects are striving toward their societal reintegration and as over time other resources in their life circumstances become availableprofessional assistance tends to be less and less needed and at some point may even impede the consolidation of life changes multiple maintenance factors and strategies contributing to the stabilisation of recovery from alcohol dependence were identified findings from our study support results from maintenance studies among treated and nontreated subjects within other cultural contexts however our study shed more light on the subjective relevance and interplay of those factors and resources not the specific components but the multidimensionality of change emerges as the most important feature of maintaining the recovery from addiction recovery appears over time as an interplay between individual actions societal reactions and positive and negative life events while subjective accounts of maintenance stage are being continuously constructed and reconstructed that is especially visible in our study where subjective accounts of recovery experiences from different points of timesubjects recovery time varied from 2 to 40 years were analysed the results from this qualitative study point to the more general aspect discussed in the literature that the questions recovery from what or what has to be maintained are negotiated during therapy and professional definitions might converge or clash with the ideas of the recovering individuals concepts which represents a sustainable problem resolution and the reasons for longterm maintenance are part of the framing of the meaning of recovery the attempts of professionals to define recovery from addiction do not focus on the normalization of deviant behaviour but rather on voluntarily maintained lifestyle characterized by sobriety personal health and citizenship where the citizenship implies working towards the betterment of ones community through participation volunteer work and efforts to improve life for all citizens professional perception of recovery is in fact quite demanding it is not merely expected that individuals would cease hisher drug use but it is requiring a major restructuring of hisher social networks as well as values knowledge and skills it is also believed that recovering alcoholics want and should pay back or recompensate to the society for their antisocial behaviour recovery definitions that place recovery within the context of global health view the resolution of substancerelated problems not as a focal point but as a byproduct of broader personal and interpersonal processes such definitions withhold the status of recovery from someone who has achieved abstinence but has failed to achieve levels of physical emotional relational and ontological health it has been increasingly recognized that the search for standard recovery and conditions attached to such a normative endeavour may sometimes set the bar too high even though humans are remarkably resilient they cannot always erase the effects of whatever it is that afflicts them moreover the demand of total abstinence may be also seen as societal form of punishment turning objectives of the change and recovery process to the individual perspective we can clearly see that some recovering addicts do in fact meet even very harsh definitional criteria of stable recovery according to the terms mentioned above both our and other studies on recovery show identity transformation and striving for honourable social identity adopting the most valued goals of mainstream society achieving peace of mind personal growth taking up creative activities as important components of recovery process however addiction is a heterogenic phenomenon in our study the second group of recovering alcohol dependants was identified who in the same way as exsmokers resolved dependence without any remarkable identity or values change that is especially true for some of scs and crgroups not affected by treatment ideologies this group effect can be interpreted in the background of the make up of the polish treatment system which is based on the medical model of addiction since the 1980s alcohol dependence was treated as a chronic progressive and incurable condition and its abstinenceoriented treatment is organized on the basis of the minnesota model the state agency for the prevention of alcoholrelated problems 2008 the view that addiction resides solely within the individual fosters significant limitations across the polish alcohol treatment system in poland professional ideologies also embraced concepts such as dry drunk emotional sobriety and serenity one can only graduate from a treatment programme in poland as cured if one has become a completely new person a person who will always be in recovery the language of addictionasillness contains layers of assumptions and implications that ultimately render viewing addicted persons as sick and lacking the capacity for the most part to control their own actions at the same time some polish studies show that the professional concepts of dependence imposed on a patient during therapy or while attending aa meetings seem to fade away when the person does not stay in touch with the institution or aa group the new social roles are internalized and addiction gradually becomes part of the past despite the therapeutic notion of its incurability limitations firstly it should be noted that this qualitative study with a sample size of 29 participants cannot provide epidemiological information on the prevalence of the identified categories in a wider population of alcoholdependent individuals but it explores the dimensionality of subjective constructs secondly qualitative data can be biased by selfattributions and social desirability this effect has been additionally addressed in this project by the inclusion of collaterals and the triangulation of various data sources that allowed checking for inconsistencies furthermore even though the validity and reliability of selfreports have been shown in addiction research memory effects might have an effect on the retrospective data this potential bias has been addressed and narrowed by providing the respondents prior to the interview with life history charts to be filled out thus crosschecking the assessment at the time of the interview with diaries and other personal records overall this data supports the accuracy of subjects reports and are consistent with findings in previous studies using similar retrospective methods conclusions we perceive addiction as a social cultural and political construct and recovery as a complex dynamic and multifaceted process in this process multiple maintenance elements come together in a combination of tangible and intangible subjective attributions and decisions physical and socioenvironmental structures cultural context and related life circumstances affect ones capacity to reach stable recovery from alcohol dependence results of our study support the usefulness of a holistic view of the maintenance stage and insight into the multidimensional mind mapping during the endeavour of individuals to maintain their problem resolution funding the work was supported by polish ministry of science and higher education as a research grant ways of overcoming alcohol dependence

the study provides an indepth qualitative understanding of the maintenance stage when recovering from alcohol dependence with a focus on the broader social context of change of addictive behaviour it explores the recovery as a subjective process within the abstinenceoriented polish treatment system organized on the basis of the minnesota model and is probes for group differences between treated and nontreated populations methods the study is based on qualitative data from a mediarecruited sample of 29 treated and nontreated former alcohol dependents icd10 in warsawpoland 20062007 they reported a recovery time of at least 2 years m recovery 11 sd 9 indepth semistructured interviews were analysed according to the problemcentred interview method using atlasti software results a wide range of maintenance strategies potentially contributing to the stabilization of recovery from alcohol dependence was identified however from the respondents point of view the change process is contingent upon the subjective weighing of specific maintenance factors and the importance attributed to their interplay this includes time management as well as ones ability to invest available resources and strengths in shaping and pursuing personal goals conclusion more commonalities than differences can be observed between groups during the maintenance stage regardless of respondents type of the pathway out of addiction however when confronting professional concepts of recovery with subjective accounts only a subgroup conforms to the invasive potentially normative definitions of recovery while others do not link their recovery with identity transformation

undocumented individuals 3 most notably american indian or alaska native and black are each more than 2fold as likely to be killed by a legal intervention injury as white individuals 2 while available data sources do not stratify such outcomes by justifiable or excessive policing practices researchers consistently find that both violent and nonviolent police interactions are associated with a range of adverse health outcomes 3 in particular police interactions perceived as unfair or discriminatory have been associated with psychological distress and multiple adverse mental health outcomes including anxiety depression and posttraumatic stress disorder 4 furthermore these adverse outcomes extend beyond the individuals involved in the encounter with data demonstrating that elevated neighborhoodlevel useofforce rates and legal intervention deaths are associated with worse adolescent development outcomes 35 and elevated rates of psychological distress and adverse physical and mental health outcomes among other community members 36 it is not unreasonable therefore to consider policeinvolved violence as a contributing factor to racial health disparities in chronic disease and quality of life researchers have mostly focused on understanding the prevalence of fatal and nonfatal outcomes as well as the adverse health consequences associated with legal intervention injuries but fewer have examined health system data to identify potential structural factors at the societal level that may underlie existing disparities and inequities related to legal intervention injuries the study by ormseth et al 7 contributes to a broader understanding of this public health issue by examining multiple years of nonfatal legal intervention injuries from across california within the context of persistent residential segregation consistent with other research 1 ormseth et al 7 found that black residents were disproportionately injured as a result of legal interventions compared with white residents despite adjusting for differential statewide demographics they also identified that observedtoexpected injury ratios varied considerably by county with injury ratios highest for black residents living in urban counties and highest for white residents living in rural counties 7 finally although underpowered to detect statistical significance it was notable that they found more highly segregated california counties experienced higher observedtoexpected injury ratios for black residents and lower observedtoexpected injury ratios for white residents this finding is consistent with an accumulating body of literature 89 demonstrating the fundamental role that persistent residential segregation has in perpetrating racial disparities in health outcomes particularly for black individuals such residential segregation primarily stems from the earlyto midtwentieth century collective practice of redlining or instituting racial zoning laws and racially restrictive covenants ie contracts prohibiting the sale related article author affiliations and article information are listed at the end of this article open access this is an open access article distributed under the terms of the ccby license jama network conflict of interest disclosures none reported additional contributions carrie musolf ba assisted in manuscript preparation

policing practices have garnered increased national attention in recent years following multiple highly publicized encounters that have resulted in the death of unarmed black citizens 1 as a public health issue legal interventions ie police or law enforcement interactions have resulted in more than 5500 fatal and 850 000 nonfatal injuries within the past decade 20112020 2 in addition to physical and sexual assaults by police that result in fatal and nonfatal injuries policeinvolved violence also includes a range of psychologically harmful eg coercion or harassment during police encounters or neglectful eg failure to aid behaviors 3 such violence disproportionately affects historically marginalized populations including american indian or alaska native black and hispanic communities lesbian gay bisexual transgender and queer individuals and individuals with other gender and sexual identities and economically disenfranchised disabled houseless and

population health research capsule what do we already know about this issue older adults face unique challenges related to emergency care including decreased attention to patientcentered and goalconcordant care what was the research question can emergency clinicians identify concerns and desired outcomes of older adults using the what matters conversation guide what was the major finding of the study what matters questions in the ed are feasible with clinicians and older adults exhibiting varied alignment introduction older adults account for over 23 million emergency department visits annually representing 18 of all ed visits nationally 1 older adults have been noted to face unique challenges related to emergency care including the potential receipt of goaldiscordant care and a decreased attention to patientcentered care 23 as a potential solution to address the underlying problems facing older adults more broadly in healthcare settings the john a hartford foundation and the institute for healthcare improvement founded the agefriendly health systems initiative in 2017 4 5 6 7 as of june 2021 4 there were over 2200 agefriendly health system participants employing the framework called the 4ms what matters medication mentation and mobility to ensure patientcentered and evidencebased care for older adults across healthcare settings with wider implementation in ambulatory and inpatient settings and less attention to the ed setting 8 9 10 within eds efforts are increasing to prioritize patientcenteredness and goalconcordant care for older adults 1112 these areas of focus are particularly relevant and important for older adults as they have been identified in the outpatient setting to have healthrelated priorities aside from typical metrics such as repeat ed visits or hospitalization 13 14 15 furthermore much of the available emergency care research regarding older adults patientcentered goals currently focuses on treating clinicians performing endoflife goals of care conversations 16 17 18 however ed treating clinicians are tasked with navigating older adult priorities not just during critical illness or end of life to date the extant literature has not assessed whether ed treating clinicians perceive priorities that differ from their older adult patients thereby potentially introducing goaldiscordant care identifying what matters and priorities within the broader older adult population has drawn concerns regarding implementation strategies in the ed clinical environment as the lines of questioning often are perceived as timeintensive 19 or beyond the scope of a traditional ed visit focused on a single injury or symptom thus far a feasible approach aligned with the agefriendly health systems to identify what matters to older adults seeking emergency care is lacking therefore we sought to describe the priorities identified by older adults and their treating clinicians as well as the feasibility of incorporating brief questions addressing what matters in the ed identifying the concerns and desired outcomes of older adults in a timeefficient approach that is aligned with the what matters domain of the 4ms framework will allow more patientcentered ed care for this growing population methods study design we performed a qualitative analysis involving cognitively intact patients and their treating clinicians study methods and results are presented in accordance with the consolidated criteria for reporting qualitative research 20 this study was determined to be exempt research by the institutional review board sample the study was conducted at two eds a community hospital and a level ii trauma center within the same health system potential older adult participants were identified based on screening within the electronic health record with recruitment taking place during rotating evening and day schedules inclusion criteria included the following age ≥70 englishspeaking ability to answer questions without the assistance of caregivers and an emergency severity index score of 3 4 or 5 suggesting lower acuity at triage exclusion criteria included a status of medically unfit or evidence of cognitive impairment we used the sixitem screener with a score of 4 on the sixpoint questionnaire indicating high risk for cognitive impairment as previously performed in edbased research 21 treating clinicians including attending physicians and nonphysician practitioners received a 5 gift card for their time participating in the interview enrollment occurred between december 2020may 2021 procedures a trained interviewer obtained verbal consent and digitally recorded interviews of older adults and their western journal of emergency medicine an initial version of the what matters conversation guide was tested in three eds to gain clinician insights regarding appropriateness and feasibility we used the final two questions previously identified by expert consensus deemed to be most salient to identify what matters for older adults seeking emergency care 23 to assess concurrent clinician impressions of their older adult patients we asked analogous questions in a separate interview to the patients ed treating clinician regarding what they believed mattered most to the older adult they were treating as suggested by stakeholder and expert guidance on the what matters conversation guide hd could ask either question 1a or 1b to ascertain fears or concerns about the older adults healthcare in the ed with a similar approach suggested for question 2a or 2b to identify outcomes most wanted when identifying fears or concerns hds approach was to start the interview by asking question 1a hd asked question 1b if the participant had difficulty understanding the question needed further clarification or it was thought that greater information could be gathered by rephrasing the question the final interview guide was pilot tested with two ed patients prior to beginning the study both patients and clinicians were interviewed during the ed encounter when disposition uncertainty still existed this occurred after the initial evaluation by the treating clinician but before laboratory and imaging results were available to inform decisionmaking hd timed interviews from the start of asking question 1 to the end of the participants response to question 2 to assess the time and operational feasibility of incorporating what matters questions into a typical ed encounter hd collected basic demographic information and ed clinical data regarding the encounter and also recorded brief field notes immediately after the interview no study authors were part of the participants medical care teams data analysis we used an iterative process of thematic analysis to synthesize the data identify patterns and develop themes across interviews 24 specifically we used the inductive qualitative approach that relies on the synthesis of qualitative data rather than relying on concepts considered a priori 25 the coding team consisted of cjg an emergency physician and health services researcher with formal qualitative training and expertise working with older adults and hd a masterslevel research associate whom cjg trained on qualitative research techniques digitally recorded transcripts were professionally transcribed and corrected when the transcript passage was incomprehensible or had errors we used nvivo 12 qualitative software to manage and analyze study data 26 the coding team began with a linebyline review of transcripts and open coding to identify key concepts following review of the first six transcripts coders developed an initial codebook that was subsequently expanded and refined through independent and then joint review of additional transcripts coding discrepancies were adjudicated between coders through regular meetings and the final codebook containing 22 codes across four domains was then applied to all transcripts both coders coded all interviews to enhance consistency recruitment interviewing and coding occurred concurrently until thematic saturation was reached 27 we followed best practices for validity in qualitative research by maintaining an audit trail and comments and revisions from group coding meetings 28 29 30 the study team collaboratively identified and agreed upon illustrative quotes the represented the identified final themes to preserve anonymity participant quotes are identified by participant type and number results we screened 58 older adults for eligibility eight refused to participate and four were noted to be cognitively impaired 2 the most common ed chief complaint category was fall musculoskeletal and a significant portion of older adults underwent both laboratory testing and radiograph imaging interviews with older adults lasted a mean of three minutes with a range of 18 minutes treating clinicians consisted of physicians and nonphysician practitioners when considering responses to the first what matters question regarding fears or concerns about the older adults ed care five main themes emerged among older adult respondents and two main themes emerged among clinician respondents for older adults these themes included the following 1 concern through a family member or outpatient clinician recommendation 2 no concern with a high degree of trust in the healthcare system 3 concerns regarding symptom cause identification 4 concerns regarding symptom resolution and 5 concerns regarding preservation of their current status for clinicians responding to what they believed the older adult patient was most concerned about the two themes included 1 concerns regarding symptom cause identification and 2 concerns regarding symptom resolution when considering responses to the second what matters question regarding desired outcomes about the older adults ed care five main themes emerged among older adult respondents and three main themes emerged among clinician respondents for older adults these themes included the following 1 obtaining a diagnosis 2 returning to their home environment 3 reducing or resolving symptoms 4 maintaining selfcare and independence and 5 gaining reassurance for clinicians responding to what outcomes they believed the older adult patient most desired the three identified priority themes included 1 returning to their home environment 2 linking reassurance and return to home environment outcomes and 3 reducing or resolving symptoms tables 3 and4 show representative quotes of the identified themes insights into older adults concerns older adults reported a wide variation of concerns when thinking about their health and healthcare during the ed visit older adults either presented to the ed at the suggestion of a family member or the recommendation of an outpatient clinician while an additional group were not concerned at all with their ed care and noted their total confidence in the ed treating clinicians when present concerns and fears of older adults included symptom cause identification and symptom resolution but more frequently also extended to include the ramifications that the acute injury or illness would have on their broader life these areas of concern for older adults centered commonly on ambulatory what matters to older adults in the ed status and preservation of their current abilities one participant statedi am just concerned that i will not get back to normal when asked to consider the older adults concerns treating clinicians referenced symptom cause identification and symptom resolution as the patients greatest concern or fear with no comment on the perceived impact that the older adult identified on daily life or function highlighting potential discordance regarding concerns one older adult and their treating clinician separately noted i have a heart condition i have an artificial knee and it looks like i might be getting another artificial knee mobility is the big issue i think he is concerned about his left knee pain that is recurrent insights into older adults desired outcomes older adults and clinicians also reported a wide array of desired outcomes for the older adult during the ed visit individuals from both groups identified that the desired outcomes of older adults during ed care included returning to their home environment and reducing or resolving symptoms highlighting concordance between patients and treating ed clinicians one older adult and their treating clinician separately noted interviewer what outcomes are you most hoping for from this ed visit participant to be able to go back to the facility where i reside i think ultimately she would like to be discharged and be told everything is looking good expressing desired outcomes from their ed visit an older adult and their treating clinician also noted that my head is clear and i can go home and get on with my life i think they would like to go home but they are also concerned about his head however older adults additionally noted obtaining a diagnosis maintaining selfcare and independence and gaining reassurance as desired outcomes from their ed visit treating clinicians linked desired outcomes of older adults most commonly identifying their desire to gain reassurance alongside their desire to return to their home environment however clinicians did not perceive that maintaining selfcare and independence were desired outcomes of older adults seeking emergency care discussion this study is the first to characterize perspectives of older adults presenting to the ed using the what matters framework the unique comparison to their treating clinicians offers evidence demonstrating alignment in some areas despite other distinct gaps between older adults and their ed treating clinicians importantly this work identifies the feasibility of incorporating the what matters questions in the ed unique to our work is the identification of what older adults are concerned about and prioritize while seeking emergency care and whether clinicians are aware of what matters to this population in our study clinicians often recognized the importance of returning to the home environment for older adults but they did not comment on patients frequently expressed concerns regarding the impact of the acute illness or injury on their ability to return to their previous functional or broader health status the emergency clinicians rarely mentioned functional changes as a concern of the older adult despite prior edand hospitalbased literature identifying subsequent objective functional decline and adverse outcomes 31 32 33 34 35 36 our qualitative study adds to the literature base by providing more indepth responses than possible via surveybased quantitative research the extant literature lacks relevant feasible modalities to address the priorities of older adults seeking emergency care many including the what matters structured tool and the serious illness conversation guide 37 have been developed and assessed in noned settings thereby limiting their translatability to patients seeking acute care in our study the average patient interview was three minutes and ranged from 18 minutes suggesting a reasonable time to completion and feasibility of clinicians incorporating the what matters questions within the time constraints of todays ed clinical practice we believe emergency clinicians are best situated to ask the what matters questions as their upfront efforts to address patient priorities concerns and desired outcomes may ultimately save time and resources in place of potentially contentious and goaldiscordant conversations after completion of the ed evaluation additionally hunold et al asked a single openended question to older adults regarding what would make their ed visit successful useful or valuable 38 without restricting when during the visit the interview occurred 62 of participants reported at least one priority in the evaluation treatment and outcomes metacategory including treatment of the medical problem accurate diagnosis and competent clinical staff our study builds upon this work by providing more indepth qualitative responses as well as standardizing the interview time during the clinical encounter after initial clinician evaluation but before laboratory and imaging results this timing ensured uncertainty regarding the disposition and allowed patients to reliably and consistently relay priorities at a critical juncture in the ed visit it remains to be determined whether these questions may be most effective in guiding ed care if asked at the initiation of the visit prior to evaluation our work has several implications regarding clinical practice cognitively intact older adults identified several concerns regarding their health in comparison to their treating clinicians suggesting that emergency clinicians may be unaware of certain patient priorities during the encounter a standardized script such as the what matters conversation guide may prompt clinicians to incorporate patientcenteredness and shareddecision making into the patient encounters identifying what matters in the ed when caring for older adults is intended to promote clinicians to pursue an evaluation treatment plan and disposition aligned with the goals of the patient potentially saving both time and financial resources if an extensive ined evaluation is not prioritized or desired by the patient the agefriendly health system initiative may serve as a platform for the broader implementation in the ed of the what matters conversation guide to target increased patientcentered emergency care of older adults creating alignment with the recent development of geriatric ed guidelines and the geriatric ed accreditation process 3940 future research should build upon this foundation and quantitatively identify domains targeting what matters that can be incorporated within novel patientreported outcome measures and may benefit from determining differences between geda and nongeda eds in addressing the what matters questions limitations there are limitations of our study to consider our study was conducted at eds within one health system and predominantly among white older adults thereby potentially restricting generalizability however we expect that many older adults will have similar experiences as we identified thematic saturation during our qualitative analyses our understanding and interpretation of the data may have potentially introduced confirmation bias which we attempted to minimize using semistructured interview guides and discrepancy reconciliation through team discussion additionally the two primary interview reviewers were not blinded to the study objectives thereby potentially introducing bias to the decision of classification of the questionnaire domains while we did follow multiple best practices for rigor in qualitative research 28 29 30 we did not return transcripts to participants for checking of our themes finally feasibility has been defined in several ways within the literature aside from the time taken to conduct the interviews additional quantitative survey feedback from older adults and ed treating clinicians may be beneficial to support further operational implementation conclusion patients and their treating clinicians noted similar concerns and desired outcomes when considering the priorities of older adults however clinicians did not as frequently recognize patients concerns about the impact of their acute condition on overall function and daily life we have identified the feasibility of incorporating these two what matters questions in the ed and the limited time needed to identify older adults priorities address for correspondence cameron j gettel md mhs yale medical school department of emergency medicine 464 congress ave suite 260 new haven ct 06519 email cameron conflicts of interest by the westjem article submission agreement all authors are required to disclose all affiliations funding sources and financial or management relationships that could be perceived as potential sources of bias dr gettel is supported by the national center for advancing translational science and the research education core of the claude d pepper older americans independence center at yale school of medicine dr venkatesh is supported by the american board of emergency medicine national academy of medicine anniversary fellowship and previously by the yale center for clinical investigation from the national center for advancing translational science dr hwang is supported by the national institute on aging by the john a hartford foundation and the west health institute dr tinetti is supported by the john a hartford foundation the gordon and betty moore foundation and the robert wood johnson foundation the funders had no role in the design and conduct of the study collection management analysis and interpretation of the data and preparation or approval of the manuscriptthere are no conflicts of interest to declare

the 4ms model what matters medication mentation and mobility is increasingly gaining attention in agefriendly health systems yet a feasible approach to identifying what matters to older adults in the emergency department ed is lacking adapting the what matters questions to the ed setting we sought to describe the concerns and desired outcomes of both older adult patients seeking ed care and their treating clinicianswe conducted 46 dyadic semistructured interviews of cognitively intact older adults and their treating clinicians we used the what matters conversation guide to explore patients 1 concerns and 2 desired outcomes we then asked analogous questions to each patients treating clinician regarding the patients priorities interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes results interviews with older adults lasted a mean of three minutes with a range of 18 minutes regarding patients concerns five themes emerged from older adults 1 concern through a family member or outpatient clinician recommendation 2 no concern with a high degree of trust in the healthcare system 3 concerns regarding symptom cause identification 4 concerns regarding symptom resolution and 5 concerns regarding preservation of their current status regarding desired outcomes five priority themes emerged among older adults 1 obtaining a diagnosis 2 returning to their home environment 3 reducing or resolving symptoms 4 maintaining selfcare and independence and 5 gaining reassurance responding to what they believed mattered most to older adult patients ed clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reductionthis work identifies concerns and desired outcomes of both older adult patients seeking ed care and their treating clinicians as well as the feasibility of incorporating the what matters questions within ed clinical practice west j emerg med 202223 4 579588 how does this improve population health identifying what matters to older adults should spur emergency physicians to pursue an evaluation treatment plan and disposition aligned with patients goals

universal healthcare is fundamental to the nordic welfare model social inequity in health is highly prevalent recent years have seen increasing research interest in unequal access to healthcare in denmark it has therefore been well described in quantitative studies how danish healthcare is unequally distributed along lines of socioeconomic variables however very few studies illuminate how specific care practices at the microlevel are influenced by social differentiation further not many studies explore how discourses of active ageing actually operate as norms of segregation through professional practice embedded in the institutions of the danish welfare state with this article we aim to contribute to existing quantitative research by examining qualitatively how social inequality is reproduced in palliative care practices palliative care is considered important for society in order to cut the increased costs of lifeprolonging treatment and important for patients if side effects of futile treatment make prolonging life a burden for patients and families greater longevity with lifethreatening diseases has also increased the focus on palliative care this ideally involves a focus on alleviating total pain ie an awareness of social and financial problems physical challenges and existential and mental problems in facing death and the notion that the needs of patients with lifethreatening illness must be identified early based on the assumption that this will provide greater clarification as death approaches healthy citizenship and inequity when ageing and dying it is well argued that western health policies rest on a paradigm of neoliberal governmentality through inculcating responsibility in individuals who are compelled to take up the role of health entrepreneurs acting upon their bodies and selves to achieve an idealised form of healthy citizenship a key feature of this is the emergence of a particular focus on the self this psychologisation or governmentalisation of human existence establishes a political logic dominated by a form of human profitability people should thus be subjects of value constantly preoccupied with a healthy lifestyle and selfrealisation to enhance their symbolic value all the way to death the idealised selfoptimising subject is permeating society culture and the way healthcare institutions organise their handling of ageing and death as a consequence successful ageing discourses have gained ground harris et al point out how these discourses often portray successful ageing in a way that emphasized older adults ability to choose the way they age through making the right decisions about their lifestyles diets and attitudes they also argue that this generates an ideal of old age or senior citizenship carter examines discourses about successful and frail seniors and considers it likely that …social structures such as racism sexism and neoliberalism may impact the way patients are placed into the social categories of successful agers or frail agers our analysis explores how these overall macro tendencies establish themselves at the micro level the question we examine is how these new distinctions between the successful ageing of subjects who take on responsibility for their health and the resigned irresponsible physically deteriorating agers are informed by social class richards notes that there has been an equity turn in palliative care research and advocates for researchers to take into account the wider political institutional and economic conditions in which poverty comes to exist and healthcare is delivered further she calls for a shift in attention from measurement to a deeper awareness of explanatory factors this article contributes to this turn by exploring qualitatively how social class is reflected in palliative communication in ways which create unacknowledged and unarticulated practices of distinction which might lead to differential treatment this is important because of the risk of reproducing inequity social class and classifying practices the understanding of class in this article draws on bourdieu since he mainly focused on the reproduction of middleclass privileges at the expense of the lower classes this enables us to understand how class is reproduced in the universal welfare context of the danish healthcare system and to explore classbased implications of different patients receiving palliative care in healthcare facilities that are embedded in middleclass norms and cultures bourdieu insisted that cultural practices should be treated as coconstitutive of how class relations are configured he also focused on the persistence of structures by developing the concept of habitus to comprehend how class structures are inscribed in peoples bodies and minds importantly he reasoned that forms of capital other than economic such as cultural and symbolic must be included in explorations of social inequality the concept of class has traditionally been one of the major sociological concepts but in the last 2030 years it has lost some of its strong position part of the explanation lies in the fact that industrial society with its clear stratification has been dismantled however the shift from industrial to financial capitalism also known as neoliberalism has not removed social inequality but rather increased it in this context it appears that class is still highly active but in more diffuse ways skeggs insists … class is so insinuated in the intimate making of self and culture that it is even more ubiquitous than previously articulated if more difficult to pin down leaking beyond the traditional measures of classification neoliberalist discourses have thus been said to marginalise class as an explanatory factor for inequality neglecting the structural circumstances that determine individual choices however lamont states that neoliberalism reinforces class differences in terms of assessing peoples moral value class can thus be understood not only as socioeconomic position or as forms and amounts of capital but also as circulating through symbolic and cultural forms ie the means by which people become judged as morally worthwhile or as having the right kind of knowledge or taste seen from this perspective class works through relational processes that comprise both a social filter and a key mechanism individuals utilise in placing themselves and others sointu explores the reproduction of inequality in medicine she finds that ideas of good and bad patients are at play in medical education and that these ideas are embedded in class differences in this article we explore how these classifying practices of value assignment shape palliative communicative encounters between professionals and endoflife patients howarth and conway criticise the sociology of death for not including class which could reveal how people of different socioeconomic status relate differently to death despite increased interest in inequity in palliative care research there are still remarkably few studies with this qualitative sociocultural class perspective especially in the nordic universalist welfare states with their redistributive aims there has been little research into the influence of social class in healthcare and even less in relation to palliation and death although social differences are discreetly admitted denmark is rarely considered as having a marked class system but is rather seen as one of the strongholds of the welfare state however despite comprehensive economic redistribution and universal welfare coverage denmark does have a range of the traditional class inequalities well known in the uk and the us this makes denmark a particularly strong case for an exploration of how classifying practices through attribution of value impact palliative encounters palliation via communication healthcare increasingly involves communication with patient involvement as a key concept firstly enhancing patients ability to communicate is expected to increase equality secondly it is assumed that palliative care is improved through reflexive dialogue in which a clear and open communication about death is encouraged partly to facilitate collaborative planning aimed at achieving a good death mccreaddie states that endoflife communication is considered entirely positive a moral imperative however the requirement for patientcentred care may clash with the ideal of a clear open and euphemismfree dialogue because it implies respect for the preferences of patient and family patients might wish to avoid open communication prefer euphemisms and understand a good death differently from professionals and perhaps even their relatives these arguments thus indicate a problem of assuming that dying people want to articulate their suffering and to participate actively in planning their final days materials and methods in 2018 the public authorities in one of the five regions of denmark expressed a desire to enhance palliative care the aim of our research was to follow the spread and effects of a conversation tool the tool was developed by the local health authorities in collaboration with professionals and patients with the purpose of facilitating palliative dialogues across hospitals and communities the concept of total pain guided the tool which focused on psychosocial challenges by asking patients questions like how are you doing is there anything about the disease you would like to know what gives you quality of life what troubles you and what do you hope the healthcare system and healthcare professionals can do for you the tool was formed as a small booklet with one question on each page and space to write notes below each question aamann and dybbroe were hired to do an evaluative research project this included two work packages one focused on patients and their perspectives and the other on organisational frameworks and interprofessional cooperation the research was designed as a multisited ethnographic investigation and the palliative conversation tool was followed at different sites following the understandings of reflexive ethnography and critical ethnography we were aware of observed practices as performance of cultures twelve patients were chosen by the professionals and followed by the researchers the patients had various lifethreatening diseases and were at different stages and ages fourteen palliative care clinicians and three gps also participated the majority of the palliative care clinicians had a bachelors degree in nursing were very experienced in the field and had had specialised training in palliation as white female middleclass researchers it was easy to blend in to the field we observed palliative conversations and invited patients and professionals to share their stories experiences and perspectives on these conversations we therefore organised two focus groups with professionals and a workshop with 16 professionals from different parts of the region we also had discussions with the early palliative care board representing patients researchers and professionals finally we regularly discussed our observations with patients professionals and relatives the actors involved were thus never objects of scrutiny but active participants all participants gave their informed consent both orally and through their active participation and tjørnhøjthomsen and hansen for the question of informed consent and ethical reflexivity participation was completely voluntary for both patients and professionals and they were informed that they could withdraw from the project at any time field notes were written without personally identifiable information and with pseudonyms for names of places and people as well as changes of gender diagnosis etc where this was considered irrelevant to the study the data consisted of over 317 pages of transcribed interviews informal everyday conversations and field notes after the fieldwork had ended the data were analysed using a dialogical communicative approach we noted differences and their relation to sites and contexts which produced the research theme of inequity in palliative care communication practices the cases we have selected two patients at opposite ends of the danish class society in terms of their different forms and amounts of capitals this is interesting because the palliative care provided was identical and the same nurse initiated the palliative conversations the two cases are chosen because they illuminate patterns identified in the whole data set as noted by flyvbjerg atypical or extreme cases often reveal more information because they activate more actors and more basic mechanisms in the situation studied in addition … it is often more important to clarify the deeper causes behind a given problem and its consequences than to describe the symptoms of the problem and how frequently they occur random samples emphasizing representativeness will seldom be able to produce this kind of insight it is more appropriate to select some few cases chosen for their validity the cases work like a magnifying glass for differentiation practices occurring more widely across the data both patients are male they have different fatal lung diseases patient 1 the privileged patient is approximately 80 years old he has not yet been declared terminal when aamann meets him the disadvantaged patient patient 2 is about 70 years old he has recently been declared terminal this life expectancy is representative of social inequality in health in denmark life expectancy for men with little education is seven years shorter than for welleducated men the men live under the same local authority patient 1 lives in a busy town while patient 2 lives in a small village at some distance from main roads which is a common difference between wealthy and poor danes a few days before the conversation the men received the small booklet they were asked to prepare for the conversations by reflecting on the questions and noting down the main points case 1 praising the successful and active agers the palliative care nurse explained to aamann before the care visit he is welloff the nurse has helped patient 1 decide whether to set up a fund as there are no inheritors the amount is around 55 million danish kroner 1patient 1 lives in a new twofloor flat near the towns lively shopping and pedestrian street there is a door phone and a wide comfortable staircase with a large roof terrace between the floors with lush lavender in flower pots and neatly arranged wicker garden furniture patient 1 and his younger friend greet us in the hall and show us into the first living room we see two sofa sets and many oriental antique figurines vases and lamps clearly expensive collectibles at the other end of the room is a large private roof terrace with panoramic views of the marina patient 1 has not written anything in the booklet he says casually but they have talked about it patient 1 and his friend assure us thats quite ok says the nurse reassuringly even though patients are supposed to write their answers on the dotted lines under each question the conversation begins as the nurse asks how are you doing patient 1 explains that his situation is stable the disease has not changed recently he can also see that many of the people i went with to fitness training they have gone he mentions a 60yearold who has already gone but says patient 1 they didnt do anything either i have lots of things to keep me occupied my cottage my garage etc the conversation turns to important everyday things and life quality patient 1 well i reckon its all about shopping a bit talking to people and driving around a bit you know patient 1s friend and when you go and do things in your garage he has recently bought the garage and does some business with cars nurse and its good exercise for your lungs getting out and about the nurse wonders whether patient 1 ever has bad days yes but then he just lies on the sofa she nods approvingly patient 1 does not have breathing problems when sitting down and otherwise he says it is a bit like exercise you get short of breath then you just have to stop and catch your breath and then you continue a bit later the nurse praises him thats the right attitude now the nurse asks if there is anything about the disease patient 1 would like to know they talk about the future patient 1 is worried about the stairs and has been out looking at some accommodation for seniors yes of course i could buy a small flat but that doesnt solve my problem of being with someone … the nurse says well find a solution and explains about care assessors she also writes down her phone number you are always welcome to call me patient 1 suggests they stop talking because the cleaning help is coming the nurse asks if it is a private company but they are from the council he receives cleaning help one hour a week the next question is about hope patient 1 hopes that he will continue to be able to drive his car so he can get around does he worry about anything the nurse asks nah he replies cause im not the type to complain about everything the nurse asks how do you feel about our talk patient 1 answers reclining on the sofa well it was fine i thoughtto talk a bit about everything patient 1s argument that other participants in the rehabilitation group have already died because they did not do anything forms part of the active ageing discourse death can be postponed through activity patient 1s own level of activity thus seems to confirm his value because he is enterprising he succeeds in keeping the disease at bay and appears as a valuable self who takes responsibility for his own health interestingly however patient 1s activities are not primarily physical exercise he drives around talks to people visits his cottage and conducts some car business in his new garage yet the nurse believes it helps his lungs by linking patient 1s social activities to keeping his lung disease in check the nurse helps patient 1 to understand himself as someone who takes responsibility for his own health and who actively fights the progression of the disease although patient 1 has not prepared properly for the meeting by writing in the booklet and sometimes just lies on the sofa he is met with respect and recognition from the nurse patient 1 is thus continuously supported by the nurses approving remarks she also places him and herself in the same boat by establishing a we and by giving him her direct phone number the appreciative nature of the conversation seems to draw on precisely the discourses of active ageing the conversation supports patient 1 and for him old age is apparently as it is promoted the longest holiday of your life this conversation is about patient 1s quality of life and it is thus an example of comforting and caring palliative communication let us now turn to the second case case 2 misrecognition of disadvantaged agers patient 2 is a retired manual worker besides his lung disease he also has a pacemaker his wife works in a factory and is therefore often away from home they live in a small village without shops many houses are dilapidated with scruffy facades they live in one of the older houses opposite an abandoned factory with broken windows and a collapsing roof in their garden are numerous rubbish bags and empty cigarette packets in the hall is a large cat box with gravel around it and various items scattered about on a small chest with no drawers aamann joined the nurse when she visited the family at their home in order to have a supportive talk with the wife of patient 2 at the time of the palliative conversation with patient 2 he is not at home but has a twoweek stay at the care facility where the nurse works the nurse introduces patient 2 on the way to his room by saying there are some problems with compliance he continues to smoke and refuses to exercise he only talks about it but doesnt do anything about it he has come to the facility to exercise but he doesnt want to get out of bed but patient 2 is also there to give his wife some respite the nurse explains recently there was a conflict he couldnt move from his bed to the car he thought he couldnt get into a wheelchair but with a little pressure he managed it the nurse explains we enter patient 2s room it exudes institution with worn furniture a neutral poster on the wall practical cold lighting from tubes in the ceiling there is a loud tv and a small bedside table full of boxes of medicine bottles of pills juice a radio a thermos flask coffee cup and sugar lumps he is lying in bed smoking an ecigarette patient 2 says the booklet is on the table the nurse searches there in piles of newspapers while patient 2 assures her that he and his wife have done as they were told last night they went through the booklet and his wife has written in it but maybe she took the booklet home with her says the nurse lets use my booklet instead the nurse starts the conversation by asking patient 2 how are you doing patient 2 does not seem happy with the place he is in he says it is worst in the morning they come with so many things and activities it gets too much and then he gets short of breath and panics he also tells me one day i had stool and she wouldnt change my pad unless i could get up myself and i couldnt and then she left when his wife came later she got very angry she could see the mess in my bum he says the nurse rounds off the topic by saying that doesnt sound reasonable you had a need which was met by a demand that you couldnt fulfil the conversation turns to important everyday things and life quality patient 2 is happy that his wife gets a little respite she has bad arthritis and is burdened by caring for her ill husband and by her physically exhausting work the nurse explains about the difference between the diseases the lung disease is something you will die from while the arthritis is very painful but not lifethreatening she continues you know its a progressive disease where you get worse and worse have you thought about deactivating the pump function when its really bad patient 2 replies quickly and breathlessly no and i dont think we should talk about it either because then ill just lie here thinking about it but… ive got some leaflets at home i could look at now the nurse asks if there is anything else about the disease patient 2 would like to know he cannot remember nurse is it perhaps difficult to describe it with words have you tried to write the thoughts down patient 2 says his eyes are getting worse and that he cannot really read or write any more nurse have you been to an optician like i have suggested earlier no… patient 2 sighs heavily cause we cannot really afford new glasses and i cant apply for financial support cause i dont know how to fill out the forms online he has asked the staff at the care facility but they are busy and the same goes for the cleaning help at home they come for one hour every three weeks and they move on quickly the nurse offers to help him to apply he seems grateful do you worry about anything the nurse asks yes cause they dont come when i call them they just say someone else is in a worse state than you when the nurse asks patient 2 what he hopes for he replies that the staff ask me how i am and maybe chat a bit patient 2 is clearly having difficulty in living up to the implicit norms of active ageing and exercising he lies passively in bed watching television or listening to the radio while smoking he also gets stressed when the nurses show up in the morning with a lot of activities in relation to the focus on peoples will and ability to take on responsibility patient 2 does not perform legitimately he is not a successful ager as he does not exercise or show any desire or ability to conform to active ageing or a healthy lifestyle it is interesting that the nurse says to aamann that patient 2 does not want to get up and only talks about it suggesting laziness and lack of willpower and selfdiscipline or even disobedience by contrast patient 2 himself says he cannot get up the comment about the refusal to change patient 2s pad is intended to show that the nurse acknowledges patient 2s situation but it is also a value judgement on his performance and his situation it does not state that the demand was unreasonable merely that patient 2 was unable to fulfil it which thus makes him appear indirectly responsible patient 2 clearly prefers to live his final days without considering how and when death might occur he does not want to talk about it although he mentions some leaflets perhaps to appear obliging instead of rejecting the nurses suggestion this theme appears in the conversation at a time when the talk was supposed to be about important everyday things and life quality although the palliative care here works as a form of social palliation for patient 2 as he gets to complain about his problems and is partly supported by the nurse it is nevertheless remarkable that the main relief for patient 2 is to talk about the disrespectful way he is treated by healthcare workers results different lives and different palliative encounters the professionals attitude and the patients approaches to the conversation it is striking how the two patients have prepared differently and how the professional attunes differently patient 1 and his friend have written down nothing and the overall impression is that patient 1 has made little effort to prepare for the conversation and has a rather nonchalant approach to it but the nurse does not consider this to be disqualifying in contrast patient 2 eagerly explains that he and his wife have done as they were told they went through the booklet and his wife has written in it he thus seems quite obedient and responsible unlike with patient 1 however the nurse does not say it is quite ok when it turns out the booklet has gone missing the difference in the two mens approaches to the conversation demonstrates their economically unequal positions while patient 2 is greatly dependent on free access to care and financial support patient 1 has the money to buy services he does not receive or is dissatisfied with the implications of this are that patient 1 holds an attitude of carefree superiority he does not need to prepare properly because he does not need to fear sanctions by contrast patient 2 is very dependent on care and benefits and seems to feel that he must cooperate and obey orders like writing answers in the booklet it is even more striking that the nurse introduces the patients to aamann in quite different terms patient 1 is not described as problematic although he seems less compliant than patient 2 who is presented as having problems with compliance despite his eagerness to cooperate the nurse also says that patient 2 only talks about doing things whereas it was quite acceptable for patient 1 to lie on the sofa we also see that the nurse trusts patient 1 much more than patient 2 she expresses full confidence in patient 1s ability to make the right choices such as lying on the sofa on certain days conversely there is doubt about patient 2s ability to assess his own activity level according to sointu clinicians perceptions of patients draw from a repertoire of social stereotypes for example good patients are seen as active participants who are involved and motivated to learn about their disease and take charge of it in contrast bad patients refuse the responsibilities of the sick role they resist doctors recommendations and make bad choices they neither take an active part in their healthcare nor do they communicate well these norms are present in our study where it seems that the nurse considers patient 1 a good patient and patient 2 a bad patient talking about death patient 2 receives a challenging question about turning off the pacemaker and the oxygen it is worth noticing that the question is not in the booklet and that patient 1 is not asked explicitly about his forthcoming death this may be because patient 2 is closer to death but nevertheless it is thoughtprovoking that the question is posed in relation to important everyday things and life quality where the nurse elaborates on the differences between the illnesses that patient 2 and his wife are dealing with this leaves an impression of a lack of compassion towards him patient 2 is however clearly reluctant to talk about death instead of reflecting on his wishes and worries he becomes short of breath and states that he would rather not speculate on it institutionalised terms such as involvement and dialogue very often presuppose a reflexive self which is a classbased and thus unevenly distributed resource howarth discusses the problem of the need to participate actively in communication about ones death because the main interest in this seems to come from betteroff middleclass people she argues that a form of stoic calm characterises workingclass culture which conflicts with the implicit perception that all endoflife patients and their families need to articulate their suffering using the correct selfreflexive terminology the problem is thus that because the conversation indirectly requires the desire and ability to reflect upon and talk about death patient 2 is perceived as someone who may suffer from poor illness insighthave compliance problems however a conversation between a healthy professional at work and an ill person in a low position in society with a loss of previous social identity is asymmetrical per se which can make equity difficult regardless of the professionals intention furthermore patient 2s fear of death might be an obstacle to professional procedures because it may prevent identification and documentation of his final wishes different classesdifferent access to active ageing the distinctions between good and bad patients are closely related to class inequality and there are thus many people who are unable to be a good patient performing a healthentrepreneurial valuable self as liveng argues when desirable old age is unambiguously presented as active this conceals the fact that older peoples possibilities to live up to its normative ideals are unevenly distributed according to dumas and laberge class dispositions towards physical activity manifest themselves during ageing they also note different classes enter ageing with different habitus the working classes for example may be more disposed than the middle or upper classes to accept bodily decline as inevitable rather than to seek improvement in their bodies in this perspective patient 2 may have an understanding of body and self that conflicts with the normative ideals as he might have accepted the weakening of his body and thus finds it pointless to exercise further he becomes confused and anxious when the staff come to his room with a range of activities the same applies to patient 1 at the opposite extreme his habitus fits into the dominant narrative of being active and keeping the disease in check the two mens previous work and life conditions are a point to consider here patient 1 was a businessman while patient 2 did hard manual work further there is a marked difference in their financial basis for enterprise and optimisation patient 1 buys a garage for fun while patient 2 cannot afford reading glasses it is striking that the nurse seems unaware of these differences in terms of class arguably instead of compensating for inequality she is reproducing it by attributing different symbolic and moral value to the good and the bad patient this can be attributed to neoliberal individualisation in which class inequalities are typically neglected and disadvantage is understood as a result of psychological deficits and moral deficiencies patient 1s driving around and chatting with people is valued as rehabilitation by the nurse there may be good reason for this macdonald whose field is dementia points out that relationships are a vital aspect of dementia care because to live is to be held in connection this obviously works for patient 1 who is free to choose what he wants to do he is also a busy man rounding off the conversation because the cleaning is coming he expresses a kind of moral superiority when he emphasises that he is not the type to complain about everything subtly distinguishing himself from people who do complain for patient 1 it is quite natural to keep going his life is pleasant with interesting hobbies socialising and financial freedom conversely patient 2 is bedridden and has poor finances yet he expresses a strong desire to be held in connection his greatest hope is that the staff would just ask how i am and maybe chat a bit in contrast to patient 1 however patient 2 finds that no one shows interest in him they do not come when he calls sointu noted even when formally all patients receive the same care informally medical students observe good patients being afforded time care and appreciation that bad patients are thought not to deserve or want in line with this patient 1 is offered help if he decides on publicly funded senior housing instead of buying a flat himself although he would probably be able to manage by himself meanwhile patient 2 seems to be perceived as undeserving as he is judged as a bad and irresponsible patient he needs welfare payments and does not make an active effort to keep going but is then sanctioned inequity in palliative care class and active ageing when dying discussion we have seen how the discourse of active ageing generates classbased distinctions between good and bad patients we have shown how the ideal of old age intrudes into the healthcare system and thereby influences the handling of ageing and death illustrating how active ageing permeates palliative care to create normative expectations with demands that many endoflife patients might be unable to meet in line with sointus point about how clinicians perceptions of patients draw from a repertoire of social stereotypes a further important point is that healthcare professionals in denmark also belong to the broad middle classes previous studies of danish prevention policy show that clinicians work is largely coloured by the professionals personal tastes and preferences based on their class furthermore nurses are also subject to the neoliberal discourses of value accumulation by taking on the role of health entrepreneurs to enhance symbolic value since class is increasingly configured through the symbolic value of the self it can be almost impossible not to adhere to the distinction between legitimate and illegitimate endoflife patients this hegemonic middleclass consciousness blocks awareness of class differences in the ability to comply with the norms of ageing this study has several limitations due to its methodological choices it is a small study and thus not representative of denmark as a whole although it does include data from both a rural and an urban area furthermore the patients were not subsequently interviewed about their palliative care experiences and the professionals were not interviewed with a focus on class there are several reasons for this the perspectives presented in this article were only systematically analysed after the project had ended further class is often perceived as illegitimate since it raises questions about moral worth in qualitative interviews therefore informants are often evasive when class is mentioned explicitly skeggs argues that to speak about class is different from living it people seldom consider themselves or their practices in terms of class unlike gender and ethnicity which are often explicitly referred to class works as a structuring absence it is thus debatable whether interviewing the patients or the professionals would have further illuminated the processes explored here however interviewing healthcare professionals about social inequality might have clarified how the discourses the culture and the institutional framework encourage them to adopt middleclass positions and praise active ageing in palliative care conversations conclusion in this article we have explored how discourses of active ageing establish new distinctions between successful and irresponsible agers and how this aligns with class as conceptualised by bourdieu and skeggs we have shown how classifying practices of value attribution shape palliative encounters we have analysed two cases and revealed how the quality of palliative care varies even when the service provided is identical privileged patient 1 is supported through acknowledgements and is thus approached as a subject of value ie a good patient while disadvantaged patient 2 is met with a form of indulgent patience and dignity violations since he is a bad patient it is particularly interesting that class is reinforced in palliative care in a universal welfare state with equal rights to publicly funded healthcare it is notable that patient 1 who is supported by his wealth is assumed to need help and receives it while patient 2 who needs greater social financial and healthrelated support is allocated a lower level of service we can thus conclude that palliative care is unequally distributed along class lines and appears to be yet another good for wellsituated privileged patients who already reap the most benefits from healthcare in the nordic welfare states if social class plays no part in our understanding of differences in health professionals ways of interacting with ageing and dying people there is a significant risk of reproducing such socially differentiated practices several quantitative studies have described this differentiation but without explaining why and how it takes place in this qualitative study our particular aim was to understand how the notion of active ageing becomes a horizon for palliative care which obscures an understanding of the importance of social class in palliative practices the analysis therefore reveals how inequality in palliative care takes place unnoticed by healthcare systems professionals and quantitative research unequal health is not mainly created in the healthcare system as it is a consequence of inequality in society but in order to achieve equity it is crucial to address the socially unequal situation of patients we therefore suggest improving the quality and sensitivity of medical training this could help mitigate some of the negative effects of class highlighted in this article such as the reliance on stereotypes when providing patient care publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the purpose of this article is to explore social inequity in palliative care in denmark a country that is seen as a stronghold of universal health care using data stemming from 2 years of research we have selected two cases for analysis they consist of palliative conversations with two quite different patients drawing on sociocultural class theory we find that the conversations involve social exclusion processes due to discourses of active ageing we find that one privileged patient performs in line with an entrepreneurial self and is supported by the nurse the other disadvantaged patient performs in a passive way and the conversation mainly alleviates the disrespect he has experienced in healthcare encounters we conclude that palliative care reinforces classifying practices and distinctions between good and bad patients when active ageing becomes a dominant factor we suggest improving the quality and sensitivity of medical training and call for increased reflexivity among professionals on the unequal situation of patients in order to reduce inequity in access to health care when close to deathin this article we investigate how palliative care is affected by discourses of active ageing we analyse palliative care conversations and our specific interest lies in how social differentiation is embedded in discourses of active ageing which imply a middleclass ideal of a selfentrepreneurial subject all citizens in denmark are entitled to free public healthcare elderly and palliative care is also a public responsibility although private services coexist although

introduction the use of simulation devices in medical education is centuries old and includes anatomical models in the teaching of anatomy threshold innovations such as åsmund laerdals resusci anne modern highfidelity manikins simulated patients and virtual reality 1 simulation is defined as follows a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice learning evaluation testing or to gain understanding of systems or human actions 2 examining the features and use of simulation technology the best evidence medical education review of the literature from 1969 to 2003 3 the authors concluded that the quality of published research for this period was generally weak however the available evidence suggested that highfidelity simulations facilitate learning under the right conditions a followup review of the literature from 2003 to 2009 using combined critical and realist review methodology identified 12 features of best practice for simulationbased education and concluded that simulation technology can produce substantial educational benefits 4 revisiting this review in 2016 mcgaghie et al 5 found that the evidence supporting sbe as a powerful educational intervention was growing in england the chief medical officers report for 2008 safer medical practice machines manikins and polo mints states that simulation offers an important route to safer care for patients and does so by improving performance reducing errors and strengthening team work the report recommends that simulation needs to be more fully integrated into the health service 6 this theme was further developed by khan et al 7 who built an argument for increasing expansion of sbe driven by patient safety and improvements in healthcare they concluded that the continuing advances in simulation technology and an indepth understanding of educational principles and practical applications of sbe to outcomebased programmes will help bridge the gap between the classroom and clinical environment this application of theoretical knowledge to the practical management of patients and the transition from student to doctor are key areas of interest in sbe research 8 reviewing the evidence for simulation to help bridge the perceived educational gap in students training and resolve the disconnect between classroom and clinical environment okuda et al 9 found multiple studies that demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge procedural skills teamwork and communication but only a few studies showing direct improvement in clinical outcomes in summarising the outcomes of technologyenhanced simulation training for health profession learners cook et al 10 found that compared to no intervention technologyenhanced simulation is associated with large positive effects for knowledge skills and behaviours and moderate effects for patientrelated outcomes reviewing the literature bell et al 11 found a mixed picture as to the effectiveness of simulations as training tools and called for more theorydriven research focussed on the instructional capabilities of the technologies used in simulation echoing this call for more theorydriven research sevdalis 12 stressed the need for simulation studies to move away from presenting selfreport data from small numbers of attendees to those that present a deeper theoretical and practical understanding of effective sbe more recently in the editorial marking the launch of advances in simulation nestel 13 reinforced the value of studies that deepen our understanding of sbe interventions and stated that more complex uses of simulation technologies researchers have a responsibility to thoughtfully align research paradigms with hypotheses and research questions this call for more theorydriven research is not confined to sbe cook et al 14 proposed a framework to classify the purpose of educational research studies in four leading educational journals the framework classified studies into one of three categories description justification and clarification their results showed that only 12 of reported articles could be classed as clarification studies with description at 16 and justification at 72 applying this framework to over 1300 abstracts from four major sbe conferences over 2 years graham et al 15 found that only 93 of abstracts could be classified as clarification studies there are a multitude of evaluation instruments and methods for the sbe researcher to choose from in reviewing the published evaluation instruments for human patient simulation within nursing education kardongedgren et al 16 found a lack of reliable and valid instruments to evaluate learning outcomes they suggested a moratorium on the indiscriminate development of new evaluation tools which focusses on selfreported satisfaction and confidence which could lead to the development of a milewide and inchdeep evaluation landscape they recommend the use of multiple instruments to evaluate a simulation in order to capture all the learning domains and to explore how actions in the simulations carry over into the clinical arena however the evaluation instruments reviewed did not address the issue of how or why the interventions being studied achieved their outcomes whether an intervention is successful or not was highlighted by ogrinc and batalden 17 who argued that traditional study designs such as randomised controlled trials nonrandomised and prospective cohort studies while useful depending on the focus of the evaluation fell short in a key component namely being able to identify the depth of contextual information that is helpful when replicating the findings in another setting one such study design is the context input process and product evaluation model 18 which seeks to answer four kinds of questions these are what should we do how should we do it are we doing it correctly and did it work however it does not specifically address the questions how and why the intervention worked the answers to which are required to provide a deeper theoretical and practical understanding of effective sbe 1213 one evaluation methodology that explores both the context and underlying mechanisms of how and why a programme works is realist evaluation 19 realist evaluation realism is a philosophy which positions itself between positivism and constructivism positivism describes reality as fixed and our knowledge of that reality which is neutralvalue free can be described by theories that are objective and generalizable positivist research aims to discover what exists through prediction and control using mainly quantitative methods with the researcher being an independent observer 20 conversely constructivism views reality and knowledge of that reality as not fixed but socially constructed and this knowledge has both multiple constructions and values constructivist researchers are active participants in the research and use both quantitative and qualitative methods 21 the realist view of knowledge is that there is a real world and through our senses brains and culture we process our knowledge of it 22 in relating this to the clinical environment there is a real world of patients signs and symptoms and these are open to a variety of interpretations which depend on the complex interaction of external influences on the clinician realist evaluation seeks to answer the question what works for whom in what circumstances and why 23 in answering this question the realist researcher seeks to identify test and refine the components of an educational programme that work as well as those that do not the three fundamental components that realist evaluation seeks to investigate are context mechanism and outcome in other words educational programmes work when they provide appropriate opportunities or resources to groups under appropriate conditions this is known as the contextmechanismoutcome configuration 19 and can be written as the formula context mechanism outcome there is no set limit on the number of proposed cmo configurations that are constructed for the educational programme under investigation the key element is the relationship within each cmo 17 the researcher gathers data in order to test the proposed cmo configurations simulation is a complex educational intervention with multiple interacting components which can make it challenging to evaluate however realist evaluation may provide more useful information about its effectiveness than traditional models of education evaluation 24 so how might a realist evaluation of an sbe programme be designed the guiding framework is the realist evaluation cycle which has four key steps 19 step 1 formulate a working theory one of the key areas of interest within sbe is the impact of medical school simulationbased learning on newly qualified doctors performance 8 exploring this example the working theory would be a oneday simulationbased course would enhance the transition from final year medical student to newly qualified doctor step 2 hypothesis formulate the hypothetical cmo configurations ie what might work for whom in what circumstances and why table 1 presents an example of the proposed cmo configurations for the sbe course aimed at final year medical students step 3 observations test the theory by gathering data on the cmo configurations using a mixed methods approach the researcher is not limited to a particular method but can choose whichever approach to collecting and analysing the data that suits the intervention under study step 4 programme specification reveals what did work for whom in what circumstances and why this provides a refined theory which will inform future interventions and programme evaluations the process then continues in an iterative cycle context the context reflects the reality into which an intervention is introduced and provides the conditions that trigger the mechanisms to produce the desired outcomes 19 and requires that all elements that are relevant to the mechanisms be considered 17 just as all social programmes are introduced into preexisting social contexts so sbe programmes are introduced into preexisting healthcare and or educational contexts therefore researchers should not ignore the contexts of m1 providing the opportunity to experience and explore the role of a newly qualified doctor in a simulated setting o1 to foster an understanding of the role of a newly qualified doctor c2 final year medical students who have extensive knowledge and clinical experience but have not had the responsibility of managing the acutely unwell patient m2 presenting a variety of realistic simulated medical and surgical emergencies using a highfidelity manikin o2 to assess and manage the acutely unwell patient using a structured approach c3 the majority of students have observed the management of a cardiac arrest m3 allowing the students to manage a simulated cardiac arrest o3 to increase understanding of team work and communication c4 before commencing as newly qualified doctors the students undertake a 6week assistantship m4 exploring the role of the newly qualified doctor and setting goals for assistantship o4 to identify and set goals for assistantship c5 the students have varying levels of confidence m5 providing immediate feedback and exploring the factors that influence when and why the students call for assistance o5 to recognise personal limitations and when to call for help their programmes and to do so is regarded by pawson and tilley as one of the great omissions of evaluation research 19 in their critical review of simulationbased research 20032009 mcgaghie et al 4 highlighted 12 features and best practice of sbe that teachers should know in order to use simulation technology to maximise educational benefit a number of these related to context and included how the intervention integrated into the wider medical curriculum and its outcomes simulation fidelity instructor training and the educational and professional context within which the interventions occurred however they cautioned that the introduction of a complex service intervention such as sbe into medical education environments would not be easy and with time may reshape the goals and practices of those same educational programmes thus changing the original context 4 acknowledging the importance of context and prompted by the recognition that sbe has several unique features including a wide variety of simulation modalities and instructional design cheng et al 25 called for those reporting simulationbased research to provide more detailed descriptions of the context within which their interventions occurred the key elements to report are participant orientation simulator type simulator environment simulation eventscenario instructional design or exposure and method of feedbackdebriefing while some of these contextual elements are easily described and can to a limited degree be standardised for research purposes eg fidelity of simulator and scenario design 26 others are not in our experience these elements usually relate to the students and how they construct their own version of the contextual reality as they interact with the faculty each other and the environment 27 this interplay between individuals and the educational programme means that the causal mechanisms are located in the social relations and context as well as the individuals 28 drawing on the experience of a realist evaluation of a simulationbased course for final year medical students conducted as part of a higher degree examples of contextual elements that can affect learning and may not be easily identified through other evaluation approaches includes students who have significant anxieties about sbe those delegates forced to attend by their line managers inadequate orientation to the simulated environment instructor training and experience and the timing of the course in relation to other significant events eg final examinations mechanism explanatory mechanisms are the central tenet of realist evaluation and comprise the processesresources and responses of stakeholders to those processes resources operating in a given context that generate the outcomes of a programme 19 mechanisms can be visible and form part of the design of an evaluation or invisible and only come to light during the evaluation process 23 mechanisms are said to fire or be triggered in a given context to create an outcome pawson and tilley explain this using the gunpowder analogy 19 in which the chemical composition of the gunpowder is the mechanism that creates an explosion when a spark is applied however if the conditions are not favourable eg damp gunpowder or no oxygen present then there is no explosion this onoff response has been challenged by dalkin et al 29 who argue that activation of a mechanism operates on a continuum similar to a light dimmer switch they believe that this has more explanatory value in understanding how interventions work leading to a graduated response of outcomes and fits with our experience where learning outcomes do not usually operate on a metnot met basis eg unskilledcompletely skilled or no confidencecomplete confidence in helping to clarify the concept of mechanism astbury and leeuw 30 highlight what mechanisms are not firstly evaluators should make a clear distinction between mechanism and programme activity for example it is not an sbe intervention in and of itself that generates the outcomes but the knowledge gained or the increase in confidence of the participants secondly mechanisms should not be considered as independent causal variables rather they attempt to explain why variables are related that is how did the sbe intervention cause an increase in participant confidence and how did this generate the observed outcomes another challenge for the realist evaluator is to distinguish between context and mechanism to help differentiate between the two dalkin et al 29 proposed an alternative operationalization of pawson and tilleys formula context mechanism outcome 19 which explicitly disaggregates mechanism into its component parts the resources offered and the changes in reasoning of the participants the new formula is written as m context → m outcome and provides both an operational and conceptual clarification of mechanism 29 for example cheng et al 25 list simulator type as a contextual element however applying the revised formula what was previously considered contextual becomes part of the mechanism simulators vary in type and level of fidelity and their effective use depends on matching the educational goals to the simulation tools used and taking into account the level of expertise of the participants 4 as a result the simulator type becomes the m the participants level of expertise is the context how the participants interact with and learn from the simulator is m and the outcome is the measurable change in the participants skill andor knowledge when considering the concept of mechanism educators should be cognisant of the educational theoriesconceptual frameworks that underpin the resources they offer as well as the change in reasoning that may occur as a result and should declare these in their evaluations so what are some of the educational theoriesconceptual frameworks that underpin sbe in their realist review mcgaghie et al 4 identified the following feedback deliberate practice mastery learning team training and highstake testing while ker and bradley 31 highlighted social constructivism experiential learning reflective learning and activity theory more recently graham et al 15 reported the ten most commonly declared educational theoriesconceptual frameworks in abstracts from simulation conferences these were in descending order cognitive theories experiential learning gaming theories learning styles deliberate practice interprofessional learning mastery learning realism selfregulated learning and the flipped classroom table 1 shows the proposed mechanisms for the simulationbased course for final year medical students using mechanisms m2 and m4 as examples we can explore the m m and educational theory for each m2 the m is the highfidelity manikin chosen because the students have extensive clinical experience and so expect to elicit realistic signs and symptoms from the manikin as well as have it react in real time during the scenario the m is the students recognising the value of a structured approach to managing the acutely unwell patient while putting theory into practice the underlying conceptual framework is activity theory which states that learning knowledge and activity are intrinsically linked and there is a relationship between one activity system and another in this case the simulated and the clinical environments 31 it also stresses the concept of contradiction and tension in learning 32 which in this example is between the students theoretical knowledge of how to manage the acutely unwell patient and their practical ability to do so the desired outcome is the students become more proficient in using a structured approach when assessing and managing the acutely unwell patient m4 the m is giving the students the opportunity to manage the scenarios as if they were the newly qualified doctor on the ward and the context is the impending 6 week assistantship the m is by allowing the students to explore the roles and responsibilities highlighted by the scenario they would set personalised goals for the assistantship the underlying conceptual framework is selfregulation theory which seeks to optimise learning and performance using goaldirected behaviour 33 this list is not exhaustive and each researcher should identify the key mechanisms they consider to be operating within their own sbe programme that are thought to produce the desiredmeasured outcomes outcome and data collection outcomes of educational interventions can be expected unexpected positive or negative in addition programme outcomes cannot just be viewed as undifferentiated wholes but rather as the complex outworking of multiple mechanismcontext effects 19 there are a number of approaches available when describing and evaluating the outcomes of educational programmes blooms taxonomy 34 classifies the learning outcomes that educators set for their educational programme into three domains cognitive affective and psychomotor using this framework the outcomes for the simulationbased course for the final year medical students are cognitiveto foster an understanding of the role of a newly qualified doctor and to increase understanding of team work and communication affectiveto recognise personal limitations and when to call for help and psychomotorto assess and manage the acutely unwell patient using a structured approach and to identify and set goals for assistantship kirkpatricks hierarchy 35 is one of the most widely applied approaches and describes the value and worth of training it has four levels with the evidence for higher levels being harder to collect reactionhow do the participants react favourably to the event learningwhat knowledge skills and attitudes do the participants acquire as a result of the event behaviourto what degree do the participants apply what they have learned during the event and resultswhat targeted outcomes occur as a result of the event at an organisational level eg improved patient outcomes another approach is the use of translational science outcomes which has been highlighted as useful for sbe research 83637 there are four levels which are said to move from the bench to the bedside 8 these are educational effects achieved in educational laboratories improved patient care practices better patient outcomes and collateral educational effects realist evaluation uses a mixed methods approach to data collection 19 which involves the collection analysis and interpretation of both quantitative and qualitative data in a single study 38 this has been shown to be of benefit when studying complex interactions 39 the triangulation of data from different sources allows for a richer and fuller explanation of the data 40 and the evaluation takes the form of an iterative explanationbuilding process 41 this methodological diversity has been recognised as an important development within medical education 5 the aim of the realist researcher is to understand the patterns of outcomes that result from the firing of different mechanisms in different contexts and the relationship between them 17 taking the evaluation of the simulationbased course for final year medical students as an example a routine course evaluation questionnaire using a 5point likert scale 42 completed immediately after the course would provide kirkpatrick level 1 data about the students satisfaction with the course the effectiveness of the debriefing relevance to their work length and timing of the course kirkpatrick level 2 and 3 data could be obtained from a followup questionnaire with space for free text sent out after the students complete their first rotation as newly qualified doctors that investigates what lessons had been learned from the course and whether these had been applied in their new role further qualitative data can be obtained from individual interviews or focus groups 40 which explore the proposed cmo configurations that is the effect of context the proposed enabling mechanisms and the extent to which the outcomes had been achieved and if not why not patient outcome and quality of care data are more challenging to collect requiring the researcher to identify or construct suitable databases that can be used to study the outcomes at an organisational level 8 discussion using a methodology that clarifies why an intervention works by examining all of its component parts context mechanism and outcome allows others to better interpret the results deepens understanding and helps to advance sbe research 81213 in our unpublished evaluation we discovered that although the students reported that the course had helped with the transition from student to newly qualified doctor not all of the students were setting goals for their assistantship the focus group data revealed that the timing of the course before the final examinations meant that the students priorities were the exams and not setting goals for the assistantship thus the context prevented the mechanism from firing which adversely affected the desired outcome pawson by his own admission does not claim that realist evaluation is perfect and mentions a number of difficulties that arise when trying to apply realist principles 23 these include the absence of an explanatory focus using only one data collection method failure to investigate the cmo configuration and the restrictive word counts imposed by some publications from our own experience the practical challenges included a poor response rate to the followup questionnaire no one turning up to one of the arranged focus groups and too many turning up to another potentially inhibiting some of the quieter members of the group so what has realist evaluation delivered so far in the field of healthcare in their review of realist evaluations marchal et al 28 found 18 papers describing realist evaluations across a variety of healthcare settings they showed that the uptake of realist methodology has been slow however they argue that even a superficial application of realist evaluation has advantages as it explores the processes and context rather than just the intervention and its outcomes they admit that more clarity is needed concerning how the termscontext and mechanismsare defined and call for more conceptual work to allow a greater understanding of these issues krupat 43 has called for research that is conceptual and thoughtful and identifies the mechanisms that mediate and moderate the relationship between action and outcome exploring and developing theories about mechanisms can add value to programme evaluation by revealing why a programme works which in turn can better inform the design and evaluation of future programmes 30 regehr has highlighted the need for health profession education research to reorientate its alignment with the imperative of proof to one of understanding and from the imperative of simplicity to one of representing complexity well 44 realist evaluation is a methodology that is able to address these issues by exploring all aspects of an intervention there are challenges in performing realist evaluations but we encourage the simulation community to adopt its principles and by doing so help clarify and define the contexts mechanisms and outcomes that are unique to our simulated version of reality and help answer what works for whom in what circumstances and why 23 availability of data and materials not applicable abbreviations beme best evidence medical education cipp context input process and product cmo context mechanism and outcome sbe simulationbased education funding while no funding for this manuscript was received the period of study for the degree of master of medical education was funded by the montagu clinical simulation centre as part of its commitment to staff development authors contributions acg produced the first draft of the manuscript and both acg and smca made significant contributions to the critical revision of subsequent versions of the manuscript and approved the final version for submission authors information ethics approval while no ethics approval for this manuscript was required it is based on a research dissertation submitted to and accepted by the university of dundee in partial fulfilment of the degree of master of medical education and supervised by smca ethics approval for this project was obtained from the university of dundee research ethics committee competing interests the authors declare that they have no competing interests

this article describes the key features of realist realistic evaluation and illustrates their application using as an example a simulationbased course for final year medical students the use of simulationbased education sbe is increasing and so too is the evidence supporting its value as a powerful technique which can lead to substantial educational benefits accompanying these changes is a call for research into its use to be more theorydriven and to investigate both did it work and as importantly why did it work or not an evaluation methodology that is capable of answering both questions is realist evaluation realist evaluation is an emerging methodology that is suited to evaluating complex interventions such as sbe the realist philosophy positions itself between positivist and constructivist paradigms and seeks to answer the question what works for whom in what circumstances and why in seeking to answer this question realist evaluation sets out to identify three fundamental components of an intervention namely context mechanism and outcome educational programmes work successful outcomes when theorydriven interventions mechanisms are applied to groups under appropriate conditions context realist research uses a mixed methods qualitative and quantitative approach to gathering data in order to test the proposed contextmechanismoutcome cmo configurations of the intervention under investigation realist evaluation offers a valuable methodology for researchers investigating interventions utilising simulationbased education by investigating and understanding the context mechanisms and outcomes of sbe interventions realist evaluation can provide the deeper level of understanding being called for

introduction in contemporary society achieving gender equality has emerged as a central objective in the pursuit of social justice and societal progress despite substantial advancements towards this cause a persistent and deeply entrenched obstacle continues to impede womens progress in their professional pursuits the inequality that exists from centuries this term encompasses the intangible yet formidable barriers that hinder womens growth and mobility and restrict their access to their limited positions in societies over the course of history women have encountered numerous challenges that restrict their opportunities and prevent them from enjoying the same privileges as their male counterparts in similar positions the gender inequality serves as a symbol of these imperceptible obstacles that perpetuate gender disparities and hinder womens advancement in various societies sectors and countries this essay aims to delve into the concept of gender inequalities explore its implications for women in their lives and unravel the multifaceted challenges it poses by analysing the underlying causes and consequences of this phenomenon and proposing potential strategies for reducing these gender inequalities we can deepen our understanding of gender inequality and actively contribute to the creation of inclusive and equitable environments for women obstacles faced by women the obstacles encountered by women in their life journeys have persisted throughout history transcending time and cultural boundaries whether in the realms of finance marketing human resources or procurement women often find themselves navigating through deeply maledominated environments this systemic gender disparity can be attributed to a complex interplay of social cultural and institutional factors the concept of the gender inequality is symbolic of the invisible barriers that limit womens growth and mobility and it manifests differently across countries and businesses all over the world despite significant promotion of diversity in companies as well as legislation for equal opportunities for women and men it must be noted that women still remain largely in the minority in decisionmaking positions this observation reflects the phenomenon of gender inequality that constitutes vertical discrimination within societies against women although gender inequality has generated research interest some authors have pointed out that theoretical models have made little attempt to develop an understanding of this phenomenon and its implications however despite these initiatives and the increasing number of qualified and trained women it is clear that they are still largely underrepresented in the decisionmaking process in most sectors indeed despite the current enthusiasm for diversity in companies and regulations for equal opportunities for both genders the numbers have not changed much in the last decade women constitute fewer leadership positions in 2018 women occupied 16 of positions on the executive committees of large belgian companies2 better than ten years ago when the rate hovered between 9 and 10 but still low compared to the overall employment rate of women and their share of the population of university graduates developed versus developing countries nevertheless women in developed countries find it comparatively easier to work in corporations relative to those in developing countries this is accounted for by various reasons as developing nations in particular present unique challenges that exacerbate gender inequities for example in countries like india and pakistan deeply rooted societal norms and limited access to education perpetuates gender disparities in the workplace or work culture and society overall from the very start this implies that in a developed country like the us women find it easier to go out look for a job and start working because their society accepts women as part of its workforce that being said every country has a different level of gender inequality a cardinal factor that affects the density of gender inequality is a countrys policies china is a fitting example of this fact when the chinese government developed and implemented its onechild policy chinese women were able to join the workforce in large numbers because their responsibilities at home were reduced methodology and findings the methodology that was used to understand the extent of inequality faced by women in the society was surveys surveys are the best method to use when trying to collect qualitative data because the researcher is able to collect detailed data in a timeefficient manner the survey consisted of 10 questions it was limited to this number of questions because participants often feel they are unable to fill longer surveys the survey also consisted of closed ended questions so that the responses of the participants could be easily interpreted while analysing the findings the respondents could tick yes or no only as an answer the survey was given to 350 women who were all working different jobs the survey consisted of the following questions q1 do you think there is gender inequality in your country q2 do you feel that women are given the same work opportunities as men q3 do you think stereotypes formed against women play a role in increasing gender inequality in the society q4 do you think the role of women should be limited to taking care of their families q5 do you think the gender of a person should decide whether they get a promotion at work or not q6 at your workplace are women treated equally as compared by their male coworkers q7 do you think women are given the same promotional opportunities as men q8 are there more men at a higher position in your company as compared to women q9 do you think men are better suited to be ceos q10 do you think women in developed countries are treated better than women in developing countries the findings of the surveys were very interesting with similar answers from most of the participants majority of the participants believed that a gender inequality existed in their country 60 of the respondents believed that women were not given equal opportunities 68 believed that stereotypes against women do play a role in increasing gender inequality 80 answered no to women being restricted only to taking care of their families 78 believed that women were not treated equally and were not given higher positions in the office and 85 believed that women in developed countries were treated better than women in developing countries domestic responsibilities of women in sharp contrast to this a family on average has more than three children in each household in the rural areas of many developing countries this increases the domestic responsibilities of the women who marry into these families ultimately reducing the number of women in the workforce similarly the values instilled in people in some scarcely developed third world countries hold them back from viewing women as an equal part of their workforce it is important to acknowledge that despite advancements gender inequalities continue to persist within corporations in developed countries as well however this observation does indicate that proactive measures have been implemented to mitigate the prevalence and impact of such barriers moving on developing countries face the unfortunate reality of limited awareness surrounding gender inequality resulting in minimal progress being made within corporate settings to address the gender gap this stark contrast can also be attributed to disparities in educational opportunities between developed and developing nations the level of education attained by women in a given country directly influences their awareness of gender inequalities and conversely their lack of awareness perpetuates sexism therefore it has become evident that recognizing the issue of gender inequality is an essential prerequisite for devising effective measures to dismantle this everexisting phenomenon gender inequality as a major hurdle apart from the gender inequality women face multifaceted hurdles in their professional lives sexual harassment a pervasive issue plaguing workplace poses a significant barrier to womens career advancement and growth in society sexual harassment in the workplace and in the regular lives of women remains a distressing reality for countless women undermining their rights dignity and professional aspirations studies consistently highlight the alarming frequency of sexual harassment incidents in workplaces and in societies overall according to a report by the equal employment opportunity commission nearly 75 of women have experienced some form of workplace harassment with a significant portion of these cases involving sexual harassment additionally a survey conducted by the international labour organization revealed that approximately 32 of women worldwide have experienced workplace sexual harassment human rights watchdog reports that in pakistan 68 women are sexually harassed still many of them remain silent and reluctant to lodge formal or informal complaints of their disturbing experiences because of the fear of losing job shame stigmatization on womens repute and not wanting their families to know about the issue in nepal research on sexual harassment in the workplace revealed that the problem is highly prevalent in workplaces as 5384 per cent of women workers reported that they have faced the issue of sexual harassment in their workplaces in japan a study conducted by the ministry of labour found that out of 2254 women respondents two third were subject to some form of sexually harassment caran et al has conducted research to find out the existence of sexual harassment among professors in a public university in brazil 407 of the participants admitted being victims of sa at work while 593 knew a fellow who had suffered sa and 704 stated that it is a common problem in the institution women tend to face sexual harassment in every aspect of their life whether its professional or private harassment of women in workplaces it is important to identify the link between gender inequality and their role in societies and at the workplace as far as the harassment of women at workplace in the developed world is concerned two third of the complainants alleged that their harasser was in a superior position to them reflecting a traditional sexual harassment profile of a superiorsubordinate relationship anita hill a prominent advocate remarked sexual harassment is about power its about power in the workplace power in your home its about power this quote underscores the power dynamics at play and the urgent need for systemic changes that challenge and dismantle oppressive structures on the one hand it is an oversimplification to say that having more women in higherlevel positions would stamp out all sexual harassment problems but on the other it is hard to deny that if more women are in supervisory managerial and executive jobs at a company it is more likely to be proactive about addressing the problem and holding harassers accountable the sexual harassment faced by women in their private lives can be resolved only by attributing the same level of power to men and women the persistence of gender inequality in terms of opportunities and representation further impedes female progress one reason why men tend to advance more quickly in the corporate world compared to women is the presence of gender discrimination which is fueled by unfounded stereotypes that view women as too feminine researchers have faced challenges in drawing definitive conclusions due to the limited representation of women in top positions for instance in fortune 500 companies only 148 of board seats were held by women even in countries like australia canada japan and europe the presence of female directors is scarce the percentages of female directors in these countries range from as low as 04 to 106 studies conducted on obstacles faced by women recent studies have delved into new areas of investigation for instance crosssectional evidence collected by baxter and wright highlights the importance of tailored surveys that target working women who have experienced repeated promotion denials such research endeavours aim to gather accurate data and generate insights into the prevalence and impact of the gender inequality faced by women the promotion denials reflect a broader systemic issue of gender bias and discrimination limiting womens professional growth and reinforcing the inequalities that exist studies conducted by anders bjorklund in the us show that on average men had a higher chance of promotion than women at all levels of the hierarchy denoting gender inequality at multiple stages in the corporation during this study a sample comprising women was asked about the negative effects of gender inequality on their professional lives and predictably 80 of them had similar answers in a study by edin richardsson where the age experience level and the quality of work done by the employees were controlled by researchers it was discovered that men were promoted to higher levels while women were discriminated against throughout the hierarchical levels and every level of society ferre and purkayastha demonstrated that the way in which institutional structures and social environments are built ensures the persistence of womens inferiority at jobs and in societies in general men are awarded privileges solely because of their gender according to dana m britton and christine l williams women are faced with systematic obstacles at every level of the organizational hierarchy and face difficulties in every aspect of their lives these barriers can take the form of an inherent gender bias that manifests itself in a variety of ways ie rarely getting promoted during promotional processes prejudice and gender oppression ingrained in men constitutes two of the main reasons behind gender inequalities in many societies gender bias engenders an inferior position for women as a consequence they become more susceptible to other adversities like sexual harassment that violates their rights meanwhile the prevalent mindset among people fails to advocate or even attempt the equal treatment of women men are given dominance in both workplaces and societal roles when male managers are instructed to make hiring decisions especially promotion decisions they tend to focus on many irrelevant aspects such as the illfounded belief that women leave the organization upon or during pregnancy the skill set of the woman her dedication and her loyal service to the company are regularly overlooked instead the negatives garner the focus of these supervisors when promotion decisions are taken in most of the cases men were promoted to positions of senior authority when the decision was up to male managers this panel consisting of male managers who sit at top positions in every firm exceedingly reinforces the gender inequality role of men in causing gender inequality both senior and junior male managers hold the belief that women lack the competence to effectively balance their familial and professional responsibilities they assume that when faced with a choice between pursuing their career aspirations or prioritizing their families women would opt for the latter these generalizations create a significant barrier in breaking through the gender inequalities and ensuring that women have equal access to the career opportunities deserve and work hard to earn to weaken this gender inequality and promote gender equity in the workplace it is crucial to address and eliminate preconceived misconceptions it requires challenging the notion that womens commitment to their families undermines their professional abilities research and evidence have consistently shown that women are capable of successfully managing both their personal and professional lives moreover it is important to foster a work culture that supports and accommodates the diverse responsibilities and aspirations of all employees regardless of their gender this includes implementing familyfriendly policies flexible work arrangements and providing support systems that allow individuals to strike a balance between their work and personal commitments the role of women in societies should be given the due importance it deserves the barriers women face when they are promoted to managerial positions are counted amongst the less destructive obstacles in their worklives in comparison to others such as sexual harassment which harms their selfesteem and their prestige in both professional and personal spheres the impact of gender inequalities extends beyond the limitations of promotions women also face other challenges which violate their rights as employees james et al proposed categorizing different forms of gender inequalities such as pay gender inequalities managerial promotion inequalities and prestige gender inequalities to better understand their causes and effects the labeling culture and its implications let us have a look at the formidable impact of the gender inequality in the corporate sector where it continues to thrive as a pervasive phenomenon according to a report published by catalyst a leading nonprofit organization focused on workplace equality women hold only 29 of senior management positions globally this stark underrepresentation of women at top leadership levels highlights the persistent existence of the gender inequality research conducted by eagly and carli reveals that gender stereotypes and biased perceptions contribute to the gender inequality stereotypes associating men with leadership qualities and women with communal traits create unconscious biases influencing the evaluation and promotion processes within organizations these biases perpetuate the gender inequality by impeding womens progress towards executive roles fuelled by various causes like the labelling culture across organisations the labelling culture often results in the assignment of negative attributes to women who challenge traditional gender norms by aspiring leadership roles women who exhibit assertiveness confidence and ambition may be labelled as bossy aggressive or difficult to work with while their male counterparts displaying the same behaviours are seen as competent and driven this genderbased perceptions creates a double standard undermining womens credibility and hindering their chances of career and professional advancement the impact of the labelling culture goes beyond individual experiences it permeates the organizational culture shaping norms and expectations around gender roles and leadership as a result even wellintentioned policies and initiatives aimed at promoting diversity and inclusion may fall short if the underlying toxic culture is not addressed women in leadership positions have to adopt a leadership style that is compatible with the companys traditionally maledominated culture they feel forced to adopt directing methods that will be met with appreciation from their male managers and senior male executives as a result they are unable to adopt the leadership style that they are most comfortable with inhibiting them from working in a manner which is the most fulfilling to themselves the independence of women as managers is challenged because they are restrained from being true to themselves and their teams as leaders advantages of diverse leadership studies have shown that diverse leadership teams yield significant benefits for organizations a report by mckinsey company indicates that companies in the top quartile for gender diversity on executive teams are 25 more likely to have aboveaverage profitability than those in the bottom quartile this data emphasizes the business imperative of reducing gender inequality and fostering gender equality within corporate leadership and the society the gender inequality in politics remains a stubborn challenge for women around the world restricting their advancement to the highest echelons of political power and leadership a closer look at the facts and figures reveals the extent of the gender inequality and the uphill battle women face in the realm of politics one striking fact is the underrepresentation of women in political leadership positions according to the interparliamentary unions data from september 2021 women constituted only 237 of national parliamentarians worldwide this glaring disparity extends to heads of state or government where women remain a minority such substantial underrepresentation highlights the ongoing struggle women encounter in accessing and assuming influential political roles decision makers in the political arena form their decisions based on the subconscious premise that there should be a higher percentage of men than women on every platform this constitutes an incumbency advantage or inertia towards women the justification offered by these decisionmakers is that it seems unreasonable to select women in a field where women have been historically absent politics is yet another career domain where disparity among the two genders is crystal clear to anyone who is even mildly inclined towards these matters the role of chief staff officer is bestowed upon women as a reward for their years of loyalty to a political candidate they are not offered the same opportunities in terms of the position that they autonomously aspire to achieve in contrast men benefit considerably from this gender disparity making their way up the political ladder astoundingly quicker estimates suggest that achieving gender parity in political leadership globally could take another 50 to 100 years at the current rate these figures underscore the urgent need for concerted efforts to dismantle the gender inequality promote gender equality challenge biases and create inclusive political environments that empower women to participate fully in the political spheres gender stereotypes and their implications the growth of gender inequality is fuelled by implicit bias and unconscious gender stereotypes this bias hampers the recruitment process creating an unfair hiring system for women to gain a comprehensive understanding of the extent of the gender inequality effect recent studies have examined not only the gender ratios and percentages of women at different hierarchical levels but also the gender pay gap within organizations shockingly even in companies that exhibit relatively equitable gender representation substantial pay disparities exist highlighting the deeprooted nature of gender inequality in the workplace hr departments attempts to design genderneutral selection processes often fall short contributing to the perpetuation of the gender disparities that exist legislations concerning equal pay exist in a lot of countries but they are not effectively executed in practice whether they are teaching jobs or corporate jobs men are paid more than women without consideration of any other factor than gender antisex discrimination laws have also been formulated in various countries but their implementation has been excruciatingly slow while women continue to be heavily discriminated against especially in the corporate sector these laws and regulations will not do much to reduce gender inequality if they are not administered properly and soon while it is important to acknowledge the structural barriers that contribute to the gender inequality it is equally essential to recognize that fellow female workers can inadvertently reinforce these inhibitions internalized biases and misogynistic stereotypes perpetuated by women themselves can impede their professional advancement this phenomenon known as the queen bee syndrome reveals a complex dynamic within workplaces the role of mentoring research indicates that women in leadership positions may be less likely to mentor or support other women hindering their progress a study published in the harvard business review in 2008 found that women in senior positions were more reluctant than their male counterparts to mentor or advocate for other women this behaviour can stem from the scarcity mindset where women perceive limited opportunities for advancement and see other women as competitors rather than collaborators sheryl sandberg facebooks coo and founder of the lean in movement pointed out in her book lean in women work and the will to lead that women sometimes hold themselves back by not supporting each other she writes too often women become envious or resentful of their female colleagues because they perceive them as competitors this phenomenon is not solely anecdotal studies corroborate its existence the 2020 women in the workplace report conducted by leaninorg and mckinsey company revealed that women are less likely to receive advice from senior leaders or have opportunities for career advancement compared to their male counterparts this disparity can be partially attributed to the lack of support and sponsorship from fellow female workers however it is crucial to avoid generalizations and recognize that this behaviour is not universally characteristic of all women in the workforce many of them actively champion and support their female colleagues challenging the gender disparity with power these women understand the importance of collaboration networking and uplifting one another to collectively overcome systemic barriers burdening them for centuries prominent figures have spoken out about the significance of female solidarity in dismantling the gender inequality madeleine albright the first female us secretary of state once stated there is a special place in hell for women who dont help other women albrights quote emphasizes the responsibility of women to support and empower one another to reduce inequality based on gender and achieve equality steps that can be taken to reduce gender inequality in order to reduce gender inequality it is important to first recognise the factors that contribute to its persistence following are the most prominent factors that play a key role in increasing gender inequality • implicit bias in evaluation and promotion implicit biases often unconscious affect decisionmaking processes and hinder womens advancement research conducted by yale university revealed that both male and female evaluators are more likely to associate men with leadership potential and higher competence leading to unfair evaluations and promotion decisions this bias increases the gender inequality by overlooking womens qualifications and potential • lack of flexible work arrangements the absence of flexible work arrangements can pose a significant challenge for women in their career progression many of them juggle multiple responsibilities including caregiving and household tasks without flexible schedules or remote work options it becomes challenging for women to achieve a worklife balance leading to a stalled career progression • maledominated networking and sponsorship networking and sponsorship are crucial for career advancement many industries and organizations still constitute maledominated networks and sponsorship structures men are more likely to have access to influential networks and senior mentors who can complement their careers this disparity in networking limits womens visibility and access to rewarding relationships adversely impacting their advancement opportunities • stereotype threat stereotype threat refers to the fear of confirming negative stereotypes associated with ones social group women may experience stereotype threat in maledominated fields leading to reduced confidence and performance a study published in the journal of personality and social psychology found that womens performance in quantitative tasks declined when reminded of gender stereotypes this phenomenon hampers womens ability to thrive and be recognized for their skills ultimately reinforcing the gender inequality • maternal bias and maternity penalties maternal bias as a form of gender bias affects women who become mothers research has shown that women experience reduced perceived competence and commitment to their careers after having children it often leads to maternity penalties in the form of decreased promotion prospects lower salaries and limited access to intellectually stimulating assignments the perception that motherhood compromises commitment and availability create additional barriers for womens growth • institutional barriers and organizational culture structural and cultural barriers within organizations contribute to gender inequality limited availability of familyfriendly policies such as affordable childcare or parental leave can hinder womens career progression additionally organizational cultures that prioritize long hours and a facetime mentality disadvantage women who seek worklife balance or alternative approaches to leadership • unconscious bias training insufficiency while unconscious bias training is increasingly adopted by organizations its impact may be limited without comprehensive implementation a study published in the journal of experimental social psychology showed that brief unconscious bias training programs had minimal longterm effects on reducing biases organizations need to invest in sustained and comprehensive training efforts to address biases effectively • gendered communication styles gendered communication styles and expectations can negatively impact womens progression research has shown that assertive communication styles typically associated with leadership are more readily accepted by men while women are often expected to exhibit communal and nurturing behaviours this discrepancy can lead to womens ideas being overlooked or undervalued limiting their visibility and influence within organizations • lack of sponsorship while mentorship provides guidance and advice sponsorship involves influential individuals advocating for an individuals career advancement women often face a shortage of sponsors who actively champion their professional growth a study by the center for talent innovation found that women were 54 less likely than men to have a sponsor which can substantially impede their access to critical opportunities and visibility within the organization • gendered performance evaluation criteria performance evaluation criteria that are gendered or biased can also hinder womens progress research has indicated that traditional evaluation metrics may not fully capture the leadership skills and qualities that women bring to the table genderneutral performance assessment frameworks that account for a diverse range of leadership styles and competencies are needed to mitigate this bias • lack of access to stretch assignments stretch assignments or highprofile projects are vital for career growth skill development and visibility however women may face minimal access to these opportunities due to bias perceived riskaversion or traditional gender roles the center for american progress reported that women are less likely than men to be given challenging assignments that can showcase their abilities and pave the way for career advancement • limited boardroom diversity the composition of corporate boards has a significant impact on organizational decisionmaking and culture research has consistently shown that diverse boards including gender diversity lead to improved performance and innovation however womens representation on boards remains low in many companies the 2020 women on boards gender diversity index revealed that women held only 226 of board seats in fortune 1000 companies the lack of diverse perspectives at the highest level of authority increases the gender inequality and hampers gender equality in leadership • digital gender divide the digital gender divide refers to the disparities in access usage and skills related to digital technologies between men and women in todays digital age technological proficiency is increasingly crucial for career advancement however women regularly face barriers such as limited access to technology stereotypes that discourage their interest in stem fields and biases that hinder their progression in hightech roles bridging the digital gender divide is essential to ensure more equal opportunities for all genders in emerging industries and digitalcentric workplaces • unconscious bias in artificial intelligence systems as ai technology becomes more popular in various aspects of organizations the presence of unconscious biases in ai systems can increase the gender disparity ai algorithms trained on biased data can perpetuate discriminatory practices in recruitment performance evaluation and promotion decisions for instance if historical data reflects biased gender patterns ai systems may unintentionally reproduce those biases leading to unequal treatment of women addressing and mitigating unconscious biases in ai systems is therefore crucial to ensure fair and equitable opportunities for career advancement • online harassment and cyberbullying the rise of online platforms and social media has opened new avenues for professional networking and communication however women are disproportionately affected by online harassment and cyberbullying which can have significant repercussions on their professional lives research by the pew research center has shown that women experience higher rates of online harassment including sexist and misogynistic attacks such harassment may erode womens confidence impede their participation in online professional spaces and limit professional opportunities for them conclusion taking it all into account it is reasonable to assert that the issue of the gender inequality remains a significant and persistent challenge for women crosssectional evidence collected by researchers globally has proven quite useful because it has laid foundation for further research in the future baxter and wright remarked that accurate data on the gender disparity phenomenon can be collected only if the right people are asked the right questions at the right time another conundrum explored by hibbs locking when surveying women on this topic was the possibility of a mightier gender inequality at the upper levels of hierarchy than the lower and that if this is the case is this phenomenon consistent throughout developed and developing countries an interesting question that arises here is are men aware of the ascending gender discrepancy and the unfair distribution of promotional opportunities such questions form basis for further research all in all the problem of gender inequality can be resolved only when this phenomenon is recognized by both men and women across the globe despite progress in various aspects of gender equality women continue to face obstacles that hinder their progressive mobility and limit their access to top leadership positions the gender inequality often defined as the barriers that prevent women from reaching the highest echelons of power and authority is just one among several hurdles that women encounter in professional environments numerous studies conducted worldwide have shed light on this issue revealing that even in countries like sweden often perceived as having relatively higher gender equality there is pervasive discrimination against women when it comes to their placement in senior roles within businesses the scandinavian countries known for their progressive policies and commitment to gender equality have made significant strides in reducing gender gaps in various areas however the gender discrepancy has not vanished indicating that there are deeperrooted systemic factors at play that need to be addressed this realization has sparked increasing attention to the subject leading to ongoing studies and research aimed at understanding and addressing the gender inequality more effectively researchers policymakers and organizations are working together to unravel the complexities of this issue examining its causes and consequences and proposing strategies for breaking this barrier the recognition of the disparity in gender as an everincreasing problem has also been amplified by women themselves due to negative conditioning and internalized misogyny who are now more conscious than ever of its existence and are experiencing its adverse effects to an alarmingly high extent noteworthy findings from various studies indicate that even when controlling for variables like age and race between both genders the gender discrepancy remains intact due to insufficient measures taken to address it systematically while individual efforts and initiatives have made a difference for some women comprehensive and coordinated action is necessary to dismantle the structural and cultural barriers that perpetuate gender disparities in the workplace to address inequality and decrease its negative impacts it is crucial to identify and mitigate the underlying causes both internally within organizations and externally within society as a whole implementing diversityenhancing policies at all levels emerges as a viable corrective measure organizations need to adopt proactive strategies that go beyond tokenism and foster a culture of inclusion and equal opportunity for all one key aspect of this approach is the implementation of policies that promote diversity and inclusion within organizations this can include targeted recruitment efforts aimed at attracting and hiring qualified female candidates as well as the establishment of mentoring programs that provide guidance and support to women as they navigate their professional journeys addressing this issue requires more than just internal organizational efforts it necessitates a broader societal transformation to challenge deeply ingrained prejudice and norms that perpetuate gender inequality this includes initiatives to promote gender equality in education media representation and cultural narratives by challenging traditional gender roles and expectations we can create an environment that encourages women to aspire leadership positions and provides them with the necessary support to succeed in addition creating a culture that values and celebrates gender diversity is crucial in dismantling the biases that contribute to the gender disparity effect organizations must foster an environment where gender equality is not only respected but actively promoted this can be achieved by challenging preconceived notions promoting inclusive behaviours and attitudes among employees and providing training and awareness programs to address unconscious biases furthermore organizations should prioritize the development and advancement of women leaders through targeted leadership development programs networking opportunities and sponsorship initiatives by recognizing and valuing the unique perspectives and contributions of women organizations can create a more equitable and inclusive workplace that makes all members better off to conclude the discussion the gender inequality remains a mighty barrier for women even in countries with a reputation for gender equality that being said by implementing proactive measures to address the underlying causes and promoting inclusion organizations can pave the way for women to break through these barriers it is essential for corporations to recognize the potential of women in leadership positions and to provide the necessary support system for them to thrive only by collectively working towards gender parity can we create a truly equitable and healthy society that fosters the talents and contributions of every individual regardless of race gender or ethnicity implementing diversityenhancing policies at all levels emerges as a viable corrective measure this includes strategies such as targeted recruitment efforts mentoring programs and flexible work arrangements the result of these efforts if appropriately and adequately implemented will emerge in form of a better and fairer world

the main method used was a survey which around 350 working women from multiple countries including pakistan turkey and lebanon responded to regarding different aspects of their professional ideologies and observations extensive secondary research was employed to explore the issues of role of women in society sexual harassment faced by women in their homes and workplaces and the magnitude of gender inequality in developing versus developed countries the main findings concluded that gender inequality is a longstanding hurdle in the path of women it exists at all levels in the society and is not limited to a single culture or country the gender inequality is not the only barrier faced by women in their journeys however it may pave way for other obstacles like sexual harassment the measures presently taken to combat the negative impacts of gender inequality on women are inadequate and require more thought and better implementation for them to prove fruitful in eradicating the issue

introduction adolescent pregnancies remain a public health concern globally 1 the greatest proportion of adolescent pregnancies occur in less developed countries and mostly among those with no education and those from poorer households 2 it is estimated that around 21 million adolescent girls between 15 and 19 years of age get pregnant annually in developing countries 34 further projections indicate growth in adolescent pregnancies globally by the year 2030 mainly due to the evergrowing adolescent population worldwide especially in african countries 5 pregnancy and childbirth among adolescents have both health and social ramifications healthwise pregnancy and delivery complications are the leading causes of death for girls 15 to 19 years worldwide 6 babies born to adolescent mothers have elevated risks of childhood morbidities and mortalities 7 socially adolescents who become pregnant face stigmatizing or other negative responses from people within their environment including their family members and friends as well as the health care setting 89 they often tend to practice unsafe abortions in countries with restrictive abortion laws 10 which may cause several complications with permanent health consequences or even death 411 globally around 39 million unsafe abortions occur among 15 to 19yearold girls each year 4 additionally adolescent pregnancy interferes with the girls future education and limit opportunities for employment 12 the use of contraceptive methods have been proven to prevent unwanted early pregnancies and in turn unsafe abortions 13 however research shows that the use of effective contraceptive methods is rather low among sexually active african youth including ghanaian youth 13 with even lower rates among rural area dwellers and those in the lowest wealth quantiles 14 available data suggest that the use of condoms is relatively more common among adolescents compared to the other birth control options because of its ready availability and low cost 15 however though condoms prevent pregnancy and sexually transmitted infections depending only on condoms for protection bears several risks especially for the girls condoms can only be an effective way of protection when used correctly and consistently for correct condom use one relies on the partners willingness to use them but this can be a challenge for adolescent girls who lack the skills and competences for condom use negotiation 16 moreover in stable relationships research reports decrease in consistent condom use over time relating their use with being loose or not trustworthy 17 for maximal protection for adolescents therefore the dual method approach ie using condoms and a hormonal contraception seems the best option 18 while there is an extensive body of scientific literature on factors influencing condom use 1920 studies focusing on factors that influence hormonal contraception use are limited to be able to address the problem of low hormonal contraception use a clear understanding of all related individual and environmental factors is needed we therefore carried out a qualitative study to understand the barriers to hormonal contraceptive uptake among adolescent girls in kintampo a rural ghanaian community which has a high annual births by adolescent 21 a rate above the national average of 14 22 yet hormonal contraceptive use among adolescents is low with an estimated prevalence of 13 among sexually active girls 23 this manuscript uses the socioecological model 24 to guide our understanding of the factors associated with nonuse of hormonal contraceptives among adolescent girls 15 to 19 years of age in the kintampo area of ghana the socioecological model posits that human behavior is influenced at multiple interacting levels including the individualintrapersonal the interpersonal the community the institutional and the public policy levels 24 in this study we have focused on the individual interpersonal community and institutional level factors individual level factors influencing hormonal contraceptive use in adolescents have been related to poor understanding of several aspects of hormonal contraceptive use including the different types of hormonal contraceptives available and how the methods work 25 poor knowledge on side effect 26 and poor knowledge on cost and legality of use 27 also limited awareness of methods perceived to be right for adolescents poor knowledge on sources of obtaining the methods poor selfefficacy and skills to use the method have been related to poor uptake of hormonal contraceptives 28 moreover poor compliance negative experiences with specific hormonal contraceptive methods fear of side effects of specific methods and fear of related health risks of hormonal contraceptive use in general have been associated with low uptake 29 30 31 in addition adolescents fear of negative stigmatizing responses related to early sex and contraceptive use from their parents peers religious leaders amongst others have been reported to negatively affect hormonal contraceptives use amongst them 16 32 33 34 at the interpersonal and community levels varied social norms exist in different cultures 35 and they either motivate or demotivate the performance of certain behaviors 36 societal norms related to sexual morality in many african cultures disapprove of all forms of illicit sex 37 people who deviate from societal norms face undesirable responses including ostracism and stigmatizing responses 37 studies have reported that social norms that discourage premarital sex and contraceptive use negatively affect intentions to use 38 as well as actual modern contraceptive use amongst adolescents 39 at the institutional level lack of access to youthfriendly health facilities poor health professionalpatient relationship lack of privacy and confidentiality at health dovepress open access journal of contraception 202112 facilities lack of indepth discussions during consultation and cost of hormonal contraceptive methods 1529 affect use of hormonal contraceptive methods next to empirical findings on factors explaining nonuse of hormonal contraception several healthbehavior related theories may provide additional explanations 40 41 42 applying the health belief model adolescents may not be using hormonal contraceptives because they do not perceive themselves as susceptible to unwanted pregnancy also they probably do not perceive the consequences of unwanted pregnancy as severe and do not believe in getting any potential benefit from using hormonal contraceptives further adolescents perceived barriers to hormonal contraceptive use and lack of selfefficacy to use may explain why adolescents do not use hormonal contraceptive methods this is evidenced by findings from halls systematic review of literature in using the hbm to guide the understanding of modern contraceptive behaviors and practice with in the general population 40 indepth information on factors influencing uptake of hormonal contraceptive methods in africa is limited in general and more so in subsaharan africa 43 besides majority of scientific publications do not differentiate in their outcome measure between hormonal contraceptive methods and other nonhormonal contraceptive methods including condoms 15 in this qualitative paper we explored the factors that limit uptake of hormonal contraceptives from the perspective of adolescents in the kintampo area of ghana methods study area description this study was conducted in the kintampo area which is situated within the forestsavannah transitional ecological zone in the bono east region of ghana it covers an area of about 7162 km 2 with an approximate resident population of 150000 the population is youthful with over 45 under the age of 15 years 44 about 40 of adolescents 15 to 19 years of age are sexually active 23 with a total fertility rate of 47 births per woman 15 of annual births are attributed to girls 13 to 19 years of age 21 contraceptive prevalence among adolescents is 25 45 the male condom is the most commonly used contraceptive method among adolescents in this region while hormonal contraceptives are only used by about 13 of sexually active girls 23 study design this was an explorative study using qualitative data collection methods from april to june 2018 two focus group discussions made up of 10 and 12 respondents respectively and sixteen indepth interviews were carried out among adolescent girls to determine factors that negatively affect the uptake of hormonal contraceptives amongst them both methods were used because the idis are effective at generating indepth personal and private information complimented by fgds that produce interesting group outputs showing divergence or convergence of opinions between the group members 4647 study population and description of participants the study included 38 adolescent girls aged 15 to 19 years thirtysix out of the 38 girls had been to school with the highest level of educational attainment being senior high school the remaining 21 girls either had a primary level or junior high school level of education two girls had never been to school about half of the girls lived with both parents the others either lived with a single parent other relatives or lived by themselves most participants were christians and the four others were muslims about two thirds had a boyfriend at the time of data collection for pregnancy prevention a few used the male condom others also used rhythmic and withdrawal methods none of the participants stated to have ever used hormonal contraception description of study tools an interview guide made up of semistructured questions was used for data collection guides for both the fgds and idis contained the same questions the guides were developed based on an extensive literature review of the factors that are reported to be associated with hormonal contraceptive use among adolescents globally guided by the socioecological model the interview guide was structured thematically under sections such as awareness of hormonal contraceptive options and their mode of action attitudes to hormonal contraceptives normative perceptions about hormonal contraceptive use among adolescents and community norms the data collection tools were pretested among some adolescents in the study area and necessary contextual adjustments were made before data collection recruitment and data collection procedure participants were purposively selected from two senior and one junior high school two adolescent health corners and three dressmaking parlors in the kintampo municipality and south district verbal announcements about the study were made in the recruitment centers in the schools we asked permission from the head teachers to talk with the girls in their classrooms we shared information about the study which comprised a summary of the study objectives and study procedures and we explained how to enroll into the study by writing their names and phone numbers on a piece of paper that was left behind prospective respondents were given up to a day to rethink about participation after they signed up for the study inclusion criteria were based on age educational background and nonuse of hormonal contraceptives any adolescent who reported ever having used hormonal contraceptives was not included in the study the idis and fgds were done face to face in either english or the local language depending on the preference of the participants the first fgd was held at a school premises in a designated room free from intrusion the second fgd was held at a church premises idis were held at school premises youth health centers and participants homes the discussions were facilitated by a female social scientist guided by an interview guide right before the start of the interview participants were again reminded of their rights given in the written informed consent forms for participants less than 18 years consent was provided by their teachers if interviews were done in school or parents if interviews were done at home in addition to their individual assent participants received copies of their signed consent forms on average an idi lasted between 25 and 35 minutes whilst an fgd lasted between 60 and 90minutes all interviews were audiorecorded and transcribed verbatim with those in twi further translated into the english language the moderator sought the consent of respondents before recording and taking notes of all discussions after conducting two fgds and 15 idis no new themes emerged and so data saturation was reached data collection ended after one more idi was done data management and analysis atlasti version 842 qualitative data analysis software was used in managing and analyzing data collected all eighteen transcripts were exported from ms word into atlasti and thematic analyses were done guided by the grounded theory technique an inductive approach was used to identify major themes that emerged from the data 41 two members of the study team independently reviewed the first three transcripts and formulated preliminary codes guided by the objectives of the study iterative reviews were done between the two team members to identify other subthemes and discussion were held when coding differed until agreement was reached established codes were then applied to all transcripts for final analysis by the first author all code summaries where again reviewed and discussed by both the first and the second author for the transcripts review process participant data related to their names were deidentified electronic files containing the audios and transcripts from the study have been stored in passwordprotected computers results reasons for nonuse of hormonal contraceptives are presented below structured by the different levels of the socioecological model quotes from both focus group discussions and interviews are included to illustrate major themes the opinions expressed by adolescents on their perceived barriers to hormonal contraceptive use were not different for both indepth interviews and focus group discussions hence results were merged it is worthy to note that the adolescent girls used the terms family planning and contraceptives loosely to refer to hormonal methods such as the pill injection and the implant so even if the girls did not specifically refer to the word hormonal in the illustrative quotes the methods they mentioned refer to what we consider as hormonal methods individual level factors of influence awareness and knowledge of hormonal contraceptive methods almost all the girls had heard of hormonal contraceptive methods which they also called family planning methods the majority of them could mention at least one form of hormonal contraceptive method the injection and the implant were the most common methods mentioned however even though most participants were aware that hormonal contraceptive methods exist and are used by women in their reproductive age to prevent pregnancy they could not explain their exact mechanism of action a typical misconception was that hormonal contraceptives destroy the mans sperm making it incapable of impregnating a woman when you use it and you have sex it destroys the mans sperm so that it cannot impregnate you knowledge of where to get hormonal contraceptives almost all the girls knew at least one source for obtaining a hormonal contraceptive method hospitals were the most frequently mentioned source and then clinics pharmacy shops and drugstores the preferred source of hormonal contraceptives was stated as the hospitals because hospitals are more equipped with personnel and equipment how can someone obtain a hormonal contraceptive method if they want to … through hospitals and some drugstores but going to the hospitals is more relevant than the drugstores few girls stated to not know where one could obtain the hormonal contraceptive method knowledge of the cost of hormonal contraceptive methods about half of the girls did not know how much it costs to get a hormonal contraceptive most of those who claimed to know only speculated that it was not expensive r please it is not all that costly it is not costly anyone who wants to do it the person can be able to afford and just do it straight only one girl could attribute a price to the the implant and few knew some organizations provide it for free madam it is free if you want to go and take out the implant they will take 30 ghana cedis from you a few of them mentioned that in their opinion hormonal contraceptives are expensive and said they presumed the cost deterred people from accessing it attitude toward hormonal contraceptive use most of the girls who were interviewed had positive attitudes toward the use of hormonal contraceptives in general but tended to be more negative when it was about adolescents using it they said that it helped to prevent unplanned pregnancy especially teenage pregnancy therefore users could work have peace of mind complete school or finish a trade they were learning mostly among married women they felt it is very useful for spacing their children they indicated that hormonal contraceptives could be used by the married unmarried women and young girls in relationships it is good … people use it to prevent unwanted pregnancy some people had unplanned pregnancies so to plan for the next pregnancy they use the family planning methods this is because if they are unable to space their birth they find it difficult to take care of the children however the use of hormonal contraceptives among married women was more acceptable to most girls compared to unmarried adults and young girls they said that adolescents who used contraceptives did not think or had no good morals they liked sex they had no selfcontrol and were promiscuous the girls were also of the opinion that adolescents who used hormonal contraceptives may become sick or infertile and so they hurt themselves by using the methods these perceived side effects were also the most often mentioned disadvantages of hormonal contraceptive use … i feel that they dont have good morals or they cant live a chaste life that is why they go for contraception … some people say that the contraceptives are not good you cant have children after using it so if i see them using it i feel that its is very bad for a young girl like me to use contraceptives other respondents did not see anything wrong with adolescents using contraceptives they said it is a way of securing their future using contraceptives would help them to prevent teenage pregnancy to be able to complete their school or whatever trade they were learning they also said it is always better than abortion and that some adolescents have already given birth and may like to prevent a second child from coming so it is good for those to use contraceptives selfefficacy in organizing and using hormonal contraceptives a few of the adolescents expressed selfconfidence in their ability to use hormonal contraceptives should they want to they claimed to know the benefits they would derive from using contraceptives and so if they decided to use it they could in contrast most respondents said it would be very difficult for them to get a method if they wanted to the adolescents indicated that they would have a negative feeling obtaining a hormonal contraceptive method from a pharmacy shop clinic or hospital they attributed this feeling to their perceived providers negative reaction towards them they all stated that providers would ask them a lot of questions including why they had come for a contraceptive method at this age how old they were what they were using those things for amongst others they also felt the providers would think of them as bad girls and judge them because of their young age as for me i will feel very shy they will ask you several questions they will say you are too young what are you using this pill for or why are you coming for this implant in addition the girls feared providers would breach the confidentiality of their use of hormonal contraceptives these negative feelings they said will make it very difficult to seek for hormonal contraceptive methods the quotation below illustrates this feeling they will ask you what you have come there for and when you tell them and you leave the place they will also tell other people maybe those people cannot also keep secrets so very soon people will start pointing their fingers at you when they see you passing when that happens i will not do it however most of these responses were based on the girls expectations only one girl confirmed to have experienced such responses from a provider besides all these worries one girl stated it would only be difficult the first time attending a clinic after that the people would know why she comes and stops asking the questions fear of perceived hormonal contraceptive side effects almost all adolescents had some form of misconceptions about contraceptives they described several negative effects attributable to contraceptive use including infertility sickness extreme weight gain or weight loss changes in the menstrual cycle and colour of blood heavy bleeding spotting constant bleeding amenorrhea dysmenorrhea amongst others other issues mentioned include body weakness dizziness fainting blood clots during menstruation miscarriages and becoming epileptic … i have heard that someone went to insert one and when she came back to work with it she collapsed and since that she is been epileptic specifically for the implant they said it could dislodge to other parts of the body i know one lady who was using the implant when it was time for her to get married the thing had made her grow so fat so they went to the hospital to get the thing out but they could not find everything one of them was missing and they could not find it moreover some of the girls expressed a strong fear of the side effects of hormonal contraceptives this fear emanates from unpleasant experiences other people have had from the use of hormonal contraceptives the thought of these perceived side effects deterred them from using the methods i had a friend who was using it but it was worrying her so she took it out and then later she became pregnant but she had a miscarriage so when we went to the hospital they said it was because she was using the hormonal contraceptive method that was why she lost the baby the implant got mixed in her blood in line with this it came out strongly that adolescents were better off using shortterm methods to prevent risks related to using longterm methods … it is just that i think we should not use the long term methods like the one for five years at least you can take the monthly injections however one girl stated the need to switch between methods if one experienced an unpleasant effect a friend of mine said when she did it initially it was good but later her bleeding pattern changed from one week to days … and she grew very fat after some time she had severe lower abdominal pain then later she lost weight and began to faint … she said it is the injection so she stopped and she is now using the pills and all those effects stopped dovepress open access journal of contraception 202112 anticipated disclosure of hormonal contraceptive use the girls had divergent views about openly disclosing their use of hormonal contraceptive methods most of them expressed lack of willingness to disclose their hormonal contraceptive use they would be worried for people including their friends to find out they used hormonal contraceptives they feared people who would find them using hormonal contraceptives would perceive them to be bad girls hence spreading rumours about them this they indicated would make them feel bad shy and embarrassed oooh … in my school when they saw someone using contraceptive they started gossiping about that person they said the girl cant live a chaste life they even think that she is a prostitute so i will not like to use it so that people will talk bad about me however for some girls it would not be a problem if people close to them got to know about their hormonal contraceptive use because they could trust them to keep it as a secret interpersonal factors peer influence participants learn a lot about hormonal contraceptives from chatting with their friends and the opinions and stories told by these friends appeared to have quite some influence on their decision to use considering examples they provided the often mentioned negative opinions of friends had a lot of overlap with the misconceptions about the side effects of hormonal contraceptive use for me it is because of the lady who went to do it and the thing got missing in her arm i hear it makes you so fat and the thing can get lost in the body that is why i have decided not to use it the positive opinions expressed by friends were that hormonal contraceptive is good protective helpful gives you good curvy shape helps in finishing school and shows you take responsibility however on the other hand when asked about the influence their friends had on them they tended to strongly state they did not care and some gave examples of how their opinion was contrary to those of friends parents influence almost all the adolescents reiterated that their parents would be very displeased if they found them using hormonal contraceptive methods they anticipated their parents would think of them as very bad girls mostly because they are not of age to have sex in the first place it is perceived as sinful behavior and being disrespectful towards the parents their parents would be disappointed in them they would nag scold them may refuse to pay their school fees or even drive them away from home these reactions from their parents would in turn make the girls feel shy and embarrassed i think they will drive me away from home … they will say i am a bad girl they will think that you have sex and you have a boyfriend they will insult you and you wont feel happy they will embarrass you and they will refuse to pay your school fees they will ask you to let your boyfriend pay for your fees however a few of the girls were more positive especially when they would first discuss it with their mothers before going for a method once they did that they were sure their mothers would not have a problem if they got to know they however alluded to the point that if they did it without preinforming their parents the parents would be angry at them anticipated response from partner some of the girls who were asked to anticipate the opinion of their boyfriends on their use of hormonal contraceptive methods had different responses they mostly did not think that their boyfriends would react negatively towards them for protecting themselves indeed some mentioned that they thought their boyfriends would be happy if they found that they were using hormonal contraceptive methods because they could have sex without worrying about pregnancy oh nowadays as for the boys they like girls who use it hahhahhaa … i think they will be happy because as you have sexual intercourse they know that nothing will come out of it one girl stated that her boyfriends displeasure about her using a hormonal contraceptive method did not matter to her as illustrated below that means he will not touch me hahhaahaaa … i will tell him the reason why i did it and if he doesnt agree then that means he wont touch me haha haha one girl strongly stated that her boyfriend would not be happy especially when she does not discuss it with him in advance community factors role of religion the majority of the girls stated that religion is against the use of hormonal contraceptive especially for adolescent girls it is considered a sin against the will of god it resembles an abortion and it is against gods planned number of children for you some christians like gyidi people they cannot use it because they are always giving birth so they cannot use it … they say it is sinful … it is against their religion they say that the bible indicates that we should have as many children as the sea sand so assuming that god has given you eight children and you continue to use the family planning so that you give birth to only 3 children it is sinful i also know an islamic lady who went to do it and her husband was angry with her because it is something they dont like her arm began to rot i dont think it is the method that resulted in her arm rotting but i think it is because her husband spoke against it … she went to take it off and the rotting stopped almost all of them indicated their religious leaders would be disappointed in them if they got to know they used contraceptive methods they expected their pastors and imams would see them as very bad girls who refuse to abide by the teachings or rules and regulations of the religion on the abhorrence of early and premarital sex including contraceptive use they will think that you are not religious and then as a child they always advise us to live a chaste life before marriage so they wont be happy with you they think that since you are using the family planning method you have a boyfriend one of the girl said she may miss out on an opportunity to get married because her imam would not recommend her in case there was such an opportunity they declared these responses will make them feel bad sad refuse to go to church or even put a stop to their contraceptive use if a man is looking for someone to marry he will say i am a bad girl so he wont recommend me he will say that i am having sex that is why i am using contraceptives i will miss opportunities because he will recommend another person perceived community norms almost all the girls perceived that the community would react negatively to their contraceptive use they maintained that society sees contraceptive use as a preserve of only married adults therefore children are not supposed to use them consequently children who use them are considered as bad girls and promiscuous and some of them may get insulted for that they also professed that if people should see them using contraceptives they would spread rumors about them in the community … in the ghanaian society when they see you using those things they will say that ah this child how can a child like you be using family planning hhaahaahaa you are a town helper only two girls seemed to be more resilient and stated that we need to quit the shyness and no please it will not affect me discussion using indepth interviews and focus group discussions we determined factors that negatively affect the use of hormonal contraceptives among adolescent girls in the kintampo area of ghana who reported that they had no experience in the use of hormonal contraceptives nonuse of hormonal contraceptives among the adolescents was explained by a combination of individual interpersonal community and institutionallevel factors at the individual level poor knowledge of the different hormonal contraceptive types and their mode of action negative attitudes towards adolescent hormonal contraceptive use lack of selfefficacy to organise hormonal contraceptives fear of real and perceived side effects of hormonal contraceptive use and fear of disclosure explained why the sexually active adolescents in this study did not use hormonal contraceptives the interpersonal community and institutional levels showed a strong association between social normative beliefs and hormonal contraceptive use amongst adolescents disapproval of hormonal contraceptive use both expected and actual by parents and peers and societal disapproval and stigma toward premarital sex and contraceptive use by the community and religious groups explained why adolescent girls in this study did not use hormonal contraceptive methods our results showed that adolescents in this study had superficial knowledge on hormonal contraceptives though they could mention some hormonal contraceptive methods their knowledge on the mode of action of these hormonal contraceptive methods in preventing pregnancy was poor studies have generally reported in support of our study the low levels of detailed knowledge of hormonal contraceptive among adolescents from different parts of the world 48 as well as the negative impact that lack of knowledge has on contraception use 3048 a lack of knowledge may be explained by the fact that young people are often not given clear correct and full information regarding matters of sex and sexuality at home and at school 4849 in the ghanaian context issues related to sex are practically not discussed at home and are sketchily taught as part of a few core and elective subjects in school 50 this may explain why the adolescents in this study did not have indepth knowledge about the different hormonal contraceptive methods and consequently did not use them to improve adolescents knowledge on hormonal contraceptives efforts should be geared towards provision of indepth knowledge about hormonal contraceptive types mode of action and side effects to adolescents when they visit the facility for contraceptives and also through mass media and school health programs a negative attitude towards adolescent hormonal contraceptive use was another important finding associated with the nonuse of hormonal contraceptives among adolescents in this study most adolescents in this study approved of hormonal contraceptive use among married adults to help them space up their children while they work however young girls and unmarried adults using contraception were perceived to lack good sexual morals this negative attitude is likely shaped by prevailing descriptive social norms that discourage premarital sex in most african societies including ghana 3951 sexual intercourse in most african societies is not an activity meant for children and societys disapproval of sexual intercourse among young people inherently prohibits contraceptive use amongst them 3951 agha et al highlighted a strong negative association between contraceptive use and social norms that discourage premarital sex and contraceptive use among adolescents 39 this finding supports results from other similar studies 5152 another barrier to hormonal contraceptive use reported in this study is the lack of selfefficacy to organise hormonal contraceptive methods this finding is similarly reported in other studies where adolescents refuse to go for contraceptives from health facilities and chemical seller shops attributable to feelings of embarrassment and shyness associated with securing contraceptive methods from the various sources 315253 the feeling of embarrassment emanates from adolescents anticipated negative reaction from providers community gossip and labelling of promiscuity as a response to early sexual activity amongst them programs aimed at building decisionmaking skills assertiveness and selfconfidence in adolescent girls could be an effective way of shaping their selfefficacy and hence improving their hormonal contraceptive use decision making and subsequent uptake an additional significant finding that explains the nonuse of hormonal contraceptives is the girls strong perception and fear of side effects of hormonal contraceptives similar to findings from other studies 295253 popular among the perceived side effects was future infertility some of the girls expressed the fear that the substance injected or implanted into the body could get mixed in the blood and stay in the system for long periods which could cause miscarriages or lead to future infertility in most african countries childlessness is stigmatized making childbirth a very important accomplishment indeed ones success in life and social status is highly associated with the ability to bear children and sometimes the number of children one has 29 therefore the use of anything with the potential to interfere with ones child bearing ability will be highly feared and avoided in addition to the fear of future infertility adolescents also expressed worry about specific side effects related to using the implant though dysmenorrhea amenorrhea headache and dizziness are supported by literature as side effects of using implants 54 the popular belief that the implant could get missing in the body and also cause epilepsy is misconstrued these misconceptions may have been fueled by ignorance and or misinformation from friends and other community members however the notion of dislodging implants appears to be common among ghanaian youth as well as adults 55 it is imperative therefore to direct interventions to disabuse adolescents minds of their negative perceptions and misconstrued ideas about the side effects of hormonal contraception use outreach to schools places of worship and market centres could be very useful for sensitizing adolescents by health workers furthermore fear for disclosure of contraceptive use emanating from societal disapproval of hormonal contraceptive use amongst adolescents was reported as a key deterrent to hormonal contraceptive use reported in this study whether actively or passively adolescents in this study would be unwilling to disclose contraceptive use to their important others they feared that if these people became aware of their hormonal contraceptive use it would be disapproved of and consequently result in stigmatization or even aggressive responses 5256 such disclosure issues which are rarely reported in hormonal contraceptive use literature are often seen within the context of a set of social norms which sanction immoral sexual practices 57 research on treatment adherence have shown that lack of disclosure can negatively influence adherence which in turn results in all kind of health issues 58 59 60 adolescents ability to disclose their hormonal contraceptive use or intentions to use especially to experienced adults such as parents and health workers may potentially expose them to the right information about the different contraceptives and their mode of action to disabuse their minds of some of their misconceptions and take away their fears to promote use interventions targeting parents and improving parentchild communication on sexualityrelated matters may be a solution lastly adolescents religious beliefs which prohibit the use of hormonal contraceptive prevent them from using hormonal contraceptives some christians and muslims believe that children are gifts from god and trying to stop them from coming by whichever means including the use of contraceptives is sinful as reported in other studies 576162 in nnalwadas study adolescents reported that contraceptive use was viewed as murder in religious circles 62 the phenomenon may explain why some religious leaders oppose contraceptive use religion is a very important component of the ghanaian society christian and islamic religions are highly practiced most of the religious laws and beliefs are consistent with and reinforce societal norms compounding adolescents dilemma to use hormonal contraceptives societal norms are very difficult to change 63 however parents religious leaders teachers and community opinion leaders are very important agents in promoting change it is important to educate them on the need for adolescents to have access to contraceptive use information and services and the risks to adolescents wellbeing if these needs are not met to conclude nonuse of hormonal contraceptives among adolescents in this study was explained by a combination of individual interpersonal community and institutionalbased factors shaped by social normative beliefs generally the reasons for noncontraceptive use reported in other studies are similar to what we found as reasons for nonhormonal contraceptive use in this study however in addition to these reasons fear of real and perceived side effects of hormonal contraceptives in general and perceived side effects of specific hormonal contraceptive methods and disclosure issues are very strong reasons for nonuse a quantitative study to test the relative significance of the identified determinants of hormonal contraceptive use to inform the content of interventions to promote hormonal contraceptive use in order to reduce the occurrence of adolescent pregnancy in the kintampo area of ghana is desirable so we plan to embark on one it is worth to mention some limitations our study findings represent opinions from a few adolescent girls in the study area and make the study findings not generalizable to all other ghanaian adolescents and for that matter other adolescents in general the strength of this paper is that though the adolescents expressed opinions believes and values were the same in both the focus group discussions and indepth interviews using both data collection methods was very useful in the indepth interviews adolescents provided sensitive information that they may have avoided had it been in a focus group discussion in the focus group discussions discussants portrayed divergent ideas where necessary made the point and gave examples to back their claim this generated very rich diverse group data during recruitment that data collection would be anonymous and that participation was voluntary we also explained that participants had the right to decline participation or withdraw their consent at any stage of the study or decline to answer any question they did not feel comfortable about and that one was free to stop the interview without having to offer any explanation finally the prospective participants were assured of strict confidentiality regarding information collected that only aggregated data will be made available as part of scientific and public dissemination written informed consent was obtained from the individual andor minor legal guardiannext of kin for the publication of aggregated study results and any potentially identifiable images or data included in this article data sharing statement data supporting the results reported in this manuscript is available upon request interested persons may contact the corresponding author ethics approval and informed consent ethical approvals were obtained from the kintampo health research centre institutional ethics review committee and the ethical review committee psychology and neuroscience at maastricht university also permission was sought from the management of the youth facilities and schools where participants were recruited we explained to the prospective study participants dovepress open access journal of contraception 202112 disclosure all authors declare no conflict of interests be it financial or otherwise in this work open access journal of contraception dovepress publish your work in this journal open access journal of contraception is an international peerreviewed open access online journal publishing original research reports reviews and commentaries on all areas of contraception in addition to clinical research demographics and healthrelated aspects the journal welcomes new findings in animal and preclinical studies relating to understanding the biological mechanisms and practical development of new contraceptive agents the manuscript management system is completely online and includes a very quick and fair peerreview system visit php to read real quotes from published authors

background adolescent pregnancy remains a public health concern globally the use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions however research shows that use of hormonal contraceptive methods is rather low among african adolescent girls of which ghana is no exception objective this manuscript uses the socioecological model to guide our understanding of the factors associated with nonuse of hormonal contraceptives among adolescent girls in ghana methods an explorative study was done using qualitative data collection methods two focus group discussions and sixteen indepth interviews were conducted among adolescent girls aged 1519 years n 38 in the kintampo area of ghana to determine factors affecting uptake of hormonal contraceptives results adolescents showed a lack of indepth knowledge related to the different hormonal contraceptive types negative attitudes towards adolescent hormonal contraceptive use fear of real and perceived side effects of hormonal contraceptives lack of selfefficacy to use contraceptives fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methodsto promote hormonal contraceptives among adolescent girls a combination of multifaceted socialpsychological personal and community level interventions are needed

nationally there are actually several forms of policies and regulations aimed at resolving and preventing cases of child marriage first at the end of 2019 the government issued the undangundang nomor 16 tahun 2019 concerning amendments to the undangundang nomor 1 tahun 1974 in the new regulation changes have been made to the minimum age for marriage if the previous regulation states that a person is allowed to marry when he is 16 years old for women and 19 years for men meanwhile the new regulation states that a person is allowed to marry when he is 19 years old for both men and women second the government through the badan koordinasi keluarga berencana nasionalbkkn has in recent years intensively carried out campaigns for maturing the age of marriage the substance of the program is to encourage people to get married when they are 21 years old for both men and women related to the national policy and local policy in dompu district the researcher views that all of these policies and regulations have the same orientation which is equally oriented towards strengthening public understanding of the risks of early marriage in addition the researcher views that local policies in dompu district are derived policies from national policies because as explained earlier that all policies both national and local are policies for maturing the marriage age of the community based on this explanation the researcher is interested in conducting research with the aim of knowing the results of the evaluation of the implementation of the policy on preventing child marriage in dompu regency in the 20162021 period prevention policies referred to in this study are several forms of policies implemented by the local government of dompu which are oriented to prevent the increasing number of cases of child marriage what becomes the urgency of this research is that in recent years dompu regency has become one of the regencies in west nusa tenggara province with the highest number of child marriage cases however one of the interesting things is the decrease in the number of cases from year to year this shows that there are good implications from the implementation of several policies and programs by the regional government so that the results of this research will later be able to become a policy reference that can be continued by policy makers in the next few years to overcome the problem of child marriage it can even be a policy reference for governments in other regions b literature review policy as we know the policy is any form of decision or choice taken by the government policy is not only understood as a form of government action but policy is also intended as an attitude taken by the government including when the government chooses to remain silent and does nothing the policy implemented by the government is a step that has clear objectives a policy does not only come in the form of a statement but is also carried out in a directed manner in order to achieve the desired goals referring to the explanation of the theory the efforts made by the local government of dompu district in preventing the increase in the number of cases of child marriage can be regarded as a form of policy because these actions are carried out by policy makers as parties who have the authority to formulate and implement policies in addition these actions are forms of action that have clear goals and are carried out in a directed and systematic manner policy evaluation policy evaluation can be understood as a form of action to evaluate a policy there are many things that are assessed such as how the process of implementing the policy what the results are and what are the strengths and weaknesses of the policy so that the final result of the implementation of a policy evaluation is to obtain an overview of the entire series of policies this description then becomes a reference for policy makers to consider whether the policy is still appropriate to be implemented or not there are several policy evaluation models that can be used as a research analysis knife the policy model is as follows 1 content input process and product evaluation model this policy evaluation model consists of several types of policy models that can be used all or only some that are adapted to the research context several types of evaluation models are contect evaluation to serve planning decisions input evaluation structuring decision process evaluation to serve implementing decision and product evaluation to serve recycling decision 2 evaluation of stake model or countenance model this policy evaluation model consists of several stages or evaluation aspects namely the stages of input process and results of the two proposed policy evaluation models the researcher uses both of them as the analytical knife of this research in the stake evaluation model researchers used the last two stages namely the process and outcome stages the researcher considers that the two stages are in accordance with the research context while in the cipp evaluation model the researcher uses the product evaluation to serve recycling decision model by using this model researchers will evaluate policy products that include several aspects of the advantages and disadvantages of the policy children marriage as it is understood that child marriage is a marriage carried out by someone who is not yet 18 years old this is based on the understanding of children according to who and child protection laws these regulations and organizations both explain that what is called a child is someone aged 0 to 18 years including those who are still in the womb prevention of children marriage as we know prevention is an effort or a group of efforts made by certain parties that aim to make something impossible prevention in this study relates to the efforts made by the government in preventing or avoiding society in this case people who are still children are involved in marriage child marriage is a problem because child marriage poses a high risk for children involved in marriage and has a negative impact on the development process of an area maybe it will be a different story when child marriage is not a problem on the basis of the existence of child marriage as a problem that prompted the presence of this research c method this research is an analytical descriptive research using a qualitative approach this research was conducted in dompu regency which was determined purposively based on the background of this research problem namely the dinas perlindungan pemberdayaan perempuan dan anakdp3a dompu regency this research conducted in may 2021 data collection techniques used interview and documentation techniques using research instruments such as researchers interview guidelines and cellular phones the subjects and informants of this study consisted of mrs daryati kustilawati as the head of the dp3a dompu regency hairil and sukma as parties involved in child marriage and mrs kalisom as the community in carrying out this qualitative research the researcher uses three components of analysis namely data reduction data presentation and drawing conclusions with verification d result and discussion the process of implementing child marriage prevention policies in dompu regency in the 20162021 period dompu district is one of the districts with the highest number of child marriage cases in the province of west nusa tenggara in 2017 dompu district ranked third as the district with the highest number of child marriage cases in the province the first and second ranks are occupied by the districts of east lombok and west lombok the case of child marriage in dompu district is caused by several things the first causative factor is pregnancy out of wedlock marriage is used as the only way out to cover the shame of the family pregnancy outside of marriage is caused by many things including promiscuity and juvenile delinquency as well as the influence of the spread of pornographic videosphotos in 2011 through a survey of the influence of technological developments on child marriage by the the forum anak dompu it was found that 62 of teenage boys and girls admitted to having watched pornographic videos it was also found that 27 of teenage girls claimed to have had sex the first causal factor is in accordance with what is explained by suryowati that pregnancy outside of marriage is the most common factor causing child marriage in indonesia for reasons of their own volition or parental coercion into something that is hardly found this means that when asked the children about whether they want to get married at a very young age the children did not answer that they wanted to in fact marriage at a very early age is the least desired by them however when they are already involved in promiscuity and they experience pregnancy before marriage then like it or not they have to be married off the second causative factor is the education factor the low understanding of the community and children about the risk of marriage is a fundamental factor in the occurrence of child marriage in dompu district ignorance of children about the risks of child marriage in various aspects occurs because at school they are never given education about it children are also very rarely included in various socialization activities held by the relevant government the second causal factor is in accordance with the study results of the pusat studi kebijakan kependudukan ugm which shows that there is a relationship between the educational status of parents and cases of child marriage parents with low educational background are assumed to be parents with minimal knowledge about the risks of child marriage with this limited knowledge it makes parents more free to marry off their children because for these parents that marrying their children is the best way to reduce the familys economic burden even though this thought is very wrong considering the bad risks when marrying a very young child the third factor is the economic factor based on research data it can be understood that most cases of child marriage in dompu occur in rural areas where the average community has low educational background and works as farmers and laborers for these people marrying off children is the best way to reduce the familys economic burden even though the facts show that marrying off children actually adds to the familys economic burden the researcher views that this idea is a misleading thought that still lives on the outskirts of society the third causal factor is in accordance with the research results of the pusat studi kebijakan kependudukan ugm which shows that poor families tend to have a strong desire to immediately marry off their children even though their children are still children this happens because there is still an assumption that marrying off children means reducing the familys economic burden even though this assumption is clearly wrong the fourth causative factor is the issue of the minimum age limit for marriage before the undangundang nomor 16 tahun 2019 concerning amendments to the undangundang nomor 1 tahun 1974 the regulation that becomes a reference related to the minimum age limit for marriage is the undangundang nomor 1 tahun 1974 the regulation states that a woman is allowed to marry when she is 16 years old the age limit for marriage is considered to provide opportunities for child marriage in indonesia including in dompu people think it is not a mistake to marry a child who is still 16 years old because the regulations allow it even though the facts on the ground show that let alone someone who is 16 years old someone who has just entered the age of 19 or 20 is still not ready to get married this unpreparedness is intended for economic mental and physical aspects the fourth causal factor has similarities with what is described by alfafan in his research that the conflict of regulation and policy is one of the factors that influence the occurrence of child marriage cases in indonesia previously the law used as the basis for marriage was the undangundang nomor 1 tahun 1974 concerning marriage in the regulation it is stated that a person is allowed to marry when he is 16 years old for women and 19 years old for men then in 2019 the regulation was amended by the signing of the law concerning amendments to the 1974 marriage law in the latest regulation the age limit for marriage was changed namely for both women and men the minimum age for marriage is 19 years however even though there have been changes to regulations and limits on the age of marriage these regulations are still not in line with government policies that encourage maturation of the age of marriage the government through the bkkn in recent years has intensively carried out a campaign to mature the marriage age the essence of the movement is to encourage people to get married when they are 21 years old for both women and men with the conflict and discrepancy between these regulations and policies it is possible to create public ambiguity the fifth causal factor is the tradition factor in dompu regency there are immigrant communities who occupy several areas in the manggelewa and pekat subdistricts the immigrant community comes from the island of lombok who is of the sasak ethnic group so that the tradition that applies to the community is the tradition of origin in the sasak community there is a tradition called the merarik kodeq tradition this tradition is a marriage tradition because it is selarian when a girl is taken away by a man and the girl is not brought home until 12 oclock at night it is obligatory for both partners to marry it doesnt matter what age as a result of this tradition one of the factors in the occurrence of child marriage cases in dompu district is the tradition factor of the sasak community the fifth causal factor is in accordance with the research results of the pusat studi kebijakan kependudukan ugm that there is a relationship between the existence of traditions in a region to the occurrence of child marriage cases of these several factors the tradition factor is the most common cause of child marriage cases in dompu district this is evidenced by data showing that the highest number of cases of child marriage in dompu regency occurred in the manggelewa and pekat subdistricts where both subdistricts were mostly inhabited by sasak people in addressing these public issues the dompu district government through the dp3a implemented several policies to resolve and prevent the increasing number of child marriage cases in the area the first policy is the establishment of the kpad this program was designed and included in the dompu regency dp3a work plan and budget at the end of 2015 and began to be implemented in early 2012 the task of the kpad is to disseminate information to the community about the risks of child marriage the socialization was carried out either through visiting community associations or inviting the community to attend meetings held by the kpad each kpad in each village has one community complaint post as well as a secretariat the second policy is the simultaneous motion module program this program was agreed upon and carried out together with the dinas kesehatan dompu the simultaneous motion module is a module that contains complete material on the risks of child marriage adolescent reproductive health and the dangers of drugs this module is socialized in the village community by making children and young couples the main targets the third policy is to make the krr for each smpmts and smamasmk level schools in dompu district this program was implemented on the basis of an agreement between plan internasional and the dp3a the dinas pendidikan dompu and ntb in implementing this policy all junior high and high school levels in dompu regency were instructed by the education office to make krr education a local content each school allocates 2 hours of lessons per class once a week the teachers who are in charge of local content are teachers who provide the bk who were sent by their respective schools to attend training facilitated by plan international and the dp3a the facilitators presented were facilitators from plan internasional indonesia in jakarta who handled the child protection program the training is not only held once but once every quarter which is located in dompu where one event is held for 3 to 4 days the fourth policy is the selection of peer counselors peer counselors are selected students from each junior and senior high school who are trained by plan international dompu and the dp3a dompu facilitators one school has 2 peer counselors the peer counselors are given training so that they have the skills to become counselors who are able to provide counseling to their peers both in the school environment and in the social environment based on the explanation related to the process of implementing the policy to prevent child marriage the researcher has several conclusions first dompu district is one of the districts with the highest number of child marriage cases in the province of west nusa tenggara for researchers of course this is not an achievement to be proud of this is one of the sad and serious problems that requires a policy resolution by the policy makers in dompu district second there are several factors that cause child marriage cases these causes are factors of pregnancy outside of marriage education economy regulation and tradition from these several factors it is concluded that the traditional factor is the most common cause of child marriage cases in dompu actually there is no concrete data that mentions this but according to the researcher the reason that makes the tradition factor the most frequent factor in the presence of child marriages in dompu is because based on the data on the distribution of child marriage cases in the area it was found that the most cases occurred in the manggelewa district and concentrated based on the data it is known that there are quite a lot of sasak people as immigrant communities who occupy the two subdistricts as it is known that the sasak people have a tradition of merarik kodeq which is a tradition that marries someone who is still a child when the child is known to have been taken away by his partner for the sasak people when a young girl is taken away by her partner then the action is considered an act that violates the norms and tarnishes the islamic religious values that are embraced by most of the sasak community so the steps that must be taken are the family is marry off his son related to this issue in this case the researcher assumes that this tradition cannot be fully justified considering the greater bad risk when forcing the child to marry according to researchers marrying children has a greater bad risk than not marrying children even if they are considered to break tradition researchers believe that this tradition can still be compromised the courage of the researcher to make such an argument is based on the facts and knowledge of the researcher related to the tradition for researchers it is perceived that a girl has been taken away by her partner and does not return home after 12 oclock in the evening does not mean that the child should be married off because it is not necessarily the girl who has committed adultery and things that are considered to violate the norms and values of the islamic religion in response to this community leaders and families should sit down together and discuss solving problems without making marriage the only solution the public must understand that marrying a young woman will be a very big risk their children cannot go to school the risk of maternal and child mortality is high and they tend to become unemployed after marriage which has implications for the increasing number of unemployed and poor people third to solve the problem of child marriage nationally there are several policies such as the enactment of the latest marriage law in the regulation it is stated that a person is only allowed to get married when someone is 19 years old for women and men in addition there is also a marriage age maturation program carried out by the bkkbn in addition to national policies the dompu district government has also formulated and implemented several policies to prevent the increasing number of cases of child marriage related to this the researcher views that the dompu district government does not only focus on implementing national policies but chooses to be more proactive if we look at several existing policies both national policies and policies at the regional level all of these policies are oriented to instilling public understanding about the risks of marriage according to the researcher when some of these policies are policies that target the strengthening of public understanding it can be said that some of these policies are appropriate because almost all problems in society stem from a lack of understanding so is the case with the issue of child marriage when the communitys understanding is strong about the risks of child marriage the community will have a more vigilant attitude towards child marriage parents will be more closely supervised children children will also think twice about doing things that allow them to be involved in marriage in fact according to the researcher the best way to solve the problem of child marriage due to traditional factors is to strengthen public understanding of the risks of child marriage a traditionalist society is a society that has a traditional understanding and is less advanced so the best way to change tradition is to change peoples perspective when the community already has an advanced understanding of child marriage then the community will be more responsive and ready to take an attitude to prevent child marriage in their environment results of the implementation of the policy on prevention of child marriage in dompu regency in the 20162021 period there are several results from the implementation of several forms of policy or child prevention programs in the dompu district which were carried out by the dompu district government in this case the dompu district dp3a in partnership with several parties in the 20162021 period first it has been able to provide good results in preventing the continued increase in cases of child marriage in dompu district in the last few years in the 20162021 period this is evidenced by the data on the number of child marriage cases released by the ministry of religion of dompu regency where from year to year there has been a significant decrease in the number of child marriage cases in dompu regency in 2017 the number of cases of child marriage in dompu regency was 234 cases in 2019 there were 186 cases of child marriage based on these data it can be understood that from year to year the number of cases of child marriage in dompu regency has decreased second some of these policies were adopted or maintained by the current government namely for one period in the future this is based on the consideration that currently dompu district is still an area with a high number of child marriage cases then the policy makers consider that several forms of policies implemented in the previous period are considered appropriate to continue to reduce the number of cases of child marriage in dompu district third people are increasingly aware of the risks of child marriage parties who were married at the age of children admitted that they had regrets when they were already involved in cases of child marriage after getting married he is faced with the real reality of life that life after marriage especially in conditions that are not ready and mature is very difficult he was faced with economic problems he had to think about what to do to earn money to support his wife and child in the past the reason that made the party married was the juvenile delinquency factor and pregnancy out of wedlock so that the two families inevitably have to marry both of them who are still students in high school after marriage the party admitted that married life was very difficult with limited work skills and still being unemployed the lives of the two people are really destitute they are still living in their parents house minimal source of income eating is really tough there is no money to buy milk the wifes body is getting thinner conflict with wife almost every day not to mention the addition of the neighbors gift because someone who gets married at the age of a child will definitely become a victim of gossip from society in addition parents increasingly understand the risks of child marriage and decide to be strict in educating and supervising their children so that they are not free to socialize for parents it becomes something that is very embarrassing when their child gets married at a very early age moreover the marriage was caused because her child was pregnant out of wedlock sometimes in these conditions parents and families are in a dilemma her child is already pregnant but the only solution is to get married what parents want is that it is possible to marry off their child at the age of the child not to be a burden of shame too heavy as long as the reason is that the child is not pregnant out of wedlock it was as if he had fallen and was hit by a ladder between her child being pregnant and getting married there are two things that must be accepted or not for the dompu community there is no other way to do it when their child is found to be pregnant outside of marriage other than having their child married off so as a conclusion that the existence of policies or programs to prevent child marriage by the local government makes the public more aware of the risks of child marriage parents should be strict in educating and supervising their children based on the results of the implementation of these policies the researcher concludes that the policies implemented have gotten quite good results the good result is that the number of cases of child marriage has decreased significantly from year to year in addition the implementation of these policies has had a good impact on public awareness and understanding of the risks of child marriage departing from this awareness and understanding so that a public perspective will be formed in order to avoid child marriage related to this explanation when referring to what was explained by nugroho that the main purpose of conducting a policy evaluation is to find out the results of implementing the policy a policy of course starts from the formulation stage this means that from the beginning a policy has been designed many things one of which is the goal to be achieved so the reason why a policy is evaluated is to see whether the goals set from the start have been achieved or not so policy evaluation must be understood as something positive so the researcher considers that when in this study one of the things to do is to evaluate policies namely to find out how much achievement and expectations a policy has it can be judged that the policies implemented by dp3a dompu district has received quite good achievements likewise it is hoped that the implementation of some of these policies has been quite successful in preventing the number of cases from increasing from year to year and having a good impact on public understanding evaluation of the implementation of child marriage prevention policies in dompu regency in the 20162021 period even though the implementation of several forms of policies or programs to prevent child marriage has succeeded in reducing or preventing the number of cases of child marriage from increasing significantly from year to year understanding the public about the risks of child marriage and making the current government adopt some of these policies there are several this is the result of an important evaluation of some of these policies the things that become the material for evaluation of the implementation of some of these policies can be explained as follows in the policy of establishing the kpad several things that need to be evaluated are first the kpad is only formed in a few priority villages based on the number of cases per village in dompu district villages with the highest number of cases become priority villages the existence of such a policy makes efforts to prevent child marriage in dompu district uneven considering that almost every village in dompu district especially in subdistricts other than dompu subdistrict for cases of child marriage is almost evenly distributed this means that when kpads are only formed in a few priority villages it is considered an effort that is carried out unequally this makes child marriage cases continue to occur in areas where kpads are not established second there is a limited budget in the implementation of the kpad program the policy for the formation of the kpad is a program that does not only reach the establishment and ratification of the parties who are the administrators but the most important thing is that the administrators carry out a comprehensive education program to the community on a regular and ongoing basis the available budget is not sufficient to accommodate all the programs planned by the management this budget limitation is also related to the number of kpads that have been successfully established when sufficient budget is available it is possible that kpads will not only be formed in a few priority villages in addition the limited budget also makes the kpad only last 2 years after it was first conceived and implemented in the simultaneous module movement policy several things that need to be evaluated are first the simultaneous module movement program is actually the dinas kesehatan dompu that is more dominant in its implementation the reason why the dp3a dompu can also join in the implementation is because of the similarity of orientation and targets for program implementation where one of the orientations for implementing the program is to understand the community about the risks of child marriage and the target of the program is children with these conditions in the process of implementing the program parties from dp3a are rarely involved dp3as involvement was only intense in the early stages of communication and coordination the facilitators are midwives who work in health centers in each subdistrict and village not even a facilitator was found from dp3a however with these conditions does not make the dp3a feel any kind of jealousy organizationally because for dp3a the most important thing is that the program is one of the programs that is claimed to be one of the programs that is also implemented by dp3a second the implementation of the program is also faced with budget constraints implementation of the program requires a large budget starting from paying incentives to the facilitators which are quite a lot the implication is that the program is only phased in one year since it was first implemented in the peer counselor election policy several things that need to be evaluated are that from the beginning the background for this program was based on the assumption that children will be more open and willing to compromise with their peers hence the birth of a peer counselor program in which children children who become peer counselors are tasked with providing education to their peers however in practice perhaps because it is influenced by the still weak ability of peer counselors it has implications for how these peer counselors carry out their duties where the implementation of their duties is still very less than optimal the peer counselors who have been selected are placed in each high school each school has at least two students who become peer counselors at the beginning after being selected the peer counselors were given training and a certain period of time by facilitators from dp3a and plan internasional in front of peer counselors the facilitators explain the tasks and functions the form of the program that must be carried out and the targets to be achieved each peer counselor has a monthly and annual work program in which the program is prepared based on the recommendations of the facilitators peer counselors are also trained on how to do counseling to their peers in their respective scopes of work both at school and in social circles however in the implementation process in the field it was found that peer counselors actually seemed to ignore their duties and responsibilities so that in the end this program was considered a program that put forward sensations and was limited to mere formalities where the program did not have a significant impact on efforts to reduce or prevent its increase number of cases of child marriage this is evidenced by the lack of intensity of peer counselors carrying out their main task namely counseling their peers the less than optimal implementation of these tasks can be caused by the status of peer counselors as high school students where their job is to study and do various tasks and the peer counselors are not professionals with this status their main task is to study in class and they have already been stressed with various school assignments so it is not surprising that the implementation of their duties as peer counselors is not optimal in addition the program is also considered a program that costs money there are approximately 50 students selected as peer counselors every month peer counselors are given incentives every month peer counselors are also given regular training with all the efforts and costs incurred it is considered quite futile without maximum results however the interesting thing is that of the four forms of policies or programs to prevent child marriage the peer counselor program is the program that is actually being adopted by the current government according to the researcher with reference to the results of the study the form of a policy or program to prevent child marriage in dompu regency which has a very broad and comprehensive impact and brings positive results is the policy of making the krr education a local content in smp and sma in dompu regency these good results were obtained because with the program all junior and senior high school students received the same educational materials about the risks of child marriage the program is considered a rational program to be implemented because it only relies on maximum communication and coordination between agencies and the budget issued is not too heavy but the effect of its implementation is very positive however based on considerations based on developing conditions the program was discontinued in the current government era this is due to several things one of which is where there are the latest regulations and policies governing educational institutions for now all high school and equivalent have become not the domain of the district government but have become the domain of the provincial government at the time when the program was passed at that time all high school and equivalent levels were still the domain of the local government based on the explanation of the evaluation of the implementation of some of these policies the researcher understands that some of the policies implemented are considered as policies that only prioritize formality and mere sensation and only cost money some policies are also considered as policies whose implementation is less targeted less effective and efficient and the impact is not comprehensive the researcher also understands that there are policies that are actually very positive namely the policy of making krr education a local content in junior and senior high schools only with communication and coordination it can become an effective efficient targeted policy and have a comprehensive impact in fact this policy is considered as the policy that has the most significant contribution in preventing the increase in the number of cases of child marriage in dompu district in recent years however this policy is not being continued by the current local government because it is constrained by regulations e conclussion 1 in recent years dompu regency has become the district with the highest number of child marriage cases in the province of west nusa tenggara even in 2017 dompu regency ranked third as the district with the highest number of child marriage cases in the province of the several factors that cause child marriage cases the traditional factor is the most common factor in the occurrence of these cases responding to this problem the dompu district government through dp3a implemented several policies such as the selection of peer counselors the formation of kpads simultaneous module movements and making krr education a local content in junior and senior high schools 2 the policies implemented have succeeded in preventing the increase in the number of cases of child marriage in dompu district in recent years in addition the implementation of these policies has had a good impact on public awareness and understanding of the risks of child marriage and there are policies adopted by the current government 3 some policies to prevent child marriage are considered as programs that only prioritize sensation and formality cost quite a lot the impact and targets are not comprehensive faced with difficult regulatory conditions so that some of these programs cannot be implemented optimally and bring more positive impact

dompu regency is one of the regencies in west nusa tenggara province with the highest number of child marriage cases there has been a decrease in the number of cases from year to year this is a good implication of the implementation of local government policies the study aims to describe and analyze the process and results of the implementation of the policy to prevent child marriage in dompu regency for the 20162021 period the study use descriptive analytical method with a qualitative approach conducted at the kantor perlindungan pemberdayaan perempuan dan anak dp3a kab dompu in may 2021 data collection techniques used interview observation and documentation techniques the data analysis technique used was qualitative consisting of data reduction data presentation and drawing conclusions by applying inductive logic the results showed 1 dp3a dompu regency implemented several policies to overcome the problem of child marriage in the period 20162021 policies have been implemented to establish the komisi perlindungan anak desa kpad the simultaneous movement module program the creation of adolescent reproductive health education for each smpmts and smamasmk and the selection of peer counselors some of these policies are the result of the formulation and agreement process and are implemented by the dompu regency dp3a together with local ngos and ngos 2 the implementation of the policy to prevent child marriage is considered successful in preventing an increase in cases of child marriage dompu local government policies currently have an impact on public understanding of the risks of child marriage 3 the policy becomes a program that only prioritizes sensation and mere formality costs a lot of money has incomplete impacts and targets is faced with difficult regulatory conditions so that some programs cannot be implemented optimally and have a more positive impact

introduction unesco estimates that there are some 3000 endangered languages in the world many of these are undergoing language shift as speakers cease using a minority language and use the majority language in its place whilst intergenerational transmission is typically seen as the key factor in language maintenance there are many factors which may influence transmission in a particular context including economic benefit perceived status educational provision and so on the impact of the internet is not well understood and is to some extent contested thus while crystal postulates that an endangered language will progress if its speakers can make use of electronic technology unesco suggests that new media including broadcast media and the internet usually serve only to expand the scope and power of the dominant language at the expense of endangered languages this paper explores the relationship between a particular technology social networking sites and a particular language welsh from the perspective of young speakers offline social networks are recognized as an important site for the development of language practice and of language norms particularly in opposition to the standard norms there is a broad agreement among researchers that social networks have a role to play in language shift it has been suggested that networks of strong ties might help minority language speakers resist pressures towards language shift it is further claimed that visible and vibrant networks make membership of a minority language community appear more attractive as well as providing more opportunity for language use and enhancing ethnic identity based around that language where the speakers of a minority language are ageing and isolated fostering social networks may enable those speakers to maintain fluency and provide the opportunity for them to pass on the language to others while online social networking sites have been the focus of a significant body of research there has been little work specifically on language and there appear to be no studies directly investigating whether online social networks play a role in language shift similar to that played by offline social networks research has claimed that the availability of electronic media can be a powerful motivator for young people and act as a stimulus to their use of a minority language within their social networks on the other hand there are concerns that english or another majority language may be considered to be the language of electronic social networking even when the minority language is used facetoface in offline social networks it does not seem unreasonable to suggest that sns might play some role in language shift in some language contexts the remainder of this paper is structured as follows first the specific context of wales and the welsh language is introduced secondly the methodology is outlined next some general results are presented followed by a more indepth examination of facebook considering language behaviours and influences on that behaviour both quantitative and qualitative data are reported finally conclusions and implications for future work are drawn the welsh context wales is a country of around 3 million people situated in the west of the united kingdom the welsh language was the only language of the majority of the population of wales until the mid 1800s there has been significant language shift towards english since that time the most recent census in 2001 showed there were 582000 welsh speakers some 208 per cent of the population and the figures have been interpreted as showing that the language has stabilised unesco considers the language to be vulnerable the concentration of welsh speakers varies considerably across the welsh local authorities with greater concentrations in the north and west the highest being gwynedd where 687 of the population are welshspeaking lower concentrations are found in the south and east with the lowest being monmouthshire where 90 of the population speak welsh in recent years the education system has played a major part in rejuvenating the language and the main growth area of the language has been the under 16s the 2001 census showed that 312 of welsh speakers were aged 315 and 323 were aged 1644 young welsh speakers are seen as being particularly significant for the future of the language iaith pawb the welsh assembly governments action plan for a bilingual wales states the assembly government is acutely aware that if welsh is to flourish young people in particular need to develop a sense of ownership for the language and to see it as their language and not simply the language of school and culture the assembly government will work to ensure that we maximize the opportunities for our young people and teenagers to use the language in everyday leisure and social situations one of the welsh language boards six strategic priorities is to increase the use of welsh among young people and give them the opportunity to use welsh socially for example through sports and contemporary music it is widely accepted that the teenage years are a critical period in the development of young peoples attitudes towards a minority language the use young people make of their minority language during this period can affect their continued use in later stages of their life and the choices they make regarding intergenerational transmission the role of offline social networks is recognised as being of crucial importance as regards the use of a minority language by young people morris observes that the greater the density of welshspeakers in the offline social network of young welshspeakers the greater the opportunity and tendency for members of that network to use welsh while young welsh speakers offline social networks have traditionally been maintained by facetoface contact and the telephone information technology is playing an increasing role figures from 2009 show that 68 of children aged 515 in wales have access to the internet at home the lowest percentage in the uk however 49 of these children visit sns at least weekly more than the percentage across uk children children aged 815 in wales are also more likely to have set up a profile on a social networking site with 58 of them saying they have done so the welsh language has been used online since at least the late 1980s and is used to some degree across a number of different online domains the research presented in this paper is a preliminary examination of the way in which young welsh speakers are using sns and in particular their use of language within these sites the main focus is on facebook as this was by far the most popular sns among the study group language choice and behaviour factors influencing that behaviour and attitudes towards the welsh language and it among young people are explored the study group were pupils in welshmedium education attendance at a welshmedium school is by parental optin depending on the area of wales these children may be more or less likely to come from welshspeaking homes non welshspeaking parents send their children to welshmedium education for a variety of reasons principally cultural but also because it is perceived to be a better quality of education while these pupils receive the majority of their education through the medium of welsh given the wider societal context they typically are also fluent english speakers methodology this paper reports a selection of results from a one year exploratory mixed method study into language behaviour within the social networks of young welsh speakers in particular the question of any effect of modality on language use was of interest following the results of fleming and debski the purpose of the study was to gather initial data that would provide both insight and direction for future research this paper focuses on the part of the data relating to the use of welsh online and particularly the use of welsh on facebook the data relating to the offline use of welsh and the relationship between the use of welsh in online and offline social networks has been published elsewhere due to the lack of any existing data which could have guided the informed formation of testable hypotheses the study focussed on data that would reveal whether or not there was a phenomenon to be studied and what patterns if any appeared to exist in young welsh speakers language behaviour that would merit further study from the data presented in this paper a number research questions emerge which could be investigated through a more targeted future study the study conducted in 2010 focussed on four welshmedium secondary schools two in north west wales and two in the south east the schools were selected to represent the different language contexts in these two parts of wales schools were selected at random and contacted via letter and subsequently by telephone schools were provided with information regarding the nature of the research being undertaken head teachers of the schools were given the opportunity to ask questions regarding the research prior to agreeing several schools declined the invitation due to time constraints in which case another school was selected at random until the four school sample was complete bilingual consent forms were sent to the parents of the pupils in the appropriate school years a sample of 50 pupils from each school for whom consent had been given was selected at random 10 from each school year these 200 pupils were asked to complete an online questionnaire hosted on survey monkey the questionnaire was anonymous and was available in both welsh and english versions questions examined the language used with teachers and friends at primary and secondary school the language used in outofschool clubs such as sports clubs first language orientation and written language confidence the language used in the home and with specific family members the use of sns and language use on those sites and the online and offline language used to communicate with three friends the data was analysed using spss this establishes a baseline of information about welsh language use in both areas and provides the quantitative data reported in this paper the questionnaire was followedup by a series of focus groups which explored the issues raised in the questionnaire in greater depth two groups typically of eight pupils were selected at random from the respondents who had completed the questionnaire at each school one group aged 1315 and one aged 1618 the size of the focus groups varied between six and ten pupils with a total of 64 pupils taking part in the focus groups overall the focus group discussions lasted 4050 minutes the focus group discussions were semistructured and made use of a set of eleven prompting questions the questions covered their use of sns their use of welsh and english on sns and the web generally barriers to the use of english and welsh and the use of the welshlanguage interface on facebook all focus group discussions were conducted in welsh the discussions were recorded for subsequent transcription and analysis using weft qda this more indepth study of language attitudes and behaviour provides the qualitative data reported in this paper this paper presents a selection and analysis of the quantitative results along with excerpts from the transcripts to provide additional context and texture due to the small sample sizes it is necessary to present a descriptive analysis of the cross tabulations in the quantitative results rather than a statistical one both the quantitative and qualitative data presented in this paper are self reported data rather than data based on observed language behaviour thus the reliability of some of the responses may be questioned due to respondents inaccurate recall or estimation or deliberate misrepresentation however for the quantitative data the sample size should minimise the impact of any individual misreporting in terms of gaining a more complete and nuanced understanding of language behaviour in sns direct observation of actual language behaviour would clearly be a useful addition to the type of study presented in this paper there is however significant ethical and methodological complexity involved in conducting such a study we are dealing with young people and with essentially personal communications while these issues may be overcome through careful study design and such as study was considered it was decided that a simpler approach was preferred for this initial exploratory study given relatively limited resources results to protect the anonymity of the schools and their pupils the schools in the north west of wales are referred to as nw1 and nw2 and the schools in the south east as se1 and se2 in reporting the results of the focus groups year 9 to 11 are denoted as while year 12 to 13 are denoted as fn and mn are used to denote individual female and male respondents where conversations are reported otherwise quotations are attributed only to the school and year first language the overall split between those pupils who considered themselves to be first language english speakers and those who considered themselves to be first language welsh speakers was fairly even however there is a marked difference between the proportions when comparing the nw with the se the majority of the pupils in both the nw schools considered themselves to be first language welsh speakers whilst in the se the situation was reversed this may be explained to some extent by the wider use of welsh as a home and community language in the nw and the fact that the majority of the pupils in the se schools come from non welshspeaking homes internet use it was clear from the focus groups that the internet was playing a significant role in the lives of young people in both areas all participants reported having broadband access at home and several also had internet access on their mobile phones or on their personal media players for many of the participants the internet was an important source of entertainment and information in the home used for social networking gaming homework shopping and viewing television programs dwin neud y ddoi ar yr un pryd soffa teledu laptop cup of tea perfect se11213 the focus groups also revealed that the pupils broad experience of the internet was one in which the english language was the norm in terms of availability of provision but perhaps also in terms of the choices that individual pupils would make m1 ond am facebook nid oes nifer o websites sydd gyda cymraeg f1 mae msn a hotmail yn saesneg mae twitter yn saesneg f2 on os fydde nhw yna fydde ti ddim yn defnyddio nhw na fydde ti mae facebook ar gael yn gymraeg ond ti ddim yn defnyddio fe m1 mae wikipedia cymraeg a fin defnyddio hwna m1 apart from facebook there arent a lot of websites that have welsh f1 msn and hotmail are in english twitter is in english f2 but if they were there you wouldnt use them would you facebook is available in welsh and you dont use that m1 there is a welsh wikipedia and i use that se11213 in addition to the perceived language norms language behaviour appeared to be influenced by availability context and the accessibility of the language used fyddain defnyddio cymraeg weithiau ar y we os ydw in cael opsiwn cymraeg yn yr ysgol i ddarllen rhywbeth ond heblaw hynny fin defnyddio saesneg se1911 the issue of the accessibility of the welsh used on websites and interfaces was raised in a number of contexts mae on haws defnyddio fon saesneg oherwydd bod chin gwybod y geiriau i gyd fel arfer mae pob website yn saesneg felly chin gwybod beth mae nhw yn siarad amdano oherwydd mae on gymraeg mae on eithaf anodd oherwydd mae nhw yn defnyddio geiriau anodd geiriau fydde chi ddim yn ei defnyddio yn y gymraeg se2911 while this type of comment may be reflecting individual difficulties in comprehension they may also be revealing weaknesses in the way that it is taught or in the design of the websites and interfaces themselves the use of social networking sites the use of sns was pervasive with only six of the 200 pupils reporting that they didnt use any sns at all as table 2 shows facebook youtube and msn dominate and presumably fulfil different complementary communication functions for the pupils the majority of facebook users had used bebo before switching to facebook as bebo became unfashionable with the perception that it was for children or little kids the use of the word adults in this context should probably not be taken to include parents and teachers but as meaning something more along the lines of mature young adults like us distinguishing between their generation and both the younger and older generations thus being on facebook would appear to be a desirable badge of maturity even among pupils as young as 9 the high levels of sns use suggest that such sites are both popular and important for these young people it also suggests that they might play a role in the formation of attitudes towards the welsh and english languages as well as providing an opportunity for language use language use and modality part of the questionnaire asked pupils to identify three friends note whether they were welshspeaking the language they would use orally with each friend and the language they would use to communicate with them electronically in a sns msn message text or email overall the vast majority of the friends identified spoke welsh a small number could not and in a very small number of cases the welsh speaking ability was not known the school with the highest percentage of welsh speakers in the respondents selected friends was nw2 with 973 the school with the lowest percentage was se1 with 884 however it is worth noting that both these percentages are significantly higher than the percentage of welshspeakers in the general population in those areas this might be explained by the pupils selecting friends from school in this activity this would suggest that welshmedium schools are particularly important for establishing social networks with a high density of welshspeakers when this density may not be reflected in the wider local community while comparing language used orally and in electronic communications the main finding is that language behaviour does not generally appear to change significantly with the modality as table 3 shows the vast majority of pupils who use a single language with a particular friend would use the same language in electronic communications as they would use orally however respondents who used both welsh and english orally with a particular friend were much more likely to use english with them in electronic communications this is an interesting finding as it suggests that the respondents who use both languages orally with their friends would change to using english in this important and often more personal form of communication the same trend is apparent in all four schools both in the north west and south east the trend of using english in electronic communications when they would use both languages orally suggests that the relationship between the languages is not equal facebook facebook appears to be particularly significant for these young welsh speakers given its popularity the perception that it is a website where welsh is used and the status associated with facebook use as a badge of maturity and achievement of adulthood because of this significance the remainder of this paper will focus specifically on facebook the popularity of facebook among the pupils reflects the popularity of facebook generally in the uk facebook is the most visited sns in the uk with 5653 of all visits to sns and the second most visited site in the uk after google uk with 778 of all website visits from the focus groups it appeared that facebook was an essential element of many young peoples social lives playing a central role in the maintenance of their social networks ymchwilydd pan tin dod adref or ysgol be ydir website cyntaf tin mynd i pawb facebook rhaid i fi checo facebook rhag ofn bod rhywbeth wedi newid rhag ofn bod rhywbeth wedi digwydd bod hwn a hwn wedi sblito lan neu bod so and so ddim yn siarad bellach neu i checo pryd maer parti chweched yn dod lan researcher when you arrive home from school whats the first website you go to everyone facebook i have to check facebook in case something has changed in case something has happened so and so have split up or so and so dont speak any more or to check when the next sixth form party is coming up se11213 the percentage of pupils using facebook was consistently high across the four schools and across the different years in common with other studies facebook was mainly used to keep in touch with people in the pupils offline social networks particularly their fellow pupils swnin deud er ein bod ni yn yr ysgol efon gilydd drwyr dydd da ni just yn siarad efo ni mae ganddo ni ffrindiau eraill da nin nabod dros y blynyddoedd ond rhan fwyaf or amser da nin cadw mewn cysylltiad efon ffrindiau agosaf the fact that fellow school pupils play a significant role in the online social network may be important in establishing language norms within facebook pan nesi ymuno a facebook roedd chydig o ffrindiau cymraeg fi yna a dim ond nhw oedd yna felly ronin siarad cymraeg efo nhw a mae o wedi dal ymlaen table 6 shows that overall the main language used on facebook by pupils was english however the point of interest in this paper given that these pupils are bilingual is the use or nonuse of welsh rather than the use or nonuse of english comparing the percentage for english only with the combined percentage for those who would use both equally or mainly use welsh gives a more even split of 557 to 442 but still in favour of english use in order to understand the reasons behind this high percentage of bilingual pupils in welshmedium education not usually using welsh a more detailed analysis of the data was conducted four main aspects were considered the community language the language of the pupils social network language confidence and the influence of facebook itself the community language table 7 presents a more detailed breakdown of languages used on facebook according to the different schools the two schools in the more anglicised south east show high levels of english use on facebook given the percentages of pupils considering themselves first language english speakers this is perhaps unsurprising however in the more welshspeaking areas of the north west while the percentages of pupils using welsh on facebook is higher than the two se schools only in nw2 is welsh alone the main language used in nw1 more than twice as many pupils mainly use only english on facebook than mainly use only welsh for the majority of pupils in nw1 welsh would not feature in their main language use on facebook it appears that living in an area in which the english language is dominant is a good predictor of english language use on facebook but that living in an area where the welsh language is stronger is not such a good predictor of welsh language use on facebook this suggests that there may be different factors influencing the use or nonuse of welsh than english or that the same set of factors has different outcomes for the two languages table 8 shows that the large majority of pupils who self identify as first language english speakers use english as their main language on facebook the majority of those who self identify as first language welsh also use english as the main language though the distribution across the facebook language categories is far more even for first language welsh than first language english again comparing the percentage of those whose language behaviour on facebook would not normally include welsh with those whose language behaviour would normally include welsh gives a split of 741 to 259 among first language english speakers but 398 to 602 among first language welsh speakers there appears to be a relationship between self identified first language and main language used on facebook it is possible that the linguistic makeup of the pupils offline social networks contributes to their selfidentification as a first language speaker and that overlaps between their offline and online social networks then influence their language use on facebook table 9 appears to show a similar relationship between language of the home and the main language used on facebook however where both languages are used at home the large majority of pupils mainly used english on facebook considering those pupils whose home language is welsh comparing the percentage of those whose language behaviour on facebook would not normally include welsh with those whose language behaviour would normally include welsh gives a split of 258 to 742 therefore the language of a pupils home appears to have a slightly stronger relationship with their normal use of welsh on facebook than their self identification as a first language welsh speaker the results in this section suggest a relationship between language use on facebook and language use in the real world while the existence of a welsh speaking offline community context seems to be linked to the use of welsh on facebook the existence of an english or bilingual community context appears to be more strongly linked to the use of english on facebook thus language use on facebook reflects the wider language context and the likely makeup of offline social networks which are then reflected in online social networks the language behaviour in online social networks cannot be understood in isolation from the offline context the language of the social network tables 10 and11 suggest that there is a relationship between the language used with friends outside school and the language used on facebook this is unsurprising as facebook networks are known to recreate offline social networks in terms of the strength of the relationship it appears that the use of english in offline social networks is more strongly related to the use of english on facebook than the use of welsh in offline social networks is related to the use of welsh on facebook this is a similar pattern to that observed when considering the community language it is interesting to note that there are a small number of pupils who use mainly welsh on facebook even though in their offline social networks they use english this may perhaps be reflecting differences in the membership of these pupils online and offline social networks nearly a third of those who use more welsh than english in their offline social networks use mainly english on facebook even of those pupils who use more welsh than english or welsh only in their offline social networks more than 30 use both languages equally on facebook this may reflect their concern not to exclude members of their online social network who are not welshspeaking demonstrating one possible effect of audience mae mwy o bobl yn gwybod saesneg na syn gwybod cymraeg tishe pawb i ddeall e se21213 however the effect of audience is not always straightforward and doesnt necessarily always result in the use of the language that is mostly widely understood by the entire network of friends os nin gwybod mai ffrindiau ni sydd yn yr ysgol fyddai yn rhoi nodyn bach i nhw achos fin gwybod bod nhw yn siarad cymraeg oherwydd bod neb arall yn gallu neud e nin teimlon fawr i neud e fel yea nin gallu siarad cymraeg i ti tin teimlon reit chuffed bod tin gallu neud e se1911 bilinguals who are effectively fluent in two languages such as those in this study have a choice of which language to use their language choice appears to be complex and influenced by conscious and possibly subconscious factors thus the choice of language for a particular message may be influenced by the sender the intended audience and the message itself while there were characteristics of facebook which appeared to influence this choice it did not appear that facebook per se was influencing this choice it seems plausible to suggest that there might be strong similarities between the choice and use of language on facebook and oral language choice and use offline however there may also be some language behaviours that are specific to written environments such as the use of text talk language confidence while the language register used on facebook tends to be very informal and attitudes towards spelling and grammar relaxed it is possible that confidence in writing welsh and english may have an influence on language behaviour the vast majority of pupils were either very confident or fairly confident in writing english as table 12 shows english was the main language used on facebook regardless of confidence in writing english the percentages of those who use english on facebook and those who use welsh appear very similar with regards to confidence in writing english this indicates that those pupils who mainly use welsh on facebook are not doing so because they lack confidence in their written english the vast majority of pupils were either very confident or fairly confident in writing welsh as table 14 shows english was the main language used on facebook regardless of confidence in writing welsh comparing tables 12 and14 shows similarities in terms of the use of language on facebook regardless of which language confidence is being examined the percentages of those who use english on facebook and those who use welsh appear very similar with regards to confidence in writing english but there appear to be some differences when considering confidence in writing welsh pupils who use welsh as their main language on facebook appear to be slightly more likely to be very confident in writing welsh however this is not to necessarily suggest direct causality it may be the case that confidence in writing welsh and the use of welsh as the main language on facebook are both influenced by greater exposure to welsh as the language of the community or the language of the home 134 143 029 not very confident 082 000 000 not confident at all 052 000 000 comparing table 13 and table 15 those pupils who use welsh on facebook appear more likely to be confident in their written welsh than those using english on facebook are likely to have confidence in their written english there are no pupils who are unconfident in welsh who use welsh on facebook whereas 56 of pupils who use english on facebook lack confidence in their written english this difference in behaviours relative to confidence suggests that the use of english on facebook is determined by more than simply confidence in the language it may be that these pupils have generally weak writing skills or strong writing skills in another language and that english is their strongest language it is possible that audience is an influence perhaps pupils consider it a more effective communication strategy to write badly in english than well in welsh on facebook another possibility is that as welsh is the language of instruction pupils may consider it more important to write well in welsh than to write well in english and that this is reflected in their language use on facebook while there appears to be a slight relationship between written welsh language confidence and the use of welsh on facebook there does not appear to be such a relationship for english the influence of facebook the influence the characteristics of facebook itself on language behaviour was considered from two aspects firstly whether the language used varied between different facebook elements secondly whether the availability of a welsh language interface was having any effect a study of the use of puerto rican spanish on myspace suggested that language use might vary according to the nature of the text eg profile information versus comments further questions in the study therefore examined language use specifically on facebook status and on personal profile information tables 16 and17 show the main language used on facebook against the language used specifically for status updates there appears to be a relationship suggesting that typically pupils general language use on facebook is the same as the specific language used for status updates though as can be seen in table 16 those pupils who mainly use welsh on facebook are less likely to only use welsh for status updates whereas most pupils who mainly use english use only english for status updates it should be noted that the language used for status updates forms part of a pupils general language use on facebook so there is some degree of overlap between these dimensions that would naturally suggest a relationship it is curious to note that two pupils who mainly use english on facebook claim to only use welsh in their status updates unfortunately the current methodology does not allow the veracity of these claims to be investigated or the reasons to be understood tables 18 and19 show main language used against language used on facebook profile comparing table 18 with table 16 appears to show a broadly similar pattern of a weak relationship however it is tables 20 and21 compare the language of profile information and language of status updates directly there appears to be a relationship between the two though once again the correlation for english appears to be stronger 701 of pupils who only use english on their profile also only use english on their status updates and 770 of pupils who only use english on their status updates also only use english on their profile for welsh the figures are 412 and 636 respectively again suggesting that welsh language use in status updates is different to that in profile information even in status updates the effect of audience on language choice can be seen as status updates are not necessarily directed to the entire online social network the use of welsh for status updates to online social networks which included non welsh speakers did not appear to be viewed as an exclusion of these people but more as a byproduct of the fact that the online social network included multiple offline social networks os ydi o yn rhywbeth i wneud efo gwaith ysgol nai neud on gymraeg achos mai cymraeg ydi gwaith ysgol fi os ydi o yn rhywbeth i wneud efo mynd allan nai neud on saesneg achos saesneg ydi iaith ffrindiau dwin mynd allan efo welshlanguage interface on facebook since the autumn of 2008 facebook has been one of a small number of applications which provide a welshlanguage interface and it is the only widely used sns to do so carrolls study of the use of puerto rican spanish on myspace observed that the englishlanguage interface lead to the adoption of english terminology therefore it might be suggested that the availability of an interface in welsh may help to normalise welshlanguage terminology within facebook and possibly in the wider domain of it in the focus groups pupils expressed a variety of views about the welsh language interface mostly relating to the style of language used this may be revealing issues of terminology regional dialectal variation and register comments such as these perhaps suggest that the effectiveness of crowdsourced interface translations bears further examination there was little evidence to suggest that the welsh language interface was a positive influence to use welsh but there was also no evidence to suggest that the use of the english language interface was consciously perceived of as a negative influence as the pupils are bilinguals the use of english in the interface is unlikely to prove any sort of barrier to use but it is interesting to speculate whether the existence of a welsh language interface or a welsh language interface that is perceived of as being poor quality might have an influence on the pupils perception of the status of welsh both as a language of it and more widely conclusions and implications for future work it is clear from the data that sns generally and facebook in particular are playing a significant role in the lives of young welsh speakers the extent to which these young speakers use the language on facebook varies the data suggests that there are a number of different factors at play but due to the small sample sizes a rigorous statistical analysis is not possible however the data indicate that it is necessary to consider language behaviour in online social networks in the context of language use in offline social networks and that in some ways this behaviour is best considered as an extension of language behaviour in offline networks just through a different medium the specific medium of facebook did not seem to directly influence their language behaviour though there appears to be some indirect influence related to specific facebook elements such as status updates in common with fleming and debskis study of irish schoolchildren young welsh speakers appear to see english as the language of the internet however their study showed that english was also the language of networked communications among pupils from irishmedium and gaeltacht schools more than 60 wrote no emails in irish among pupils from irishmedium schools more than 90 rarely or never sent sms messages in irish and the same was true for more than 65 of pupils from gaeltacht schools while fleming and debskis study did not explicitly consider sns it seems plausible that similarly low levels of irish use might have been observed in contrast the use of welsh online and in electronic communications appears to be normalised to a much greater extent than irish fleming and debski do note an apparent relationship between the amount of irish used in facetoface conversations and in text message based conversations a similar relationship between offline and online use appears to be true of welsh there are difficulties in making meaningful comparisons with previous studies largely due to the lack of them but also because of differences in the methodology the sns or the focus of study within the sns the study by carroll supports the general finding that the language behaviour of bilinguals within sns is complex and influenced by a range of factors his observation that different language behaviours occur in different elements within a sns is also echoed in the data presented here a previous study of the use of welsh on facebook found that there were a number of groups where welsh was used and that welsh was also being used on personal profiles this data combined with the data presented in this paper shows that facebook provides an online venue in which welsh is an everyday language of communication it is interesting to note that the average declared age of those identified as welsh speakers in that study was 2636 and the youngest was 18 given the popularity of facebook among young welsh speakers their apparent relative lack of presence in facebook groups might indicate that they are mainly using facebook to engage with their own social networks rather than to engage with the wider welsh speaking population in the communal spaces on facebook the initial study presented in this paper suggests a number of relationships and raises a number of questions future work needs to address the issue of small sample size in order to facilitate rigorous statistical analysis in particular to verify and quantify the strength of the relationships which are suggested by the current data the apparent imbalances in the use of the two languages and the causes of this imbalance need to be investigated among the wider questions raised by the data are which websites do young welsh speakers typically use which languages are they available in and which languages are they used in to what extent is the welsh it terminology understood and used by young welsh speakers which sns if any are used by younger welsh speakers do patterns of language use change over time are different patterns of language use observed in different sns and if so why are there quantifiable effects either in terms of perceived status or use of welsh due to the welsh language having a presence in it the study presented in this paper relies on self reported data rather than direct observation future work could directly examine the actual language behaviour of young welsh speakers in sns coupled with a mapping of the languages of contacts in their online network using traditional social network analysis techniques while this approach is likely to provide a rich source of data the methodological and ethical issues require careful consideration in addition to validating and exploring the general findings of the present paper two events in the lives of young people merit particular scrutiny as they potentially involve radical reconfiguration of their offline social networks moving from primary to secondary school and the end of school education both these events may disconnect young welsh speakers from their existing offline social networks and the welsh speakers in those networks speakers to continue using welsh both outside school and when they leave school and to foster a sense of ownership of the language among those who do not come from welshspeaking families or communities does yna ddim byd yn stopio ni rhag defnyddior gymraeg ar y we ni just yn ddiog nin methu bod yn bothered i siarad cymraeg se11213 perhaps the most potent force for change would be the desire among young people for online content and services in welsh heightened desire and expectation leading to increased demand could broaden the range of online domains in which welsh can be used unless the expectations of young welsh speakers with regards to the role of welsh in it can be raised it is difficult to see how their future use of welsh in it can ever extend much beyond the social domain as noted previously the choice of language for a particular message may be influenced by the sender the intended audience and the message itself while there is nothing in the data to suggest that facebook itself is directly influencing language behaviour there is some evidence to suggest that language behaviour may differ between different facebook elements perhaps because they fulfil different communicative functions or are perceived of as being addressed to different audiences however this effect of audience may not be as great as might have been anticipated as pupils appear not to treat the audience for status updates for example as being homogenous rather messages may be addressed to only part of that audience and it is the language of that part of the audience which influences language choice even if this excludes some of the wider audience who will receive the message online social networks may have a role to play in maintaining contact with those welsh speakers and with the language the need for a critical mass of welsh speakers in a social network and the possibility of there being a tipping point when the proportion of welsh speakers falls below a threshold and the use of the language diminishes rapidly or ceases all together also needs to be examined comparative studies of other minority language contexts may help to shed light on the wider factors influencing language use such as prestige official status or economic benefit the study presented in this paper needs to be seen in the broader context of young welsh speakers experience and practice of using welsh in it this includes the language used to teach the subject in school the availability of welshlanguage software and the extent to which it is discussed in the welshlanguage media while it was not a particular focus of the current study it appears that english is perceived to be the language of it in terms of the availability of content and services but also in terms of actual use of it dwi ddim yn meddwl bydd en syniad da oherwydd ar ôl i ni adael yr ysgol bydd pob cyfrifiadur nin gweld yn y saesneg os i nin dysgu sut i wneud pethau yn cymraeg bydd en fwy anodd i wneud pethau yn y saesneg oherwydd bydde ni ddim yn deall beth mai geiriau yn dweud se2911 mae wikipedia saesneg efo fel chwech tudalen ar rhywbeth a maer un cymraeg efo un paragraff considered against this wider context it could be suggested that the use of welsh on facebook limited as it is is a relative success story for the language mae ganddoch chi grwpiau cymraeg a tin cael dy annog i siarad cymraeg wedyn dwyt mae yna lot mwy o bobl cymraeg arna fo dwin meddwl nw21213 mae ein facebook ni yn ddarn cymraeg or rhyngrwyd lle maen ffrindiau ni yn siarad cymraeg nw11213 however it could also be argued that this is yet another example of the language being restricted to the social domain and perhaps failing to establish itself across the wide variety of domains supported by it i siarad efo pobl dwin nabod dwin siarad cymraeg o hyd ond saesneg ydi bob dim arall nw1911 many of the challenges facing the use of welsh in it are the same as those facing the use of welsh generally fundamental challenges still exist in providing opportunities and incentives for young welsh

social networking sites feature significantly in the lives of many young people where these young people are bilingual social networking sites may have an important role to play in terms of minority language use and in shaping perceptions of that language through a quantitative and qualitative study this paper investigates the use of language in social networking sites by young welsh speakers focussing particularly on facebook language choice and behaviour factors influencing that behaviour and attitudes towards use of the welsh language in information technology are explored the data suggests that there are a number of different factors at play and that it is necessary to consider language behaviour in social networking sites in the context of offline language behaviour

introduction i took note of the gray cubicles and the nonergonomic workstations curious about how they influenced productivity watching the employees while focusing on my own experience i noticed the discomfort as we unconnectedly shifted in rigid chairs and contended with unforgiving desks with our body language mutually signaling a struggle to adapt to the unyielding furniture my back hurts and there is no real alternative to move myself elsewhere or a manager around to complain to the lack of fresh air sealed windows and an insufficient air conditioning system contributed to a sense of stagnation in the atmosphere while i felt unmotivated and rather dire i wondered how this stale environment affected their physical and mental wellbeing the open layout amplified distractions with loud conversations and various office sounds easily traversing the space creating a symphony of disruption for the workers trying to concentrate how can this office play with my organizational settings and with contemporary places of work with especially one form being based on focusing researchers experience within an organizational context organizational autoethnography a progressive subfield of autoethnographic research illuminates the complexities and diversities inherent within workplace experiences grounded in the fusion of self and culture this methodology has been extensively applied across diverse sectors the approach has been efficaciously employed to investigate a broad spectrum of experiences and positionalities within organizational settings as it can be a tool for gaining a deeper understanding of specific organizational phenomena such as a process occurrence or specific situation in a contemporary place of work notable instances include hunniecutts exploration of gender dynamics through the lens of a female soldier in boot camp denkers critical dissection of exploitation within the bartending industry and sambrook and herrmanns examination of australian construction organization from within however despite the growth and development of organizational autoethnography its adoption as a primary mode of data inquiry within the academic realm remains limited while several studies have incorporated this approach within their research frameworks its adoption within academia has been comparatively slower yet those studies that have integrated this approach have yielded insightful results numerous studies have served as pivotal examples in our discussion further contextualizing the diverse applications of autoethnography in workplace research miller focused on the emotional labor of academic professionals while riad explored the complex intersections of motherhood and an academic career cohen et al critically engaged with the prevailing metaphor of worklife balance in an autoethnographic conversation between three scholars whereas kempster and stewart delved into leadership dynamics within academia cullen broached the topic of workplace spiritualization sobredenton examined systematic discrimination and workplace bullying and van amsterdam highlighted the oftignored intersection of motherhood and academic work further expanding the scope of autoethnographic workplace research sambrook et al deviated from traditional methodologies to examine employee engagement from a more interpretive angle pheko probed into the darker aspects of academia studying the experiences of academic mobbing within the power structures of academic institutions popova conducted an autoethnographic reflection on her sexuality and decadelong employment in an lgbtinclusive organization offering insights into the role of inclusive practices in organizational culture bohonos used nightmarish autoethnography to prompt discussions about racially abusive language in the workplace capturing the propagation of hateful language and its impact on creating hostile environments for people of color working under a pseudonym van de berg utilized autoethnography to grapple with the trauma of her husbands infidelity and its impact on her emotional recovery and academic identity shedding light on the significant role of the academic workplace in her recovery process the breadth of studies covering various focus areas from aspects of gender and sexuality to nuances of leadership and power dynamics illuminates the potential of autoethnography to provide nuanced and deeply personal perspectives on contemporary workplaces these studies whether opting for an analytical stance or leaning toward a more evocative narrative underscore the predilection toward the organizational dimension of autoethnography when exploring workplacerelated phenomena that said it is somewhat vital to recognize that autoethnography when employed in an organizational context may not universally fit all research questions or environments therefore it is incumbent upon researchers to critically appraise its appropriateness for their line of investigation given this complexity it is worth noting that autoethnography can manifest in multiple forms namely realist expressionist impressionist and conceptualist joe the diversification of autoethnography into distinct subsets and methodologies equips scholars with the versatility and adaptability to address specific workplacerelated concerns differently various autoethnographic approaches become imperative especially when contemplating contemporary workspaces which often manifest as organizational and spatial hybrids these varied methodological forms allow for the nuanced exploration of the dynamics within these spaces understanding the interplay between their unique structural and cultural elements and their subsequent impact on occupants experiences this paves the way for a more comprehensive grasp of modern workplaces organizational and spatial peculiarities offering deeper contextually grounded insights typology of autoethnographic representation the profound work of adams et al provides a comprehensive delineation of the variegated forms of autoethnographic representation these are meticulously classified into four distinct yet interconnected categories realist impressionist expressionist and conceptualist autoethnographic methodological forms each category reflects a unique perspective and representation mode enriching autoethnographic researchs overall breadth and depth to start realist autoethnographies are fundamentally rooted in the concept of verisimilitude striving to create a convincing illusion of reality this approach leverages personal experiences as a gateway into the realm of cultural understanding aiming to describe the cultural milieu as evocatively as possible the resultant narrative often rich in detail and depth is known as a thick description of cultural life something that geertz would define as essentially a rendering of what goes on what it is like from the natives point of view or how they experience his or her world the inherent realism of these autoethnographies imbues them with a sense of authenticity and groundedness enabling readers to connect with the experiences depicted in a deeply personal manner with the thick description underlining the detailed and nuanced representation of the phenomenon at the core of the realist autoethnographic approach is the intricate coupling of theoretical frameworks with documented personal narrativesa process that heavily leans on individual experiences to clarify and understand theoretical precepts the practice around the latter fosters an enriched understanding of theoretical paradigms and offers a potent means to communicate scholarly findings to a wider audience therefore the subsets of organizational and analytic autoethnography previously discussed briefly in the backdrop of exemplifying past scholarly work that employed autoethnography to comprehend the workplace can be aptly categorized under the ambit of realist autoethnography on the other hand we have impressionistic autoethnographies predicated on capturing an overall experience in its fullest essence this approach strives to portray detailed representations of the researchers surroundings or the examined context the autoethnographer seeks to immerse readers in the experience presented by crafting impressionist text aiming to foster an enriched understanding of the phenomenon at hand this immersion engenders a sense of shared experience blurring the boundaries between the reader and the researched several key characteristics distinguish impressionistic autoethnography from realist and other autoethnographic methodological approaches which we will discuss shortly first impressionistic autoethnographers employ their personal experiences as the primary data source they construct a narrative of their lived experience by drawing from their memories thoughts and emotions second impressionistic autoethnographers harness literary devices to generate a sense of immediacy and engagement for the reader autoethnographers tend to infuse their experiences with life and dynamism by employing methodological forms such as metaphor smile and vivid lively imagery last but not least impressionistic autoethnographers emphasize the subjective personal and emotional aspects of their experiences rather than aiming for a detached objective account of their experiences these researchers endeavor to share their stories authentically and evocatively next expressionistic autoethnographies deviate from the objective factual stance commonly associated with traditional research methodologies instead they lean heavily toward evoking moods and expressing the researchers internal feelings and emotions the expressionistic approach validates the essential role of personal and subjective experience mainly by deviating from traditional objectivity and detachment and by its innovative use of language paired with crafting imagery and symbolism using the latter enables the autoethnographer to construct a more robust and nuanced depiction of human experiences for example in a recent work by rafi the author uses expressionistic autoethnography to process and define the personal spiritual beliefs of researchers religious journey from islam through atheism to religious mysticism with that in mind expressionistic autoethnographies serve as a conduit for the visceral emotional aspects of experience offering a unique and deeply personal insight into the culture or the cultural situation being studied conceptualist autoethnographies the fourth category identified by adams et al represent a distinct form of research method that sets out to contest widely accepted norms and assumptions with it autoethnographers seek to navigate and question the takenforgranted constructs within societal and cultural life inviting critical discourse into the research process here personal narratives are positioned as more than just episodic anecdotes these narratives replete with authentic experiences and memories transform into tools of potent conveyance highlighting cultural experiences and breaking down the barriers of silence that often surround the intricacies of cultural existence personal stories are leveraged to illuminate and expose often challenging the silence enveloping controversial unexplored or misunderstood aspects of our shared cultural life conceptualist autoethnographers engage in a nuanced dance of interpretation and comprehension they unveil the intricate intersections and interactions between the personal and the cultural emphasizing how individuals are shaped by the culture they inhabit and reciprocally how their actions mold that very culture in its audacious challenge to assumptions and its boundarypushing nature conceptualist autoethnography reveals the elaborate network of connections linking individual experiences with broader cultural dynamics providing a unique lens to perceive the complexities of human cultural life the latter is predominantly done through critical autoethnographic representation emphasizing identifying and addressing biases power imbalances and injustices inherent in these experiences the papers representative examples have been meticulously chosen based on criteria ensuring their alignment with the methodological approaches presented emphasizing relevance and clarity each example illuminates the methodology in question while showcasing both its common and unique facets selected for robustness diversity and comprehensive explanatory ability this systematic selection not only guarantees validity but also enriches our understanding as we articulate these interconnected autoethnographic approaches it becomes evident how these varied methodological approaches offer a more nuanced perspective on the workplace therefore we will further explore these subforms of autoethnography and their profound implications within workplace research autoethnographic forms for workplace exploration 41 realist autoethnographic forms for workplace research with a focus on workplace environments and the very nature of work we delve into specific autoethnographic subtypes that prove exceptionally valuable for such inquiries joe within the realm of realist autoethnography three distinct subtypes surface as particularly pertinent for examining the workplace among them analytic autoethnography originally proposed as an adjunct to the more traditional evocative approach espouses a realist or analytic tradition that proves beneficial to researchers this approach provides an avenue for weaving personal experiences into broader sociocultural and political narratives enabling researchers to critique and dissect prevalent discourses within cultural contexts in the quest for transformative change in a manner that wall would call doing a moderate autoethnography the application of ethnographic strategies within this framework requires a meticulous research approach often involving the researcher as a fullfledged member of the study group or setting transparency about this role in the resulting publications and a profound commitment to evolving theoretical comprehension of broader phenomena as applied to the workplace analytic autoethnography allows researchers to plumb their personal experiences and observations within an organization offering novel insights into the cultural underpinnings power dynamics and social constructs of the workplace and the researchers unique position within these structures to illustrate a researcher may leverage analytic autoethnography to unpack their experiences as budding employees within a large corporation exploring how the companys culture and power dynamics shaped their work and colleague interactions this perspective promotes a deeper understanding of overarching social phenomena within the organization such as the ramifications of corporate culture on employee wellbeing and productivity it expands the theoretical comprehension of the phenomena under study two other types of realist autoethnographies described by adams et al could be deemed highly suitable for workplace researchboth exhibit suitability when studying workplace environments and dynamics reflexive interviews empower researchers to document and explore their personal experiences facilitating a rich augmentation of fieldwork particularly valuable for capturing the researchers unique perspective thereby leading to a deeper understanding of cultural phenomena within a given context applying this approach to workplace research permits a thorough exploration of interviewees experiences and perceptions illuminating the organizational culture power dynamics and societal structures underpinning the workplace for instance a researcher may delve into employees experiences within a specific workplace through reflexive interviews concentrating on their views of the organizations culture and dynamics this methodology enhances the understanding of individual workers experiences within the organization and unravels how larger societal phenomena influence these experiences reflexive interviews also pave the way for critical selfanalysis yielding a more selfaware research approach with that this approach can empower researchers to engage with interviewees as reflective subjects thereby fostering a more collaborative and ethical research process in contrast layered accounts illuminate the interplay between personal experiences and collated datas ensuing interpretation and analysis this method acknowledges the strata of consciousness and reflexivity that pervade a researchers account of personal experiences contextualized within a cultural milieu layered accounts encapsulate the researchers personal experiences reflections on overarching social and cultural contexts shaping these experiences and significantly the perspectives and experiences of others involved such as colleagues or community members applying layered accounts to workplace research a researcher could weave together personal experiences as an employee with reflections on the organizational culture power dynamics and societal structures of the workplace thereby providing a more multifaceted and nuanced narrative the inclusion of colleagues perspectives and experiences further enriches the account yielding a broader more comprehensive view of the workplace experience see table 1 for the summary of realist autoethnographies impressionistic autoethnographic forms for workplace research impressionistic autoethnography blends vivid descriptive language with an artistic writing approach to artistically convey the researchers subjective experiences emotions and sensory nuances rooted in personal storytelling and detailed narrative representations of their observations memories and emotions within this context adams et al highlight three subforums that are especially advantageous for researching workplace settings first collaborative autoethnography arises as a valuable method for examining personal experiences and perspectives through a collaborative reflexive lens to generate a shared narrative encompassing group members myriad perspectives and experiences this approach underscores collaboration reflexivity and dialogue endeavoring to create a comprehensive account that faithfully mirrors the heterogeneity of group members perspectives and experiences with that being said collaborative autoethnography shows promise in dissecting complex and sensitive issues facilitating a more nuanced layered understanding of personal experiences embedded within culture to illustrate a cadre of researchers might employ collaborative autoethnography to delve into their collective experiences within a specific organization giving special attention to the organizational culture power dynamics and social constructs shaping the workplace this approach can cultivate a more comprehensive and diverse understanding of the workplace and illuminate how personal experiences are situated within broader sociocultural contexts in doing so the research group could for instance unearth the unspoken norms shaping team dynamics or shed light on systemic issues impacting worker wellbeing thereby contributing significantly to the body of knowledge surrounding organizational culture and behavior two additional subforums come to the fore when facilitating a deeper understanding of the workplace whether as a physical entity or an organizational body on one side sensory and physical accounts offer a unique perspective in autoethnographic research enabling the exploration of personal and cultural experiences through the prism of sensory perception physical embodiment and the passage of time such an approach entails a joe heightened awareness of sensory and physical facets of personal experiences encompassing visual impressions auditory cues olfactory stimuli gustatory experiences and corporeal sensations linked to the researched phenomenon for instance in a workplacefocused autoethnographic study sensory and physical accounts could capture the researchers interactions with the physical environment such as the spatial layout ambient lighting and thermal conditions the sensory undercurrents of work could also be delved into for example documenting the sounds and scents characteristic of a specific working environment second impressionistic narratives of space and place offer invaluable insight into how spaces and places imprint upon and shape identities essentially these narratives are woven from the impressions that chosen spaces and places leave on the researcher through these accounts researchers can scrutinize how their personal experiences are molded by the physical and social milieus within which they unfold and the reciprocal influence they exert on these environments in the context of a workplacefocused study this could entail exploring the researchers personal experiences of their workplaces physical and social terrain complementing this the researcher could attain a more tangible and experiential understanding of their workplace and elucidate the contextual factors that frame personal experiences for example winklers work serves as an instructive exemplar of this approach where he weaves a compelling autoethnographic narrative elucidating the relationship between his personal journey of learning danish and his workplaces physical and social context as projected in table 2 these impressionistic narratives of space and place can illuminate a more nuanced and layered understanding of personal experiences within a cultural context particularly within a workplace environment however fully engaging with these experiences emotive dimensions requires shifting toward expressionistic autoethnographies expressionistic autoethnographic forms for workplace research navigating further into expressionistic autoethnographies we encounter subforms that emphasize the creation of aesthetic and evocative narratives these narratives are designed to vividly represent the thoughts emotions and actions of the individuals involved enabling readers to resonate with or gain an empathetic understanding of the depicted experiences distinguished by its accent on evoking emotions and fostering active reader engagement evocative autoethnography is less about imparting information and instigating a dialogue the narrative written predominantly in the firstperson is intended to provoke an emotional response often unveiling intimate aspects of personal life and foregrounding emotive experiences presented in various formats such as poetry short stories fiction novels or photographic essays evocative autoethnography can facilitate a comprehensive exploration of varied facets of a researched workplace especially from an insiders perspective the first exemplar of this expressionistic approach that would fit the context of workplace research is the subform of emotional renderings which zeroes in on the researchers exploration and articulation of their emotional responses and affective experiences in connection with their personal journey situated within a cultural milieu emotional renderings can foster a nuanced multifaceted understanding of personal experiences and how they are enmeshed within broader social and cultural constructs for instance in an autoethnographic study centered around a workplace emotional renderings could encapsulate the researchers experiences of workinduced stress anxiety or fulfillment the researcher could introspect on their work environments emotional toll or boon on their overall wellbeing and the influence exerted by the workplaces organizational culture and power dynamics on their emotional landscape through this lens the researcher could attain a more embodied experiential understanding of their workplace and the contextual factors that embed personal experiences within broader social and cultural realms as we venture further into the domain of expressionistic autoethnographies we come across the realm of confessional research accounts these accounts a characteristic of autoethnographic research encompass the researchers exploration and articulation of their deeply personal experiences and emotions in a profoundly intimate and candid manner this modality involves the researcher divulging private aspects of their personal experiences often adopting a confessional or cathartic style intending to expand understanding of a specific culture discipline or phenomenon take for example an autoethnographic study of a workplace here confessional research accounts could encompass the researchers experiences of stress anxiety or satisfaction tied to their professional roles and their struggles navigating power dynamics or organizational culture within the workplace this approach allows the researcher to attain a more embodied and experiential comprehension of their professional environment and insight into how personal experiences are positioned within broader social and cultural contexts through this lens the researcher is a participant and a narrator providing a human dimension and emotional depth to the portrayal of the workplace environment the researcher allows readers to empathize with their journey by revealing the raw nerves of their experiences fostering empathy understanding and a feeling of our common humanity third there is the approach of producing devotional texts devotional texts encompass the researchers exploration and articulation of personal experiences and emotions connected to their spiritual or religious beliefs and practices the implementation of this approach includes the researcher divulging intimate aspects of their spiritual or religious experiences often adopting a confessional or cathartic style to expand understanding of a specific culture discipline or phenomenon picture for instance an autoethnographic study conducted within a religious or spiritual community in this setting devotional texts may detail the researchers experiences with prayer meditation or other spiritual practices and their personal struggles with faith or belief within the community this approach empowers the researcher to attain a more embodied and experiential comprehension of their spiritual or religious community and insight into how personal experiences are situated within broader social and cultural contexts in the workplace context devotional texts may be particularly insightful if religious or spiritual values influence the place of work or if the researchers religious or spiritual beliefs influence their perceptions and experiences of the workplace for example a researcher could explore how their religious beliefs influence their perceptions of teamwork and leadership within their organization or how a catholic hospitals mission and values influence the practices and interactions within the workplace this evocative approach thus provides a rich and multilayered understanding of the workplace shedding light on often unexplored spiritual or religious dimensions lastly we delve into the realm of collaborative witnessing this approach paves the way for researchers to place their focus on the lives of others recounting them in an evocative manner through shared storytelling and conversation collaborative witnessing intertwines the roles of the storyteller and the listener fostering a joint narrative in which both parties participate equally reciprocally engaged in an enduring relationship and dialogic exchange in workplace research collaborative witnessing invites multiple researchers to share their experiences and interpretations of the collective autoethnographic data this strategy can unfold a nuanced and multifaceted understanding of personal experiences in the workplace culture and how broader social and cultural contexts shape these experiences collaborative witnessing could prove particularly insightful in examining the collaborative nature of knowledgebased work imagine for instance a group of researchers working in a technology startup they can weave together their individual experiences and perceptions of the companys dynamic and fastpaced work environment shedding light on the challenges and triumphs of innovation and team synergy collaborative witnessing can be used when individuals share their past experiences with the clear aim of developing committed relationships with one another this approach could also elucidate the importance of the physical and spatial aspects of the workplace in supporting collaboration performance for instance the researchers could reflect on how the openplan design of the office the availability of shared workspaces and the use of technologyenabled meeting rooms affect them personally and subsequently shape their collaboration and communication practices in this manner collaborative witnessing can provide a rich multilayered and collaborative understanding of the workplace environment see table 3 conceptualist autoethnographic forms for workplace research transitioning to the final cluster and informed by the categorization by adams et al we examine the types of conceptualist autoethnographies that can be of value when researching workspaces leading off with critical autoethnography this approach emphasizes the critical analysis of personal experiences in conjunction with the social and cultural construction of identities it involves researchers introspectively engaging with their personal experiences and then using the lens of critical theory to scrutinize and interpret these experiences in the wider backdrop of social and cultural contexts the goal of critical autoethnography is to act as a catalyst for personal and societal emancipatory changes by pinpointing and challenging deeply entrenched power dynamics inequities and social injustices when applied to the exploration of work environments critical autoethnography can be an impactful tool for deep understanding of personal experiences nested in cultural contexts especially within the intricacies of multidisciplinary teams or complex sociocultural settings here critical autoethnography hones in on the thorough analysis of personal experiences and the social and cultural development of identities within the workplace it may be used to identify and address power disparities injustices and inequities intricately woven within organizational culture another instance of how critical autoethnography may illuminate underrepresented or vulnerable groups in a particular environment is the experiences of women people of color and lgbtqiaþ persons to set an example a researcher might critically explore their experiences as a member of a marginalized group in the workplace focusing on the challenges they face and the strategies they employ to navigate them through this approach the researcher can offer insights into the lived experiences of marginalized groups providing a foundation for more inclusive and equitable workplace practices advancing to the next conceptualistic approach we encounter insider texts this method leverages personal experiences and insider knowledge of marginalized groups to shed light on power dynamics often revealing inaccuracies and harms of past research thus casting fresh perspectives on cultural practices and experiences for instance insider texts can provide valuable insights into phenomena such as workplace bullying exploring its prevalence consequences and mechanisms what is more these texts could offer an enriched perspective on the influence of managerial coaching on the wellbeing of subordinates within the workplace last but certainly not least are community autoethnographies this approach invites researchers to collaborate with community members to investigate and address specific issues these autoethnographies provide a platform for narratives often silenced or overlooked illuminating lifes everyday neglected and distorted aspects they also open avenues for cooperative research in selected organizational settings mainly to uncover workplacerelated issues that would otherwise remain uncovered take for instance the environment of a coworking space here researchers could partner with community members to delve into the dynamics of the work community unveiling issues like subtle bullying or systemic racism that might lurk beneath the surface researchers can delve deeper into organizational contexts through such a collaborative and coproduced autoethnographic approach shedding light on intricate dynamics that inform the broader workplace culture see table 4 for the summarized examples concluding debate autoethnographys role in workplace research this paper accentuates the potential of autoethnography as a methodological paradigm for deciphering the complexities of workplace dynamics and organizational cultures recognizing autoethnographys immersive perspectiverooted in the lived experiences of individuals within their professional realmsthis methodological paradigm moves beyond mere personal narratives this paper delves into various autoethnographic methodologies structured around adams et als framework each offering distinctive attributes that collectively paint a comprehensive picture of organizational landscapes and the varied ways individuals traverse these realms engaging in a lively debate about applying autoethnography in workplace research unveils its exceptional aptitude to bring subtle and often concealed facets of organizational life to light elements like the sensory physical and emotional dimensions the nuanced influence of spaces and places on identities the dynamics of power and even spiritual experiences within the workplace are not usually the subject of conventional organizational studies autoethnography emphasizing subjective experiences and narratives invites these elements to take center stage thus endowing a more comprehensive and nuanced understanding of professional life consequently this exploration underscores autoethnographys capability to penetrate the depths of contemporary workplaces enriching our understanding of these multifaceted everevolving spaces however exploring such personal and intimate experiences also raises important ethical considerations exposing personal and potentially sensitive information requires rigorous attention to consent confidentiality and potential harm furthermore the inherent subjectivity of autoethnography prompts debates around reliability validity and generalizability can personal narratives be accepted as valid insights into broader organizational dynamics how can these narratives inherently unique and contextual nature be reconciled with the scientific pursuit of generalizable knowledge rather than undermining the value of autoethnography these debates can be viewed as an invitation for researchers to continue innovating in this field for instance strategies such as collaborative autoethnography insider texts and community autoethnographies help address these issues by incorporating multiple perspectives and deeply involving those being studied in the research process finally using autoethnography in workplace research is more than just a methodological choice it is a commitment to humanize the workplace validate workers lived experiences and stimulate conversations that could lead to more inclusive empathetic and effective organizations the further exploration adaptation and integration of these approaches in organizational studies promise a future of research that is not just about organizations but also for them and the people within them

purpose this conceptual paper seeks to critically evaluate and illuminate the diverse autoethnographic methodologies that are pivotal for understanding the dynamics of contemporary workspaces the objective is to contribute to the ongoing scholarly debate on the value of autoethnography in workplace research and explore how it can shed light on complex organizational phenomena designmethodologyapproach the paper adopts a narrative literature review approach focusing on four main forms of autoethnography realist impressionistic expressionistic and conceptualistic autoethnographies each form is discussed and dissected emphasizing their specific subforms and illustrating their application through representative examples the paper engages in a critical debate on utilizing autoethnography in workplace research findings the findings illuminate how autoethnographic methods can be used to gain nuanced and complex understandings of personal experiences situated in workplace culture as well as how broader social and cultural contexts shape these experiences the study also highlights the potential of these methods to explore marginalized and silenced stories within workplaces and contribute to the knowledge on power dynamics inequalities and injustices embedded in the organizational culture practical implications the following contribution discusses approaches for conducting autoethnographic explorations of selected work environments offering researchers valuable insights into these methods application through better comprehension and application of these methodologies researchers can enhance their contribution toward cultivating more inclusive and equitable workplace environments originalityvalue the paper stands out in its extensive review and critical discussion of the autoethnographic methods as applied in workplace research it expands upon individual autoethnographic studies by providing a comprehensive multifaceted perspective delving into the merits and limitations of these approaches in particular context of researching contemporary places of work

introduction the coronavirus sarscov2 that causes the disease covid19 has caused significant disruption in everyday life on a global scale several public health measures have been put in place to reduce the transmission of the virus and to minimize the impact of the disease 12 these measures include isolation of those who have acquired the infection and quarantine of their close contacts 3 quarantine refers to separating and restricting the movement of people who are exposed to a contagious disease to see if they become sick whereas isolation means separating infected people from those who are not known to be infected 4 the effect of various public health measures to contain the covid19 pandemic is not yet fully understood 3 however recent studies increasingly support quarantine measures as an effective precaution to curb transmission of the virus 5 6 7 moreover quarantine appeared to be an effective virus mitigation measure in several countries during previous sars outbreaks in 2003 including singapore canada and china 8 9 10 there are various kinds of isolation and quarantine measures as well as systems to follow up on the implementation of these measures worldwide 11 in finland isolation and quarantine measures are home based with an official notification about the measures and regular phonebased follow up by health officials quarantined persons without symptoms are usually not tested persons in quarantine are allowed to go out in public as long as they are not in contact with other people however going to work school or shopping is not permitted during quarantine 12 this is based on the communicable diseases act infectious disease law that stipulates that both quarantine and isolation are obligatory 13 breach of the law is punishable by up to three months of imprisonment however follow up on the adherence of the law is not systematic those in quarantine found themselves isolated at home without their usual routines this rise in unstructured time combined with the enormous stress of the pandemic and its farreaching consequences on both health and the economy has led to widespread concerns including worry about social stigma 14 stigma is a welldocumented global barrier to healthseeking behavior engagement in care and adherence to treatment across a range of health conditions including infectious diseases 15 16 17 18 it may also occur due to patient isolation and quarantine procedures 1920 stigma operates across different levels including in the public sphere through public policies in organizations and in communities through cultural values norm and attitudes in communities stigma also operates in interpersonal relations related to family and friends and on an individual level related to the knowledge and skills of individuals to manage stigma 21 22 23 24 although previous studies indicate many similarities regarding stigma across countries stigma is also known to be contextspecific which necessitates understanding stigma in the given context 25 coronavirus and covid19related stigma has been reported in number of countries such as in india ethiopia japan and uganda 26 27 28 29 30 31 stigma against healthcare workers associated with the care of coronavirus patients has been reported widely as well 32 however little is known about the nature of coronavirus and covid19related stigma which is paramount for developing effective stigma reduction strategies several studies have investigated the psychological experience of quarantined individuals during major infectious disease outbreaks 33 34 35 but less focus has been given to social and behavioral research that is necessary to develop meaningful support strategies for those isolated or quarantined 36 this study aims to review the forms drivers outcomes and impact of social stigma towards those with coronavirus and covid19 and their family members and to shed light on their quarantine experiences in order to develop operational recommendations for public health officials in finland and other similar cultural settings to better support people during and after quarantine or isolation materials and methods this study is comprised of indepth interviews with people from households that experienced coronavirus and were in home quarantine or in isolation for a period of time the interviews were conducted between april and may 2020 by a researcher trained and experienced in qualitative data collection and analysis methods those eligible to join the study were people from households located in the capital area of helsinki in finland with at least one covid19 pcr confirmed case and at least one additional person living in the household respondents included children defined as over the age of 12 youth ages 13 to 17 and adults over the age of 18 any number of household members could participate in the study recruitment the study was part of a larger covid19 household transmission protocol that explored the extent of household transmission 37 individuals who were recruited for the transmission study which included a series of household visits to test for the virus and antibodies could also participate in the qualitative interview study during the final household visit recruitment took place through the finnish institute for health and welfare website or via an sms message that was sent to pcr confirmed cases in the capital area the study coordinator contacted those interested in joining the study by phone to assess eligibility and to schedule a series of home visits a qualitative interview was conducted 28 days after the household indexs pcr confirmation when they were expected to have recovered from the virus to protect the interviewer from potential transmission of the virus a phone call was made to each household before the visit to ensure household members were free of symptoms all but one interview was conducted in finnish sampling the sampling was based on maximum variation in which the overarching principle was to engage respondents from different types of households including couples without children families with children and families with teens so that their aggregate answers could be considered to reflect those of close to the whole population 38 interviews were conducted until no new information was generated and accordingly data saturation was reached 39 conceptual framework and tools the conceptual framework of health stigma informed the development of the stigma question guide it included drivers and facilitators manifestations outcomes and impacts of stigma the drivers and facilitators are factors that encourage stigma drivers are conceptualized as inherently negative conversely facilitators may be positive or negative influences drivers and facilitators determine whether stigma marking occurs meaning stigma is applied to people or groups once a stigma is applied it manifests in a range of stigma experiences and practices 25 stigma manifestations influence a number of outcomes for affected populations as well as for organizations and institutions which then together influence longer term impacts of stigma the study explored selfstigma which is defined as a stigmatized group members own adoption of negative societal beliefs and feelings associated with their health status 25 in this study selfstigma explored negative feeling towards self among confirmed coronavirus individuals and their household members the study also explored perceived stigma which are the perceptions of a stigmatized group regarding how people treat them in this study perceived stigma explored how laboratory confirmed coronavirus cases and their household members perceived treatment by others this framework was selected as it is not only theoretical but facilitates an understanding of the factors that facilitate and mediate the stigmatization process for individuals and also informs intervention development 25 participants were asked to describe any negative experiences with people during their quarantine or isolation to record their experiences of stigma the question guides also included a set of openended questions that explored their experiences in quarantine or isolation such as tell me about your time in quarantine how did quarantine influence your life what was difficult for you during quarantine interviews interviews ranged from 20 to 60 minutes and were conducted in a private room or space in the homes of the respondents interviews were conducted individually to allow for the exchange of sensitive or confidential information all interviews were conducted in finnish except one that was conducted in english they were audio recorded and transcribed approximately 5 of completed interview transcripts were cross checked by another transcriber to ensure accuracy and the level of detail analysis the analysis was based on a thematic analysis conducted by the first author 40 the analysis of stigma followed the health stigma framework 25 that included identifying codes and categories within each construct of the framework analysis of the quarantine experiences were based on an inductive coding process the process started with a data familiarization process during which the analyst read the transcripts multiple times to get an overall idea of the dataset and to create an initial set of codes that resulted in a codebook coding was conducted for each interview using the codebooks emerging new codes were also included using nvivo12 followed by refining and expanding codes and developing categories the initial analysis was shared with the study team to get consensus on the emerging categories and the ways to explore relationships and patterns across the interviews in the final stage the analyst developed the interpretation the syntheses of the results served as the foundation for operational recommendations to support people in quarantine and isolation ethics the finnish communicable diseases law and the law on the duties of the finnish institute for health and welfare allowed the implementation of this research without seeking further institutional ethical review written informed consent was obtained from all cases and contacts willing to participate in the investigation before each interview a written consent for children under the legal age of consent was obtained from a parent or legal guardian as well as from children under the age of 15 results participant characteristics the study included 64 participants from 24 households in the capital area of helsinki in finland each household included at least one pcrconfirmed sarscov2 positive individual and 14 family members almost half of the households had children onequarter of the families had teenagers one household was a single parent household and the remaining households were couples without children or households where children no longer lived with their parents the sample included 14 teenagers or children and four households included healthcare workers most adult participants were in the age range of 3049 the sample included approximately an equal number of female and male respondents the pcr confirmed cases occurred in households during februaryapril 2020 the majority were confirmed in week 11 and week 12 while the remaining cases were confirmed in week 9 week 10 and week 13 among pcr confirmed cases there was one teenager and three children who were confirmed positive household members who did not have symptoms were not pcr tested perceived stigma this section describes drivers manifestations outcomes and impact of perceived stigma see fig 1 framework for perceived stigma most adult respondents had experienced stigma while stigmatizing experiences among children and teenagers were less common all stigma experiences of teen and child respondents included parent involvement such as informing their friends or their families about their coronavirus status on behalf of the child or teenager respondents explained that most experiences of stigma occurred after quarantine because during quarantine their social contacts were minimal and accordingly there were few opportunities for stigmatizing experiences perceived stigma did not differ between respondents who experienced the infection during different periods of time nor between people who had wide social support networks or narrow social networks with whom to communicate stigmatizing experiences did not vary between respondents from different types of families or between those who were covid19 pcr confirmed cases those who tested negative and those did not know of their coronavirus status or between those with severe symptoms and those with mild symptoms or among different types of families those who did not report perceived stigma explained they had not thought of coronavirus as something stigmatizing they included households with teens and children and in many of these households the infected individuals had experienced only mild symptoms drivers of perceived stigma respondents believed that they were stigmatized because of fear of getting infected with sarscov2 or because they were blamed for contracting the virus some respondents also believed that people were angry with them for putting others especially children at risk of infection a number of respondents highlighted that fear of contracting the virus was prominent because people were unsure how long individuals stayed infectious and whether the infection was followed by immunity and if so for how long healthcare workers experienced particular blame for contracting the virus people think that we should not have any other life but being nurses or doctors we should not be allowed to go out and contract the virus perpetrators and manifestations of perceived stigma respondents identified four types of stigma perpetrators linked with different types of social networks the most distant social network of stigma perpetrators included those who had no personal relationship with the respondents but who communicated by posting comments on social media and traditional media sites stigma manifested in blame for being irresponsible and careless after talking to media i got so many negative comments i could not believe the reactions of people they blamed us for being reckless it felt really bad i decided not to speak up again the second network of stigma perpetrators were those who had an indirect link to the social networks of the respondents such as being parents at the same school as the respondents children or living in the same neighborhood but not having a personal relationship with respondents they stigmatized respondents by blaming them for contracting the virus gossiping and by being overly interested in their coronavirus and covid19 experiences yes we heard through friends that some people were accusing us of not informing everyone in the neighborhood about our infection i am very sensitive about this kind of gossiping the third network of stigma perpetrators included friends acquaintances and colleagues with whom participants had not been in close contact before contracting the virus stigma manifested in the reluctance to interact with the respondents there are many friends who are very straight forward that they wont meet with us even outdoors the fourth networks of stigma perpetrators were those who had been in close contact with the respondents before or during quarantine or isolation stigma manifested in being overly curious and continuously questioning them about coronavirus the modes of transmission and the ease of the transmission it was quite obvious that they were afraid of my infection it was tiring to answer the same questions over and over again they also wanted us to give them instructions how to protect others from the infection and they did not believe that we had not received any such instructions outcomes of perceived stigma stigmatizing experiences resulted in respondents reluctance to disclose their coronavirus status respondents frequently explained that disclosing their status to those that they had exposed was seen as a duty but they disclosed to others only on a need to know basis some respondents explained they did not hide their coronavirus status from others but only talked about it if asked i still carefully consider every time i am in a situation in which i should tell about my covid19 status outcomes of stigma among teenagers and children included insecurity about how to deal with friends and worry about the reaction of colleagues and friends at school i am bit nervous about going to school i know that people know we had coronavirus at home impact of perceived stigma respondents highlighted that perceived stigma negatively impacted their social contacts in many ways and accordingly reduced their quality of life my life is not the same there was more going on and more people around it feels empty now selfstigma this section describes drivers manifestations outcomes and impacts of selfstigma see fig 2 framework for selfstigma participants were asked to explain the kind of negative feelings they had towards self to better understand how they defined selfstigma participants explained that selfstigma meant feelings of being contagious or infectious and accordingly worry about infecting others which was particularly common after the quarantine or isolation ended almost all adults had negative feelings towards self whereas none of the children youth or healthcare workers or their family members expressed selfstigma selfstigma did not differ between respondents experiencing the coronavirus during different periods of time nor between people who had wide social support networks and those who only had a few people with whom to communicate selfstigma did not vary between respondents from different types of families between or between those who were covid19 pcr confirmed cases those who tested negative and those did not know of their coronavirus status or between those with severe symptoms and those with mild symptoms drivers of selfstigma respondents highlighted that negative feeling towards self were driven by limited and changing information about the virus as well as limited and often contradicting information about quarantine procedures respondents also highlighted that information about quarantine did not include many concrete or practical instructions which led to uncertainty about how to manage daily life during quarantine or isolation and how not to infect others some respondents worried that the health authorities had ended their quarantine time only because there were not enough workers to follow up with all positive coronavirus cases similarly some covid19 pcr positive cases worried about being potentially infectious as their quarantine ended while they were still symptomatic in addition respondents expressed insecurity surrounding immunity as yet another reason that kept them worried about potentially still being infectious i had hoped that once i was done with quarantine that my life would return to normal but it did not i continued to be worried about transmitting the infection to others some respondents who did not know about their coronavirus status often struggled for several weeks to get pcrtested for sarscov2 during which continuous uncertainty played a central role in their lives the same uncertainty continued after quarantine manifestations of selfstigma adult respondents explained that selfstigma created stress when leaving the house and when in close proximity to others in shops markets and even outdoor areas such as in parks meeting friends in the street and greeting people made some respondents tense some worried about being blamed by others for being outside of their home covid19 pcr respondents expressed greater stress about encounters with people outside of the house than others i was thinking that neighbors are watching and wondering why im going to do the shopping healthcare workers and their family members did not express fears about being infectious after quarantine on the contrary they were confident about having immunity that protects them and others it may come back covid19 but i would be really surprised if no antibodies were detected in me children and teenage respondents did not explain situations in which they felt difficulty interacting with people outside their house on the contrary some of them claimed having breached quarantine to meet friends my sister told me not to go out but it was so frustrating to stay at home i really missed my friends so i met my girlfriend outside of the house a couple of times outcomes of selfstigma adult respondents explained that selfstigma made them reluctant to meet people outside of their household and in particular with people who belonged to highrisk groups many of them expressed being devastated about not being able to meet elderly or sick parents in person and not knowing when they would able to do so i know i am no longer sick but i havent been able to meet with my parents i really do not dare to do that this is a real tragedy for us but i am too worried about infecting them adult respondents also prolonged their quarantine after the official quarantine time had ended by an additional one to even three weeks because of fear of infecting others we just wanted to be on the safe side and continue our quarantine for an additional two weeks two adult respondents expressed guilt about having infected people outside of their household who belonged to highrisk groups respondents did not express guilt about infecting members of their own household which they saw as inevitable i felt so guilty for having infected my mother i visited her every day my isolation was all about worrying about my mother impact of selfstigma in general respondents agreed that selfstigma was a burden that created psychological stress these negative feelings that i have towards myself are creating so much tension and stress in my life coping mechanisms to manage stigma respondents explained they managed stigma in multiple ways some of them felt that the best way to avoid stigma was to challenge the fear of being stigmatized by telling everyone with whom they had been in contact about their coronavirus status however not all respondents could overcome the fear of stigma to do so we told everyone so nobody will come later to blame us others explained that they avoided stigma by following the instructions for isolation or quarantine and ensured that everyone who knew about their coronavirus infection knew that they were doing the right thing to prevent the transmission of the virus we were always at home as they requested us to do this was also a way to avoid conflicts and reduce the fear people had towards us some respondents reduced selfstigma by convincing themselves that they had done everything they could have to avoid contracting coronavirus others believed that increasing quarantine time by an additional week or two reduced selfstigma we took decisions based on the available information there was nothing more we could have done at that time to avoid the infection quarantine and isolation experiences this section describes key characteristics linked with quarantine experiences as well as communication and everyday routines during quarantine and isolation worries about health respondents from households with severe or prolonged coronavirusrelated symptoms or from households where household members had difficulty accessing testing or being admitted to the hospital often described their quarantine experience as having revolved around symptom management and worry about escalating symptoms and even death for some respondents this was an overwhelming experience respondents explained thinking about death in particular when a friend or someone they knew was hospitalized or when media reported about high infection rates and fatalities abroad respondents explained that they passed the time by analyzing their changing symptoms i was living in continuous worry and fear no one was able to explain how the illness will develop some respondents found themselves caring for their sick household members which consumed all of their time and energy many of them felt incapable of the task and therefore considered it a heavy responsibility some respondents felt sorry for their children who were ignored and forgotten while they managed the illness among other household members my life was revolving around my sick husband i could not rest or think i just kept going from one day to the next i wanted him to be admitted to hospital as i did not want to carry all that responsibility myself children and teen respondents explained being worried when seeing one or both parents severely ill some of them worried about the condition of their parents and what they could do to help the situation others were more worried about practical issues such as what to do if both parents ended up in the hospital neither children nor teenagers seemed worried about their own health i was scared when both of my parents were sick i went through an emotional rollercoaster when my parents were ill some respondents were consumed with worry about the people they exposed to the coronavirus or who contracted the virus from them i had no time to think about myself or worry i was so devastated about my mother i felt so guilty for infecting her others worried about friends and family members in highrisk groups who may get sick or about not being able to socialize with them we havent met with my parents since this all started i am so worried and we are all so sad i kept thinking of my parents a lot boredom some respondents from households with mild covid19 symptoms described quarantine as monotonous with the same daily routines some were irritated about their everyday lives teen and child respondents also frequently described quarantine as tiresome and dull one of them explained that quarantine made him and his friends extremely passive respondents who used to meet with friends and had an outgoing and active lifestyle were particularly bothered about the restricted lifestyle in quarantine it is exhausting to be at home all days are the same although i manage to work from home just fine the days are the same others with mild symptoms did not consider that their everyday life had changed much since they contracted the virus they explained spending a lot of time at home working from home or having little social contact outside of their home our life is already like quarantine so this situation has brought us no major changes for us communication over half of the participants had at least one person in the household who was communicating regularly with others who had contracted the virus the most common communication channel was a whatsapp group that was established among people who attended an event during which they contracted the virus or a preexisting whatsapp group where friends who had contracted coronavirus were already communicating i dont know what i would have done without my group i was talking to them daily it helped me to ensure that i was going to manage this those who did not belong to such peer support groups included participants who did not know the mode of transmission of their infection or those who were elderly respondents explained that regular communication with others including listening to the illness episodes of others and finding similarities with their own experiences reduced worry about their own health and the health of other coronavirus positive household members communication with peers also provided an opportunity to share their own experience with those who understood their situation respondents said that being part of a group empowered them together we can make it in addition respondents mentioned that groups provided information about how to access testing and they helped them prepare for being positive for sarscov2 communicating with others in the same situation was also important to healthcare workers for some respondents participation in coronavirusspecific communication groups was a negative experience as continuous discussions about the topic made the illness highly present in their lives and a source of stress one respondent felt that the active whatsapp communication by his partner made him an outsider for other respondents active whatsapp communication with other household members was a great source of information for the whole household it was a bit too much for after a while with all the information i received from the group i felt that there was nothing else in my life than corona so i started distance myself from the group female respondent from a family with children some respondents discussed their infection in other personal whatsapp groups to share coronavirus and covid19 information with others or to get attention some respondents explained that they had the role of corona experts in those groups whose advice friends sought through the group my friends who are worried about corona keep consulting me about their symptoms i turned out to be corona expert teen and child respondents did not explain having established any coronavirusspecific groups some of them communicated with friends from time to time about their infection but more often their discussions related to quarantine and the problems that it brought to their lives such as cancelled graduation parties sports and travel we used to talk about corona in the beginning with friends but not so much anymore now we wonder when all this will end and we get back to our lives and our activities many respondents highlighted that they were cautious talking about worries and fears related to coronavirus with their own family members to avoid elevating problems some respondents clarified that talking about the infection might increase their fears or generate more serious situations i did not want to open up discussion about my fears with my family they were worried enough i thought it may upset them more respondents explained that media coverage was exhausting and stressful and some of them had stopped actively following it other participants claimed following all news related to coronavirus on a daily basis several adolescent respondents felt that the media coverage irritated them and accordingly they no longer followed the coronavirus coverage regularly i stopped following news about coronavirus some time ago it was making me depressed some respondents mentioned that following media coverage had been helpful as it allowed them to prepare themselves for the possibility of contracting the coronavirus i was not surprised about it i knew what to expect i had heard so much about it over the past weeks everyday routines not many respondents took precautions with their living arrangements to protect others in the household from coronavirus some considered their house too small to take any special precautions others felt it unnecessary because they discovered the infection late and accordingly had been living together without precautions for a while a few respondents had not thought of such precautions or they explained not having received any such instructions from the health authorities those who organized their everyday life to avoid transmission of the virus within the household slept in different rooms lived on different floors or in other areas of the house used separate kitchen utensils separate toilets and bathroom or undertook more intensive cleaning procedures leaving the house during quarantine varied from those who did not leave their house the entire time to those who took short walks and those who took a regular walks with their dog or children on a daily basis some participants were far too sick to leave their house and others were unsure about what they were allowed to do and discussions in whatsapp groups confused them further they said we can go to the backyard but we do not have a backyard we live in an apartment building in the middle of the city family relations some respondents believed that quarantine created tension at home between the household members one respondent explained her child was having constant tantrums due to the shift from an active lifestyle to being at home but several respondents saw some positive developments from quarantine such as getting closer to their partner having more time as a family or time to relax we have gotten closer one another due to this experience that we shared discussion to our knowledge this is the first study in finland exploring covid19related social stigma and the quarantine and isolation experiences the study indicated that social stigma poses a challenge by impacting social relations and by creating psychological distress which is likely to affect quality of life particularly after the illness quarantine and isolation experiences were characterized by worry about health and boredom communicating with others who contracted coronavirus was common but fears and worries were only cautiously communicated to family members living arrangements did not include specific precautions to prevent further transmission at home activities outside the home during quarantine were limited but varied the study findings indicated that respondents did not feel a sense of closure after their isolation and quarantine had ended because of perceived stigma and selfstigma and worry that they could still infect people around them stigma reduced their willingness to disclose their coronavirus status or any household association with it leading to psychological and social distress stigma is known to result in delayed health seeking behavior among symptomatic patients including testing which can speed the transmission of the virus rapidly 4243 this can be particularly problematic in countries where the focus of the national covid19 prevention strategy is testing and contact tracing followed by isolation and quarantine such as currently in finland the study findings also indicated that the way adults communicated about coronavirus in the social networks of their children created stigma the public and in particular parents will benefit from guidance on how to communicate about coronavirus and covid19related issues marketing of destigmatizing wording has been identified as helpful to reduce stigma elsewhere 4445 in addition stigma has been successfully reduced by communicating the rationale behind potentially stigmatizing concepts of quarantine isolation or suspect cases 11 fear and blame were drivers of coronavirus and covid19 stigma which are also common drivers of infectious disease stigma worldwide 46 47 48 in todays world fear is easily generated by an overabundance of news mixing facts rumors and fake news 49 misinformation about covid19 has also rapidly spread around the world through social media 50 accordingly the provision of factual information about transmission and the nature of the virus have been found to be an effective strategy to reduce stigma 434451 stigma reducing information should include expert information about the disease such as contagiousness number of diagnosed people fatality rate and seroprevalence in the community in addition the information should also provide people with tools about how to prevent the infection to ensure that people feel confident about being able to protect themselves which in turn will prompt their willingness to apply protective measures 43 new and innovative ways to communicate about sarscov2 and covid19 should be considered 52 overall provision of accurate information about covid19 is challenging as information is rapidly evolving therefore health authorities should focus on ensuring that the public is aware of trustworthy and updated sources of information where they can look up continuously changing information about the virus as a means to help build public confidence to manage better their interactions with those who contracted the virus having a trusted source provide information to the public is crucial as demonstrated in an antistigma intervention in sicily where trusted health experts engaged themselves with the public through an online platform and successfully reduced covid19related stigma 43 blame for infection could be reduced through messaging that anyone can contract the virus and anyone is vulnerable 44 blame could be reduced by using emotions in the communication though symbols or metaphors 53 special attention should be given to address blame for the infection that is directed towards healthcare workers who are already likely to be under high pressure stigma towards healthcare workers caring for covid19 patients has been identified in a number of countries worldwide 31 in particular actions are needed to promote their wellbeing during and after the outbreak the uk has developed a digital learning package for healthcare workers wellbeing during and after covid19 that might be worthwhile to explore in finland and in other settings 54 as both traditional media and social media promoted stigmatizing attitudes stigma capacity building training could be organized for media representatives and social media influencers such as raising awareness about how to recognize stigmatized groups and how stigmatization is enacted the content of antistigma training often includes information about the ways to identify stigmatized persons about responsibility for their condition about the moral and physical peril linked to them as well as labels for the stigmatized group 55 the study discovered that perpetrators of stigma belonged to different types of social networks ranging from close friends to those who had no personal relationship with the respondents likely those who stigmatize persons with coronavirus and their family members do not necessarily understand the harm they cause through their actions and words messages of empathy could be promoted to develop a more sensitive and caring atmosphere for those with coronavirus and their household members stigma reduction efforts that focus on promoting emotional approaches could be used as guidance such as contact interventions 5255 at the same time those with coronavirus and their family members need to be empowered to manage dealings among the social networks of those with coronavirus during and after quarantine children and teenagers could be provided with special back to school instructions to reduce the worry about how to meet friends at school guidance about how to deal with members of highrisk groups after quarantine would be important as well due to changing and contradictory information received during the epidemic uncertainty was central in the experiences of those quarantined and isolated as was similarly identified in recent study in china 11 this highlights the need for a national communication strategy under which all authorities and academic institutions communicate at all levels to ensure that that all health personal disseminate the same information in the same way 56 the findings showed that health officials left out a number of important audiences in communications about the virus firstly those who cared for sick household members were usually not in touch with health officials this left caretakers without critical information and opportunities to discuss and get advice many caretakers were overly stressed about the responsibility they were left to manage secondly children and teenagers did not have a specific channel to communicate with health officials to gain information or share fears and concerns thirdly asymptomatic household members or those who tested negative received less attention although they seemed to have equally pressing uncertainties compared to others a recent study in china concluded that the close contacts of those with coronavirus suffered from physical and psychological problems that must be addressed 11 there is a need to explore how to engage all household members in the communication with health authorities who follow up and provide assistance for families with coronavirus models for expanding communication to families instead of patients could be taken from countries that have a system of family doctors where communication is often also family based 57 digital platforms could be considered to reach all household members individual behavior is of central importance to control the spread of coronavirus 32 the study showed that quarantine and isolation may be accepted interventions among the public in finland although boredom among more social and active participants during quarantine and isolation was prevalent there were also those who did not perceive quarantine particularly different from their everyday life as reported also in canada 58 moreover participants used physical activities as coping mechanisms to manage the boredom such as walking and jogging similar to a study in china that showed that quarantined individuals focused on physical health to manage the situation 11 communicating with other people with coronavirus via whatsapp developed naturally based on the current communication culture in which whatsapp groups are based on themes and or social networks and are a major channel to communicate with others 59 respondents noted that finding others in the same situation and having the opportunity to discuss the infection and related developments were of utmost importance as identified in a number of studies elsewhere 60 communicating with others with coronavirus provided information and reduced worries however communicating with peers did not reduce selfstigma or uncertainties around coronavirus and covid19 on the contrary sometimes discussions in peer whatsapp groups confused the situation further moreover whatsapp groups have also been identified as major channels of misinformation 61 communicating about coronavirus and covid19 within families was more problematic as household members feared they would elevate the problem by talking about it emotional support group communication for children and youth has been identified as a way to help participants express sorrow and worry 62 there are limitations in our study that must be acknowledged sampling following maximum variation was fulfilled in terms of engaging different types of households however variation regarding the age group of participants and the time of onset of illness had only limited variation which may have been influenced by the mobile and webbased recruitment process that may have excluded elderly participants who are potentially less likely to communicate through those channels or less comfortable using the devices in addition the perceptions reported in interviews might have been influenced by social desirability bias given the potentially sensitive nature of topics such as feelings and family dynamics conclusion this study provided valuable information about how to support those in quarantine and isolation which can be used to ensure health interventions are acceptable to the public it resulted in a set of recommendations to reduce stigma including promotion of destigmatizing language addressing fear of infection by promoting reliable sources of covid19 information and addressing the blame of infection through messages that reinforce ideas that anyone can get infected in addition recommendations include conducting stigma trainings for media and social media influencers using emotions as a communication approach empowering those with coronavirus and covid19 and their family members to manage stigma and advocating for the creation of a national communication plan to ensure aligned messaging about coronavirus and covid19 across the country to better manage quarantine and isolation the study recommended ensuring the delivery of sufficient and practical information about coronavirus covid19 and quarantine to all household members including children teenagers asymptomatic and sarscov2 negative individuals the information should address practical matters related to everyday life and how to stay active in quarantine and isolation all relevant data are within the paper and its supporting information files

the covid19 pandemic has intensely changed the everyday lives of people worldwide this study explores the forms and outcomes of coronavirus and covid19related social stigma and the experiences of people who were home quarantined or isolated in finland during the spring 2020 the findings of this study can be used to improve support for those quarantined or isolated and to develop strategies to reduce the stigma associated with coronavirus and covid19the study is based on qualitative onetoone interviews with households with at least two members and at least one pcr confirmed covid19 case recruitment took place via website or sms messages sent to pcr confirmed cases in the capital area of helsinki sampling was based on maximum variation to acquire different types of respondents the framework of health stigma was used to develop question guides and analyze stigma quarantine and isolation experiences were explored through openended questions the analysis was based on thematic analysisthe study included 64 participants from 24 households perceived stigma among respondents was driven by fear and blame for infection and it manifested in various ways leading to a reluctance to disclose their coronavirus status to others selfstigma developed from conflicting information and advice about coronavirus and covid19 led to difficulties interacting with others outside of the house and reluctance to meet people after quarantine and isolation quarantine and isolation experiences included uncertainty health concerns and boredom communication with others in similar situations was perceived vital whereas discussions with family members about worries and fears related to coronavirus and covid19 was not preferred

introduction although symptoms of nonaffective psychotic disorders typically emerge during adolescence or early adulthood 1 it has long been recognized that a subset of people experience their first episode of psychosis in old age 23 defined in the context of very lateonset schizophrenialike psychosis as after 60 years old 3 the symptomatology underlying vloslp appears to be similar to psychosis in younger adults although fewer negative symptoms are present 4 epidemiology has been less well characterized 5 and while there is consistent evidence that vloslps are more common in women than men 46 whether rates vary by age migration or other potential social determinants of risk such as traumatic life events or social isolation remains largely unexplored previous findings with respect to age have been mixed showing both increased 7 and decreased vloslp rates with advancing age 8 9 10 it is also unclear whether these patterns differ between men and women in line with the literature on psychosis incidence in younger adults 1112 several studies have also reported higher risk among migrants 1314 but this literature remains sparse particularly outside of the united kingdom indeed in general the vloslp literature has predominantly consisted of smallscale crosssectional studies although these have led to the identification of several potential risk factors including sensory impairments 15 social isolation 1617 premorbid schizotypal traits 16 and traumatic life events 18 19 20 21 results have not been consistently replicated 22 epidemiological investigation in large populationbased longitudinal studies is largely lacking with limited exceptions 10 older people have consistently been omitted from studies that have elucidated a robust set of risk indicators for psychotic disorders at younger ages 23 24 25 26 the principal aim of this study was to delineate the epidemiology of vloslp in a national populationbased cohort of people living in sweden since 1920 we aimed incidence of nonaffective nonorganic psychotic disorders in older people to examine variation in incidence rates by potential risk factors for vloslp hypothesizing that advanced age female sex migrant status lower socioeconomic status family history of psychotic disorders sensory impairment gestational exposure to world war ii social isolation and death of a partner or child would increase risk methods study design and setting in sweden all people granted residency are given a unique national identification number allowing record linkage across national health and administrative registers psychiatry sweden is a linkage of these national registers for the study of psychiatric disorders using this data we established a longitudinal cohort of people born between 1920 and 1949 and living in or who immigrated to sweden on or after their 60th birthday participants born before 1932 were enumerated and identified from the 1960 and 1965 censuses whereas those born since 1932 have been followed prospectively through the registers in our study participants were followed from their 60th birthday until the end of followup emigration from sweden dementia diagnosis death or psychotic disorder diagnosis whichever came first we excluded those who died before age 60 years emigrated from sweden before age 60 without return or were diagnosed with dementia before diagnosis with a psychotic disorder outcome we identified all participants recorded in the swedish national patient register diagnosed with nonaffective psychotic disorder according to the international classification of diseases revisions 810 since 1980 the swedish national patient register contains records of approximately 70 of all psychiatric admissions in the healthcare system from 1970 83 by 1973 97 from 1974 to 1983 80 95 from 1984 to 1986 and has been close to complete since 1987 27 recording of outpatient data began in 1997 and was close to complete from 2001 covariates data on age sex birth period and region of birth were obtained from the swedish register of the total population we categorized region of birth as sweden africa asia north america europe finland south america oceania middle east russiabaltic and other to investigate the possible role of gestational exposure to maternal stressors experienced during wwii we categorized participants into the following birth periods based on earliest likely gestational date 19201924 19251929 19301933 1934august 1939 september 1939may 1946 and june 19461949 we created a disposable income variable grouped into quartiles based on all cohort members with disposable income from all sources at age 60 recorded in the same calendar year using data from the longitudinal integration database for health insurance and labour market studies using administrative registers the lisa collects information annually on workrelated information such as income employment education and insurance for the total swedish population aged 16 years and older we linked participants to their children via the multigenerational register to derive a measure of psychosis family history based on whether their biological children had ever received a psychotic disorder diagnosis we also linked this register to the cause of death register to obtain data on death of a child before cohort exit before child age 12 months or age 18 years these exposures were grouped as follows had children no child death had no children and death of at least one child we also created a variable on death of a partner in the 2 years preceding cohort exit using census data or the lisa database thereafter linked to the cause of death register this variable was grouped as follows had a partner but did not experience partner death death of one or more partners and had no partner we created binary hearing and visual impairment variables using diagnoses from the national patient register recorded before cohort exit missing data missing data were limited to income for income we included data at age 5559 for those with missing data at age 60 years where possible we conducted completecase analyses dropping those with remaining missing data on income from analyses statistical analysis we used cox proportional hazards regression to model survival in the context of time to vloslp diagnosis in relation to exposures of interest reported using hazard ratios with 95 cis initially we examined univariable associations between each exposure and the outcome recording overall fit of each model using akaikes information criterion where low scores indicated better fit using a forwardfitting modeling strategy we added variables with the lowest aic scores to a multivariable model with age sex and their interaction included as a priori confounders model building was tested via likelihood ratio test age was modeled as a timevarying covariate using lexis expansion to examine age atrisk during followup which was grouped into 5year age bands between ages 60 and 90 years and older in sensitivity analyses we excluded migrants diagnosed with a psychotic disorder within 2 years of immigration to sweden to mitigate the possibility of including prevalent cases in our sample in addition we conducted a sensitivity analysis to examine any differences in results after excluding those diagnosed with dementia within 2 years of diagnosis with vloslp given that these individuals may be considered to be experiencing the dementia prodrome we also tested our final model for violation of the proportional hazards assumption analyses were conducted using stata version 13 results from 3 007 378 people contributing 39 764 686 personyears of followup time we identified 14 977 cases diagnosed with vloslp during the followup period corresponding to a crude incidence rate of 3766 per 100 000 personyears atrisk after excluding participants with missing income data 2 955 796 cohort members were retained including 14 825 cases median ageatfirst diagnosis of vloslp was 68 years for men and 70 years for women compared with the remainder of the population people with vloslp were more likely to be women from the lowest income quartile have no children have children with a psychotic disorder have no partner in the 2 years before cohort exit be born outside of sweden and be born in the youngest birth period incidence by age and sex a significant interaction was observed between age and sex in crude and fully adjusted analyses 3819 p 001 adjusted model lrt χ 2 3156 p 001 this suggested that vloslp incidence increased with age for men and women but at an accelerated rate for women after age 80 years proportional hazards modeling after adjustment for age and sex we observed strong associations between almost all variables of interest and risk of being diagnosed with vloslp full adjustment following multivariable model building led to some attenuation in observed associations but most risk factors remained associated with vloslp for example migrants from africa north america and europe were at elevated vloslp risk after adjusting for all other covariates including income at age 60 those born in later birth periods particularly those with gestational exposure to wwii or born after wwii were more likely to receive a diagnosis of vloslp compared with those born 19201924 lower income at age 60 years was strongly associated with future risk of vloslp with the highest rates in those in the lowest income quartile participants whose children had a history of psychotic disorder were over twice as likely to develop vloslp than those without such a family history as were those without children participants without a partner 2 years before cohort exit or whose partner died were also at higher vloslp risk there was weak evidence that people who lost a child in infancy were more likely to develop vloslp than those with children who did not die in infancy although death of a child before age 18 years was not associated with vloslp risk in our final model interestingly and contrary to our hypotheses those with a history of sensory impairment were less likely to receive a diagnosis of vloslp this finding was independently present in the domains of visual impairment and hearing loss sensitivity analyses results from the sensitivity analysis excluding migrants who presented for psychosis within 2 years of arrival to sweden and who may have been prevalent cases did not substantially differ from results based on the full sample results from an additional sensitivity analysis excluding those diagnosed with dementia within 2 years of diagnosis with vloslp were also very similar to results involving the full sample proportional hazards there was some evidence that the proportional hazard assumption was violated for several variables inspection of the data stratified by time suggested the effects of income and sensory impairments on vloslp risk weakened over time whereas death of a partner was only associated with risk in the youngest cohort incidence of nonaffective nonorganic psychotic disorders in older people discussion summary of findings in this nationwide cohort study investigating the epidemiology of vloslp we found substantial incidence after age 60 years the overall incidence rate of 3766 per 100 000 personyears atrisk was toward the higher end of previously reported rates of vloslp in a recent systematic review 5 the overall rate of nonaffective psychotic disorders in those aged 60 years and older was found to vary substantially across studies ranging from 143 per 100 kpy in northumberland 28 to 399 per 100 kpy in camberwell 14 rates increased with age beyond 80 years old and were generally higher in women than men a disparity that widened with increased age rates were higher for those born later including those with some gestational exposure to wwii consistent with epidemiological research in younger adultonset samples we found raised rates among some migrant groups particularly from africa and europe these findings were unlikely to be explained by prevalent cases among migrants or by income itself a strong predictor of vloslp unexpectedly rates were lower in those with sensory impairments finally we found higher rates among those without a partner or children those whose children had a history of psychotic disorder and those who had experienced the recent death of a partner or child in infancy strengths and limitations this is the largest populationbased cohort study to examine the incidence of vloslp we used swedish registry data which are highly complete and reliable for research purposes 2930 this enabled us to include a relatively high number of cases and to obtain precise estimates for potential risk factors we note several study limitations including the need to consider whether reliance on registerbased diagnoses could have biased results on the one hand we may have underestimated true incidence as those with vloslp may be less likely to contact services due to higher levels of functioning 16 and limited social contact 31 by contrast given that recording of psychiatric diagnoses in swedish registers only began in 1973 we may have included some prevalent cases which would have overestimated incidence nonetheless our followup period began in 1980 and we excluded those with a recorded psychotic disorder in the 7 years prior register coverage improved over this washout period during which most prevalent cases would be expected to present to services we may have expected more prevalent cases among older birth cohorts who were more likely to have experienced the major risk period for psychosis before routine registration of psychiatric diagnoses began by contrast we found stronger vloslp risk in our younger birth cohorts this may be explained by differential ascertainment bias over time whereby younger cohorts were more likely to be diagnosed with vloslp after 60 years old either because of more complete register coverage since 1987 or because of improved clinical awareness of vloslp as a distinct set of syndromes from dementias in later life to mitigate the possibility of vloslp representing misclassified dementia with psychosis symptoms we excluded those diagnosed with dementia before psychotic disorder in general when an older patient presents to services with psychotic symptoms we would expect dementia to be assessed and ruled out before a psychotic disorder diagnosis was given however we cannot exclude the possibility of psychosis representing misdiagnosed dementia in some cases or the reverse it is also possible that in some patients vloslp represents a prodrome for future dementia 33 correspondingly a danish registerbased study identified higher rates of subsequent dementia in those with vloslp compared with the general population and osteoarthritis patients 34 to examine whether our findings were influenced by including those who may be experiencing the dementia prodrome we conducted a sensitivity analysis excluding individuals diagnosed with dementia in the 2 years following diagnosis with vloslp results were very similar to those involving the full sample suggesting that our findings are unlikely to be explained by the inclusion of this group in this study we could not link our cohort with their parents hence we could not delineate secondgeneration migrants from the swedishborn population however we would not expect a large number of secondgeneration migrants in this cohort given the birth periods covered we were also therefore unable to investigate parental history of psychotic disorder instead we used offspring psychotic illness as an indirect proxy this will have overestimated the prevalence of psychosis family history and our strong estimates for this variable may therefore be conservative we also had to make some assumptions about coding death of a partner in the 2 years before cohort exit we do not consider this will have introduced any substantial biases in our data in addition we did not examine other mental health diagnoses such as depression substance abuse or bipolar disorder in this study future studies examining premorbid mental health conditions in those with vloslp could provide valuable insights into the mental health trajectories of this group throughout adult life before the emergence of latelife psychosis finally the proportional hazards assumption was violated for several exposures warranting further exploration of potential reasons for variation in these effects over time in future studies for example the attenuation of a protective effect over time in those diagnosed with sensory impairments may be attributable to better clinical awareness of physical health morbidities in people with psychosis meaning of findings we have precisely delineated a substantial incidence of nonorganic psychotic disorder occurring in later life which our results suggest is distinct from psychosis associated with dementia there is already evidence that people with vloslp have greater preserved functioning compared with those with adultonset psychosis 1617 but are more socially isolated 31 this is consistent with our observations of greater risk with older age particularly for women 463536 and given that this population were less likely to have children or a partner in the 2 years before diagnosis together these findings suggest that this group may harbor unrecognized psychiatric morbidity requiring clinical attention our findings also raise questions about the biological andor social mechanisms underlying increased psychosis risk in older women which may begin from the welldocumented secondary peak in incidence in their late 40s 3237 we found higher rates in later birth cohorts independent of age with highest rates in people gestationally exposed to wwii or born thereafter although this may reflect greater exposure to malnutrition or traumatic events occurring during or in the immediate aftermath of the war we recommend interpreting these results with some caution give that they could also represent a period effect related to changes in vloslp recognition and diagnostic trends occurring from the 1980s psychosis incidence was higher among migrants to sweden from africa north america russianbaltic regions europe and finland corresponding with previous vloslp findings 131438 and those from the younger adultonset literature 111239 several potential explanations have been proposed including stressors experienced preand postmigration and during migration itself 11 contrary to hypotheses we found lower rates of vloslp in those with hearing and visual impairments this contrasts several previous smallscale studies 1540 one possibility is that our populationbased sample reflects underdetection and treatment of sensory impairments in older adults with psychosis at a nationallevel as observed for other physical health problems such as cardiovascular disease in those with serious mental illness 4142 such disparities may reflect reducedhelp seeking behavior or providerlevel factors such as the separation of specialist physical and mental health services 42 clinical uncertainty in providing suitable care for patients with psychosis or diagnostic overshadowing where physical symptoms are misattributed to mental illness 43 participants with vloslp were more likely to experience a range of social disadvantages than the population atrisk including lower income greater social isolation and adverse life events one interpretation of these findings is that exposure to structural inequalities and social stressors may have longlasting effects on psychosis risk into later life in the younger adult onset literature low ses has consistently been associated with psychosis risk 44 45 46 although our findings regarding income could be attributed to social drift during the prodromal phases of psychosis this interpretation seems less readily applicable to vloslp patients who would have had to maintain sufficient levels of functioning throughout their adult life 47 to be atrisk of vloslp at cohort entry similarly as suggested for younger adults with psychosis our findings regarding social isolation could be interpreted causally 4849 or may reflect premorbid impairments in social functioning limiting ones ability to form and maintain stable intimate relationships leading to reduced fecundity 50 51 52 our findings regarding the recent death of a partner or loss of a child in infancy correspond with previous smallscale studies suggesting that traumatic life events could be associated with vloslp 18 19 20 21 and with the wider epidemiological literature on psychosis in those aged 65 years and younger 53 54 55 our findings extend this research to suggest that the loss of a child in infancy might convey longstandingalbeit modestincreased risk of psychotic disorder several decades later on the other hand this finding may be another manifestation of the association between vloslp and longterm social disadvantage that we did not observe similar effects for the loss of a child at other ages was somewhat surprising further wellpowered studies will be required to understand whether such stressors have more pernicious effects before age 60 years further research is now needed to replicate these findings and examine potential biological and psychological mechanisms underlying these associations with the aim of identifying potential targets for intervention supplementary material supplementary data are available at schizophrenia bulletin online

background there are limited data on the epidemiology of very lateonset schizophrenialike psychosis vloslp and how this relates to potential risk factors including migration sensory impairment traumatic life events and social isolation methods we followed up a cohort of 3 007 378 people living in sweden born 19201949 from their 60th birthday earliest january 15 1980 until december 30 2011 emigration death or first recorded diagnosis of nonaffective psychosis we examined vloslp incidence by age sex region of origin income partner or child death birth period and sensory impairments results we identified 14 977 cases and an overall incidence of 377 per 100 000 personyears atrisk 95 ci 371383 with evidence that rates increased more sharply with age for women likelihood ratio test χ 2 6 3156 p 001 after adjustment for confounders rates of vloslp were higher among migrants from africa hazard ratio hr 20 95 ci 1427 north america hr 14 95 ci 1019 p 04 europe hr 13 95 ci 1214 russianbaltic regions hr 16 95 ci 1419 and finland hr 16 95 ci 1517 vloslp risk was highest for those in the lowest income quartile hr 31 95 ci 2933 rates were raised in those whose partner died 2 years before cohort exit hr 11 95 ci 1013 p 02 or whose child died in infancy hr 12 95 ci 1014 p 05 those without a partner hr 19 95 ci 1819 or children hr 24 95 ci 2325 and those whose child had a psychotic disorder hr 24 95 ci 2226 interpretation we identified a substantial burden of psychosis incidence in old age with a higher preponderance in women and most migrant groups life course exposure to environmental factors including markers of deprivation isolation and adversity were associated with vloslp risk

a s the need for longterm care increases with the steady growth in the number of older adults relocations into residential settings will increase about 70 of people older than age 65 will require time in ltc services and 40 will require nursing home care for a period of time relocation is a move from one permanent home to another permanent home and it is considered a significant life event skinner noted that a forced relocation can have disturbing effects on an older adult including loss of social and community connections even with planned relocation however encountering a new and unfamiliar environment requires an older person to rethink ways in which life will differ adjustment can take a few weeks to several years many factors determine how this new life will evolve including past adaptive strategies and life experiences family support systems socioeconomic resources and cultural values moving from a familiar environment to an unfamiliar one involves adaptation the concept of adaptation has appeared in the literature of many disciplines in which it refers to relationships between creatures and their environments in health services research lawton and nahemows classic theory of environmental press is based on the concept of adaptation and examination of relationships between people and their environmental contexts conceptually adaptation has been used extensively in health care disciplines as a foundation for practice and research indicators of successful adaptation to ltc have included developing a sense of identity and place having care needs met knowing and being known to other residents maintaining or developing social networks experiencing continuity of lifestyle and maintaining control over life situations in this study we defined adaptation as a normal process by which a person encounters a perceived challenge in the environment and successfully manages that challenge as measured by increased quality of life activity engagement and social participation related to adaptation is the cultural heritage that a person brings to the ltc facility on relocation evans crogan and schultz found in a study of the meaning of mealtimes in a nursing home that resident preferences were rooted in childhood and family they suggested that dining experiences such as a soul food day that connect with residents personal remembrances can increase quality of life because culture affects the learned beliefs values customs actions communication and life ways of a person it can be expected to permeate all aspects of life in an ltc facility lack of social support chronic illness and cognitive impairment are prompting older americans of all cultural backgrounds to enter ltc facilities as with their white counterparts minority older adults are entering these settings in greater numbers because they are part of the growing population of older adults attention to cultural differences has only begun to make inroads into daily life in these facilities quality of life is a complex construct that has been used synonymously with terms such as wellbeing life satisfaction and functional health lawton asserted that qol is a collection of dimensions consisting of objective and subjective factors that may include behavioral competence objective environment perceived qol psychological wellbeing and healthrelated status other factors associated with qol in an ltc facility include interaction with family and friends personal qualities roomandboard items number of health problems staffpatient ratios and continuity of care these factors attest to the importance of a personenvironment match when qol issues for nursing home residents are considered incorporating meaningful activity and social connections into the lives of older adults whose occupational performance has been circumscribed by illness and disability is particularly important to residents qol engagement in activity involves the performance of a task whether it is selfcare work leisure or instrumental activities of daily living social participation is sometimes difficult to distinguish from activity engagement because both involve activity moseys definition of social participation as organized patterns of behavior that are characteristic and expected of an individual or a given position within a social system highlighted the influence of social context on the individual the gerontological literature has concentrated on personal care and iadls and how they contribute to health and functional status these obligatory tasks are essential to ones survival but perhaps even more significant to an older adults wellbeing are discretionary activities involving social and meaningful occupations the findings of kendig browning and young supported the proposition that activity and social support systems are important in mediating the impact of illness on wellbeing on the basis of findings from previous studies we created an occupationbased cultural heritage intervention central to the intervention was that person and environment factors contribute to the residents transition to an ltc facility implementing the obchi during this relocation period highlighted the residents cultural heritage the significance of the intervention lies in the potential for modifying relocation stress and facilitating a more meaningful transition into ltc facilities for older adults this intervention aligns with the professions mandate to facilitate productive aging in a variety of settings the intent of this study was to determine whether the obchi facilitated older adults adaptation to their new home we describe a 2yr study funded by the national institutes of health and answer the following research questions 1 what are the differences at baseline between groups on the measures of qol family support physical and mental health activity engagement social participation and environmental factors 2 what relationships were found at baseline between these person and environment variables 3 does the intervention improve participants qol activity engagement and social participation method design we used a quasiexperimental nonequivalent controlgroup design with pretests and posttests site matching and randomization were initially proposed but because of recruitment issues adding four additional sites that were not randomized was necessary however we considered the mix of or predominant ethnic groups residing in each facility to keep to the original plan as much as possible we compared residents who received the cultural intervention with those who received a typical activity group without culturally specific elements we obtained institutional review board approval from texas womans university for all sites and approval from another universitys managed facility at the initiation of the study and we renewed the approvals on a yearly basis all participants gave written informed consent to participate sample participants were recruited from 10 ltc facilitiesspecifically skilled nursing unitsin a southwestern metropolitan city however in three of those facilities the number of participants was insufficient to form a group resulting in seven sites for the intervention and control groups residents who participated in the study met the following criteria age ³55 yr relocation into the project site during the previous year receiving licensed nursing care but not in a hospice or locked unit white or africanamerican english speaking and able to participate in interviews as determined by a score of £5 on the short portable mental status questionnaire development and implementation of the obchi and control groups we chose a group approach to intervention on the basis of support from the literature structure and format for both control and intervention groups were identical each group consisted of eight 1hr sessions that took place twice weekly for 4 wk protocols were structured to include specific guidelines group names expectations of group leaders and members methods of delivery equipment lists and recommended scripts for facilitators the group format consisted of an introduction warmup activity discussion and closure control and intervention groups differed by content the content for the control group consisted of the usual activities determined by examining calendars of activities in the ltc facilities and by reviews of current literature protocols included structured activities of exercise poetry writing current events and crafts we derived content for the intervention protocols from qualitative interviews conducted with residents in six ltc facilities that focused on people and cultural characteristics of older adults relocating to ltc facilities the interviews generated themes of family traditions that shaped their lives food as part of family roots enjoyment of music home family occupations of work and leisure and spirituality for our second aim we designed group protocols for the intervention incorporating these themes and based on principles delineated by clark et al cole and howe and schwartzberg the protocols were reviewed by one expert each in the fields of nursing and occupational therapy to test content validity recommended changes were incorporated into the final protocol manual further information about the intervention can be obtained by contacting gayle hersch two certified occupational therapy assistants conducted the groups assisted by a trained graduate research student both assistants were blinded to group assignment one was trained in the intervention protocol and the other was trained in the control protocol a third certified occupational therapy assistant trained in both intervention and control protocols served as a substitute when needed the initial series of eight sessions for both intervention and control groups was monitored by one of the investigators to ensure that the protocol was followed instrumentation pregroup tools included the medical outcome studies short form 12 duke social support and stress scale and sheltered care environment scale the yesterday interview and quality of life index nursing home version were administered before and after the intervention and served as outcome measures sf12 we used the sf12 to assess physical and mental health status it has excellent reliability and validity with the physical and mental function component scores being highly predictive of the scores obtained from the full sf36 dusocs the dusocs was developed to measure covariates of family and nonfamily support and stress this 24item selfreport instrument has the respondent rate on a 3point scale the extent to which types of family members or nonfamily members provide support reliability tests have found cronbachs as of 71 for family support and 70 for nonfamily support sces the 63item sces measures the influence of the ltc facilitys environment on adaptation it assesses three domains of social climate relationship dimensions personal growth dimensions and system maintenance and change dimensions internal consistencies for six of the seven subscales were acceptable to high and the resident influence subscale indicated moderate internal consistency yi the yi documents engagement in activities and social relationships it uses a simple grid to record a persons report of activities during the previous day including social partners kinds of assistance needed locations in which activities occurred and whether activities were obligatory or discretionary obligatory activities are considered essential for survival and seen as a constraint in contrast discretionary activities are selfchosen and address needs for affection knowledge or pleasure for this study we describe only the number of activities spent in obligatory and discretionary activities a study by horgas et al reported good interrater reliability for activity codes and domains with ks 80 qli the qli determines qol among nursing home residents it rates satisfaction and importance measures for several constructs related to qol by means of four subscales health and function social and economic psychologicalspiritual and family for each subscale and overall score satisfaction items are weighted by importance responses and summed higher scores indicate high satisfaction or high importance and lower scores indicate high dissatisfaction or low importance the overall qli scores can range from 0 to 30 internal consistency for the total qli scale has been described in 26 studies and is supported by cronbachs as ranging from 84 to 98 data collection procedures and management before the group sessions began enrollees were administered pregroup tools by a trained data collector with a geriatric nursing background who was blinded to the groups and sites postgroup tools were administered to determine changes in qol activity engagement and social participation after the group activities participant names were coded for confidentiality data analysis the yi was coded and analyzed by research team members to account for reliability of codes thirty raw codes were initially identifiedfor example personal care shopping resting and listening to musicand were collapsed into seven main categories selfcare activities of daily living iadls leisure activities social interaction spirituality rest and social participation these categories were then identified as obligatory or discretionary activities we examined the distributional properties of the data using means standard deviations frequencies and percentages group differences in participant characteristics were examined with x 2 tests of associations a series of analyses of variance and correlational analyses was used to address the research questions more specifically we conducted a onefactor betweengroups anova to assess group differences in qol family support physical and mental health activity engagement social participation and environmental factors we used correlational analyses to examine the relationships between baseline person and environment variables we used repeatedmeasures anovas to address research question 3 repeatedmeasures anovas contained one betweengroups factor and one withingroup factor we conducted repeatedmeasures anovas using a mixedmodel format to allow for inclusion of participants with only baseline measures results participant characteristics twentynine participants completed the group sessions with a range of 24 per group they were recruited from seven ltc facilities and matched on the basis of ethnicity predominantly africanamerican predominantly white and mixed africanamerican and white there was differential representation of ethnic groups in intervention and control groups africanamericans constituted 688 of the participants in the intervention group and whites constituted 615 of the participants in the control group the median age range was between 71 and 75 yr for both groups and the control group had a higher percentage of participants age 80 most participants were female additional information on participant characteristics is provided in table 1 although all participants had to pass the spmsq participants with lower scores were disproportionately represented in the intervention group we detected no significant differences at baseline between the intervention and control groups other than cognition for which 692 of the control group fell into the normal to mild cognitive impairment range in contrast to 438 of the intervention group findings from the baseline tools we conducted posterior power analyses to assess the detectable effect given the study sample size given an a level of 05 and 29 participants the power to detect a large group main effect and moderate associations was 80 given the repeatedmeasures anova and a correlation across time the power to detect a moderate interaction effect was 80 using baseline scores as dependent variables and study group as the factor results from the anovas showed no significant differences between groups on baseline measures however as measured by the sf12 both groups had lower physical and mental scores than the norm evidence of the frailty of this sample the intervention group showed a trend for a significantly lower physical health score than the control group we calculated correlations of participant characteristics with qol and found that qol was significantly and positively correlated with the sf12 physical health score mental health score sces personal growth dimension and dusocs nonfamily support score qol was significantly and negatively correlated with dusocs family stress score and social stress score findings from the outcome measures results from the repeatedmeasures anova showed that scores for the overall qol health and function and psychologicalspiritual subscales improved over time for both groups we observed no significant differences between groups for the social and economic and family subscales the control group showed an overall slightly higher increase on all qol subscales compared with the intervention group for the yi examination of activity engagement and social participation revealed an average of 1314 hr was spent awake preintervention and postintervention for all participants a greater percentage of time was spent in discretionary time than in obligatory time both preintervention and postintervention but the results of the repeatedmeasures anova showed no significant difference between groups discussion although literature on relocation into ltc facilities exists little is known about interventions that facilitate the adaptation process in addition outcomes of adaptation vary depending on the discipline and research focus in this study we applied the obchi model by testing a cultural and social intervention and measuring the outcomes of qol activity engagement and social participation as indicators of adaptation we found no literature showing how an organized cultural heritage intervention might affect ltc adaptation thus this research was without precedent the outcome measure of qol an indicator of adaptation did improve for both intervention and control groups over time increased qol may be attributed to several factors one in particular is the clientcentered approach whereby all participants received planned and meaningful group activities led by a certified occupational therapy assistant group sessions were structured for both groups and differed only by content the structured activities provided the opportunity for activity engagement and social participation to occur in both groups engagement of residents in smallgroup interaction and meaningful occupations fostered a sense of connection with other group members as indicated by the positive comments made in the midsession and final satisfaction surveys completed by all participants on the basis of hertz et als research one of the interventions suggested for postrelocation is to provide opportunities for participation in social gatherings and activities that are tailored to the interests and values of residents underlying such interventions is the assumption that meaningful activities are integral to the health promotion of the individual participants activity patterns and social relationships not only served as measures for adaptation but also provided an understanding of life in ltc other occupational therapists have studied the everyday life of communitydwelling older adults in this study findings from the yi provided a description of how residents spend their time in an ltc facility onethird of time was spent in obligatory personal maintenance tasks yet many activities in which residents engaged were discretionary and included iadls leisure activities both alone and with others and social interaction with residents staff and family an important element of the day was resting which included sleeping napping and doing nothing rest and sleep are now considered in the occupational therapy practice framework to be a performance area of occupation that support s healthy active engagement in other areas of occupation the question commonly asked of clients by therapists tell me about a typical day takes on greater importance when one sees the extent to which these performance areas play a part in a residents life implications for occupational therapy practice the findings from this study have implications for occupational therapy practice in longterm care expanding to include the following tasks limitations limitations include recruitment challenges that decreased the number of available group participants frailty of an ltc population which is characterized by cognitive deficits hospitalizations and death limited our ability to reach the initial projected sample size originally site matching site randomization and matching residents by ethnicity gender and age to the control and intervention groups were proposed however we did not completely accomplish this goal because of the limited availability of participants and the attempt to obtain a working group size adaptation may be influenced by length of stay in an ltc facility and reasons for admission although all study participants had been in the ltc facility £ 12 mo the lengths of stay differed and we did not obtain reasons for admission additional limitations were reduced power to detect changes inability to examine potential moderating effects and change in group facilitators possibly affecting the continuity of the group sessions directions for future research findings from this study demonstrate that a clientcentered approach with specifically planned and meaningful activities in a social context can result in increased qol for newly admitted residents with that observation additional research questions arise further consideration of an appropriate measure for adaptation and identification of alternative measures is needed to understand the relocation phenomenon investigating features of the intervention that made a difference in residents lives including dosage duration and effects on activity engagement and social participation is crucial other research possibilities include examining the cognitive element and its relationship to benefits and having groups of like ethnicities rather than mixed ethnicities the temporal factor appears to be a determinant in knowing just when to implement the intervention that is how soon after admission will give the best effect also further investigation into the environmental features of ltc facilities influencing the adaptation of the resident is needed as more older americans from diverse ethnic backgrounds relocate to ltc facilities the role of occupational therapy will expand to reach not only those requiring rehabilitation but also those entering to age in place occupational therapists responsibility then will become one of facilitating the adaptation process so that residents lives are satisfying and meaningful s nursing research the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institute of nursing research or the national institutes of health

we investigated the effectiveness of an occupationbased cultural heritage intervention to facilitate adaptation to relocation into longterm care ltc facilities as measured by quality of life activity engagement and social participation method we used a quasiexperimental nonequivalent control group design with preand posttests residents receiving the cultural intervention were compared with residents in a typical activity group eight sessions two per week for 4 wk were facilitated by certified occupational therapy assistantstwentynine participants completed the group sessions qualityoflife scores improved significantly over time for both groups statistically a greater percentage of time was spent in discretionary than obligatory time pretest and posttest with no significant difference between groupsthe study demonstrated effectiveness of a structured occupationbased social group intervention that improved quality of life an indicator of adaptation it also provided a description of activity patterns and social participation of ltc residents

a introduction the measurement of tolerant views and practices towards the plurality of indonesian society can be classified into two dimensions socioreligious and sociopolitical in the socioreligious dimension trust and tolerance among youngsters from diverse backgrounds and interests are still a fundamental problem for example it can be seen during the indonesian reform period when religious activists and minority groups experienced violent behavior as a result of the states failure to manage religious diversity and the plurality of society similar cases occurred in africa between muslims and animists and in india between hindus and muslims in norway christian and muslim religious leaders have sought to gain followers and influence among their coreligionists by claiming to be better at checking social and political influence than their fellow religious leaders the aforementioned instances indicate that underneath the surface of the prevalent attitude of religious tolerance navigating the nexus government policies in cultivating religious … underlying differences could lead to conflicts and give rise to extremist groups higher education as an agent of social change must be aware of problems related to intolerance and inclusivity strengthening religious moderation is important to ensure that educational institutions play a crucial role in sowing and strengthening diversity such institutions are expected to carry out this role so that the depiction of islam in indonesia looks friendly hospitable tolerant moderate and dignified in the eyes of the world indonesias muslim schools are also essential as they can educate children to understand and practice religion while promoting a sense of nationalism meanwhile the state islamic higher education in indonesia can also serve as a role model because the values of tasamuh tawasut tawazun and itidal are developed and infused within it these values are incorporated in an integrative manner into all courses while consistently developing an educational model that is in line with pancasila as the basis and the philosophy of the state this notion is proven by research showing that literarybased learning is useful in promoting and developing religious moderation further a study states that in most parts of the world higher education institutions act as channels of social mobility as they support the establishment of national professions and industries higher education is expected to play a major role in building the state and the nation the rise of discussions and movements on religious moderation in indonesia shows evidence of university participation therefore higher education and ptkin in particular must oversee and ensure that the implementation of religious moderation in indonesia can run effectively and productively religious moderation in indonesia has been observed from various perspectives umar in his writing of islam moderat dalam politik luar negeri indonesia kontemporer stated that there are three discourses on islam in indonesian foreign policy using a genealogical approach meanwhile hilmy analyzes moderate ideology in nahdlatul ulama and muhammadiyah another study was conducted by niam which is about pesantren as a miniature of moderate islam in indonesia in addition muhsin et al examine revolutionary movements by forming a moderate student organization called lembaga dakwah kampus achilov and sen have also discussed moderate islam and whether devout muslims and moderate muslims have political differences in attitudes and behavior furthermore menchik practically this research is expected to assist policymakers in making civil society governance more appropriate in addition this research is also expected to help stakeholders understand state policies to achieve interreligious harmony under the pancasila values b literature review academic policies the term policy is generally used to describe the behaviour of a person such as an official a group or a particular institution to solve the problem at hand in the united nations policies are guidelines for action the guidelines can be simple or complex general or specific broad or narrow vague or clear loose or detailed qualitative or quantitative and public or private in this sense policy is usually in the form of a declaration regarding guidelines for action certain directions for action or particular programs or plans this opinion is reinforced by knoepfel et al who define policy as a series of decisions or actions as a result of structured and repeated interactions among various actors both public and private these actors are involved in various activities such as responding to identifying and solving a problem that is politically defined as public the policy adopted thus implies two things a group of problems with specific characteristics and policymaking as a process when considering the perspective of educational advancement the implications of national education policy refer to endeavors aimed at enhancing the overall standard and quality of a nations existence by cultivating its national culture therefore in making decisions problems will always be found in this context policies are related to academic issues namely education and teaching research and community service programs according to lian these three areas are the basic pillars of a mindset that must be carried out in a balanced manner and adapted to the demands developments and needs of the times academic policies must refer to applicable laws and regulations and consider the principles of preparing a policy all forms of academic policy development models will certainly have implications for educational and teaching models curricula learning materials and instructional activities in the classroom in general a learning model is a form of learning that is illustrated from start to finish and is presented specially by educators and education staff in other words the learning model is a wrap or frame for the application of an approach method and learning technique religious moderation moderate is generally interpreted as a method of thinking interacting and behaving in a balanced manner in addressing two situations this moderate attitude follows islamic principles and community traditions namely balance in faith worship and morals according to esposito the terms moderate and moderatism are conceptual nomenclatures that are difficult to define the interpretation of this phrase varies depending on the religious groups or scientists involved leading however the use of the term religious moderation is not without problems this term is usually juxtaposed with radical moderates are conventionally those who seek gradual change by working within the existing political system radicals by contrast seek to overthrow that system in its entirety furthermore schwedler examines the debate among scientists about this moderation when it is attributed to muslims according to him scientists differ on whether the term moderate is more appropriate to use as an objective or a tactic scholars who understand the term moderateradical as an objective state that the majority of muslims use a fundamental approach in seeking changes to social political and economic relations and therefore tend to be radical on the one hand scientists who use moderateradical as a tactic argue that their entryislamic groupsinto the existing legal constellation such as participating in the general election can be categorized as moderate on the other hand islamic groups that use a violent approach to achieve their goals are categorized as radical meanwhile islam and khatun explain that western scholars use the term as a process rather than a category when comparing the use of the term moderate by the west and islam they previously tended to use a harsh and radical approach when allowed to participate in democratic practices in subsequent developments this islamic group began to accommodate democratic navigating the nexus government policies in cultivating religious … practices and abandoned its old antiwestern attitude to become prowestern islam and khatun also highlight that the use of the term moderate by the west has significant political connotations they emphasized that the characteristic of the western enterprise of moderation is merely a political one for them it has nothing to do with a belief or legal system the moderate attitude in the western perspective has nothing to do with the belief system held by muslims a viewpoint that is afterward refuted by islam and khatun in this case religious moderation is not merely a position between the extreme left and the extreme right religious moderation is an intellectual moral legal and behavioral approach that promotes nonextremism what schwedler and islam and khatun said above can make it easier to understand the concept of religious moderation in the indonesian context religious moderation is the practice of religion that is not extreme or radical and always does not emphasize violence with this character it prioritizes tolerance harmony and cooperation with different religious groups developing an understanding of religious moderation in the indonesian context is so important considering that there are various religions and ethnicities within it the notion of religious moderation encourages individuals to practice their religious beliefs in a contextual manner acknowledging that variations and variety are inherent aspects of divine decree which cannot be disregarded if this practice is implemented it can be reasonably asserted that religion will serve as a catalyst for promoting peace and fostering humanitarian values c methods the method used in this research is mixed methods with a sequential exploratory model which combines qualitative and quantitative research sequentially in the first stage the research was carried out using qualitative methods to prove deepen and expand the data obtained in the second stage the research was conducted using quantitative methods to obtain descriptive and comparative data primary data sources include lecturers students and ptkin leaders in indonesia the sampling technique used is simple random sampling ie sampling is done randomly without regard to strata in the population because the population tends to be homogeneous here the researcher collects data concurrently and then compares the two data sets to determine whether there is convergence difference or some combination in this strategy mixing occurs when the research reaches the stage of interpretation and discussion this methodsmixing is done by integrating or comparing the results of qualitative and quantitative data side by side in the discussion d results ptkins seriousness in realizing religious moderation is realized through various policies that regulate the activities of the tridarma of higher education almost all ptkin leaders in indonesia have policies that regulate efforts to develop religious moderation on campus according to mujiburahman in his interview he said that life had entered an extreme period many students do not know their purpose thus the initiated program required new students to live in the dormitory for two months to receive education one of which was islam and nationality its mission is to instill the values of religious moderation with a national perspective in addition to this our attention is also directed towards the psychological domains of students with the aim of cultivating an understanding of islam as a comprehensive way of life rather than only a cognitive pursuit the notion that warrants consideration is the concept of moderate islam ptkin must be able to become a center for the development of religious moderation therefore ptkin seeks to make religious moderation one of the main issues in teaching research and community service activities related to this the academic communityin this case lecturers and studentsresponds positively to various efforts to develop religious moderation on campus this can be seen from the results of the questionnaire calculations presented in tables 1 and2 below is rejected and the alternative hypothesis is accepted to strengthen the results of the quantitative calculations above this research also describes several policies in the academic field that are used to develop religious moderation this policy is outlined in several academic programs covering the fields of education research and community service as follows academic policy in the field of education there one of the ptkin leaders emphasized that implementation of the pancasila course is not only an individual need as a citizen but also a state need progress in citizen education will automatically increase the greatness of the country this issue is important so that ptkin graduates can become indonesian citizens who have a national character desire to advance the country and care for their nation this policy also received support from the on campus lecturers do not discriminate against students be it those from muhammadiyah nu alirsyad or others another proof is that the campus also uses students as friends and discussion partners we never make a problem out of differences in belief whether its about prayer or other acts of worship leaders and lecturers always provide space for tolerance so there are rarely coachman discussions that cause tension the hadith nearly 98 of students learn about the complexities of religious texts in responding to the dynamics of life this aligns with the narrative of a student who admits that the lecturers explanation of how to understand religion is very clear and detailed because it involves many perspectives one of the courses that is always available on the ptkin campus is differences of opinion in implementing religious law often lead to divisions and hostility among muslims we emphasize to students that these differences are addressed carefully for example some khilafiah issues such as reciting qunut the number of cycles of tarawih prayers praying together out loud congregational dhikr tarekat baiat commemoration of the birth of the prophet isra miraj and so on in this nuance students are educated to become broadminded undergraduate candidates apart from that we also encourage them to study the legal basis of each opinion so that they have lots of references and arguments so in this way students will be trained to be wise in their differences in religious understanding differences in understanding religion will continue to exist in peoples lives because everyone has different opinions and perspectives things like this must be instilled in students so that they do not understand religion only from one point of view or use one approach with this the students are not easy to blame when they find differences with themselves and can avoid radical ideas e policy regarding the freedom of lecturers to explain religious teachings from various schools of thought to minimize extreme and radical religious views among students ptkin encourages lecturers to explain religious issues according to different schools of thought this policy received a positive response as the lecturers were really enthusiastic about providing religious insights from various references and points of view lecturers always provide opportunities for students to discuss differences in religious sects during lectures and outside lectures the intensity of the discussion depends on the dynamics of issues that are currently developing whether on a local national or global scale the more sensitive an issue is the higher the intensity of discussions involving lecturers and students these discussions can occur in person or virtually specifically one of the courses developed in the ptkin curriculum is masailul fiqh one lecturer stated we use several steps in explaining khilafiyah the first is mutual tolerance we need to put forward an attitude of tolerance when a conclusion refers to qhathi sources of law the second is not to force an opinion no matter how much we believe in one opinion which is ijtihadiyyah this should not make us deny other opinions let alone oblige everyone to follow our opinion the third is prioritizing equality finding common ground is recommended in islam the fourth is to continue to explore the problem or tafaqquh tafaqquh means the earnest effort that we make to understand gods law we continue to try to improve our tafaqquh so that we can understand the arguments that are used as the basis by the scholars in their concluding opinions the fifth is mutual respect did the differences of opinion among the scholars make their relationship tenuous or humiliate each other no absolutely not thats how we deal with differences of opinion students and community organizations should follow in the footsteps of their scholars who have inherited the knowledge of the prophets consistently the approach used by the lecturer is in line with the students opinion that the ptkin lecturer has provided insight into khilafiyah in a more there is a concern that if religious radicalism is increasingly mushrooming it is predicted that it can distort and even oppose pancasila as the nations ideology the facts show that the proliferation of radical and fundamental religious ideas cannot be separated from the influence of globalization many students do not fully understand the meaning of globalization and only take it in a negative light if these symptoms are not immediately addressed there will be many differences that lead to disunity therefore my friends and i try to explain broadly the currents in islam which are one form of the different opinions of the ancient people in islam there are actually many sects that spread and teach islam in various versions apart from the interview above the quantitative data also shows students acknowledgment that most lecturers at ptkin try to explain to students the relationship between local culture and traditions and contextual religious values harmonization between these components is vital to create a harmonious life that protects and complements each other academic policy in the field of research in addition to policies governing education and teaching ptkin campus leaders also regulate lecturer campus leaders through lp2m socialize about research guidelines that will be approved by each campus planning implementation and reporting of research on campus must be carried out in a directed measurable and programmed manner by referring to the national higher education standards and taking into account aspects of the integration of science and islamic sciences that are rahmatan lilalamin to build a religious moderate and tolerant society to strengthen the interview results above the questionnaire calculation also showed that most lecturers stated the importance of research themes that used the pancasila and indonesian nationalism paradigms as national their publications have complied with systematic scientific principles and methods in accordance with scientific autonomy academic culture and applicable standards a lecturer explained that the planning implementation and reporting of publication activities on campus are carried out in a directed measurable and programmed manner by referring to the national higher education standards and taking into account the islamic aspects that are rahmatan lilalamin to create publication substance that promotes religious moderate and tolerant attitudes among students and the general public what was done by ptkin lecturers received positive responses from students students acknowledged that the lecturers had explained the importance of studying programbased scientific publication themes from an indonesian perspective apart from socializing the identity of the archipelago this publication also reaches out to national and international journals in order to gain wider recognition the results of the questionnaire filled out by students show that ptkin lecturers are committed to campaigning for indonesian insights and themes in scientific publications both in periodical journals and popular media in overall 974 of lecturers apply policies regarding the publication of scientific papers from an indonesian perspective academic policy in the field of community service the following academic policy is on the aspect of community service ptkin leaders also regulate one lecturer expressed his opinion as follows religious standards in community service activities are the minimum criteria regarding the depth and breadth of community service material in islamic sciences that are rahmatan lilalamin to build a religious moderate and tolerant indonesian society the depth and breadth of the community service material refer to religious standards for the results of community service as a lecturer i agree with this policy considering that people must be properly educated to love their country and nation more what was done by the ptkin lecturer above received appreciation from their students the results of e discussion the existence of ptkin has helped the government carry out tasks to improve the quality of society and the nation through access to higher education the majority of ptkin campuses have provisions governing education and teaching that incorporate the values of pancasila and indonesian nationalism all ptkin leaders make pancasila education a compulsory subject the existence of the pancasila education course has played a significant role in laying a strong foundation for islamic higher education in indonesia watson states that there is a complementary relationship between religious education and citizenship education this is also in line with research conducted by mason that suggests that these schools should be required to provide a civic education that is welldesigned to help cultivate in children an appreciation of the importance of these virtues they should be required to cultivate in children a capacity for critical reflection in line with policies in the academic field the entire lecture process must pay attention to islamic values in which learning outcomes are achieved through patience perseverance honesty and trustworthiness in addition the process is also carried out by prioritizing good morals meaning that learning outcomes are achieved through good character thus lecturers must prepare a semester syllabus by incorporating the campus vision and mission that lead to religious moderation the hope is that the learning process takes place in the form of interaction between students and lecturers that is carried out humanely and andragogically according to gözükara behaviors academic success and the future academic policies that lead to religious moderation also regulate the management of differences in the lecture process almost all lecturers educate about the importance of tolerance in dealing with differences in religious beliefs that are constantly developing in society tolerance has been proposed as a necessary response to global research on cultural and religious diversity in addition hjerm et al also mention that tolerance is often invoked as something to which individuals and societies should aspire especially given that diversity in all its forms is increasingly a feature of contemporary democracy the majority of ptkin also condition their lecturers to educate students and introduce them to the importance of practicing islam in a polite manner and not using violence purwanto also agrees on this matter deradicalization education or peace education must be realized in higher education since the complex challenges of life are increasing nowadays this policy is very important considering the widespread patterns of communication and dissemination of religion which involve actions that lead to violence and are far from peaceful other studies also show that islamic moderation is said to be one of the key factors contributing to the promotion of peace in muslim societies one way for lecturers to campaign for peaceful islam and nonviolence is through discussion forums regarding differences in religious sects in structured and nonstructured lectures generally the policy of religious moderation in the academic field of the ptkin campus also encourages its lecturers to explain religious issues according to different schools of islamic thought this policy received a positive response as the lecturers were enthusiastic about providing religious insights with multiple references especially on religious issues containing multiple interpretations in line with this muhtada said that pluralism and multiculturalism values are strongly promoted in islamic teachings and can be a significant starting point for developing diversity management in the islamic context the students acknowledged that the role of the majority of lecturers in introducing islam to various religious sects made the way of religious thinking much broader this is in line with the findings of van that the role of academic advisors and lecturers has a positive effect on student development including academic achievement personality development career development and social development in addition to opening students insights and religious thoughts more broadly campus policies in the field of education and teaching condition the lecturers to explain the relationship between local culture and traditions and religious values contextually these three variables are meeting points that cannot be denied in the process of islamic dawah the lecturers illustrated the dawah process as a process of grounding the islamic religion by not abandoning the culture of the local community and local traditions that have characteristics this is in line with the opinion of schlehe and nisa that there is harmony between nusantara in indonesia the term religious moderation itself is rooted in the islamic tradition through its long history and practice among the people islam is not only a belief that stands alone but has intersected with the culture and traditions that existed in the arab world at that time the majority of lecturers have a collective awareness to explain to students the relationship between local culture and traditions and religious values contextually abdullah argues that the paradigm of integration of islamic sciences science and culture has a major influence on shaping religious perspectives both social and cultural saihu et al also believe that culture is a part of religion in the sense that the latter authentically aims to help bless people and perpetuate peace among them the ptkin campus academic policy also encourages lecturers to conduct research and community service with study programbased themes from an indonesian perspective this is in line with the results of research by mayrl and oeur which found that new research into the demographic and institutional contexts of student religious engagements would greatly enhance our understanding of the role of religion in the academy amir said that pancasila ideology was included to realize the spirit of love for the motherland these various policies in the areas of education research and community service positively impact the academic atmosphere by implementing religious moderation on campus this is in line with the findings of ekawati et al which state that they are fixing the curriculum system in education to be even more effective in preventing and deterring radicalism these results are supported by the findings of quantitative data based on quantitative data analysis the results of which can be seen in table 2 the average score of the two questionnaires is above the middle value or in other words the hypothesis that academic policy at ptkin supports the development system of religious moderation in indonesia is acceptable in addition as the results of the calculations are presented in table 3 above it can be concluded that policies in the academic field whether carried out by lecturers or students provide significant support for the implementation of religious moderation in ptkin f conclusion religious moderation is one of the topdown policies and is formulated explicitly in the national midterm development plan document that has been stipulated by the president this policy is strategic because it is oriented towards interreligious harmony and relates to national stability as part of the government system ptkin implements religious moderation through campus internal policy products the qualitative finding is strengthened by statistical analysis using the ttest and a significance value of less than 0005 is obtained which means that the null hypothesis is rejected in other words it can be concluded that ptkins academic policies support the development of a system of religious moderation in indonesia in summary this study concludes that academic policies on religious moderation should be strengthened for the longterm preservation of national harmony

this study aims to analyze the implementation of religious moderation at the state islamic higher education ptkin in indonesia through academic policies in the fields of education research and community service programs it is based on the empirical examination of the spread of radical extreme and exclusive religious sects among higher education civitas academica in indonesia the research combines qualitative and quantitative approaches mixed methods simultaneously data sources were randomly obtained from leaders lecturers and students at ptkin through interviews observations questionnaires documentation and focus group discussions data analysis was carried out through data

introduction over the last two decades hookup culture has expanded the boundaries of normative sexuality and introduced casual sexual interactions as a distinct pathway for relationship development dates and hookups can be understood as two sides of the same coin in the american courtship process as 1 3 scripting sex in courtship predicting genital contact in… they both carry the potential to lead to a relationship despite the flexible placement of sex in the courtship process recited dating scripts remain traditionally gendered and sexually conservative the traditional dating narrative states that men initiate plan and pay for dates sexual activity is involved but not beyond kissing and potentially groping within this narrative men initiate most of the sexual activity and women make sure the sexual activity stays within the parameters of respectability this dating narrative reflects a culturallydetermined script for appropriate behavior in the dating context sexual scripts sexual scripting theory conceptualizes the sexual act as being a negotiated outcome taking place on three interrelated levels the cultural the interpersonal and the intrapsychic sexual scripts function as blueprints for appropriate behavior on the cultural level that influence how individuals choos e a course of action and evaluat e behaviors already performed on the interpersonal level on the intrapsychic level scripting of ones innermost desires and motivations takes place speaking to the fact that individual desires are linked to social meanings in the context of dating the cultural script dictates who asks who pays who initiates the sexual activity as well as when where and how much sexual activity is appropriate on the interpersonal level negotiations are made between an individuals intrapsychic desires and societys expectations for proper behavior in a given cultural scenario in this paper we examine the sexual outcomes of dates as part of a scripted process which allows us to assess how sexual processes in dates compare between the cultural script and reported practices which reflect negotiations made on the interpersonal and intrapsychic levels this is important because s ites of disjuncture between cultural and interor intrapersonal sexual scripts are a particularly promising location for the study of change in sexual scripts historical context of traditional dating scripts the heterosexual dating script recited today originated in the early twentieth century when the dating system became the dominant courtship norm at this time gender roles were shifting as young single men and women started socializing with each other in public spaces dates took place at dance halls movie theaters and other venues of commercial entertainment all of which required money that men had and most women didnt dates then relied on mens money which gave men control over date initiation and made them feel entitled to seek sexual compensation from women the earlytwentieth century dating script then consisted of men asking women on a date men paying for the nights activities and then men initiating sexual activity women were tasked with receiving mens advances and limiting the amount of sexual activity that took place in the 1920s sexual activity in the form of necking and pettingcaresses above the neck and caresses belowwere customary and expected elements of any date as part of what women owed to men for financing the nights activities importantly however many women took advantage of this customary practice to explore their own sexual desires in respectable ways activities beyond necking and petting such as those involving genital contact were still conventionally reserved for marriage and would put a womans reputation at risk if she were to go too far in other words necking and petting were part of the twentiethcentury dating script but genital contact was not because women risked losing their respectability women walked a fine line as they were responsible for limiting sexual activity but they were also expected to compensate men for financing their dates contemporary dating scripts in many ways the extant literature suggests that the contemporary dating script looks strikingly similar to the script from over a century ago despite increasing egalitarian views expressed by young adults this script dictates that men initiate and pay for dates and women limit whatever sexual activity is initiated by men this sequence of behaviors has been reported consistently by scholarship over the last 30 years although much of the research on dating scripts has focused on first dates scholarship on dating practices in general has found that the early stages of the courtship process are characterized by the traditionally gendered script wherein men take an active role and women remain passive bartoli and clark focus specifically on the scripting of typical dates finding traditional gender behaviors are not limited to firstdate contexts furthermore despite variation in how relationships progress sassler and miller find more consistency than contestation with traditional gendered scripts rose and frieze argue that gender roles are more operative early in courtship than at later stages in part because relationship continuation to exclusivity often depends on the adequate fulfillment of these roles ultimately dates that take place before an exclusive relationship is established seem to follow the traditional dating script an exclusive relationship is often the point at which the labels boyfriend and girlfriend are introduced and a couple becomes officially monogamous importantly exclusivity requires an explicit conversation as exclusive relationships are formed through verbal discussion of relationship status or the talk dates on the other hand are not always accompanied by a conversation to define the interaction as such individuals rely on cultural scripts and gender roles to navigate the ambiguity in the early stages of the courtship process 3 scripting sex in courtship predicting genital contact in… for example scholars have found that women rely on mens initiation and payment to confirm that an interaction is in fact a date and that mutual romantic interest is present alternative scripts while it is conventional for men to initiate dates it is not unheard of for women to do the same in 1993 mongeau et al found that most college students reported experiencing at least one heterosexual femaleinitiated date data from the online college social life survey collected between 2005 and 2011 shows that 12 percent of dates reported by surveyed college students were femaleinitiated additionally england et al reported that over 90 percent of students including both men and women approve heartily of women asking men on dates femaleinitiated date processes in the twentyfirst century have been largely neglected by scholarship but morr serewicz and gale examined whether variations in the traditional script including gender of dateinitiator would lead to differences in how a first date script was recited they conclude that traditional gender roles appear to be alive and well in the scripting of first dates while also noting that femaleinitiated first dates result in greater complexity in expectations for sexual behavior their analyses suggest that a femaleinitiated date signals a different sexual script but this script has been largely uninterrogated in research on dating scripts over the last 20 years because we cannot assume that dates with nontraditional scripts follow the same sexual processes as dates with traditional ones this study approaches maleinitiated and femaleinitiated dates as separate processes standards for sexual behavior in the 1920s women were responsible for limiting sexual activity on dates to necking and petting due to the pressures of what can be considered a sexual double standard wherein women would lose their respectability if they went too far but mens reputations would be unaffected today the dominant cultural script dictates that genital contact is not appropriate on a date but it is unclear if this is also true in practice given the changing circumstances of respectability in contemporary america with the rise of a hookup culture around the turn of the twentyfirst century hookup culture encompasses a set of values ideals norms and expectations that are part of the system that accepts casual sexual interactions as a feature of not replacement for courtship within the hookup culture context women can engage in sexual activity beyond petting without risking their reputations this has led to an increasing lack of consensus among scholars regarding whether a sexual double standard still exists and if so to what extent in fact crawford and popp describe the heterosexual double standard as a now you see it now you dont phenomenon given the inconsistency in empirical evidence supporting its existence if the influence of the sexual double standard has decreased in the twentyfirst century as some scholarship suggests then women may not feel compelled to limit sexual activity given their reputations would not be at risk this may be especially true if men both ask and pay for a date leaving women to feel like they owe something with that being said many scholars argue for the continued relevance of the sexual double standard to some extent either suggesting different ways of conceptualizing it or proposing new methodological approaches to measure it lack of empirical evidence aside it seems that gender remains central to evaluations of sexual behaviors in at least some contemporary social settings the inconsistencies in reports of the sexual double standard in the twentyfirst century may be attributed to the fact that the scripts for appropriate sexual behavior are context dependent in other words the operation of the sexual double standard is affected by whether sex takes place within the context of a hookup or a date which are two distinct cultural scenarios reid et al report a general consensus among college students that sex on a date is a situational impropriety even if the pair has previously engaged in casual sex in another study reid et al found students described sex as acceptable for women in a hookup context because it signals sexual agency but within the context of a date women are expected to moderate their sexuality to show that they are dating material other scholars have found that both men and women express losing interest in dating someone who is perceived to be promiscuous suggesting a conservative single standard for sexual activity in dating contexts the traditional dating script may not have changed much in the last 20 years but sexual norms and the parameters for appropriate sexual behavior certainly have regarding standards for sexual behavior in contemporary america there is a distinction to be made between being respectable and being relationship material historically the sexual double standards regulation of womens respectability also regulated whether a woman was considered marriage material in other words a loss of respectability corresponded to a loss of relationship prospects this equation between respectable and dateable no longer holds true in all contexts we propose that there is a relational standard for sexual behavior which speaks to the belief that going too far or engaging in genital contact on a date disqualifies someone from being considered relationship material although women are held to higher standards and lower benchmarks of how much sexual activity is too much the relational standard also applies to men to the extent that heterosexual women report being less interested in dating men who are perceived to be promiscuous in sum the sexual double standard speaks to who can have sex and still be respectable the relational standard speaks to where sex can happen and still lead to a relationship there seems to be a general consensus that the cultural script for dating dictates that dates are not appropriate contexts for sexual activity that involves genital contact 1 3 scripting sex in courtship predicting genital contact in… research addressing sexual activity in dating contexts however tends to stop with the cultural script and does not entertain the possibility that practices might not align with recited expectations with that being said kuperberg and padgett found that while sex was more likely to happen in hookup contexts onethird of dates in their sample included sex certain sexual behaviors such as oral sex and intercourse may be considered inappropriate on a date but in practice it is not uncommon for dates to involve genital contact in other words college students may recite a cultural script with sexually conservative date outcomes but this does not align with reported practices which reflect negotiations taking place on the level of interpersonal scripting given this inconsistency this study investigates how sex is being rescripted on the interpersonal level in dating contexts by examining how genital contact is associated with traditional and nontraditional components of dating scripts and standards of sexual behavior research questions and hypotheses because recited dating scripts are still enacted to the extent that men ask and men pay on most dates there are assumptions that sexual activity has also remained traditionally conservative over the last two decades there have been dramatic shifts in sexual norms as evidenced by the incorporation of casual sex alongside dates in the courtship process scholarship focuses almost exclusively on the changing sexual norms in the context of casual sexual interactions not dates while at the same time research on dating practices continues to focus on the traditionally gendered behaviors often overlooking the possibility of changes in the sexual script regarding the extent of sexual activity on dates in this study we examine sexual outcomes of dates as part of a scripted process with consideration for the possible disjuncture between a dates cultural script and its interpersonal one in doing so we assess how sexual processes in dates compare between cultural expectations and reported practices our first two research questions examine how sexual practices are associated with script components from a dominant cultural scenario first we explore whether traditional components of the maleinitiated dating script lead to traditional sexual outcomes specifically which components of the traditional dating script explain the likelihood of genital contact on a date because traditional dates are not supposed to involve genital contact we hypothesize that the likelihood of genital contact will decrease when dates are traditionally scriptedthat is when men pay on maleinitiated dates because women are the gatekeepers and men are the pursuers of sex in the traditional dating narrative hypothesis 1 states that the likelihood of genital contact will decrease on maleinitiated dates when men initiate more of the sexual activity compared to when women initiate or when respondents indicate being unsure of who initiated more sexual activity second we examine the sexual processes of femaleinitiated dates specifically which components of the alternative dating script explain the likelihood of genital contact on a date given femaleinitiated dates signal a different type of cultural script that has yet to be thoroughly explored we are interested in identifying the sexual outcomes of these dates in addition to which components of the script are associated with nontraditional sexual outcomes hypothesis 2 states that the likelihood of genital contact on femaleinitiated dates will decrease when women pay for part or all of the date but it will increase when women initiate more of the sexual activity due to the lack of research on femaleinitiated dates our hypotheses are exploratory in one of the only extensive studies of femaleinitiated dates mongeau et al find that males tend not to equate a direct date initiation as a direct sexual invitation despite previous research that suggested otherwise more recently emmerssommer et al speculate that men may be less likely to expect sex when women initiate the date or women split the bill when mens currency of asking and solely paying is absent they perceive that theyve lost their card to play if you will in terms of sexual expectations on dates our third research question attends to the interpersonal level of sexual scripting where individuals make negotiations between their intrapsychic desires and the cultural expectations for appropriate behavior the sexual double standard relational standard and interest in another date are contextspecific and subjectspecific factors that play a role in the interpersonal scripting process we examine how attitudes about sex and gender as well as ones personal desires are reflected in the sexual outcomes of a date specifically which attitudes about sexual behavior are associated with the likelihood of genital contact on a date for maleinitiated and femaleinitiated dates hypothesis 3a states that the likelihood of genital contact on maleinitiated dates will decrease when respondents hold a sexual double standard when respondents hold a relational standard and when respondents indicate being interested in going on another date historically genital contact did not take place on dates because of the sexual double standard and womens need to maintain respectability although the sexual double standards influence is contested it may still inform ones behavior on a date therefore if the respondent expresses holding a sexual double standard then the likelihood of genital contact will decrease in addition the relational standard may limit the extent of sexual activity on a date because dates carry the potential for romantic interest and future relationshipbuilding so if respondents believe that engaging in genital contact may disqualify them as a potential boyfriend or girlfriend then they would be less likely to engage in genital contact on a date as such we hypothesize that genital contact on maleinitiated dates will decrease when respondents express holding a relational standard similarly individuals interested in going on another date will be more likely to conform to the cultural expectation that genital contact does not take place f ew individuals wander far from the formulas of their most predictable successes given a femaleinitiated date itself represents a deviation from a traditional script we suspect that sexual activity will not follow the same expectations for sexual behavior as such we hypothesize that the likelihood of genital contact on a femaleinitiated date will increase when a respondents beliefs do not reflect a sexual double standard or a relational standard thereby reflecting more egalitarian ideals similarly hypothesis 3b states that the likelihood of genital contact on a femaleinitiated date will increase when respondents indicate being 1 3 scripting sex in courtship predicting genital contact in… interested in going on another date because there are no established guidelines that preclude sexual activity when there is romantic intent again these hypotheses are exploratory given the lack of extensive research on femaleinitiated date processes method data we used data from the online college social life survey which was developed by paula england and collected between 2005 and 2011 from a convenience sample of 24131 students across 21 institutions of higher education in the united states the survey was optional to students 18 and older administered in entrylevel college courses and took students about 20 min to complete most students who completed the survey were offered extra credit and students who opted out of the survey were offered an alternative option for extra credit students were asked to respond to questions about their experiences and attitudes regarding sexual activity hookups dates and relationships the ocsls is the only dataset of this scale to provide this level of detailed information about college students dating practices types of sexual activity and standards for sexual behavior all of which are needed to answer our research questions although our findings are not generalizable beyond those who took the survey given the large sample size recruited from 21 institutions and the near100 percent response rate we believe like other scholars that they reflect the practices of a significant crosssection of the us student population our analysis draws from student reports of their most recent date after respondents were prompted now some questions about the last date that you went on with someone you were not already in an exclusive relationship with although we do not know if the respondent has been on previous dates with this person the fact that they are not in an exclusive relationship suggests that they are still in the early stages of the courtship process due to our interest in gendered sexual power dynamics in courtship rituals we limited our sample to selfidentifying heterosexual cisgender respondents who are not married and who do not have any children because we are interested in the types of sexual behaviors that take place on a date we limited our sample to those who indicated any level of sexual activity took place on their most recent date when asked did anything sexual happen happen on your date it is worth noting that over 60 percent of all dates involved sexual activity after dropping cases with missing data on one or more explanatory or control variables our total sample is comprised of 7377 respondents measures our dependent variable was dichotomous measuring the extent of sexual activity on the respondents most recent date with someone with whom they were not in an exclusive relationship after being asked if anything sexual took place on their most recent date respondents were asked which behaviors did you engage in and instructed to check all that occurred from a list of descriptions of various sexual behaviors when respondents selected at least one of the behaviors that included genitals in its provided definition or described anal or oral sexual activity genital contact which we operationalize as indicative of a nontraditional sexual outcome was considered to have occurred on the respondents most recent date the reference group then is traditional sexual outcomes or no genital contact which could be categorized as petting our decision to dichotomize this variable aligns with prior approaches that operationalize questions about sexual activity to examine specific sexual behaviors explanatory variables the key explanatory variables indicated who paid for the date and who initiated more of the sexual activity we constructed a categorical variable from responses to the question who paid for the date we converted the responses into genderspecific categories man scripting sex in courtship predicting genital contact in… paid woman paid or both paid and no money was spent we collapsed women paid and both paid into one category because women paid on less than two percent of dates respondents were asked overall who initiated more of the sexual activity we converted the responses into the following categories man initiated more woman initiated more and i dont know we measured the relational standard based on the survey item if someone has hooked up a lot im less interested in this person as a potential girlboyfriend the 4 response options ranged from strongly disagree and disagree to agree and strongly agree following the conventions established by england and bearak the creators of the survey we dichotomized these items into disagree and agree those who agreed with this statement were classified as holding a relational standard we measured the sexual double standard based on two survey questions where respondents were asked their opinion on the following statements if women hook up or have sex with lots of people i respect them less and if men hook up or have sex with lots of people i respect them less the statements were separated by 15 other survey items to account for bias stemming from the respondents conscious understanding that should not judge men and womens sexual behaviors differently both of these statements were measured by 4 items strongly disagree disagree agree strongly agree because we have no reason to believe the distance between each item is equal we dichotomized the responses into disagree and agree respondents who agreed with the first statement and disagreed with the second statement were classified as holding gender values that align with the sexual double standard our construction of the relational standard and sexual double standard variables followed conventions established by other scholars who have operationalized these survey items in similar ways we operationalized respondents interest in going on another date as an indicator of potential romantic interest based on the date respondents were asked at the end of the date were you interested in going out on another date with this person and selected between the following 4 items no i wasnt at all interested possibly i didnt really know yet maybe it had some appeal yes i was definitely interested because being possibly interested and maybe interested are particularly ambiguous and we have no reason to believe that the distance between each item is equal we dichotomized these responses into not definitely interested and definitely interested this variable construction lends itself to a more conservative estimate control variables gender race and age were operationalized as demographic controls respondent gender was indicated by a dummy variable derived from the question what is your gender controlling for gender addresses potential sources of biases reported by previous research which finds women underreport and men over report sexual behavior measures for racial and ethnic identity were derived from the question if you had to pick one racial or ethnic group to describe yourself which would it be where respondents selected from 14 racial categories we recoded responses into 5 racial groups white black hispanic asian and other age is determined from the question how old are you respondent age ranged from 18 to 25 the average age of the sample was 20 with the majority of cases concentrated between 18 and 21 years we controlled for alcohol consumption and drug use before or during the date given previous research identified the influence of alcohol on sexual activity for alcohol consumption respondents were asked to indicate how many beers glasses of wine mixed drinks or shots and malt beverages they consumed before or during their most recent date if respondents indicated having 1 or more of any of these beverages alcohol was considered to be involved respondents were asked to indicate what if any illegal drugs they used before or during the date by selecting all that applied from a list including marijuana amphetamines cocaine ecstasy heroin and mushrooms an other option was also provided if respondents selected 1 or more of these options drugs were considered to be involved because sexual history has been found to influence sexual activity we controlled for respondents disposition toward sex using three variables number of sexual partners a sexual history including maintaining multiple casual sexual relationships at the same time and a preference for having sex when in love respondents were asked how many people have you had intercourse with we defined 3 categories from the responses 0 to 1 past partners 2 to 5 past partners and 6 or more past sexual partners about 25 percent of respondents indicated having had intercourse with 0 to 1 people about 50 percent of respondents indicated having had sex with 2 to 5 people and about 25 percent of respondents indicated having had sex with 6 or more people respondents were asked have you ever had two ongoing sexual partnerships involving intercourse at the same time we controlled for respondents association between sex and love as indicated by responses to the following statement i would not have sex with someone unless i was in love with them this statement was measured by 4 items ranging from strongly disagree to strongly agree we dichotomized the responses into disagree and agree because we have no reason to believe that the distance between each option is the same other versions of the model included controls for immigrant status location of high school religiosity political views parents relationship status where respondent met their date respondents desire to be in a relationship and respondents overall enjoyment of the date in order to ensure statistical power we excluded these from the final model because they carried littletono significance and their presence did not notably change the coefficients of interest it is important to address the issue of coercion and feeling pressured to engage in certain sexual behaviors especially given the gendered power dynamic when men initiate and pay we could not include a variable indicating whether the respondent 1 3 scripting sex in courtship predicting genital contact in… was pressured into sexual activity because the variable would only apply to the subset of the sample that did engage in genital contact rather than applying to anyone who engaged in sexual activity with that being said it is important to note that less than 7 percent of respondents in our sample reported feeling pressured to engage in genital contact with 6 percent of respondents reporting performing oral sex or hand stimulation because they felt they owed their partner an orgasm but did not want to have intercourse and less than 2 percent of respondents reporting engaging in sexual intercourse because they felt verbally pressured analytic strategy we obtained univariate descriptive statistics for the sample to assist in the operationalization of the previously described measures and examine sample distributions to determine potential differences between maleand femaleinitiated dates we use ttests and chisquare test for independence to examine the relationship between key variables of interest and demographic controls by genderspecific date initiation this information guided the decision to run separate models for maleand femaleinitiated dates to allow us to identify unique relationships between key variables and genital contact by traditionally scripted maleinitiated dates and alternatively scripted femaleinitiated dates we used logistic regression to assess how much datespecific and individuallevel attitudes predict genital contact occurring on a date with separate models for maleinitiated and femaleinitiated dates we conducted all analyses using stata 16 first we conducted simple logistic regressions that provided unadjusted model coefficients for each variable in the model separately we followed these analyses with a multivariate logistic regression the unadjusted and adjusted model coefficients from our bivariate and multivariate analyses were exponentiated allowing us to report and compare odds ratios this approach allows us to report and compare changes in odds ratios between the unadjusted bivariate comparisons and the fully adjusted multivariate logistic regression we examined regression diagnostics and assessed for goodness of fit prior to selection of the final models in our assessment of missing data we determined that our data was missing at random given there were no significant relationships between missing values and other variables no variables had levels of missingness above 2 percent based on our analyses of missingness in the data we proceeded with a complete case analysis with complete case analysis a total of 657 observations were dropped the final analytic sample was 7377 the sample size of dates initiated by women is significantly smaller than that of dates initiated by men but we conclude that the sample still holds enough power for complete case analysis results univariate bivariate analyses table 2 displays descriptive information about the distribution for the total sample and subsamples of maleinitiated and femaleinitiated dates male initiation of dates which aligns with the initial stage of traditional dating scripts represents 891 percent of the total analytic sample while female initiation of dates which aligns with alternative dating scripts represents only 109 percent of the total analytic sample bivariate inferential tests demonstrated significant differences between maleinitiated and femaleinitiated dates by genital contact genital contact took place on over 56 percent of dates with sexual activity occurring on over 63 percent of femaleinitiated dates and on approximately 56 percent of maleinitiated dates based on this descriptive information alone we can see that there is a discrepancy between the widelyrecited cultural expectations for sexual behavior and what is actually being reported as practiced on dates although men paid for the majority of maleinitiated dates women contributed at least part of the payment on 17 percent of dates and no money was spent on 15 percent of dates among those dates following a maleinitiated script men paid and initiated most of the sexual activity on approximately 36 percent of dates in other words more than 60 percent of dates violate the traditional scriptdefined as men asking paying and initiating sexual activityin some way on femaleinitiated dates which violate the script from the outset men still paid 41 percent of the time women paid or both paid on 33 percent of femaleinitiated dates and no money was spent on 26 percent of femaleinitiated dates in addition we observed differences by gender initiation with demographic controls such as age 47 p 0001 and gender 817 p 0001 and key explanatory variables such as the presence of the sexual double standard 94 p 0002 for age we observed an average age of 202 years with an average of 205 years for respondents reporting femaleinitiated dates and 202 years for respondents reporting maleinitiated dates we did not observe differences in relational standard interest in another date or racialethnic identification between maleand femaleinitiated dates given the significant variation by this initial stage of courtship we choose to model predictors of genital contact separately for maleinitiated and femaleinitiated dates which likely correspond with two different courtship scripts in contemporary america table 3 displays the results of a series of simple logistic regressions that provide unadjusted odds ratios of genital contact regressed on each explanatory variable separately this approach allowed us to compare our bivariate results directly with the odds ratios of our multivariate analyses the unadjusted models demonstrated that variables associated with scripts and attitudes were significant within the maleinitiated date sample the bivariate analyses of the femaleinitiated date sample however demonstrated no significant association with scripts and attitudes except for when women initiated the sexual activity in addition bivariate analyses indicated significant explanatory factors were similar across both maleand femaleinitiated date models multivariate analyses table 4 shows the results of the multivariate logistic regression models that regress genital contact occurrence on dating scripts attitudesbeliefs and identified control variables among maleinitiated dates the odds of genital contact increased by about 31 percent when no money was spent and approximately 39 percent when women paid for part or all of the date compared to when men paid holding all else equal when women initiated more of the sexual activ ity on maleinitiated dates the odds of genital contact increased by approximately 39 percent compared to when men initiated more of the sexual activity there was no significant difference in the odds of genital contact when the respondent indicated that they did not know who initiated more of the sexual activity compared to when men initiated these results support hypothesis 1 which predicted that the odds of genital contact would decrease on maleinitiated dates when men paid for the date or when men initiated more of the sexual activity among femaleinitiated dates the odds of genital contact increased most when no money was spent with about a 71 percent increase in odds compared to when men paid the odds of genital contact when women paid or both paid on a femaleinitiated date increased by approximately 45 percent compared to when men paid among femaleinitiated dates the effect of who initiated more of the sexual activity on the odds of genital contact was not significant we hypothesized that the likelihood of genital contact would decrease when women paid for all or part of a femaleinitiated date and that it would increase when women initiated 1 3 scripting sex in courtship predicting genital contact in… more of the sexual activity hypothesis 2 then was not supported because women paying actually increased the odds of genital contact and the effect of women initiating more of the sexual activity was not significant when respondents expressed a sexual double standard the odds of genital contact occurring on a maleinitiated date increased by about 35 percent when respondents indicated holding a relational standard that is they are less interested in someone who hooks up a lot as a future boyfriend or girlfriendthe odds of genital contact on maleinitiated dates decreased by about 16 percent when respondents expressed interest in going on another date the odds of genital contact occurring on a maleinitiated date increased by approximately 30 percent hypothesis 3a was partially supported by these estimates as expected holding a relational standard was a significant predictor associated with decreased odds of genital contact on a maleinitiated date unexpectedly however holding a sexual double standard and being interested in another date were both significant predictors associated with increased odds of genital contact among femaleinitiated dates the sexual double standard and relational standard were not significant predictors of genital contact the odds of genital contact on a femaleinitiated date increased by approximately 43 percent when respondents expressed interest in another date we predicted that the odds of genital contact would increase on femaleinitiated dates when respondents indicate being interested in another date and when respondents do not reflect traditional values as indicated by holding a sexual double standard or a relational standard due to the lack of substantial significance hypothesis 3b was inconclusive it is also important to note that we observed consistency in the significance of control variables such as gender alcohol consumption and sexual history across both maleand femaleinitiated dates the effect of gender on genital contact was significant in both multivariate models with the odds of reported genital contact decreasing when the respondent identified as a woman for both maleand femaleinitiated dates alcohol increased the odds of genital contact additionally the effect of the number of previous sexual partners as well as the effect of having experience maintaining multiple casual sexual arrangements at one time increased the odds of genital contact for both maleand femaleinitiated dates discussion in contemporary america hookups and dates are both acceptable pathways to relationship formation but they are governed by different sexual scripts the sexual behavior in hookups is ambiguously defined and anything from kissing to intercourse is acceptable dates on the other hand are associated with more conservative sexual approaches scholarship has established that casual sexual interactions can lead to dates but we have not explored the extent of changes of sexual practices within dating contexts most scholarship that examines emerging adult sexual practices focuses on hookup contexts not dates because traditional dating scripts are still recited and largely enacted to the extent that men initiate and pay there are assumptions that the sexual processes that follow have not changed this study investigated the sexual processes of dates among college students in the us first we asked whether components of the traditional dating script led to traditional sexual outcomes then we asked whether components of an alternative dating script led to nontraditional sexual outcomes lastly we asked how attitudes about sexual behavior and romantic interest affected the sexual outcomes of both traditional dates and nontraditional dates 3 scripting sex in courtship predicting genital contact in… the traditional script maleinitiated dates consistent with previous scholarship on dating scripts sexual activity is more restricted on dates when men pay on maleinitiated dates this is also true when men initiate more of the sexual activity the increase in odds associated with women initiating sexual activity is expected given the logic of the traditional cultural narrative in the traditional script sexual activity is limited because women are expected to limit it it follows then that more sexual activity would occur if women were not only allowing sexual activity but were also the ones initiating it genital contact may be more likely to accompany nontraditional components of the script but it is not absent in traditional ones in other words individuals may be following traditional components of the dating script such as men paying while still engaging in nontraditional sexual outcomes this suggests a discrepancy between the cultural scenario and actual practices which may be evidence of changing sexual scripts the alternative script femaleinitiated dates although the majority of dates in our study were maleinitiated over 88 percent of students in our sample agreed with the statement that it is okay for women to ask men on dates given this wide social acceptability in addition to increasing egalitarian views and inclinations the low number of femaleinitiated dates that we observe today reflects a lag in practice it is likely then that we will see an increase of femaleinitiated dates in the future and it is important for us to become attuned to their processes as distinctly different from dates that are maleinitiated in many ways conservative sexual practices are associated with traditionally gendered dating scripts but there is no such association when scripts veer off the dominant cultural scenario femaleinitiated dates which deviate from the traditional dating narrative before they even start do not follow a recognizable sexual script as evidenced by the general lack of significance in the model this lack of substantial significance among femaleinitiated dates prompts more questions than it provides answers but it does tell us that the processes for sexual conduct are different when traditional scripts are not followed ultimately we find that predictors of genital contact on femaleinitiated dates are not the same as the predictors for genital contact on maleinitiated dates future scholarship should attend to femaleinitiated dates and their sexual processes as part of a distinct cultural scenario qualitative research may be needed to assist scholars in identifying and characterizing new sexual scripts that come from femaleinitiated date scenarios the effect of who paid on the date is of particular interest specifically the effect of no money being spent as it is the explanatory variable with the most substantial statistical significance among femaleinitiated dates when no money is spent and genital contact happens the interaction seems to fit the description of a hookup but the respondent specifically identified the interaction as a date this brings up questions about what defines a date notably almost 20 percent of all dates were classified as having no money spent while it is possible that college students intentionally seek out free date activities due to their low income they also continue to identify men paying as a defining feature of a date this speaks to an underlying question of how a date is confirmed in this scenario given the act of men paying on a date plays such a strong role in defining the interaction when women initiate the date and no money is spent the classification of a date is determined by different criteria in this way no money being spent could signal a more egalitarian date formula given neither person in the date scenario holds financial power over the interaction at the same time the fact that no money being spent is the most significant predictor of genital contact on a femaleinitiated date suggests that some dating practices may be informed by the sexual scripts guiding hookups in ways that have yet to be uncovered sexual respectability double standards and future dates the sexual double standard relational standard and interest in going on another date speak to beliefs about what is appropriate and respectable sexual behavior examining the effect of standards for sexual behavior on the sexual outcomes of dates sheds light on the interpersonal scripting process that influences decisions to engage in sexual activity interpersonal scripts provide the bridge between what the parties want and what they believe is deemed to be socially appropriate and normative for a first date on maleinitiated dates the effects of script components aligned with our expectations but the attitudes about sexual behavior and romantic interest did not the sexual double standard may signal a general lack of respect which may lead to the increased odds of genital contact assuming limiting sex is considered the proper respectable thing to do being interested in another date increased the odds of genital contact on a maleinitiated date which is counterintuitive to the relational standard which would dictate that sexual activity is withheld if there is interest in pursuing a relationship while it is possible that respondents retrospectively identified being interested in another date to justify whatever sexual activity took place we cannot be sure the positive association between interest in another date and genital contact on a maleinitiated date may also reflect how sexual boundaries and practices are being negotiated within dating contexts on the interpersonal level in ways we are not yet aware sex may serve as an added signal of mutual romantic interest after an interaction has been confirmed as a date and relational intent has been established whether through verbal cues or as indicated by a man initiating and paying it would seem then that despite the continued practice of certain components of the traditional dating script with men initiating and men paying on the majority of dates there is a discrepancy between the recitation of conservative sexual scripts and the sexual practices taking place notably neither the sexual double standard nor the relational standard had a significant effect on whether genital contact took place on a femaleinitiated date suggesting that standards for appropriate sexual behavior carry less weight on 1 3 scripting sex in courtship predicting genital contact in… femaleinitiated dates this is further demonstrated by the positive relationship between genital contact on femaleinitiated dates and being interested in going on another date sexual activity may assume different meanings in the context of a femaleinitiated date for instance having sex on a femaleinitiated date may not be considered a violation of the relational standard because of some agreedupon mutual interest that takes place outside of the context maleinitiated malefunded date contextual negotiations although women no longer depend on men to invite them out and pay for them men still initiate the majority of dates scholars have suggested that the contemporary adherence to gender roles in dating scripts may be attributed to ambiguity regarding the legitimacy of a date and uncertainty regarding the other persons intentions dating most certainly has been influenced by the sexual ambiguity of hookup culture even if conservative sexual practices are recited alongside traditional dating scripts current research often equates sex with hookups when looking at how sexual activity has been reordered in the courtship process sex may still be restricted in the scripted narrative recited by college students but in actual practice there seems to be more room for negotiation especially when the date veers off script these negotiations start on the interpersonal level of scripting where expectations for appropriate behavior confront individual desires we can see evidence of these negotiations in our observations of how the relational standard and being interested in another date are differentially associated with nontraditional sexual outcomes the relational standard for sexual behavior reflects the traditional expectation that sexual activity it limited in contexts where one might seek a boyfriend or girlfriend given the date is a context for romantic development it makes sense that holding a relational standard would be associated with a decrease in the likelihood of genital contact being interested in another date reflects a desire to pursue a possible romantic relationship with someone but unlike the relational standard interest in another date was associated with an increase in the likelihood of genital contact we can understand this as evidence of changing sexual norms men still initiate and pay for most dates but when the script is altered in any way we see significant changes in the sexual processes so although the traditional script is still relevant it is time to examine alternative scripts and their sexual processes regarding sexual practices dates are not as homogenous as recited scripts have led us to believe and only a minority of dates follow the traditional script completely the dominant norm isnt the only norm and this study suggests that what seems to be dominant on the surface is more diverse than we realized the further we get from the dating script the more ambiguous the nature of the interaction and the more nuanced the sexual scripts become in the case of the femaleinitiated dates there is a normlessness when it comes to sexual outcomes we see that the likelihood of genital contact increases whenever the traditional script is violated does veering off the script also reflect more egalitarian practices related to sex perhaps we are slowly moving away from these traditional dating scripts in the form of sexual negotiations in this way if we attend to the sexual processes of dates we may find that the traditional dating script is not as enduring as we have come to believe conclusion this article examines whether genital contact is associated with traditional or alternative components of dating scripts we examined variations of a dating script and their ability to predict genital contact this study highlights the variability of sexual scripts in dating practices suggesting that the sexual scripts associated with dates are not as homogenous or conservative as they have appeared we cannot assume that traditional date components lead to traditional sexual activities scholars have grappled with the enduring relevance of traditional dating scripts despite evidence of increasingly egalitarian views although we do see gendered patterns in scripted behavior when it comes to the initial logistics of the date it seems like the sexual rules are more contextual and there may be more room for negotiation than scholarship has previously assumed our findings suggest a discrepancy between what college students are saying and what they are doing the absence of sexual activity on dates relative to hookups has monopolized the focus of discussions about dating and the sexual processes in hookup culture with the way hookup culture has incorporated casual sex alongside dates in the courtship process it is important that we attend to how these changes in sexual norms may inform the sexual processes of dates as research on traditional gender roles in courtship and the stalled gender revolution looks to dating scripts to shed light on gender inequalities it is crucial to examine the function of sex in dating and to understand what scripts are actually being practiced and what factors may be informing them limitations and future research this study has some limitations that should be addressed and considered when interpreting the results for one as previously mentioned the ocsls survey data comes from a convenience sample which means it is a nonrandom sample and therefore not generalizable with that being said given the large sample size with a nearperfect response rate we believe that the data set reflects the attitudes and practices of a significant crosssection of the college student population extra credit was offered to students who took the survey which decreases selection bias students took the survey privately online which decrease s desirability bias and improve s the validity of responses 3 scripting sex in courtship predicting genital contact in… the respondents subjective assessment may also present a limitation to this study given we do not know if the other person on the date would have defined the interaction in the same way this is especially true of dates that veer off the traditional script we were also limited to the respondents most recent date which is not necessarily representative of their typical dating experiences another limitation of this study is that we do not know if the couple has gone on a date prior to the date in question research on dating scripts pays closest attention to first date scripts though scholars who have examined dating scripts more generally have found similar gendered patterns future research should consider how the number of previous dates shapes sexual outcomes for instance it is possible that first dates follow the cultural expectation for no genital contact with future dates involving more sexual activity even if the other components of the date remain traditionally gendered before exclusivity we also do not know how a date is being defined it is generally accepted that dating implies some level of romantic or sexual interest beyond that however the definition of a date is taken for granted as dates are often defined in terms of their script components for example women report relying on the act of men paying to signal that an interaction is a date the variety in scripts classified as a date by respondents however suggests the need for a better understanding of what constitutes a date beyond the traditionally gendered signifiers although we do not know the respondents criteria for what qualifies as a date we do know that the interaction was classified as a date with someone they were not in an exclusive relationship with in this study we limited our analysis to dates where sexual activity occurred future research could estimate multinomial logit models to examine the effects of dating script components and attitudes on three sexual outcomes no sexual activity petting and genital contact this type of analysis may provide a more nuanced understanding of the sexual scripting process future research might also consider the different operations of the sexual double standard and the relational standard data from the online college social life survey reported that only 16 percent of surveyed college students held a sexual double standard in that they indicate they respect women less if they hook up with a lot of people but not men over 70 percent of students held what we call a relational standard in that they report being less interested in someone as a potential girlboyfriend if they hook up a lot the sexual double standard may be less articulated as college students are becoming more likely to recite egalitarian ideals the relational standard however remains pervasive in its influence in contemporary america it seems that being chaste matters more for relationship building than reputation building this distinction between who is considered respectable and who is considered relationship material is important for understanding the persistence of traditional gender roles in courtship despite increasing egalitarian ideals our study sheds light on nuances of the dating script and sexual processes that require additional attention these questions may become even more important as the dating landscape is shifting within the context of the covid19 pandemic with stayathome orders mask mandates and heightened safety precautions dating logistics have been changing and sexual scripts are being reformulated in the future we may expect to see an increase in femaleinitiated dates as indicated by kendricks preliminary research on pandemic courtship culture which suggests that women have been more intentional about taking an active role in dating during the pandemic in highlighting how the sexual processes of femaleinitiated dates differ from maleinitiated dates our study creates an important point of departure for future research on femaleinitiated dates funding no funding was received to assist with the preparation of this manuscript availability of data and material the original online college social life survey was designed by paula england and the codebook was provided by jonathan bearak the data and survey instrument can be accessed at pages nyu edu ocsls 2010 code availability statacorp 2019 stata statistical software release 16 declarations conflict of interest the authors have no conflicts of interest to declare that are relevant to the content of this article publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

despite increasing egalitarian values expressed among college students dating is still characterized by traditional gender roles because traditional dating scripts are predominantly recited and enacted to the extent that men initiate and pay there are assumptions that the sexual processes have not changed this study investigates the sexual processes of maleinitiated and femaleinitiated dates among college students in the us using data from the online college social life survey we ask whether traditional components of the dating script explain traditional sexual outcomes nongenital contact as well as whether alternative dating scripts explain nontraditional sexual outcomes genital contact using multivariate logistic regression models we found that violations of the traditional script are associated with higher odds of genital contact for maleand femaleinitiated dates however the predictors of genital contact for femaleinitiated dates are not the same as those for maleinitiated dates this study highlights the variability of sexual scripts in dating practices suggesting that the sexual scripts associated with dates are not as homogenous as we have previously believed

situations such as bullying or a negative selfconcept positive and problematic behaviors can coexist and manifest in diverse ways across youth experiences and in the varied domains that young people inhabit in schools in families with peers online and in afterschool programs a positive youth development perspective on afterschool and social media a positive youth development perspective suggests that when the strengths of youth are aligned with the assets in their contexts thriving occurs pyd has been extensively documented through research about youth development and afterschool programs in the five cs model positive development is operationalized as competence confidence connection caring and character when young people exhibit the five cs they contribute positively to themselves to others and to civil society ross and tolan suggest that digital contexts such as social media also have the potential to be pyd contexts they indicate that because pyd is focused on this alignment between youth strengths and the context the digital setting is a context brimming with opportunity for positive interactions to occur and that digital media shares many of the same characteristics of traditional pyd settings that make them ideal for positive development to occur in particular ross and tolan highlight that young people can build their social emotional skills and relationships online although measures do not currently exist to capture pyd in digital spaces it is possible that the cs can be operationalized in digital settings for example youth can demonstrate caring by engaging empathetically with others online in the present research we employed the pyd perspective and in particular the relational aspects of caring and connection conceptualized within the five cs model to understand the links between youths inperson and online interactions afterschool activities shape social and emotional outcomes afterschool activities can help adolescents develop the skills associated with positive peer relationships and a healthy sense of self research has shown many positive outcomes associated with highquality activity participation for youth for example in a metaanalysis of 68 studies of afterschool programs that seek to promote personal and social skills in youth researchers found an association between youth attending afterschool programs and increased positive feelings about themselves and their schools and increased positive social behaviors russel et al reported that middle school programs provided opportunities for identity formation and leadership development which can be helpful to address the transition from elementary to middle school russell et al concluded that afterschool programs play an important role in developing youths social skills and provide a space less demanding than the school day where youth have opportunities to form and sustain relationships this overview of research associated with activity participation suggests that afterschool contexts have the potential to promote social development and emotional development next we review youth social media use and how social media engagement might also shape social and emotional development for youth social media experiences like afterschool activities social media use can be related to prosocial behavior within online communities despite the perception of mostly negative online experiences only a quarter of teens describe social media as a primarily negative experience in fact in nationally representative studies of teens aged 1317 using social media 81 felt more connected to their friends and 68 of online friends supported them through tough times through social media there are ways that teens interact online which may shape their social behaviors and the majority of teens used the internet as a healthy venue for social interaction for example frequent online communication was associated with higher quality friendships and frequent phone use email and messaging is related to increased social competence adolescents who are doing well socially may also benefit from online activity because it supports the formation of friendships for example the stimulation hypothesis suggests that the time that youth spend online involves intimate disclosures which enhances closer friendships furthermore interactions through texting and social media have been found to promote a sense of belonging this online communication has also been found to facilitate better selfconcept clarity across social situations finally social media can improve adolescent social connectivity and sense of belonging as well as provide a forum for selfdisclosure and identity exploration this research suggests that rates of problematic experiences online are relatively low and that the majority of youth are more likely to have positive emotional and social developmental experiences it is important to acknowledge that like any context in the lives of youth there is the potential for less desirable youth behaviors and interactions amidst the potential for positive development according to common sense media 8to 12yearold youth spent an average of 4 hours and 44 minutes per day on screen media which increases with age such that 13to 18yearold youth spend an average of 7 hours and 22 minutes online per day given the average amount of time spent on social media per day youth often spend more time using digital media than participating in afterschool or other supervised programming young peoples use of social media can span the spectrum of positive to problematic behavior in a recent metaanalysis of cyberbullying victimization studies varied quite widely in prevalence estimates due to inconsistent definitions and time periods assessed pew research has demonstrated that the more frequently teens are online the more likely they are to be cyberbullied cyberbullying and online victimization has also been related to student experiences in school such as number of detentions suspensions and truancy when measuring recency and frequency the rate of cyberbullying was rather low in a populationbased sample of 120000 only one in 20 girls and one in 50 boys experienced cyberbullying despite these inconsistent and relatively low rates of cyberbullying it remains important to document if and how the potential for this risk may exist in the lives of middle school youth connecting afterschool with social media the research described above suggested that high quality afterschool programs can contribute to positive social and emotional outcomes such as better selfesteem school bonding and prosocial behaviors notably high participation in these programs has been found to influence prosocial behavior social media also has the potential to contribute to young peoples social connectivity and identity development the structures philosophies and strategies of afterschool activities may reinforce standards for positive and supportive interactions on social media and inperson and virtual friends might connect across these two domains pragmatically it is also possible that being engaged in an afterschool activity limits the amount of time that a young person has available to check and participate in social media an alternative is that engagement in afterschool activities may facilitate online connections with friends beyond inperson experiences and lead to increased interest in engaging online despite the potential for positive engagement in both domains and in particular the potential for social media to deepen relationships which started in person research has not yet linked these two domains in the present research we were interested in two indicators of afterschool participation and their associations with youth online engagement first given that high participation is related to inperson prosocial behavior we incorporated the amount of time that youth spend in afterschool programs to assess whether this type of dosage either limits online engagement or enhances youth social and emotional skills second we examined whether youth are connected to their inperson peers from afterschool as friends online given the potential for both positive and problem behavior in the online space our hypothesis about this indicator was openended overall we hypothesized that being a part of afterschool activities may be related to more supportive online behaviors due to possible scaffolding that may occur in these programs which typically offer mentoring and structured peer interactions in particular we focused on outcomes related to seeking support and providing support via social media acknowledging the potential for risks online we examined the links between these afterschool indicators and experiencing negativity online given the application of a pyd theoretical framework and existing research documenting the positive and prosocial ways that youth engage online we expected a positive association between afterschool indicators with the pydfocused outcomes and a negative association with the risky outcome method procedure as part of an ongoing longitudinal study of the social contexts and behavioral consequences of adolescent social technology use middle schools in the northeastern united states were recruited in 2019 based on varying school enrollment size internet accessibility and diverse racialethnic composition sites were also selected that had robust afterschool andor sports activity offerings upon obtaining approval from the wellesley college institutional review board and institution and school districtlevel permissions we worked with liaisons in one school and in one districtwide afterschool program spanning three schools to distribute informed consentoptout forms to parents through paper flyers parent email listservs school enewsletters and direct emails for the fall 2019 data collection members of the research team proctored the online qualtrics survey in person during a prescheduled advisory period or afterschool program break lasting up to 60 minutes youth primarily used school or afterschool programprovided chromebooks and the survey took about 2540 minutes to complete because survey links were emailed to youth through their google classroom or afterschool program listserv those who were absent during the survey administration were able to participate from home an honorarium was provided to schools for participating as well as gift card incentives to teachers and program coordinators to help with survey recruitment youth who participated in the survey were given an embossed pen snacks and were entered into a drawing prize for a chance to win a 25 gift card measures checking social media to indicate how often youth check social media we asked on a typical school week how often do you check social media responses were 1 2 3 4 5 6 the average score for checking social media was 350 experiencing negativity online experiencing negativity was measured with an average of three items adapted from a scale of internet harassment developed by ybarra and colleagues youth responded to three items requesting how often a certain online experience happened to them you were hurt by someone making you feel left out online someone made a rude or mean comment to you online or by text and you were hurt by someone making you feel left out online on a scale of 1 to 5 the average score for was 140 and α 77 giving support youth were asked how often they post something to make others feel good respond positively when friends share good news and try to make friends feel better when they share bad news these indicators were developed by the project team responses ranged from 1 to 5 the average score for giving support was 327 and α 82 online support seeking behaviors support seeking behaviors on social media were measured with an average score of five items adapted from the facebook measure of social support using subscales perceived support and negative social support youth responded to five items when i am stressed out i turn to my friends for help on this site the support i get on this site makes me feel better when i have a need that friends ignore on this site im hurt this site makes me feel close to people and its important that my friends like or comment on my posts responses were on a scale of 1 to 5 the average score for seeking support was 227 and α 85 social media friends from afterschool youth were asked who are your friends on social media if they selected friends from afterschool activity or team they were coded as and compared with youth who did not select this category fiftythree percent of youth in the present sample were social media friends with peers from their afterschool activities social media friends from school youth were asked who are your friends on social media if they selected classmates in upper grade they were coded as and compared with youth who did not select this category similarly if they selected classmates in your grade or younger they were coded as and compared with youth who did not select this category fortyfive percent of youth reported friends who were older classmates and 59 of youth reported same or younger age classmates social media friends from afterschool and pyd 36 as described by researchers and practitioners however we use this language here because of relevance to ease of understanding for youth demographics three demographic indicators were included as covariates in the present analyses two gender categories were assessed female youth were compared to male youth if youth responses to their gender did not correspond to one of these two options they were included in the analyses but their specific gender effects were not sufficiently powered to detect effects in the present analyses four race categories were assessed black and latinx and asian youth were compared to white youth free or reducedprice lunch participation was used as a proxy for income youth who received free or reducedprice lunch were compared to a combined group of youth who were unsure or who did not receive free and reducedprice lunch finally youth grade in middle school was assessed continuously sixth grade seventh grade and eighth grade demographics and descriptive statistics for all indicators are included in tables 1234 analysis plan the purpose of this analysis was to test the hypothesis that there is an association between afterschool experiences in terms of time spent in afterschool and having social media friends from afterschool with youth pydrelated experiences online using linear regressions conducted in spss we tested the relationship between afterschool experiences and four outcomes pydrelated outcomes included providing support and seeking support the risky outcome included experiencing negativity checking social media was included as an outcome which could span the categorization of positive or problematic covariates were included in this model to account for potential differences in background race gender income and grade level social media friends from school were also included as covariates in order to understand the potential for afterschool sm friendships to have a unique role in the way that youth typically interact online results checking social media as shown in table 1 linear regression suggested that having each type of friend on social media was related to increased checking of social media compared to the group of youth who did not indicate having that type of friend on social media sameyounger age classmates older classmates and afterschool the amount of time in afterschool was not related to checking sm in this model youth enrolled in the freereducedprice lunch program were also more likely to check social media than those who did not report participation in this program seeking support online having sm friends from afterschool and having sm friends who were older classmates were both positively associated with seeking support when compared with youth who did not report having social media friends from these groups the amount of time in afterschool was not related to seeking support online youth who reported being female and were enrolled in the freereducedprice lunch program also were more likely to seek support online than male youth and youth who did not report enrollment in free and reducedprice lunch respectively providing support online having sm friends from afterschool and sm friends in the sameyounger grade were associated with providing more support online when compared with youth who did not report these types of social media friends the amount of time in afterschool was not associated with providing support online note n 474 sm social media a 0 white 1 black latinx or asian b 0 male 1 female c 0 not reporting freereduced lunch 1 reporting freereduced lunch d 0 not reporting this type of friend on social media 1 reporting this type of friend on social media e time reported in days attended p 001 experiencing negativity online the only indicator associated with experiencing negativity online was having older classmates as sm friends compared with those who did not report this type of sm friend neither afterschool indicator was related to experiencing negativity note n 425 sm social media a 0 white 1 black latinx or asian b 0 male 1 female c 0 not reporting freereduced lunch 1 reporting freereduced lunch d 0 not reporting this type of friend on social media 1 reporting this type of friend on social media e time reported in days attended p 006 discussion the purpose of this exploratory research was to assess the relationship between afterschool participation and pyd experiences online research has not yet assessed the relationship between these two realms of influence in the lives of youth the present study showed preliminary evidence that there is a link between youth afterschool connections and online experiences in terms of the peers that span both contexts despite this connection few afterschool programs offer guidance on prosocial behaviors in the digital worlds of youth recognizing the need for positive reinforcement of social technology use prior research has found that frequent checking of social media and online communication is related to both positive and negative online influences so this outcome was assessed to better understand the context of social media use youth in afterschool programs were checking social media more frequently which can be either an indicator of feeling connected to ones supportive online networks or the need to browse passively without connecting the frequency of youth in afterschool checking social media could be due to the fact that increased network size and diversity of contacts would result in more activity to check other research has also found that afterschool programs use social media to communicate directly with youth in these cases youth may be checking social media more frequently to keep up with information and interactions from their afterschool programs which informally extends the offline interactions into the online worlds we found partial support for the hypothesis that afterschool experiences would be associated with pyd exhibited by youth onlinetime in afterschool was not related to pyd online but friends from afterschool did relate to indicators of pyd online the finding that the amount of time in afterschool did not relate to any of the tested positive or problematic indicators was contrary to our expectations this finding suggests that to understand the experiences of youth on social media in terms of afterschool future research should look beyond solely participation in programming anecdotally afterschool may be considered a way to limit the time youth spend online however this idea does not bear out in the current data with more evidence pointing to the relationships and connections from afterschool being extended in the online environment furthermore it is possible that social media use might be concurrent to attendance in afterschool and the boundaries of experiencing being on media and being in person are disintegrating the peer relationshipbased component of afterschool was related to each of the pydrelated outcomes in the present study there was a positive relationship between having a sm friend from afterschool with seeking support online and with providing support online the association between having sm friends from afterschool and school with both seeking and providing support is consistent with research which suggests that youth who are doing well socially might also be doing well online and that social media might be a way for youth to extend and deepen their friendships it is also notable that the present research did not find evidence for experiencing negativity online in relation to having sm friends from afterschool rather the evidence suggests that older classmates outside the afterschool environment may contribute to negatively perceived online experiences which suggests that having older classmates may be a risk factor to consider when counseling youth about their online networks this finding may in part alleviate some protectionist concerns that when youth leave the supervision of an afterschool space problem behaviors will occur our suggestions for future research about afterschool would include a focus on how variation in program practices such as a facilitated supportive environment and the establishment of peer and community norms within and beyond programming might also shape pydrelated outcomes online addition of these types of afterschool experiences may also illuminate the nonsignificant finding related to the amount of time in afterschool namely it might not be only the amount of time in that program but the quality of time spent in an afterschool program including the ways that quality programs facilitate development of relationships in afterschool programs limitations and future directions these findings should be interpreted in light of a few limitations this research capitalized on an existing dataset to explore how two afterschool experiencesamount of time in program and friends from afterschoolmight relate to social media experiences for middle school youth afterschool programming also varies widely in focus content and structure and similarly might result in different social media experiences future research should explore specific types of programming and their relationship with youth experiences on social media in addition although this sample is diverse in terms of demographic indicators they engaged in problem behaviors at similarly low rates as those in their age group and participated in programs at high rates future research should assess the relationship between activity participation and social media in samples that may have less access to afterschool activities finally the present research utilized selfreport data which may not provide the full picture of youth experiences on social media or in afterschool programming the present research also was conducted before social distancing and remote learning were introduced to schools and afterschool programs as a result of the covid19 pandemic during this time school and afterschool programming could have been provided entirely or partially in the digital context this experience may have changed youths perception understanding and engagement in digital spaces and is also necessary to document in future research furthermore questions remain about how to assess the rapidly changing digital context diverse methods including selfreport observed and networked methods could be employed more detailed information about the links between activity participation and social media engagement should be elucidated particularly in the unique cases when afterschool activities make intentional efforts to support youths positive and informed engagement on social media we hope that this research though preliminary provides inspiration for future research conclusion taken together these findings indicated preliminary evidence of a link between afterschool activity participation in terms of friends from sm and pydrelated social media use furthermore these findings may provide afterschool practitioners with ideas on how to develop programming that may provide social role modeling for how their youth connect to peers online peer relationship building is a natural part of afterschool program environments knowing that youth in afterschool programs may continue to connect with each other digitally outside of the program time and space may prompt program staff to be more intentional in talking about how friendships carry over to different settings friends can support each other through different aspects of their lives and programs can infuse frequent opportunities for peer relationship building we encourage afterschool program practitioners to also take a pyd perspective on digital spaces given the findings in the present research they may continue to support these types of caring and connected behaviors online by sharing messaging about engaging with their friends from afterschool in supportive ways in and outside of the program future research may take up the unanswered questions that arise from these preliminary findings including what features of activity participation can shape online peer communities and how activities and online behaviors can be explicitly linked to foster positive youth development author note research supported by 1r15hd09428101 eunice kennedy shriver national institute of child health and human development the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health we have no known conflict of interest to disclose we extend our gratitude to the youth who participated in this survey and the youth workers educators who helped facilitate recruitment and access we also acknowledge and appreciate alyssa gramajo for project coordination amanda m richer for data management and the wcw writing seminar for their feedback on this manuscript

positive youth development has been extensively documented in contexts such as the family school and afterschool emerging theory and research indicate that digital contexts such as social media may also be venues through which young people develop skills and attributes associated with the 5 cs model of positive youth development and thriving this research attempted to understand if and how middle school youths inperson and online networks connect and if they do connect do these connections relate to engaging in beliefs and behaviors associated with pyd results suggest that in this sample middle school youth include peers from afterschool in their online networks and those who have friends from afterschool and school engaged in pydrelated social media behaviors at higher rates than those who were not connected to inperson networks no association was found between the amount of time spent in afterschool contexts and any of the positive or problematic social media outcomes in this study implications for youth development professionals considering the influence of social media on youth and next steps for research on afterschool activities and social media use of middle school youth are discussed

introduction global migration has led many countries to become multicultural societies language barriers have been identified as a major obstacle to migrants receiving appropriate healthcare in sweden there is a law stating that people who do not understand or speak swedish have the right to an interpreter in all contacts with public authorities in a foreign country the family can be an important support as many migrants have a limited social network healthcare professionals often rely on family members as interpreters although they feel insecure in encounters with families from other cultures than their own individualized and holistic care should focus on the interaction between healthcare staff patients and families it is important to investigate the families perspective because family members represent a basic social unit in healthcare their involvement is perceived as a source of mutual support security and fulfilment for the patient the family member who is a relative of an individual who needs an interpreter in herhis healthcare contacts also faces problems in communication when using an interpreter because of the trinity of the individual family members and healthcare providers no previous study has been found focusing on adults experiences and describes their family members use of interpreters in healthcare encounters literature review from the patients and healthcare staffs perspective the benefits of using professional interpreters were their ability to interpret literally objectively and without having any relation to the patient a previous study found that patients were unaware that healthcare staff could access interpreting services for their healthcare consultations reliance on family members as interpreters is common in healthcare earlier studies have found that the positive aspects of using family members as interpreters are that they can protect confidentiality within their own communities offer support in consultations and enable shared understanding of advice and instructions once the consultation is over however professional interpreters have been found in previous systematic literature reviews to be more effective than other types of interpreters in bridging communication barriers research on interpreter use in healthcare has previously focused on experiences of using interpreters from the perspectives of healthcare staff and patients however there are studies focusing on bilingual young peoples experiences of interpreting the youngsters felt that they were being used because of limitations in interpreter services family members saw this as part of their responsibilities as family members concerned about the wellbeing of the person for whom they were interpreting however no previous studies have been found investigating how adults experience and describe their family members use of interpreters in healthcare encounters when their family member face language barriers in these encounters the families perspective is important because healthcare professionals provide healthcare to the individual and the family and healthcare staff face the need to use interpreters in their contacts when they meet language barriers examining the family members perspective gives the opportunity for etic knowledge of the use of interpreters in healthcare encounters therefore it is best to examine the variations and similarities of experiences that exist in family members experiences of the use of interpreters in order to supply the missing piece to ensure a holistic view of all parties involved in the healthcare encounter the familys expertise and involvement must be recognized acknowledged and used throughout the healthcare process furthermore this study contributes to the increased knowledge and understanding of interpreter use in healthcare and the implications this has for healthcare such as improved healthcare outcomes and lower costs for healthcare through the tool of improved communication aim the aim was to explore adults experiences of their family members use of interpreters in healthcare encounters method design an exploratory qualitative approach was adopted focus groups were used for data collection as the group process enables members to express views that might not have been disclosed in an individual interview participants and procedure purposive sampling was used to ensure a range of participants differing in age and educational level and representing different perspectives the study included adult individuals who had serbocroat as their native language and who had accompanied a family member and thus experienced the use of an interpreter in healthcare encounters from a family member the reason for choosing this migrant group was that individuals from former yugoslavia constitute the second largest group of migrants living in sweden 2009 representatives of migrants associations for former yugoslavians in south sweden localized in an immigrantdense region were contacted to invite people to participate a time was set for an information meeting all participants also received written information about the aim of the study focusing on the use of an interpreter in healthcare encounters from their perspective as a family member on the implementation of the study and stating that participation was voluntary written information was given in swedish and serbocroat and the first authors contact details together with a prepaid envelope those interested in participating sent their address to the first author who contacted them to set a time and place for the interview two men and eight women aged 2961 years length of residence in sweden 1218 years with different educational levels seven with high school level and three with university educational level had participated in the study all were refugees born in former yugoslavia and with valid residence permits three focusgroup interviews with 10 individuals were conducted two groups comprised female participants and the third group had two men and one woman data collection data were collected between may and september 2009 a semistructured interview guide was used as a prompt to encourage discussion on the basis of a literature review and experiences from previous studies the interview guide was translated into serbocroat to improve the quality of the information received and to increase reporting within the group as preferred by informants all interviews were conducted in serbocroat by the same investigator who was a native speaker thereby reducing communication barriers examples of questions in the interview guide were how did you perceive the use of interpreters for your near ones what functioned well what functioned less well and why written informed consent including information about the voluntary nature of participation and assurance of confidentiality was obtained before the interviews thus the participants were informed again that the focus was on their family members use of interpreters in healthcare encounters and about the implementation of the study the first focus group was held to test the interview guide and the role of the moderator the focus group turned out well and the data were found to be of good quality requiring no corrections and were therefore included in the analysis the focus groups took place in a setting chosen by participants in a secluded room at an immigrants association for former yugoslavians in an office at the first authors workplace and at one informants workplace the moderator conducted the focusgroup discussion with participants and made field notes immediately after the sessions to recall the group discussions mini focus groups were used in order to make it possible for the moderator to take notes and observe the group interaction these notes described topics discussed impressions of the topics discussed interaction patterns and group dynamic and level of participation nonverbal communication was also registered each session lasted about 1 h and included three to four individuals the interaction in each group was lively with knowledge transfer and supportive communication body language was noted demonstrating active engagement the interaction in the focusgroup interviews was particularly intensive while discussing literal interpretation and interpreters nationality interviews were audio taped transcribed verbatim and then translated into swedish by the first author the translation was checked by a professional translator and showed high agreement ethical considerations swedish law was followed written informed consent was obtained from the participants to preserve the confidentiality of the data the tapes and transcripts were anonymized and coded by number the analysis and presentation of the data were carried out in a way that concealed the participants identity participants could withdraw from the focus groups at any time without explanation all data were stored in a locked space to which only the first author had access to preserve the confidentiality of the participants they agreed that discussions held within the group should be confidential and not be shared outside it the first author pointed out that she could not guarantee that others in the group would maintain confidentiality data analysis data analysis was performed as described by krueger and casey as this method considers the influence of interaction in the group to identify patterns and discover relationships between ideas the data sources included field notes summary expressions and verbatim discussion analysis of data proceeded simultaneously with data collection until no new information emerged analysis started with notes directly after the group interviews about what the informants said and the interaction in the group thereafter the text from field notes and interviews was read several times to give a comprehensive picture of the data the text was coded and opinions with similar meanings were grouped in subcategories according to their differences and similarities the process of grouping codes assisted in developing an understanding of the patterns in the data comparisons were made during the whole analysis between subcategories and the text as a whole when no new information appeared subcategories with similar meanings were combined into categories rigour investigator triangulation was used to validate the findings the first author performed the analysis and established subcategories categories were checked and discussed with the coauthors to ensure that they agreed with the interview material quotations were used to illuminate the results and to verify the categorization to ensure conformability to increase the credibility analysis proceeded to the point where no new information was obtained this was reached after three focusgroup interviews as krueger and findings three categories experiences of the use of professional interpreters experiences of being used as an interpreter and experiences of what needs to be improved when using interpreters were identified from family members experiences of the interpretation situation with the respective subcategories the second category the experiences of being used as an interpreter was an incidental finding stated by the majority of the respondents experiences of the use of professional interpreters communication aid some participants found the use of professional interpreters beneficial for their relatives they felt that a professional interpreter ensured a literal transfer of information and privacy during an intimatesensitive examination furthermore they valued the existence of a law to ensure them the same right to correct information as native swedes in contacts with healthcare this inspired trust among family members in supporting their relatives in matters relating to healthcare i appreciate that he professional interpreter interpreted wordforword from swedish to bosnian whatever your condition y in sweden you have the right to phone and ask for an interpreter some family members disliked their loved ones using professional interpreters because the interpreters could give information they did not want the patient to hear especially bad news they related this to generational and cultural issues in their home country theres still the old idea that you shouldnt say it directly to y patients y you tell the family trust in professional interpreters depending on their education gender language competence and national background the participants perceived that professional interpreters education skills in both languages and medical terminology increased their trust in the interpreters other essential factors were same gender as the patient wearing nonprovocative or neutral clothes and being of the same age the interpreters professional attitude was important shown by their behaviour towards the patient and the ability to keep the code of confidentiality continuous use of a particular professional interpreter and facetoface interpretation were felt to give security for their near ones it the professional interpreters sex is significant for elderly women in gynaecological examinations y for elderly men if a young girl comes to interpret for them they might feel uncomfortable ythe professional interpreter should be properly dressed you cant come dressed just any way for example with dirty wrinkled and torn clothes y the professional interpreter comes and introduces himself and behaves professionally towards you observes confidentiality and also informs you about professional secrecy there were informants who found it important that the patient and professional interpreter had the same origin and the same native dialect it was the language that conveyed about the national background they suspected the professional interpreters objectivity if heshe had a strong national agenda and doubted whether the patient answered honestly in those interpretation situations y it depends on the interpreters nationality y it can feel a bit uncomfortable y whether he interprets everything or not and the patient doesnt understand swedish and it can happen that he interprets subjectively some of the informants did not trust the professional interpreter to maintain confidentiality they felt that there was no guarantee that the interpreter would not take advantage of the information given during the consultation modes of interpretation depending on the situation the informants stated that modes of interpretation were dependent on the care situations the patients age and gender using telephone interpretation family members or bilingual healthcare professionals as interpreters could be advantageous in sensitive matters as they felt the patients trusted these modes more in relation to mental health some accepted an unknown professional interpreter which gave the opportunity to remain anonymous on subjects that were difficult to talk about using telephone interpretation was considered a good alternative for young people it the mode of interpretation depends on the disease y when it comes to sensitive healthcare staffs adaptation of language to patients preferences needs to be improved when better collaboration between patient professional interpreter and healthcare using the interpreters developing the professional interpreters professional attitude things that the people find it hard to talk to strangers about its better to have bilingual health care staff if theyre available y then you know that the information wont go any further and that a psychiatrist cant pass the details to others the informants perceived that the family members predominantly preferred a facetoface professional interpreter as it enabled observing body language the interpreters professional attitude and good language skills were also factors that helped ensure adequate treatment for their relatives especially regarding bad news a professional interpreter on the spot is better because if youre with the doctor and say it hurts here pointing at the body y feel more trust when y you can see through his reactions y its better to have a professional interpreter who can express himself better so that the patient will understand better the potential influence of negative personal feelings between patient and professional interpreter could be a risk when using facetoface interpreters family members as interpreters were perceived as a disadvantage because of their limited language knowledge and also as it could have negative effect on the family members work and private life when shehe was obliged to follow the patient to different encounters there were also negative experiences of the use of bilingual health professionals because they were perceived as not interpreting objectively and because interpreting was not part of their work assignment and therefore was regarded as stressful for the staff informants felt that on unexpected visits their relatives seldom had access to a facetoface professional interpreter in those cases the healthcare staff expected accompanying family members to interpret or use telephone interpreters however facetoface professional interpreters were mostly used when visits were planned importance of professionalism according to the participants the ideal qualities of a professional interpreter were skill in languages and medical terminology and ability to adapt to different dialects most of the informants emphasized that the professional interpreters need to have a professional attitude by being polite introducing themselves and showing empathy some considered that a professional interpreter wearing neutral clothes and of middle age could improve an interpretation situation ythe professional interpreter should introduce himself be normally dressed talk both languages fluently y master the terminology used in examinationsy professional interpreters different roles informants felt that the professional interpreter had an important role as a communication aid there were informants who found it important that professional interpreters transfer the information literally and objectively even regarding bad news for example a cancer diagnosis others considered that professional interpreters should adjust the interpretation to the patients age hearing and educational level y the professional interpreter should not translate wordforword but should adapt the information to a level that old people understand there are some who dont hear well dont see well dont understand well someone not well enough educated who thinks that certain words are too complicated and someone who thinks that some words are shameful and shouldnt be used most informants felt that the professional interpreter could also have an important role in helping patients with practical matters such as meeting the patients at the entrance and getting to know them others approved the current policy forbidding professional interpreters to have any contact with the patient outside the interpreter situation so that their role as family member was to help with practical matters and not interpret problems with the use of professional interpreters participants found it problematic that healthcare staff did not book professional interpreters or ask for patients wishes about the use of aprofessional interpreter and that they expected the accompanying family member andor bilingual healthcare staff to act as an interpreter the healthcare staffs unwillingness to book professional interpreters was related to economic issues in their opinion other factors that were perceived as problematic were professional interpreters who broke off the consultation prematurely ythat they care staff just dont want to book professional interpreters y that its because of the cost how they can best save money nobody has even asked if my mother needs an interpreter ysomeone from the family has come and can act as interpreter it has happened that he professional interpreter apologized for having to end a conversation because he had to go to the other side of town to interpret for others lack of information about the availability of a professional interpreter sometimes informants found that written information sent to the patients home did not state whether a professional interpreter was booked the family members then had to ensure that a professional interpreter would be present during the consultation when he patient is called y i phone to check if an interpreter has been ordered it sometimes says in the letter that an interpreter is ordered but not always experiences of being used as an interpreter an incidental finding but one stated by the majority of the respondents was the experiences of being used as an interpreter practical and emotional support informants discussed a number of benefits deriving from interpreting experiences there were emotional benefits in enjoying helping the family and having their interpretation skills trusted more than an unknown interpreter they valued the opportunity as interpreters to obtain more information as they were able to ask additional questions share understanding of advice and give practical and emotional support during after the consultation ywhen i interpret for my mother i find out much more than when its a professional interpreter y because im the one who asks questions not my mother there were also disadvantages of interpreting it was a great responsibility it takes time from their work and family life and it was difficult to ensure complete information transfer because of limited language skills moreover there were negative emotional consequences some participants felt that they could not be objective and transfer complete information others reported that some consultations involved sensitive information difficult to interpret because they could be blamed for holding the ideas expressed by healthcare staff y feels great responsibility y must learn certain words in swedish that you dont use every day i cant be there to interpret every time its needed although i try leave work early organize it somehow so the children dont have to be there but there have been situations when i was forced to have my children with me for example my fatherinlaw had diabetes and y i interpreted for him about what he could eat or not i get the feeling that he didnt like me telling him as if it was me forbidding him to eat things family members conflicting roles family members discussed their role of interpreting negative news some felt that it was important to ensure literal transfer of information to their relatives because it was the law and the healthcare staff expected them to do it those situations were perceived as emotionally difficult and they wished not to be used as interpreters others felt it was their duty not to transfer all information but to adapt it to patients in a gentler way they explained that it was related to a generational and cultural issue from the home country where the older people were not comfortable with such statements further they stated that it was emotionally difficult to pass negative news on to relatives as it might upset them the informants who adapted the information in the interpretation situation preferred being interpreters for their near ones ycould never interpret a cancer diagnosis for someone close to me y would put it in a milder wayy older people are not used to the direct way of expressing a message like that but according to the law y you have to interpret wordforword participants considered that they could be more objective in their interpretation when they interpreted for persons with whom they had no close emotional ties experiences of what needs to be improved when using interpreters healthcare staffs adaptation of language to suit patients preferences it was suggested that to facilitate professional interpreter use healthcare staff must ensure that both the interpreter and patient have correctly understood the information this could be done by healthcare staff using easy swedish and simple medical terminology and by talking slowly a doctor can y try to explain to a professional interpreter in simpler swedish there were also desires that healthcare staff should not expect family members to act as interpreters in all care situations and that they should ask about the patients preferences better collaboration between patient professional interpreter and healthcare the participants wished that professional interpreters should be employed permanently to ease availability and access they also suggested that it would be better to clarify the policy for when and how bilingual healthcare staff should be used as interpreters other suggestions included written information in both languages in the letter that patients received at home better cooperation with other care institutions better accessibility to professional interpreters and continuity in the use of professional interpreters furthermore better documentation of the patients communication status including the appropriate language and practical help such as booking a taxi was important someone suggested developing an agency for nonswedishspeaking patients where they could turn for help in booking interpreters y that there is better contact with home help y that professional interpreters are available important that gps write that the patient also needs help to get from home to the hospital there should be a single number that they patients can call to get an answer in their own language so that they themselves can talk y mostly you have to be able to speak swedish yourself to be able to book a professional interpreter developing the interpreters professional attitude it was emphasized that to facilitate communication with patients professional interpreters should be trained in the native language and how to encounter different people further the professional interpreter should ensure that information is correctly understood by patients and meet the patients before consultations to get to know each other the professional interpreter should be available at the appointed time and throughout the consultation yafter every conversation you should ask the patients if they have understood everything to be able to talk more with the doctor about it y that they professional interpreters should do that it ought to be their duty ythere should be enough time set aside for the patient y both patient and professional interpreter should come at least fifteen minutes earlier if they are meeting for the first time y to make contact and get to know each other discussion this study is the first investigation focusing on experiences of a near ones use of interpreters from adult family members perspective the main findings were that there was great variation in family members experiences of using interpreters for their near ones family members had different views about whether the professional interpreter should interpret literally or not the type and mode of interpretation and the interpreters professional role in situations where they were used as interpreters family members felt their role was to act as practical and emotional support which could lead to both positive and negative emotions the experiences of interpreting were related to the nature of the consultation for some participants literal transfer of information was essential in all consultations others did not want their relatives to have bad news translated which was related to generational and cultural issues it was an interesting finding when people from same culture perceived this differently this study was based on individuals from former yugoslavia of differing age and educational status but with similar migrational and socioeconomic status the degree of individuals acculturation and educational levels may influence their healthcare needs and experiences of the use of professional interpreters however more studies are needed to investigate whether this may be because of acculturation and whether the findings also apply to other migrant groups thus some informants desires were contrary to the swedish health and medical services act which states that patients need to be fully and directly informed about serious health conditions and contrary to professional guidelines in sweden which state that professional interpreters should translate literally culture has an impact on how people respond to illness in all countries the model of healthcare social policy and health education is strongly influenced by cultural and religious factors it is common in many countries not to convey negative news directly to the patient and inform the family instead this is important to consider in interpretation situations where there is a difference between what is stated in healthcare laws which aim for patient autonomy and cultural groups where patient autonomy may be seen as harmful the professional interpreters use of the right dialect associated with hisher origin was important for having trust in the process this finding was in contrast to earlier studies of patients and healthcare staffs perspectives where professional interpreters dialect was not related to the ethnic origin of interpreters except insofar as it ensured better understanding the professional interpreters use of dialect was important for some informants and might be because of history besides the alphabet serbocroat languages differ in vocabulary grammar and intonation the dissimilarities between family members and patients perspective may be because of the different roles they have during the consultation this was not directly compared in this study and needs to be further studied trust between parties in interpreter consultations is essential as a prerequisite for effective communication and to provide quality care furthermore other personal qualities of professional interpreters discussed by participants were similar to the patients and healthcare staffs preferences in sweden there is a legal right to access an interpreter in all encounters with public authorities the recommendation is to use licensed healthcare interpreters particularly trained for this however the incidental finding suggests that there will always be some situations in which family members contribute as interpreters in healthcare the duties of the family members in interpretation situations were perceived differently by informants there was disagreement regarding the role of the family as interpreters especially in the delivery of bad news this was in contrast to patients wishes for literal interpretation in previous studies healthcare professionals were suspicious of the ability of family members as interpreters in conveying essential information to migrant patients and family members as the interpreters focused on the wellbeing of their near ones this studys finding is in agreement with previous findings that judgements of family members as interpreters should be made on a casebycase basis as they may have varying abilities to interpret for their near ones it is important that healthcare staff allow patients and their families to decide an acceptable level of involvement on the basis of the trust patients have in family members as interpreters however in the first instance the healthcare staff should explore patients wishes through the use of an independent professional interpreter participants in this study experienced an emotional disadvantage with the interpreter role for their family members it had a negative impact on their social life and they wanted their relatives to receive social support in the form of practical support and information from different healthcare institutions which has not been previously described healthcare staff need to examine family functions in relation to families social properties to meet their wishes social support from healthcare services could be very important in maintaining and promoting the health of participants and their relatives additional support in the form of increased collaboration between different healthcare institutions is also warranted to facilitate appropriate healthcare for foreignborn people the limitations and potential dangers of family members as interpreters include lack of familiarity with medical terminology misrepresentation translation errors a tendency to summarize or omit data subjectivity and ethical conflicts as also found in young peoples experiences of interpreting finally an interesting finding was that the informants felt that healthcare staff did not ask about either the patients wish for a professional interpreter or the family members wish to interpret this is contrary to the swedish health and medical services act and world health organization recommendations in which the main goal is individualized care and autonomy healthcare staff are required to involve the patient in the decision process and avoid placing a family member in the emotional position of conveying devastating news to a family member it is essential that both the patients and the familys voices be heard to achieve communication and good patient care and autonomy limitations and strength of the study our study is limited because of the number of participants only 10 people took part and of these only two were men the collection and analysis of data in the study proceeded until no new information was added the study attempted to recruit an equal balance of men and women withoutsuccess however in europe it is mostly women who are involved in the care of their family members as represented by the participants in this study the difficulties of running a mixedgender focus group for example the peacock effect could also be viewed as a limitation in this study men have a tendency to speak more frequently and with more authority when in groups with women which might lead to limited possibilities for women to express their views however there were no signs of dominance as the interaction in the group was lively all expressed themselves in an equal way and after the analysis of the three groups no new information was added to the data one limitation of this study could be that there was no assistant moderator during the focusgroup interviews for practical and financial reasons therefore a mini focusgroup design was chosen to make it possible for the moderator to facilitate the group process and also to take notes about the interactions during and after the interview mini focus groups also eliminated the risk of frustration resulting from participants not having enough time or opportunity to express themselves in larger groups an effort was made to minimize the effect of the absence of an assistant moderator furthermore allowing participants in focus groups to respond in their native language increased their comfort level with the moderator who had a similar cultural and linguistic background which also helped to maximize the quality of data otherwise the disadvantages could be that it limits the total range of experiences because the group was smaller a group with fewer participants will have fewer total experiences than a larger one conversely larger groups work well when the participants do not have a lot of knowledge about the topic however the outcome depends more on the involvement of the participants in each group and their interaction than on the actual number of participants when having an exploratory aim one should run groups of smaller size as the prime objective is to obtain the maximum amount of information there was lively interaction in the focus groups and after three groups had been analysed no new information was added to the data the study provides a deeper understanding of the studied topic and as the results were carefully collected and analysed they may be transferred to other settings or groups with similar characteristics participants were from former yugoslavia of differing age and educational status but with similar migrational and socioeconomic status the slight differences between the informants backgrounds may have the result that some family members felt less confident and were afraid to express their views however there were no indications of this during the focusgroup interviews the ability to communicate in the group was supported by the openness of informants while discussing sensitive topics such as the interpreters nationality crosslanguage research has the potential for altered meaning the use of interpreted data must be noted as a limitation in this study however the translation of data was checked by a professional translator for accuracy in the transcriptions another limitation might be that the interviews were held at different venues after participants desires in our study the venue for the focus groups needed to be both neutral and socially acceptable to participants however the venues were accessible and easy to find neutral and quiet so that participants were not likely to have needed to explain their reason for their presence the strength of the investigation was that focus groups worked well with the current population through the good interaction and group climate during the interviews conclusion the findings emphasized that there was no agreement in family members experiences of their near ones use of interpreters instead it depended on the situation and the individual perceptions differed as to whether the interpreter should interpret literally or not the type and mode of interpretation the interpreters professional role and the families roles when used as interpreters family members desired to adapt interpretation to the patients preferences the nature of interpretation and their own satisfaction with interpreting for near ones implications for nursing practice healthcare professionals need to be aware of different family members views about interpreting literally and objectively it is vital in individual care planning to provide information about the patients right to an interpreter and to ascertain individual preferences nurses need to organize a good interpretation situation with the patients active involvement and choose the appropriate interpreter according to the nature of the interpretation the patients preference and family members satisfaction with interpretation for their near ones healthcare professionals also need to be able to cooperate with members of the patients social network to ensure communication and retain autonomy in patientcentred and highquality healthcare

the aim was to explore adults experiences of their family members use of interpreters in healthcare encounters background language barriers are a major hindrance for migrants to receive appropriate healthcare in a foreign country family members often need support in care of migrant patients no previous studies focusing on adult family members experiences of the use of interpreters in healthcare have been found method a purposive sample of 10 adult family members with experiences of the use of interpreters in healthcare encounters data were collected between may and september 2009 by focusgroup interviews and analysed with qualitative analysis according to a method described for focus groups findings three categories emerged from the analysis 1 experiences of the use of professional interpreters 2 experiences of being used as an interpreter and 3 experiences of what needs to be improved when using interpreters the main findings showed no agreement in family members experiences interpretation should be individually and situationally adapted however when family members acted as interpreters their role was to give both practical and emotional support and this led to both positive and negative emotions use of simple language better collaboration in the healthcare organization and developing the interpreters professional attitude could improve the use of professional interpreters the type of interpreter mode of interpretation and patients preferences should be considered in the interpretation situation in order to achieve highquality healthcare healthcare professionals need to organize a good interpretation situation casebycase choose the appropriate interpreters with the patient in focus and cooperate with members of the patients social network

introduction globally breast cancer is now the leading cause of cancer accounting for 117 of 23 million new cancer cases 1 in 2020 it accounts 7 of 99 million all cancer deaths annually and the second leading cause of all oncological deaths 1 in the recent decades while there has been a decline in stomach cervical and penile cancer the incidence of breast colorectal and prostate cancer has been rising 2 by 2040 there would be three million new breast cancer cases diagnosed annually 3 the prevalence incidence and mortality from breast cancer varies enormously within and between the countries 1 these variations may be attributed to a set of reproductive metabolic lifestyle and environmental and occupational factors 4 5 6 7 8 9 10 besides advancement of medical technology availability and accessibility to cancer screening and treatment have increased the diagnosis of this disease and its burden in lowand middle income countries 11 deaths due to breast cancer has long term consequences on growth and development of children and social wellbeing of families as mother spouse or daughter 12 breast cancer and its treatment deteriorate the physical mental and functional health of the patient 1314 the fiveyear survival of patients with breast cancer varies from 87 in united states 84 in china 83 in sweden 62 in iran 49 in malaysia and 44 in uganda 15 16 17 18 19 20 21 comorbidity depression among patients with breast cancer is very common including mild depression 22 overall cancer patients have a lower quality of life literature document strong socioeconomic gradient of breast cancer screening prevalence survival and treatment discontinuation the breast cancer screening and prevalence are lower among women belonging to low socioeconomic status in lmics 2324 however the risk of mortality from breast cancer is high among women belonging to low ses 1725 the fiveyear survival rate of women belonging to poor ses was 786 compared to 838 for high ses 17 racial differences in survival of breast cancer are also large 26 treatment discontinuation is one of the major factors that affect the span of treatment and disease progression it is often associated with symptoms exacerbation relapse comorbidity death and higher economic burden at later stage 27 financial crisis due to high outofpocket expenditure for treatment of breast cancer is the major reason for treatment discontinuation 28 women in india are at a disadvantage not only due to the high morbidity but also due to familial neglect of health care 29 the disease burden due to breast cancer in india is higher than the world average in 2020 india with 178361 new cases and 90408 deaths accounting for 13 of global mortality due to breast cancer only 130 among women in india breast cancer accounts 135 new cancer cases and 106 of cancer related mortality 30 many of the breast cancer mortality are premature and could have been saved with timely screening and medications 3132 the agestandardized incidence rate of cancer among indian females in 2018 was 90 per 100000 females per year similar to males 31 studies suggest that rising burden of breast cancer in the younger ages needs special focus in terms of reduction in treatment cost quality management along with improved referral pathway and financial security against the disease the discontinuation of breast cancer is important as cancer patients often come from outside of the state to get treatment it primarily affect women in working and reproductive age group the mortality level is high and there has been rise in risk factors of breast cancer the economic and social loss due to the disease is numerous to women mother children and family and also to the nation to our knowledge no scientific study on treatment discontinuation of patients with breast cancer examined in indian context in this context this paper examines the socioeconomic variation in treatment discontinuation of the patients with breast cancer in a tertiary health care centre in india data methods study design the study was a prospective noninterventional study study site the study was conducted jointly by the tata memorial centre mumbai india and the international institute for population sciences mumbai india tmc is one of the countrys largest and the oldest public sector tertiary cancer hospital and registers more than 50000 patients annually and iips is the leading demographic research and training center in the country the study was designed by tmc and iips and the data collection was carried out at tmc sample design tmc is one of the leading public sector tertiary care health center in india located in mumbai and dedicated to cancer treatment and research patients with cancer comes from all over the country and are often referred from other health centres on the country the total number of patients registered for breast cancer treatment at tmc was 4518 in 2019 2505 in 2020 and 3588 in 2021 we have selected a total of 500 patients that account for about 8 of the breast cancer patients registered for treatment at tmc between june 2019 and march 2022 our selection of 500 cases is guided by the fact that it provides enough power for disaggregated analyses of the economic condition of breast cancer patients and captures those treated under private and general category according to who protocol 200 samples is the minimum requirement for any health study 33 assuming 79 of catastrophic health spending by cancer households in india 34 and 95 confidence interval with 5 margin of error a 255 sample size would require to estimate treatmentrelated cost a similar procedure has been adopted in a lancet study on catastrophic expenditure and treatment attrition among colorectal cancer patients in india 35 our sample size is about twice higher than the required sample on average 12 to 15 newly invasive breast cancer patients were registered every day in the hospital and 4 to 5 patients were selected randomly the data was collected on working days only there was disruption in data collection during march 2020march 2021 due to covid19 restriction sample collection two separate questionnaires were developed and canvassed a household questionnaire and an individual questionnaire the household questionnaire covered demographic and socioeconomic characteristics of a participants household at the time of registration at tmc the individual questionnaire collected information on treatment history about current breast cancer diagnosis treatment history at tmc detailed record of the direct and indirect health expenditure for each hospital visits during the entire course of treatment comorbidities and selfrated health status of patients data collection was carried out by three medical social workers appointed in the project on daily basis the data were collected and stored at tmc server and validated by principal investigators and researchers on weekly basis the data collection began from june 2019 and followup was continued till march 2022 although during the planning of the study it was decided to collect the baseline sample within one year period but due to covid19 pandemic less patients were visited in the facility and hence the data collection timing shoots up to two years data were collected for base line and selected questions during each visit of the treatment at the end of treatment and six months after completion of treatment often the data collection was contingent on the visit of patients for the services inclusion and exclusion criteria the following inclusion criteria was set for data collection • pathologically confirmed new invasive female breast cancer cases • intending to receive entire treatment at tmc • age 18 years • patients willing to provide the information the exclusion criteria was as follows • inability to follow up • recurrent or progressive breast cancer cases follow up each participant has been followed from their date of registration to their date of treatment conclusion or treatment discontinuation the date of registration is termed as baseline whereas date of conclusion is termed as endline an active follow up mechanism was set up to collect information from each of the participant or their accompanying person whenever they visit the facility censoring we censored the data for 71 patients who had died or discontinued treatment for various reasons and not concluded in study time period the discontinued patients were categorized in three major groups discontinued due to death discontinued due to financial crisis and other reasons survival time survival time is calculated at the time between the date of registration of the patients at tmc and conclusion date or date of last treatment just before the discontinuation other variables a set of sociodemographic economic and households variables were used in this study these are age of the patient level of education marital status financial dependent health insurance coverage patients category family type religion major source of income household income household size place of residence state of residence distance from native place age at diagnosis of cancer is the difference between date of cancer diagnosis and date of birth of the patient statistical analysis descriptive statistics kaplanmeier survival estimation and cox proportional hazard model were used to examine the socioeconomic profile and correlates of treatment discontinuation among the patients kaplanmeier survival estimated the probability of discontinuation of breast cancer treatment each survival estimate used number of days under treatment at tmc as measure of time and whether patients discontinued as the final event the km estimate of survival time s is given by where n i is the number of patients observed at time t i and d i is the number of patients discontinued at time t i coxproportional hazard model was used to examine the socioeconomic correlates of patients treatment discontinuation at tmc the model estimates the risk of a patient to discontinue the treatment at time t given that the patient continued treatment up to time the final event of interest for each of the patient was status of their treatment within the given span of time the cox proportional hazard model is specified by where h i is the hazard function of discontinued patients at time t i to the patients who continued the treatment given the specified set of independent variables denoted as x i and β i is the parameters to be estimated ethical consideration the study obtained approval from the institutional ethics committee of the tmc and was registered on the clinical trial registry of india with ctri no ctri201907020142 on 10072019 results table 1 shows the sample characteristics of 500 patients with breast cancer undergoing treatment at tmc about 56 were under 30 years 574 were between 3150 years and 37 were 50 years and older the youngest age at diagnosis was as early as 21 years the mean years of schooling were 7 years and over fourfifths of the patients were married and financially dependent only 9 of the patients were covered by any health insurance scheme majority of the patients were registered under the general category to get treatment at tmc the majority of the patients belonged to the hindu religion and 52 were from the unreserved social class more than half of the patients were from outside of the state of maharashtra on average a patient travelled 1044 kms to get breast cancer treatment at tmc half of the patients were inhabitants of rural areas and 16 resided in urban slums of the 500 patients registered for treatment 429 patients had concluded their treatment at tmc the socioeconomic variation of the concluded patients almost remains the same as of the baseline figure 1 presents the flow chart of the patients discontinued and the reason of discontinuation about 71 patients discontinued their treatment among them 24 patients discontinued due to financial reason 26 due to deaths and 21 for other reason a total 429 patients had completed the treatment s k i 1 ni hi h0 exp table 2 presents the socioeconomic variation of the patients who discontinued treatment at tmc overall 142 of the patients were discontinued the treatment and deaths being the major cause of treatment discontinuation followed by financial crisis a higher percentage of the patients discontinued treatment were over 46 years never attended schooling not currently married treated under general or nonchargeable category diagnosed at stage iv of cancer had atleast one comorbidity and labour as major source of household income among those who discontinued treatment death accounts the largest share followed by financial reason the highest discontinuation due to financial reason were reported by the households with selfemployment followed by service and pension the higher discontinution due to death were reported by households with agricultural income followed by selfemployed discontinution due to financial reason was higher in urban areas while a at tmc the patients are classified as a general b private and c nonchargeable during the registration a patient registers either as a general or as a private patient depending on their ability to pay for treatment the cost of treatment for private patient category is much higher while the waiting time for availing treatment is much lower than their other counterpart discontinued treatment due to death was higher in rural areas figure 2 shows the kaplanmeier survival curve for the discontinued patients at tmc with overall survival rate is 858 patients who sought treatment under general or nonchargeable category had higher probability of discontinuing treatment than the private patients table 3 presents the hazard rates of discontinued patients by socioeconomic variables the estimated hazard shows that compared to the patients aged 45 years and below patients aged 46 years and above were more likely to discontinue treatment similarly patients who are not currently married had advanced stage of cancer had at least one comorbidity belonged to household size 7 and more and from maharashtra were more likely to discontinue treatment at tmc on the other hand patients with education level up to secondary and higher secondary or above were significantly less likely to discontinue the treatment discussion the rising prevalence of breast cancer is a major public health challenge in india there is dearth of comprehensive studies on socioeconomic and health condition of the patients with breast cancer seeking active oncological treatment and reasons for discontinuation we document the sociodemographic and economic profile of treatment discontinuation of breast cancer patients undergoing active cancer treatment the followings are the salient findings of the study about threefifths of the patients with breast cancer were under 50 years and the median age was 47 years this is suggestive that majority of the patients are in child bearing age and a significant proportion are in prime child bearing ages cancer to young mothers has adverse implications on child breast feeding rearing and caring of children besides over 90 are under 60 years of age suggesting that it may adversely reduce the work potential these findings are consistent with literature suggesting that the average age is low compared to developed countries more than 50 years in usa and europe 3637 we found about 14 discontinued treatment and the discontinuation was significantly higher among poorer women less educated and older women the discontinuation is primarily due to three reasons death financial crisis and defaulted during twoyear period 5 discontinued due to financial crisis and 5 died the survival rate was little higher as it was for twoyear reference studies suggest fiveyear survival rate ranging from 20 to 80 in india 21 the discontinuation of services due to death was higher among poor less educated and those in higher stage iiiiv of breast cancer studies suggest that half of the incidence and mortality of breast cancer is under 50 years in countries with a lower human development index 38 39 40 discontinuation of services due to financial reason were also higher among poor and less educated our findings suggests that the economic condition of majority of the patients with breast cancer was poor over 86 patients were treated as general or nonchargeable cases moreover during the covid19 pandemic the financial situation of most of the patients worsened significantly 41 our study also showed that more than half of the patients travelled from outside of the state distance is an important factor for cancer patients to continue treatment as they have to make frequent visits to the hospital during the course of treatment 42 studies also suggest that distance is negatively associated with the stage of diagnosis appropriate treatment and outcomes and quality of life 41 43 44 45 distance majorly contributes to the increased cost of travel and arranging accommodation close to the hospital the effect is more prominent for patients coming from rural areas cancer treatment facilities in india are limited in number and mostly metrocity centric the socially and economically disadvantaged population from rural areas faces numerous challenges in access to cancer treatment patients from remote and rural areas travel long distances for treatment which has a significant effect on their economic and health status health insurance plays a significant role in reducing financial burden we found lower coverage of insurance among the patients compared to entire population 46 in 2018 the government of india launched a comprehensive cashless health insurance scheme ayushman bharat for the bottom 40 of the population providing ₹500000 per family per year for health care expenditure this scheme has the potential to deliver quality health care for cancer by linking reimbursement directly to the evidencebased management guidelines recommended by indias national cancer grid which is important for a disease where affordability of treatment is a big issue 4748 according to a recent study there are 1575 hospitals in india where cancer treatment costs can be reimbursed through this scheme however only 438 hospitals including tmc have multimodality treatment facilities 47 we have some limitations of this study first this study is limited to patients treated at a single tertiary care hospital and may not be generalised though tmc cater services to all economic group we believe that majority patients treated at tmc are poor second we have not followed up patients for longer duration the breast cancer associated mortality would have been higher in fiveyear period third some of the patients who left discontinued treatment could not be contacted fourth the study period also coincides with the covid19 pandemic which might affect the economic condition of the households of the study participants conclusions our study called for free screening of breast cancer for socially and economically disadvantageous women in public health centres and strengthening referral mechanism for early treatment of the patients with breast cancer the health infrastructure for female cancer screening and treatment is inadequate and even nonexistent in many states of india public investment on cancer treatment in terms of providing financial safety net will benefit women and reduce the burden of the disease health insurance should not only reduce the outofpocket burden for the treatment but should encourage the patients to continue their planned treatment in respective facilities abbreviations funding this research was funded by an extramural grant from the womens cancer initiative and nag foundation and intramural grant from iips the content of the article is solely the responsibility of the authors and does not necessarily represent the views of the funders the funders had no role in study design data collection and analysis decision to publish or preparation of the manuscript competing interests the authors declare 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

the study examined the socioeconomic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisiswe used primary data of 500 patients with breast cancer sought treatment at indias one of the largest cancer hospital in mumbai between june 2019 and march 2022 this study is registered on the clinical trial registry of india ctri201907020142 kaplanmeier method and coxhazard regression model were used to calculate the probability of treatment discontinuationof the 500 patients threefifths were under 50 years with the median age being 46 years more than half of the patients were from outside of the state and had travelled an average distance of 1044 kms to get treatment the majority of the patients were poor with an average household income of inr15551 a total of 71 14 patients out of 500 had discontinued their treatment about 52 of the patients died and 48 of them discontinued treatment due to financial crisis over onefourth of all deaths were reported among stage iv patients 25 patients who did not have any health insurance never attended school cancer stage iv had a higher percentage of treatment discontinuation due to financial crisis hazard of discontinuation was lower for patients with secondary hr048 95 ci 027084 and higher secondary education hr 042 95 ci 019092 patients from rural area hr 079 95 ci 042150 treated under general or nonchargeable category hr 060 95 ci022160 while it was higher for the stage iv patients hr 361 95 ci 158829 integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality provisioning of free treatment for poor patients may reduce discontinuation of treatment

introduction in recent years the deep involvement of parents in their childrens education has become a social phenomenon that has attracted much attention and parents educational involvement behaviour has become a major issue that needs to be studied in depth by academics family education is the foundation of all education and has a significant impact on educational justice and the quality of future citizens earlychildhood highquality parental investment is consistently linked to lifelong good mental and physical health similarly the education of their children deserves sustained attention because it is an important component of the nations human capital and the familys investment in their childrens education will directly determine their childrens educational status and govern their childrens access to resources in the education process which in turn will have a critical impact on their ultimate educational level and attainment their childrens future development and life trajectory are influenced the main body of investment in education consists of two parts the family and the government public investment by the government has an integral impact on educational vol 12 issue 3 e issn 22266348 to link this article doi106007ijarpedv12i318566 published online 17 september 2023 equity in society the governments of australia japan and brazil have been promoting education in their countries by increasing their fiscal spending on education the chinese government promotes educational equity by regulating taxes expanding access to college establishing an equitable human capital transmission mechanism and investment system and increasing thirdparty education funding for government school societies to provide a favourable investment environment for family parents to invest in education at present chinas economy is facing a stage of development and social transformation and chinese residents concept of education is quite different from before chinese parents are fully aware of the functional role of education in individual development and social development and their demand for education has gradually emerged educational issues have become the most concerned most direct and most realistic prayer for the interests of rural chinese parents the governments investment in education has increased significantly in recent years but family education expenditure is still the main pillar of education expenditure in the past ten years the average annual growth rate of household education expenditure in china has been around 107 in 2021 the national general public budget for education was 5377 billion an increase of 517 over the previous year in the same calibre among them the central government spent 8055 billion on education an increase of 366 over the previous year one of the crucial aspects of individual financial planning is the planning of investments which entails creating several investment strategies the cost of financing an investors estimation of future profit potential and historical profit experiences all have an impact on the choice to invest there is a close relationship between educational investment decisions and educational investment and the quality and correctness of decisions can determine the effectiveness of educational investment and the direction of educational development studying the factors that influence educational decisionmaking can help parents provide targeted rational l and effective educational investment decisions that can contribute to the continuous improvement and development of education literature review it is clear from the literature that parents investment in their childrens education can be influenced by a variety of factors according to sharma there is a significant relationship between investment decisions and the demographic profile of the respondent including gender age educational attainment and socioeconomic class in their study celhay gallegos found that in lowincome families the investment in education that children receive is influenced by parents beliefs and material investments demographic factors of investors such as gender age and education have much significance in the investment decision process investment decisions based on gender male participants were found to be more aware of the increased availability of negative emotions following suboptimal financial decisions than female participants based on yuliana kholilah pls analysis of lq45 companies listed on the indonesian stock exchange for the years 20142017 the findings indicated that the presence of a female chief executive officer can mediate the relationship between investment decisions and the value of the company gender diversity influences differences in levels of optimism selfassurance and risk preferences the feminine nature of women affects the quality of investment decisionmaking and this has an effect on the enhancement of a companys value females have been found to be more conservative in financial markets than males which led chen to conclude that females were more riskaverse than males due to individual characteristics and systematic factors other studies also contradicted the experimental findings exposing that there were no significant differences between men and women susanto et al who explained that women were exposed to fewer risks than males and that their approaches were distinct supported the research according to xu using survey data on migrant workers households from the china labor force dynamics survey the number of children and their personality traits influence fathers investment in their childrens education the number of children was significantly and negatively correlated with childrens education level with each additional child in the household reducing the number of years of education in the sample by 163 the increase in the number of siblings was more detrimental to the educational attainment of children than the increase in the number of sisters in terms of birth generation the increase in the number of children is less conducive to the increase in the educational attainment of the younger generation of children lotto supports that employed families are more likely to make prudent financial decisions because the majority of them are believed to have access to official financial literacy education due to their higher levels of education furnham cheng demonstrates that intelligent people from more affluent social backgrounds are more likely to have higher levels of education and occupation as well as higher incomes and thus make more active investment decisions elizabeth et al are of the opinion that demographic factors such as profession have an effect on the behavioural biases that investors have namely disposition bias made the observation that investors with jobs unrelated to finance tend to have less selfassurance than those with jobs in the financial industry comparing investors with nonfinance employment to investors with finance jobs in addition research shows that investors in business class are more susceptible to the effect of behavioural biases than salaried investors are the researchers discovered that a persons line of work has a more significant association with overconfidence optimism and temperament bias than the herding bias households with different incomes have different considerations regarding investment decisions yusnita et al during the period of march to may 2021 primary data were collected through the distribution of questionnaires using the snowball sampling technique and as many as 247 samples were collected using crosstabs analysis and multiple regression analyses the data were analyzed the findings of the multiple regression test indicated that both individual income and financial literacy had a positive and statistically significant impact on the investment decisions of tasikmalayans there is a significant influence of variable income on financial behaviour as well as a significant effect of variable lifestyle and the factor of financial knowledge income and lifestyle all have significant effects on financial behaviour thus influencing investment decisions bonneau grobon present new stylized data regarding the inequality of access to higher education in france based on parental income on average a 10percentile increase in parental income is associated with a 56percentagepoint increase in the proportion of children with access to postsecondary education parental education had a significant positive effect on childrens educational attainment and the positive effect was higher for mothers than for fathers wagner walstad supports that employed families are more likely to make prudent financial decisions because the majority of them are believed to have access to official financial literacy instruction due to their higher levels of education a persons level of knowledge influences their ability to make investment decisions it can be said that the more education a person has the more cautious they will be when deciding to invest particularly in the context of managing and spending money based on the benefits expecting an average return on average financial risk was negatively influenced by marital and income status this was studied by distinguishing married men from married women single males were found to have the highest risk tolerance and highest willingness to invest followed by married males followed by unmarried females and finally married females examine the functions of marital status and gender in investment decisions by analyzing data on asset allocation in individual retirement accounts it is discovered that there is a significant difference between married and single households in their allocation decisions for hazardous assets the influence of subjective norm variables on the investment decisions of investors may be moderated by social demography moderating variables which include age and investing experience however social demography factors such as gender profession and education are not moderating investors objective norm variables senda et al found that among the demographic factors age income and investment experience influence investment decisions through the chisquare test methodology this study is a quantitative surveybased investigation according to creswell the survey is a research method used in the social sciences to characterize the attitudes ideas beliefs perceptions behaviours or attributes of a sample utilizing the powerful precise and widely accepted instruments of statistics for measurement categorization and analysis quantitative methods related to literature express aspects or qualities of literature as mathematically as possible the researchers determined the sample by simple random sampling of 437 parents of different age groups from shandong china the demographic information of the participants is shown in table 1 results parental investment decisions in children were studied based on variables such as parental gender number of children occupation income education and age techniques including the arithmetic mean standard deviation independent test and oneway analysis of variance were used for the data to analyze it the ttest and analysis of variance were used to determine if there were statistically significant variances between two sets of data and between more than two groups a ttest was used to determine whether there were statistically significant differences in parents investment decisions about their childrens education based on their gender although cohens calculation is the one that is most often used to determine effect sizes there are other calculation techniques like hedges d and glasss that may also be found in the literature cohen suggests that the impact size be classified as weak if the d value is less than 02 medium if the d value is between 05 and 08 and large if the d value is more than 08 as can be seen in table 5 there is a statistically significant difference in parents education investment decisions about their children in terms of their gender the cohen effect value showing the size of the difference was 021 in the motor characteristics factor which also indicates that there is a statistically significant difference in the investment decisions of parents regarding their children by gender therefore it can be concluded that mothers investment decisions for their children are higher than fathers investment decisions for their children oneway analysis of variance was used to find out whether there were statistically significant differences in parents investment decisions regarding their children depending on the number of children occupation income education level marital status and age table 3 anova results by number of children table 3 shows that there is a statistically nonsignificant difference in parents investment decisions for their childrens education depending on the number of children table 4 shows that there is a statistically significant difference in parental education investment decisions for their children depending on the job therefore the difference in parents jobs has a significant effect on parents investment decisions about their childrens education parents whose occupation is farmer place more importance on investment decisions for their children and those whose occupation is government official place the least importance on investment decisions for their children 5 there is a statistically significant difference in parents investing choices for their kids based on their income therefore the parents investment choices for their childrens education are significantly influenced by the disparity in their income in contrast parents with earnings below 3000 pay the least attention to their childrens investing choices while parents with incomes between 3000 and 4000 pay the most there is a statistically significant difference between parents investment decisions for their offspring based on the level of education as shown in table 6 consequently the difference in educational attainment between parents has a substantial effect on parental investment decisions regarding their childrens education parents with secondary education are more influential in their childrens investment decisions whereas parents with no formal education are the least influential table 7 shows that there is a statistically significant difference in parents investment decisions for their children depending on their marital status thus parents marital status has a significant effect on parents investment decisions regarding their childrens education parents who are alone with their children place more emphasis on investment decisions for their children table 8 anova results by age table 8 shows that there is a statistically significant difference in parents investment decisions for their children depending on their age thus parental age has a significant effect on parents investment decisions regarding their childrens education in particular younger parents are more important in their childrens investment decisions and older parents invest less in their childrens education in comparison discussion it has been detected that parental investment decisions in children are related to the variables of parental gender parental occupation parental income parental education parental marital status and parental age there is research that supports that mothers and fathers make different decisions about their childrens investments due to their respective genders in terms of meeting their childrens investment needs showed that of the 1084 parents living in this area of iganga district in eastern uganda fathers willingness to pay for goods is lower for daughters but not for sons the coefficient for daughters is negative and significant indicating that fathers are 010 standard deviations less willing to pay for their daughters than their sons the coefficient for mothers with daughters is positive significant and similar in magnitude to the coefficient for daughters implying that the net effect of daughters on mothers is 0 also the article reports whether mothers spend the same on daughters and sons with the same pvalue similarly in serbian roma mothers also have a positive impact on childrens investment and for lowincome families the choice of the mothers investment level seems to be crucial for childrens educational investment is crucial it is seen that the influence of parents occupations on their childrens educational investment decisions is very important a study of national data for brazil linking multiple administrative data sets and taking an integrated approach to examine the impact on education and other key aspects of childrens lives found that parental occupation affects parents willingness to invest in their childrens education and that unemployed parents directly increase dropout rates by 15 percentage points anand discover that money and time investments in education are negatively correlated with the intensity of a parents occupational identity in the same vein the correlation between social class and occupation and saving and investment it is clear that occupation is one way of determining social class and incomefinancial status which is related to how much a person must save and invest beltran discovered that families with varying occupations have varying effects on their childrens investment decisions with the mothers occupation having the most significant impact different incomes also have a different impact on parents decisions to invest in education adil et al found from a study of korean households that individuals with low incomes are unable to make quality investment decisions when faced with investing conducted three sets of mediated analyses through a study using data from the 2014 consumer empowerment index survey of the korea consumer agency to verify that households in different income brackets in korea make different decisions about investments using the 20032017 consumer expenditure surveys orestes p hastings evaluates two candidate pathways the fact that may account for connections between familial relationships and financial investment in children in the united states these pathways are differences in economic resources and differences in longterm commitment hastings compares the differences between married cohabiting and single parents parents who are not married or who cohabit make less investment in their children than married parents income explains the full difference for single people but just a small portion of the difference for couples who cohabit which suggests that commitment and preference may play a role in the difference the yearly household income of the households who took part in this research fell somewhere between 300000 and 500000 in british pounds it was discovered that different income classes in the united kingdom have different school choices and differing attitudes toward investing in their childrens education with the mothers attitude often dictating the familys approach through her research lippi nd discovered that parental education affects their propensity to invest in their offspring in the study the results indicate that mothers with higher education appear to negatively influence their daughters financial behaviour while fathers with higher education degrees appear to positively influence their sons financial behaviour in the context of a 10fold expansion of chinas higher education sector since 1999 investigates the role of parental input in university admission using logit regression they determine that an increase in a parents level of education considerably increases their childs likelihood of enrolling in college and there is a difference in the level of educational attention and the level of investment received a study by liu yang found that lesseducated parents had higher educational expectations than moreeducated parents the findings of the study indicate that investors require training programs workshops and seminars that improve their financial literacy and financial knowledge allowing them to surmount behavioural biases when making investment decisions those with a higher level of education are more inclined to invest actively using the 20032017 consumer expenditure surveys hastings schneider study disparities in parental financial investments in child care education and enrichment activities depending on the family structure of the household we analyze two alternative paths that may explain correlations between family composition and financial investment in kids variations in disposable income as well as variations in longterm commitment they evaluate the differences that exist between married cohabiting and single parents parents who are not married or who cohabit make less investment in their children than married parents several empirical studies investigate disparities in time spent with children by family structure employed social demography moderating variables on 400 respondents in the greater jakarta region the test results indicate that subjective norms variables have no significant positive effect on willingness to invest but can be moderated by sociodemographic variables like age and investment experience based on the cgss2006 data gu et al found that families with complete families have a more complete investment structure for their children and parents are more willing to invest in their children while singleparent families rely more on grandparents to care for and invest in their children alani hawas found that the rural family environment and the marital status of parents can influence the learning environment of children directly affecting their performance conclusion in this study researchers examined whether gender occupation income education age and marital status had significant effects on demographic factors and their impact on chinese parents decisions to invest in their childrens education these differences reveal the subjective motivations that influence chinese families decisions regarding education investment the findings of this study serve as a reference for future research on chinese parents investment behaviour toward their childrens education the goal of this study was to examine the level of variance among various demographic parameters and their impact on chinese parents decisions regarding educational investment the statistical results indicated that parents gender occupation income education age and marital status significantly influenced chinese families investment decisions in their childrens education however the number of children did not influence chinese parents decisions regarding educational investment this study aims to examine these demographic factors to help researchers and policymakers gain insight into the educational priorities and values of chinese parents this allows us to demonstrate how various demographic factors influence the understanding of the importance of education and the allocation of educational resources among chinese parents understanding how demographics influence parental decisions can reveal the barriers and challenges faced by different types of chinese parents when making decisions about investing in their childrens education

investment in their childrens education is one of the most tangible ways through which chinese parents demonstrate their interest in their childrens academic lives this investment behaviour is almost inevitable for chinese parents this study aims to investigate the demographic characteristics that influence the educational investment choices made by chinese parents a sample of 437 rural chinese families was randomly selected for the study data were collected both offline and online and analyzed using ttests and anova with ibm spss version 26 software the results revealed that factors such as parental gender occupation income education marital status and age significantly impacted the educational investment choices of chinese parents within the sample however the number of children did not have an influence on the educational investment decisions made by chinese parents the researchers specifically focused on parents living in rural regions these findings provide a crucial foundation for ongoing research on the educational investment behaviour of rural chinese parents and have implications for studying the variable nature of educational resources in chinese society

introduction the first victims of covid19 were older people which raised distinction in the way of treating them and highlighted the ageism present in societies ageism 1 manifests itself when one age group addresses another based on stereotypes created to discriminate against people based on their chronological age 2 whether due to ideological aspects based on characteristics attributed to an age group or practicalbehavioral aspectsthrough judgments beliefs and attitudes in the context of the pandemic this phenomenon became evident in the treatment given to older people over 60 years old in the association with stereotypesnegative images and deterioration of physical and cognitivebehavioral capacities 3 prevention procedures were used to justify attitudes of depreciation and discriminationstigmatization of older people 45 it is important to emphasize that stigma is a markimpression that is carried throughout life established by society to categorize people and the attributes considered as common and natural for members of each of these categories 6 the stigma that permeates old ageaging was boosted during the pandemic when prejudiced attitudes made some people think that the pandemic was an older peoples problem and only the older people should be in social isolation 7 since old age is associated with economic spending social burden and symbol of unproductivity 8 this stigma also arises as a consequence of the nonenforcement of laws that protect and guarantee the rights of brazilian older people 9 this problem disregarded a history of epidemic outbreaks that occurred over the centuries and showed that the best preventive measures for the advancement of highly contagious pathogens were vaccination quarantine and lockdown 10 of the entire population not just risk groups during social distancing it was necessary to seek means that would serve as a bridge between people and the new knowledge that emerged about the disease as well as to achieve forms of socialization during distancing for this it was possible to use the internet which despite having negative aspects in its use such as the consumption of untrue content and excessive time in front of the screen which cause concerns repercussions on wellbeing exhaustion and sleep disturbance is of great importance for streamlining communication and disseminating information social networks are the methods of choice for posting common activities especially the youtube™ platform due to the ease of sharing videos capable of expressing opinions transmitting knowledge spreading news and being used as a source of information on healthrelated matters 11 in view of this videos on the youtube™ platform gained national repercussion and visibility raising relevant debates and reinforcing the importance of this study especially by demonstrating ageism based on narrated situations and its repercussions for the older population in addition it is important to demonstrate how these narratives relate to the theory of stigma 6 with a view to strengthening the fight against the problem in this context the objective of this article was to analyze the repercussions of ageism directed at older people during covid19 through the content available on the youtube™ platform method exploratory study with a netnographic qualitative approach developed based on the methodological rigor criteria of the coreq checklist which has been frequently used for ethnographic approaches applied to the study of cultures and online communities within consumer and marketing research netnography is distinguished from other types of qualitative research on the internet by presenting in a single term a set of guidelines for carrying out computermediated ethnography and its integration with other forms of cultural research 12 the youtube™ video sharing site has the virtual address this investigation was not submitted to the research ethics committee for consideration because it was the use of publicly accessible data as established by the ethical standards of the platform itself as well as by resolution 5102016 of the brazilian health council 13 and by the federal law 125272011 14 videos were searched based on the following inclusion criteria having been posted from march 20 2020 to may 2021 address content related to ageism and covid19 be available in portuguese english or spanish having been presented by older people whether they are narrating their own experiences andor those of third parties videos with reproduction difficulties with duplicate content or of dubious character as well as those that did not contain content referring to the repercussions of ageism on the covid19 pandemic the selection and data collection took place in february 2022 through the keywords ageism ageism in the pandemic ageism in covid19 prejudice against older people in the pandemic ageism in the pandemic age discrimination stereotype gerontophobia old age ageism old phobia old age stigma prejudice and its correspondents in portuguese and spanish these keywords were combined to create the expressions ageísmo pandemia ageísmo covid19 preconceito contra idosos na pandemia preconceito de idade na pandemia gerontofobia pandemia etarismo pandemia velhofobia pandemia idosismo pandemia violência idoso pandemia ageism pandemic old age pandemic gerontophobia pandemic ageism covid19 edadismo pandemia discriminación por edad pandemia e discriminación por edad covid19 the content search and selection process was carried out by a researcher and is detailed in figure 1 the information from the final corpus of the videos was organized in a table in microsoft excel and identified by title access link channel and date of posting and duration data analysis was guided by an indepth study of the videos in which an attempt was made to understand the reports narrated individually through bardins 15 thematic content analysis which focuses on qualifying the subjects experiences as well as their perceptions about an object and its phenomena allowing the discovery of social processes still little known about specific groups and the adoption of new approaches in addition to the revision and creation of new concepts and categories during the investigation 15 in the preanalysis the materials to be used and the keywords were chosen the videos were searched and the material was selected by watching all the videos it was possible to know the content of each one of them to obtain the first impressions and to constitute the corpus of the study of relevance for the research based on the inclusion and exclusion criteria in order to explore the material all the content of the videos was transcribed into text format in a word file then the material was read and possible errors were corrected videos in english and spanish have been translated into portuguese subsequently the typed material was read exhaustively and the contents were codified by cutting out the recording units related to the theme of the repercussions of ageism in the covid19 pandemic this phase was validated by two researchers doctor and master with expertise in the subject and in the study of the theory of stigma 6 for the interpretation of the material the recording units were grouped by similarities and differences generating the categorization whose interpretation was performed based on goffmans theory of stigma 6 which discusses how society establishes means to categorize people and attributes considered common and natural for the members of these categories as certain marks or characteristics that stigmatize the subjects and as derogatory attributes that can make the subjects react or accept the conditions that are imposed on them as normal or abnormal such theory helps to identify central features of stigmatized peoples life situations and how they affect social and personal identity each video was identified with a number from one to nine and each excerpt relevant to the research was identified with the initials of the person who expressed themselves in the video with the expression without identification being used for a person whose name was not revealed results the selected videos are characterized in chart 1 based on the categories prepandemic expressions of ageism expressions of ageism during the pandemic and feelings and attitudes of the older person towards the repercussions of ageism data analysis revealed content related to ageism that was culturally accepted albeit veiled directed at older people even before the pandemic the content of the videos presented findings that demonstrate ageism in the prepandemic period and the subsequent addition of new ageist elements strengthened from the health political socioeconomic and cultural crises the repercussions of ageism generated feelings and revealed attitudes of prejudice and discrimination experienced by the older population discussion the netnographic findings made it possible to verify the configuration of the ageist manifestation that stigmatizes older people by excluding this population from digital learning spaces disregarding the ways of being an older person and disrespecting the right to have access to public transport thus the labeling and stereotype of sick weak burdensome unproductive disposable contributed to mistreatmentviolence marking as subject of risk disrespect for the right of priority in vaccination and the outbreak of negative feelings and attitudes to face the problem of ageism the establishment of normative attributes to categorize people in what is considered common and natural imputes estrangement and deterioration of social identity 10 making it different the installation of these normative attributes can revert to stigma what is negative about the moral status of a person in relation to another such normative determination imposes social categories of forced framingfitting permeated by stereotypes 11 about the older person which implies prejudicediscrimination the exclusion derived from stigma surprised men diagnosed with covid19 marked by class and gender privileges not used to being demoted in interactions when compared to other groups 16 exclusionary attitudes can be implemented against older people reverting to ageism 17 in this sense stereotyped expressions about the perceptions one has about other people based on age are aggravated by the intersection of social markers of discrimination throughout life when the stigmatized person starts to have the same beliefs about his identity as those who stigmatizes in order to avoid negative experiences and feelings related to the deterioration of the social image many stigmatized older people can assume behaviorsattitudespractices in advance to respond andor create barriers and defend themselves against ageism through withdrawal social isolation or even aggressiveness in view of this it is essential to carry out actions that promote the selfcare of the older person in order to avoid biopsychosocial deficits 18 interinstitutional strategies aimed at advocating and supporting the older population to know recognize and establish effective measures to face ageism and its repercussions the absence of effective responses andor coping strategies includes not only those that can be taken by those who suffer stigmatization but those that could be carried out by the entire apparatus of public devices which makes many older people ignore their own wills become depersonalized and abdicate their rights favoring the growth of ageism as an inappropriate but common practice however there was a loss of hope meaningpurpose in life the imposition of marks of asexuality mental illness and suicide as they judged themselves to be inappropriate to live collectively in old age 4 chart 4 fragments of the feelings and attitudes of older people towards ageism on the youtube™ platform feira de santana bahia brazil 2022 attitudes we seniors are disciplined we take care of ourselves we find different ways of living we make handicrafts or masks we cook we practice gardening we read and we connect with our emotions to face discrimination source own authors the labeling of older people in the covid19 pandemic was another significant finding in our study it should be noted that the ageist label imputes the idea of being incapable favors discrimination 19 limits opportunities and reverberates in a feeling of indignation at the impossibility of learning to use technology especially in the period of greater social isolation and lockdown despite having the intellectual capacity to do so and showing a strong advance in the number of older people with internet access especially in relation to the use of smartphones 20 another important finding concerns the derogatory images and attitudes of life in old age which constitute the pillar of support of ageism 4 and are manifested through expressions of sick and burdensome to the health system which highlights a serious social problem installed which can put the lives of the older population at risk as seen in countries like spain and italy which have established genocidal measures against older people in nursing homes 21 in some countries protocols explicitly used age as a criterion for the allocation and nonallocation of treatment with an age limit for access to intensive care and the use of ventilators 22 the establishment of purely age criteria strengthens labels that are harmful to health which directly compromise access to health services and interfere with the quality of health care 23 this bad practice through decisionmaking on whether or not to maintain the life that is breathing with the help of a mechanical ventilator in the occupation of an intensive care unit bed continues to be perverse and takes many lives as it takes into account mainly the age of the subject 17 restrictions based only on chronological age reinforce discrimination and reduce human life to arbitrary numbers which disregard values and choices thus despite ethical recommendations aiming at fairer resource allocation protocols it is still essential to educate health professionals to recognize institutional ageism 24 negligence in care and the occurrence of physicalpsychological violence in spaces of protection such as long term institutions were not exempt from suffering from ageism both managers and professionals who work in these spaces are able to perceive the configuration of violence in some particular situations violence before institutionalization motivating reason for sheltering institutionalization as an act of violence when the family disregards the older persons autonomy regarding their desire to go to the institution or not or when they abandon the older person and absence limitation of public policies lack of state actions little effectiveness of existing legislation 25 in view of this the institutionalized older population that already suffered from the effects of isolation and social negligence 26 saw itself as a victim of discrimination through the media discourse that revealed exclusionary speeches of social nonacceptance provoking identity shame selfhatred selfdeprecation and selfisolation 10 if on the one hand there was a narrative that the older population was the most affected by covid19 3 on the other hand there was the representation of the vulnerable subject dangerous and disposable becoming the other of the pandemic in this sense older people would be the only ones capable of dying from the disease or transmitting it an idea that was perpetuated for a long period of disease dissemination 4 as a consequence there was a lack of priority in investments in the health of these people 4 which led to the curtailment of the right and opportunity of the older population to benefit from therapeutic measures in this sense it is urgent to insert the principles of geriatricsgerontology as a strategy to face ageism clinicalfunctional assessment implementation of individualized care for older peoplefamilies combating the stigma of old age aging and ageism 27 and investment in mental health literacy to recognize specific disorders and psychological distress and seek professional help 28 combating ageism involves directing care to older people in terms of their physical mental and social health needs evaluate the specificities of the subject its context autonomy and independence fulfillment of rights and duties and mainly respect for the individualities limitations and potentialities of each subject it also means establishing a social education pact as a pillar of intergenerational reconnection respect and empathy the contributions of this study to geriatrics gerontology are highlighting the need to disseminate knowledge about ageism the repercussions and ways to combat this phenomenon which although old was originally evidenced in 1969 by the psychiatrist and gerontologist butler 29 and strengthened during the covid19 pandemic in addition it encourages the developmentimplementation of focal public policies capable of including older people and respecting their rights the limitations of the study are search for videos on only one platform and the time frame since due to the fact that the pandemic was not over by the end of this study other videos continue to be published on the platform in order to deepen these phenomena future studies are needed based on primary data which listen to older people about the repercussions of ageism the implications for the geriatricgerontological practice lie in recognition of situations of ageism and stigma that surround social relations adoption of selfmonitoring postures to avoid deleterious consequences remediation of traumatic situations including postpandemic ones thus older people actively seek wellbeing to continue their lives in the best possible way with the exchange of knowledge and experiences various activities that help financially relax and help in the redefinition of life as they see themselves as capable subjects with high selfesteem and personal affection 30 conclusions the repercussions of ageism directed at older people involve the social spheres generated from social isolation as a measure to contain the pandemic feelings of worthlessness and selfdeprecation noncompliance with the rights of older people by institutions generational conflicts between older people and the young repercussions on lifestyle as they fail to carry out their common activities of daily living because they feel incapable and because of the effort to use technology more and more as a means of communication and repercussions on health as older people are victims of negligence and recklessness within health institutions these repercussions can cause physical cognitive social and psychic sequelae whose permanence time and consequences require future investigations the demands brought about by this study affirm the need to deconstruct the idea that aging is a painful and survival process the need for greater socioprofessional and media inclusion of appropriate content with a focus on health education to increase digital literacy it is also essential to teach coping measures so that older people know how to handle prejudiced situations professional gerontologists need to act through an expanded clinic focusing on the therapy of psychosocial repercussions in the face of social stigma and discrimination which were enhanced throughout the pandemic through the use of compassion empathy and solidarity authorship • isis bastos barbosaconceptualization data curation writing first drafting writing revision and editing research methodology • pricila oliveira de araújoproject administration formal analysis conceptualization data curation writing proofreading and editing research methodology obtaining funding supervision • vinícius de oliveira munizformal analysis data curation writing proofreading and editing • isabela machado sampaio costa soaresformal analysis data curation writing proofreading and editing • anderson reis de sousaformal analysis data curation writing proofreading and editing • evanilda souza de santana car valhoproject administration formal analysis conceptualization data curation methodology supervision edited by yan nogueira leite de freitas

objective to analyze the repercussions of ageism directed at older people during covid19 through the content available on the youtube™ platform method netnographic exploratory and qualitative study whose data were collected in videos on the youtube™ platform a thematic analysis of bardins content was performed and the elements were discussed in the light of the theory of stigma results three categories explain the repercussions of the investigated phenomenon expressions of ageism preexisting to the pandemic with expressions of exclusion disregard and disrespect expressions of ageism during the pandemic from the risk group label that strengthens stereotypes of sick and incapable people and feelings and attitudes of the older people towards the repercussions of ageism which led to repercussions on social interactions lifestyle and health of older people conclusions the repercussions can cause physical cognitive social and psychic sequelae and the fight against its impacts starts from the educational sphere towards a social pact that allows a respectful and empathetic coexistence between generations

introduction journalism constitutes the systematic practice of collecting editing and disseminating news to the intended audience with its primary objective being the provision of information to the public this procedure is commonly referred to as the newsroom process a robust newsroom possesses the potential to effectively establish advocate for and communicate specific agendas nevertheless in light of the increasing prominence of social media the effectiveness of the traditional newsroom is subject to change journalism is widely regarded as a paramount component within the field of mass media as described by mcquail mass media refers to the organized means of openly and distantly communicating with a multitude of receivers within a short timeframe however the emergence of the internet has prompted a reevaluation of the influence exerted by traditional mass media these advancements in communication technology have profoundly impacted media assessment including the fundamental concept of agendasetting agendasetting an inquiry into the medias role in shaping public discourse has been a subject of scrutiny for over six decades continuous technological progress continues to reshape the character and structure of media warranting a comparative exploration of agendasetting within the domain of social media the primary mass communication medium of the latest generation nepals unique journey in mass communication spans centuries with the printing press arriving in 1851 four centuries after its invention in 15thcentury germany by johannes gutenberg in contrast to western nations where online news platforms emerged in the 1990s nepal embraced them in 1995 and social media has notably outpaced the growth of online journalism in the country as of june 2023 the nepal telecommunication authority reports 3888 million fixed and mobile broadband users representing 133 per cent of the population this highlights the integration of internet usage into the daily lives of nepali citizens with social media platforms playing a prominent role and accounting for the majority of bandwidth usage the covid19 lockdown in nepal substantially increases internet consumption placing strain on internet service providers to meet heightened consumer demands during this period traditional newsrooms face challenges due to governmentimposed lockdowns leading to changes in audience habits many turn to social media as a primary source of information the surge in internet users combined with the dominance of social media underscores the evolving landscape of media consumption and its impact on traditional media outlets especially in extraordinary circumstances like the covid19 pandemic objectives social media has become an inescapable communication medium that permeates every sector of human life and journalism is facing its direct impact this article aims to explore two specific objectives  assess the impact of the rise of social media platforms on the dissemination of information and the integrity of traditional media  evaluate the agendasetting power of social media in nepal by examining these objectives we can gain insights into the transformative effects of social media on journalism and understand its role in shaping public discourse and news consumption patterns theoretical perspective the theory of agendasetting explores how the media influences public perception and emphasizes the importance of specific issues this study builds upon the foundational work of maxwell mccombs and donald shaw in the 1970s who developed the agendasetting theory with a focus on the influence of newspapers before their contributions debates surrounding the medias effect ranged from theories emphasizing high media influence to those proposing lower levels of impact the decline of traditional media according to the world economic forum from 2006 to 2016 newspaper circulation in india increased by an impressive 60 per cent in stark contrast to the united kingdom which saw a 12 per cent decrease in the united states germany and france newspaper circulation declined by 7 per cent 3 per cent and 3 per cent respectively in 201516 newspaper circulation in india peaked at an impressive 612385810 copies as reported by the registrar of newspapers for india in 2022 subsequently data from the office of registrar of newspapers for india shows that during the 202021 fiscal year newspaper circulation in all languages stood at 386648237 copies however unlike in india and other countries specific data concerning the extent of this decline in nepal is not readily available media executives do acknowledge a continuous decrease in newspaper circulation the outbreak of covid19 further exacerbated the situation resulting in a decline not only in newspaper circulation but also in the number of printed pages this decline confirms the weakening circulation trend kantipur media group holding the largest market share in the nepali media industry acknowledges the loss of its newspaper market according to mahesh swar the ceo of kmg newspapers have experienced a substantial decline of at least 70 per cent in market share during this transition he further stated we lost 70 to 80 per cent of the market due to covid19 and there is no possibility of returning to the previous situation once the pandemic is over the decline in newspaper circulation is a global phenomenon and nepal is no exception the impact of covid19 has accelerated this trend necessitating a reevaluation of the newspaper industrys future amidst the growing dominance of digital media the introduction of radio marked the beginning of broadcasting followed by the emergence of television as the subsequent new media however with the rapid advancement of technology television has now transitioned to the online realm local cable television networks have expanded their reach to a global audience while terrestrial and satellite tv stations in nepal have also made the shift to online platforms the emergence of online television alongside satellite cable and terrestrial tv has transformed the concept of accessibility previously it was challenging to determine viewership for specific programs even when considering the ratio of televisions per population as stated in census data researchers used to rely on estimations based on ratings which often included a margin of error however the introduction of fiber to the home directtohome and online streaming systems now enables realtime data on program popularity for television channels applications and videosharing platforms provide live viewer counts allowing anyone to track the number of viewers for live tv content furthermore the rise of overthetop platforms has revolutionized the production and distribution of cinema and television programs these advancements have had a significant impact on print media however media operators express concerns about the potential for misinformation dissemination through social media emphasizing the need to strengthen traditional media as the landscape continues to evolve striking a balance between the benefits of new media platforms and the integrity of traditional media becomes crucial for the industrys future patan prospective journal the rise of social media as an integral component in recent times social media has become an indispensable element for every media platform this interdependence among different media outlets concerning news dissemination was not observed before rajendra dahal former president of press council nepal and founding editor of himal khabarpatrika shares his experience to illustrate this shift i listen to the newspaper on radio sagarmatha every morning the radio broadcasts newspaper content including editorials i no longer need to read newspapers even through the radio the content comes from newspapers so it doesnt matter if i read newspapers it has also saved me time radio stations now broadcast newspaper content in the morning as do television channels furthermore radio broadcasting has transformed into an audiovisual medium through social media platforms radio programs can now be watched by users on videosharing sites like tiktok facebook and youtube just as newspapers began to be read on the radio radio itself has evolved into a visual medium as a result the emergence of social media alongside traditional media necessitates a redefinition of mass media in the digital age presently kantipur television is not solely reliant on its mobile application for broadcasting television content kantipur television programs can also be viewed on videosharing sites like youtube as of june 5 2023 kantipur televisions youtube channel has garnered 31 million subscribers this significant viewership reflects the number of people who watch news and programs from kantipur televisions video content shared on youtube kantipur is not the only channel streaming traditional media content through social media as of the study period june 5 2023 nepal televisions youtube channel has over 717000 subscribers himalayan television has surpassed 13 million subscribers ap1 television has amassed over 1 million subscribers avenues television has gained more than 600000 subscribers and sagarmatha television has accumulated over 550000 subscribers the recently established television channel galaxy 4k has achieved an impressive 880000 subscribers on its youtube channel through their facebook page approximately 200000 users also follow kantipur television on twitter kantipur serves as just one example other television channels and social media platforms like facebook and twitter are also extensively utilized the reliance on satellite channels on social media platforms underscores the fact that traditional media cannot stay detached from the influence of social media most newspapers in nepal are now available online and it is rare to find news sites that do not integrate social media beyond media outlets the ability to share personalized content has increased the number of online visitors engaging with social media platforms undoubtedly as traditional media increasingly rely on social media there is a transition in the role of agendasetting to the new media this shift is not solely due to the propagation of traditional media content on social platforms rather social media possesses distinct production and consumption attributes constantly creating new influencers today social media influencers wield more influence than television hosts newspaper columnists and radio presenters advertisers who once favored traditional media are now drawn to social media underscoring the evolving impact of social media in its agendasetting capacity social media dominates social media has given rise to an influential brand in nepal known as the routine of nepal band users across platforms like facebook instagram and tiktok take its content seriously as it conveys various information and messages according to its founder victor poudel ronb ensures that all content is uploaded only after undergoing multiple verifications even though it is not a news media in contrast traditional media often presents news in a biased manner to serve certain interests news outlets cater to numerous interest groups rather than prioritizing the public ronb aims to provide a clear account of peoples issues which has fostered increasing trust among its followers victors argument is backed by the impressive reach of ronbs social media pages as of june 5 2023 routine of nepal band has amassed 4 million followers on its facebook page 730000 followers on twitter over 12 million followers on instagram more than 727000 followers on tiktok and nearly 200000 subscribers on youtube the accessibility of diverse content through social media has rendered the need to seek information from original news sources obsolete furthermore social media algorithms priorities topics of interest for users through the use of artificial intelligence user preferences are determined and technology itself determines which subjects will be presented to each individual embracing an alternative path traditional print and electronic media have often fallen short in addressing issues pertinent to the people with the extensive scope of traditional media not all subjects receive the attention they deserve resulting in the filtering out of many important topics sudhir sharma the former editor of kantipur daily argues that when social media particularly youtubers pick up these filtered subjects they gain popularity this highlights the potential for social media to reach the same status as traditional media if it covers a wide range of sectors and genres patan prospective journal since its inception journalism through newspapers has served as a platform for exchanging ideas however the debates surrounding newspaper articles often failed to find space within the newspaper itself as a public sphere similarly radio and television discussions lacked room for dissenting thoughts in their studios audiences relied on these mediums to form opinions on various subjects but there was minimal room for response or feedback within the oneway communication paradigm known as the linear model this is because among the countless viewers or readers only a few would have their voices acknowledged the advent of the secondgeneration internet referred to as web 20 introduced interactivity challenging the established linear model of newspapers radio and television this is the underlying reason why freely accessible social media pages like routine of nepal bandh have become more influential compared to heavily invested traditional media outlets including newspapers radio television and online platforms if traditional media had provided free access to peoples issues the chances of social media becoming what it is today would have been very low as social media has become the primary channel for the exchange of ideas individuals organizations political parties and even leaders no longer wait for traditional means to convey their thoughts during election periods political activities are more prominent on social media than ever before prompting the election commission to issue guidelines for social media usage the influence of social media has grown immensely the guidelines were necessary as the uncontrolled spread of information became a concern this issue is likely to become even more complex in the future case study 1 campaign against sexual violence occupy baluwatar 2013 emerges as a groundbreaking social media movement against genderbased violence setting an agenda that mainstream media fails to cover in nepal this movement highlights incidents ranging from financial exploitation of returning female migrant workers to rape cases microblogging platforms like twitter and facebook played a pivotal role in initiating this campaign initially known as occupy baluwatar engaging young activists such as jagannath lamichhane vidushi dhungel arpan shrestha kashisdas shrestha stuti basnyat ishan sauvidhya khadka ujwal thapa pranika koyu the campaign aims to draw attention to the issue of gender violence according to activist jagannath lamichhane occupy baluwatar was established in response to the governments failure to address the issue of gender violence leaving a void that the movement seeks to fill inspired by the persistent coverage by alternative media outlets at the time of occupy baluwatar only 25 per cent of the population had access to the internet and social media was still in its early stages although not as influential as it is today social media connects a critical mass of urbaneducated youth the occupy baluwatar campaign symbolizes the collective passion of marginalized communities and draws inspiration from the social mediadriven occupy wall street movement in the united states during the early stages of social media adoption occupy baluwatar made a sensational impact in the realm of agendasetting patan prospective journal case study 2 earthquake and hashtag gobackindianmedia the 2015 earthquake in nepal showcases the diverse ways social media can be employed during this period social media served two main purposes firstly it becomes a platform for coordinating rescue and relief efforts following the earthquake secondly it plays a significant role in countering the aggressive portrayal of nepal by indian media the hashtag gobackindianmedia becomes a prominent case in point facebook the most popular social media site at that time hosted various groups dedicated to providing relief to earthquakeaffected areas people from all walks of life including students businessmen and traders joined these groups leveraging the strength of social media these groups collected relief materials and distributed them in the affected regions simultaneously a movement emerged to address the biased coverage of the earthquake by indian media as media content from india focused on sensationalism and ratings a campaign against indian mainstream media gained traction this social mediadriven campaign can be seen as a direct challenge to the mainstream media the hashtag gobackindianmedia originated organically on social media as individuals expressed their dissatisfaction the campaign not only resonated within nepal but also spread to india and pakistan on twitter the hashtag trended worldwide holding the top position for a considerable duration the significance of the campaign is evident from the fact that it remained a top trending topic on twitter for 10 consecutive hours on world press freedom day may 3 2015 the demand for the indian media to leave nepal stemmed from their biased onesided and insensitive reporting by turning a tragedy into a television spectacle indian prime minister narendra modis visit during the earthquake response was seen as a public relations exercise rather than a sincere endeavor to aid the country ramesh aryal a youth from kathmandu initiated the hashtag with the message we love india but we hate indian media to warn the indian media against misrepresenting the situation the social media outcry compelled the indian media to retreat usergenerated social media content has effectively set robust agendas and successfully challenged the influence of the powerful indian media during the local elections held in 2022 all eyes were on the kathmandu metropolitan city it was during this time that an online news article highlighted the controversy surrounding the use of the national flag by balendra shah the mayoral candidate for the kathmandu metropolis the article raised questions about the compliance of balendras actions with nepals laws regarding the national flag being a popular rapper with a significant following on social media balendra attracted considerable attention patan prospective journal following the publication of the article balendras supporters became actively engaged in an online campaign against the news outlet they worked to diminish the number of facebook likes for the news organization balendras social media supporters responded aggressively on various platforms including the mainstream media even resorting to sharing news articles favouring balendra to counter the attack the trend of unfollowing on facebook has surged to the extent that over one hundred thousand followers have unfollowed the onlinekhabar facebook page this impact has also rippled into the newsroom to mitigate the ongoing damage onlinekhabar has initiated the practice of publishing stories that support balen shah the use of social media played a significant role when balendra secured a resounding victory over candidates from the nepali congress and cpnuml parties two prominent social media groups routine of nepal bandh and meme nepal were instrumental in balendras electoral success despite his nonpolitical background these groups effectively promoted his candidacy given the ongoing shutdowns and strikes by political parties in nepal the facebook page routine of nepal banda emerged as a crucial platform for establishing the electoral agenda for the 2022 local elections additionally the meme nepal facebook page with over 14 million followers actively campaigned for balendra shah by creating videos songs and satirical content targeting opposition candidates apart from these two prominent groups balendras election campaign extensively utilized organized and unorganized social media platforms such as tiktok twitter and youtube the election results demonstrate the influence of social media and its ability to shape the agenda in the kathmandu metropolitan city elections showcasing the power of online platforms in political campaigns in the case of balen shah nepali traditional media fell short of effectively gauging his popularity the discernible impact of social media on the agendasetting process came to the forefront during this election source agendasetting study 2023 can journalism serve as an alternative to agendasetting the case study sheds light on this question while social media demonstrates its strong influence in agendasetting it raises an important and sensitive question about the role of mainstream journalism in this context experts involved in the study are asked to provide their insights and they collectively agree that social media content may not undergo the rigorous editing process associated with journalism despite its agendasetting function social media is not purely a journalistic medium it is concluded that while social media can disseminate information to the public it does not necessarily provide news in the true sense all the experts acknowledge that social media gains significance because mainstream media often fails to directly cover issues closely connected to the people the gap left by the mainstream medias limitations is filled by social media platforms particularly youtube paudel the founder of routine of nepal bandh criticizes mainstream media for conveying onesided messages and becoming a tool for propaganda a sentiment that resonates with other participants to some extent it is not uncommon for media outlets patan prospective journal volume 3 number 1 june 2023 rishikesh dahal 126 to face scrutiny when there is an imbalance in the flow of news and ideas when social media highlights such issues it provides an opportunity for mainstream media to improve in other words social media can be seen as a social auditor of mainstream media however there is a risk associated with social media in terms of promoting incorrect agendas due to the presence of raw and unverified content in recent times the rapid spread of disinformation misinformation and misleading messages through social media has become a concern the erosion of credibility within the news media landscape is a multifaceted phenomenon primarily attributed to political predisposition corporate encroachments and instances of selfimposed censorship within this milieu notable political actors including kp sharma oli rabi lamichhane and balen shah have undertaken concerted endeavours to discredit conventional newsrooms often harnessing the amplifying capabilities of social media platforms concurrently newsrooms find themselves ensnared in a crisis of professionalism contending with challenges to their integrity and objectivity while influential political figures and social media influencers mount assertive campaigns against their legitimacy conclusion simultaneously traditional media outlets have been compelled to embrace social media in response to the growing reach and impact of technology organized social media groups have demonstrated their ability to wield greater influence than mainstream media as exemplified by the mobilization surrounding balendra shahs election as the mayor of kathmandu metropolitan city social media has become the primary platform for addressing public concerns and shaping the agenda based on peoples needs consequently there arises a necessity to redefine the role of media as a whole just as the fourth estate monitors the three branches of government social media has the potential to function as a watchdog of the watchdogs there have been inquiries on social media regarding the content produced by mainstream newsrooms this scrutiny has prompted the newsroom to heighten its vigilance such monitoring via social media serves as an inspiration for journalism to fortify itself given these dynamics it appears that social media could be positioned as a fifth estate however it is crucial to acknowledge the inherent risks of misinformation as disinformation poses a constant threat to democracy to harness the potential of social media as a catalyst for positive change comprehensive reforms within traditional media are imperative by doing so social media can be integrated as a facilitator of constructive transformation ensuring the dissemination of accurate and reliable information while maintaining democratic values political party leaders have placed significant emphasis on social media the news sector has been utilizing content sourced from social media platforms this underscores the increasing effectiveness of social media in its agendasetting role however there is a pressing need for refinement in social media content it is essential for all stakeholders within the media ecosystem to

this article examines the influence of social media on traditional medias role in shaping public opinion and agendasetting in nepal social media has emerged as a powerful medium surpassing traditional media in terms of influence and reach drawing on the theoretical framework of agendasetting this study explores the current state of social media in nepal using case studies and interviews with experts as primary sources and considering social medias purpose use and impact the article presents a comprehensive analysisthe findings reveal that social media increasingly plays a stronger role in agendasetting while traditional medias ability to shape opinions and facilitate debates is diminishing with its fastpaced dissemination affordability and visible impact social media has overtaken traditional media in setting the agenda however the unrestricted production of content on social media poses risks as it lacks an editing process traditional media now relying on social media faces intensified competition to remain relevant and avoid weakening news media must invest in content research and adapt to changing usage patterns upholding journalistic standards while leveraging the strengths of social media is crucial for traditional media in nepal

in the individual life course whereas the major theoretical frameworks that have been used to study adjustment to retirement assume that retirement processes are related to experiences in the past empirical insights regarding earlier life experiences and retirement adjustment are limited the central question of this study is to what extent and how can variation in retirement adjustment be explained by earlier life experiences in the literature on retirement adjustment several qualitative studies have pointed at the importance of life histories for understanding perceptions of retirement and adjustment earlier life experiences in the work family leisure and health spheres seem to be associated with the ease of adjusting to retirement however insights regarding earlier life experiences and retirement adjustment based on quantitative studies are scarce only few studies explicitly pay attention to more distal life experiences these studies examine the impact of either work histories or family histories on retirement quality and retirement adjustment problems this study aims to contribute to the literature on retirement adjustment in three ways first compared with earlier studies on life histories and retirement adjustment we will build to a greater extent on the life course proposition of multispheral development consistent with this proposition we will not solely focus on earlier life experiences in one life sphere but simultaneously test the impact of earlier life experiences in the work health and family spheres on adjustment difficulties given that predictors of retirement adjustment might differ between men and women we will pay attention to gender as a potential moderator of life history effects on retirement adjustment second the retirement transition involves two developmental challenges adjustment to the loss of the work role and the development of a satisfactory postretirement lifestyle most retirement adjustment studies are based on general measures of psychological comfort such as happiness morale life satisfaction or retirement satisfaction which do not distinguish between these developmental processes this study aims to improve our understanding of the first developmental challengeadjustment to the loss of the work roleby directly asking retirees about the extent to which they miss aspects of work since they retired missing work has been studied as a predictor of postretirement morale satisfaction with retirement and intentions to unretire but relatively little is known about the factors that predict this developmental facet of the postretirement process itself third instead of using a general measure of missing work after retirement we will pay attention to the multidimensional nature of the adjustment process the loss of the work role might imply multiple changes such as the loss of income social contacts status daily structure and purposeful activity not only might the ease of adjustment differ across these dimensions but also predictors might differ as taylor shultz spiegel morrison and greene argue a composite criterion that simply combines different dimensions may mask more complex relationships between the predictors of adjustment and particular facets of adjustment in this study we focus on three workrelated aspects that retirees might miss after retirementmoney income social contacts via work and statuswhich resemble the dimensions that van solinge andhenkens distinguish in their measures of preretirement anxiety regarding the loss of the work role especially when examining the role of earlier life experiences in the adjustment process it is important to study these dimensions separately given that the direction of some relationships can be hypothesized to differ between dimensions this article is based on panel data collected in 2001 20062007 and 2011 among 1004 dutch older persons who were all employed at the first wave of data collection and fully retired within the observation period retrospective information on earlier life experiences provides the possibility to study the relationships between life history experiences and adjustment resources and retirement transition characteristicswhich are established correlates of retirement adjustment will also be taken into account in the analyses in the netherlands all individuals are covered by a flatrate basic public pension scheme and about 91 of employees are covered by earningsrelated occupational pension plans in which participation is mandatory income replacement rates are relatively high in recent decades there has been a strong early exit culture in the netherlands theoretical background the main theoretical perspectives that have been used to study variation in retirement adjustment are role theory continuity theory and the life course perspective role theory assumes that the transition into retirement might be especially difficult for individuals who are highly invested in their work role and for whom the work role is central to their selfidentity continuity theory generally suggests that most adults will be able to achieve positive results adapting to life transitions because during their earlier life they have developed relationships activities frameworks of ideas and adaptive skills that create continuity in their lives when making these transitions the life course propositions of lifelong and multispheral development imply that specific life periods cannot be understood thoroughly without information on preceding experiences in different life spheres to integrate these theoretical frameworks wang and colleagues propose a resourcebased dynamic perspective for studying adjustment to retirement in this perspective adjustment is conceptualized as a process which is dependent on individual resources and changes in resources the extent to which retirees miss moneyincome social contacts and status can also be expected to be dependent upon the amount of financial and social resources offered by work changes in these resources due to retirement and the availability of alternative resources moreover the importance individuals attach to specific workrelated resources may play a role work history in the literature two main arguments can be found that link work histories to retirement adjustment based on a financial argument it can be expected that employment histories characterized by continuity and upward mobility are positively related to retirement adjustment given that pension benefits are dependent upon income and years of service retirees with these work histories are likely to have an advantageous postretirement financial situation which might facilitate adjustment to retirement we therefore hypothesize that retirees who have worked continuously fulltime or followed an upward career path are less likely to miss the moneyincome provided by work than those who had a more discontinuous career via a nonfinancial argument adjustment to retirement can be expected to be relatively difficult for retirees who followed a continuous or upward work trajectory these retirees may be highly attached to their jobs and might have had fewer opportunities to invest in alternative roles over the course of their working life in that respect they might perceive the social changes associated with retirement as troublesome we hypothesize that retirees who have worked continuously fulltime or followed an upward career path are more likely to miss workrelated social contacts and status than those who had a more discontinuous career health history the health situation of retirees is often found to be an important resource that enables retirement adjustment insights regarding the effects of health problems earlier in life are limited though the experience of severe health problems earlier in life can be expected to increase expenditures and suppress earnings which might affect retirees financial situation and adjustment negatively we hypothesize that retirees who experienced severe health problems in midlife are more likely to miss the moneyincome provided by work than those who did not experience these health problems workers who have had health problems earlier in life might experience more difficulties adjusting to the social dimensions of the retirement transition as well during midlife they might have had fewer capacities to develop alternative roles activities and relationships next to work compared with those who did not experience health problems furthermore persons in poor health might be less capable of replacing lost relationships and sources of status by new ones which might make the retirementrelated loss of these social resources relatively difficult it can be expected that retirees who experienced severe health problems in midlife are more likely to miss workrelated social contacts and status than those who did not experience these problems family history in studies on retirement adjustment it is generally hypothesized that married retirees experience less adjustment problems than unmarried retirees the broad categories of whether retirees are married capture however a lot of diversity in terms of marital histories which might be associated with retirement experiences individuals who have ever been divorced have been found to have significantly lower wealth in preretirement years than the continuously married group although remarriage partly offsets the negative divorce effects a divorce earlier in life might also result in a relatively large drop in terms of income after retirement for the partner that earned the most during the marriage because of pension sharing we hypothesize that retirees who have ever been divorcedboth those who repartnered and those who remained singleare more likely to miss the money income provided by work than the continuously married group divorces are often accompanied with changes in social networks although divorced persons are more involved with friends than persons in their first marriage divorces negatively affect neighborhood contacts participation in clubs and outdoor recreation repartnering however seems to reverse negative effects of divorce on social integration moreover having a partner can be expected to offer access to relationspecific resources and to offer a stable role or identity especially for divorced persons who remained single therefore the social contacts and status provided by the work role can be expected to be highly relevant we hypothesize that divorced retirees without a partner are more likely to miss workrelated social contacts and status than those who have continuously been married or repartnered after divorce the role of gender in the literature on retirement adjustment two main arguments can be found on the role of gender on the one hand women might experience less difficulties adjusting to the loss of the social dimensions of work than men given that they have more experience in terms of role transitions and career interruptions and might be more inclined to perceive the family role as their primary role on the other hand it can be expected that women experience more financial adjustment difficulties when leaving the work role compared with men given that they might be more financially vulnerable due to their more interrupted work careers employment in secondary labor market positions and lower likelihood of being married however given that the previously discussed life history factors will capture many of these differences between men and women gender differences in terms of adjustment to the loss of the work rolenet of the life history effectsare expected to be limited it might be the case however that the impact of certain earlier life experiences on adjustment differs between men and women previous research has shown that the financial status of women in later life is more strongly affected by prior marital dissolution than the financial status of men and persists until remarriage therefore it can be hypothesized that the effect of being divorced and single on missing the moneyincome provided by work is stronger among women than among men with respect to the social contacts dimension of missing work the impact of being single and divorced can however be expected to be stronger among men than among women the experience of a divorce has been found to have a significant positive effect on support from colleagues and acquaintances among men but not among women this suggests that colleagues are particularly an important source of social support for divorced men which might make the social changes due to retirement challenging design and methods sample the nidi work and retirement panel data are threewave panel data collected by the netherlands interdisciplinary demographic institute in 2001 data were collected among a random sample of civil servants aged 5064 years working for the dutch central government and all workers aged 5064 years of three large dutch multinational private sector organizations a mail questionnaire was sent to 3899 older workers in total 2403 questionnaires were completed in 20062007 a followup study was carried out among surviving and traceable participants of the first wave a total of 2239 questionnaires were mailed out of which 1678 were returned the third round of data collection took place in 2011 among all 1638 surviving and traceable respondents of the second wave the wave 3 questionnaire was returned by 1276 respondents the base sample for the analyses consists of 1080 respondents who shifted from being in paid work at wave 1 to being fully retired at either wave 2 or wave 3 given that this study focuses on adjustment to retirement those who did not make use of an retirement arrangement but stopped working because of unemployment or disability were excluded from this base sample respondents for whom information on the dependent variables is missing or who did not answer the central questions regarding midcareer experiences were eliminated from the sample this results in an analytic sample of 1004 retirees on average respondents were retired for 25 years when they answered the adjustment questions measures dependent variables to measure adjustment to the loss of the work role across dimensions fully retired respondents were asked during waves 2 and 3 to report to what extent they miss various aspects of work since they stopped working we used the responses provided at the study wave immediately following the respondents full retirement missing moneyincome and missing social contacts via work were both measured by oneitem indicators missing status was measured by a twoitem scale which was constructed by taking the mean score of items that ask about the extent to which respondents miss selfesteem and prestigestatus since they stopped working response categories ranged from 1 to 5 but were reversely coded in the analyses high scale scores indicate that respondents miss the specific work aspect very much social contacts are the workrelated aspect that respondents are most likely to miss followed by financial resources and status in the multivariate analyses we standardized the dependent variables to obtain effect sizes for the dummy variables independent variables to measure continuity of the work career respondents were asked to indicate the age at which they started working and for how many years in total they have been out of the labor market after that this information was used to calculate the number of years spent in the labor market at retirement specific work and health experiences in midlife were measured by two questions that asked for several life experiencessuch as employer change parttime work and severe health problemswhether respondents had these experiences before age 40 and between ages 40 and 50 we constructed a dummy variable per life experience indicating whether the respondent has had the particular experience before age 50 information about upward mobility was acquired via the question how would you characterize the course of your career between ages 40 and 50 to measure marital histories information about the marital and partner status is combined with retrospective information about whether respondents have ever been divorced the following categories were distinguished marriedcohabiting never divorced marriedcohabiting ever divorced no partner never married no partner ever divorced no partner widowed in the analyses we control for the respondents gender the study wave at which the dependent variables were measured and the time elapsed since the respondent made use of an retirement arrangement in addition given that resources and retirement transition characteristics are established correlates of retirement adjustment we take preretirement financial resources preretirement perceived satisfaction with life subjective health voluntariness of the retirement transition and age at retirement into account table 1 presents the means standard deviations coding and wording of survey questions for all variables in general item nonresponse was low and was dealt with by using multiple imputation procedures the variables with missing cases were imputed 25 times using information from the dependent independent and control variables thereafter the regression models are estimated for all these 25 data sets and the results are combined analyses the relationships between earlier life experiences and the different dimensions of missing work after retirement were analyzed by estimating linear regression models and combining the estimation results by seemingly unrelated estimation sue is an appropriate technique when estimating different equations based on the same data it combines the parameter estimates and variance matrices of the separate regression models thereby allowing to test crossequation differences between coefficients to deal with the structure of the data we control for organization in the analyses and used standard errors that allow for intradepartmental correlation results table 2 presents the sue results for the different adjustment dimensions the models are estimated in two steps in the first step the relationships between earlier life experiences and missing moneyincome social contacts via work and status are examined in the second step resources and retirement transition characteristics are added to the equations life history experiences in model 1a the extent to which retirees miss money income is regressed on information about earlier life experiences and control variables the results show that experiences in both work and family spheres are associated with missing financial resources after retirement as predicted in hypothesis 1a those retirees who experienced an upward career patheither a steep or a more gradual upward trajectoryare less inclined to miss moneyincome after retirement than those who did not experience upward mobility examination of interaction effects with gender suggests however that the effect of gradual upward mobility is significantly stronger for men than for women 35 t 239 p 017 the steep upward mobility effect does not differ significantly by gender as shown in model 1a the coefficients of years in the labor market midlife employer change parttime work and severe health problems are not statistically significant regarding marital histories the findings indicate that retirees who repartnered after divorce are more likely to miss financial resources than those who have continuously been married as expected in hypothesis 3a divorced retirees who remained single do not differ significantly from the continuously married group in terms of missing financial resources the results regarding missing workrelated social contacts after retirement are presented in model 1b none of the effects of the studied work and health history experiences is statistically significant marital histories however are found to be associated with missing workrelated social contacts as expected in hypothesis 3b divorced retirees without a partner are more likely to miss workrelated social contacts than their continuously married and repartnered counterparts moreover they are more likely to miss workrelated social contacts than single never married retirees whether we used the scores provided at wave 1 2 or 3 is dependent upon the type of variable and the moment at which the respondent shifted into fulltime retirement for those who were already fully retired at wave 2 we used the wave 2 measures of partner status health and retirement transition characteristics for those who transitioned into full retirement between waves 2 and 3 we used the wave 3 measures of these variables the earlier life experiences preretirement financial resources and preretirement perceived satisfaction with life were measured at either wave 1 or 2 se coef se coef se coef se coef se coef statistically significant regarding marital histories the results show that single divorced retirees are more likely to miss workrelated status than continuously married single never married and single widowed retirees the difference with the repartnered group is in the expected direction but not statistically significant at the 5 level se with respect to gender the results show that men and women do not differ significantly in their likelihood of missing moneyincome social contacts and status after retirement inspection of interaction effects suggests that the impact of marital experiences differs between men and women on some dimensions as expected in hypothesis 4b the effect of being divorced and single on missing social contacts is smaller for women than for men 45 t 192 p 055 but is strictly not significant for the other adjustment dimensions the impact of being single and divorced does not differ between men and women the effect of being repartnered after divorce on missing status is significantly smaller for women than for men 39 t 230 p 022 f tests of crossequation differences between coefficients show that the effect of a steep upward career path differs significantly across all three studied dimensions money income vs social contacts money income vs status and social contacts vs status those retirees that experienced a steep upward career path are less likely to miss moneyincome after retirement but more likely to miss status whereas no association is found with missing social contacts the coefficient of being single and divorced is significantly larger for missing status than for missing moneyincome another noteworthy result is the role of the control variable time elapsed since retirement which differs significantly between the money income and social contact dimensions the findings show that the more years have elapsed since retirees made use of an retirement arrangement the less likely they are to miss workrelated social contacts for the financial dimension this effect is not statistically significant the role of resources and transition characteristics in models 2a2c resources and retirement transition characteristics are added to the equations preretirement financial resources are negatively associated with missing money income after retirement for preretirement satisfaction with life a negative effect on missing financial resources is observed as well those who had more financial resources and were more satisfied with life in preretirement years are less likely to miss financial resources after retirement for the social contacts and status dimensions these effects are not statistically significant the perceived health situation of the retiree is relevant for all studied adjustment dimensions retirees in good health are less likely to miss workrelated moneyincome social contacts and status compared with those in poor health also a voluntary retirement transition is related to fewer adjustment difficulties on all studied dimensions those who retired at a relatively older age are less likely to miss moneyincome than those who retired earlier for the social adjustment dimensions the effect of age at retirement is not statistically significant comparing the effects of earlier life experiences between the life history models and the expanded models provides insights into the extent to which the effects of earlier life experiences are mediated by the established correlates of adjustment the results show that the effects of career path and marital history generally remain statistically significant when taking resources and retirement transition characteristics into account suggesting that these life history effects cannot be fully explained by the established correlates of adjustment discussion the difficulties retirees experience when adjusting to the loss of the work role are often assumed to be dependent upon experiences earlier in life in line with the life course notion of multispheral development this study shows that earlier life experiences in both work and family spheres are associated with missing work after retirement regarding work histories the findings show that retirees who had a steep upward career path in midlife are less likely to miss moneyincome equally likely to miss social contacts and more likely to miss status compared with those that did not experience upward mobility these findings clearly point out that retirees can miss work for different reasons depending on their career path in midlife probably midcareer pathways set the stage for experiences during late careers and ones postretirement situationeither by limiting or promoting resources and opportunitiesand consequently shape retirement experiences marital histories were found to play a role as well this study shows that divorced retirees without a partner are most likely to experience difficulties adjusting to the social changes accompanied with the loss of the work role they were not only more likely to miss social contacts and status compared with continuously married retirees but also compared with single never married retirees suggesting that among those living without a partner it is important to take diversity in terms of marital histories into account also the longterm negative financial consequences of divorce experiences are reflected in the data those retirees who repartnered after divorce were found to be more likely to miss financial resources after retirement compared with continuously married retirees generally men and women did not differ in terms of their difficulties adjusting to the loss of the work role although the implications of marital experiences were found to differ slightly by gender as expected being divorced and single has a slightly stronger impact on missing workrelated social contacts for men than for women paying attention to the multidimensional nature of adjustment appears to improve our insights into the postretirement process the results show differences across dimensions in terms of the incidence of adjustment difficulties and processes over time moreover predictors were found to differ across adjustment dimensions suggesting that some effects might have been overlooked when using a combined measure of missing work after retirement generally social contacts were found to be the workrelated aspect that retirees are most likely to miss the longer individuals are retired the less likely they are to miss workrelated social contacts which might either suggest that retirees compensate workrelated contacts by other contacts or perceive workrelated contacts as less important over time for financial resources and status the incidence of adjustment difficulties is lower and no time effect is observed this may indicate that for many personsat least in our dutch sampleretirement is not necessarily associated with an important loss of financial resources or status the lack of a time effect could suggest however that for those retirees who do miss financial resources or status the likelihood of experiencing difficulties does not decline the longer they are retired probably income and status remain important needs among retirees which may be relatively difficult to compensate for after retirement no support was found for the hypotheses regarding various work and health history factors these findings may suggest that not the amount of time employees have spent in the work role but rather the investments they made within the work role shape their retirement experiences for the interpretation of the research findings it is important however to take the dutch country context into account with regard to retirement savings and income much more is organized at a collective level in the netherlands than for example in the united states where individual workers mainly carry the risks and responsibilities replacement rates are relatively high and the income poverty rates among the elderly are low in this respect especially adjustment to the loss of the moneyincome provided by the work role might be relatively easy in the netherlands and its relationships with earlier life experiences might be relatively weak whether the incidence and predictors of the different dimensions of missing work after retirement are similar in other countries is an important question for future research studying other routes of exiting the labor market such as disability or unemployment might also be a relevant venue for future research leaving work due to disability or unemployment is likely to result in much less favorable outcomes than the retirement experiences examined in this study given its relatively poor prospects and inherently involuntary character three limitations of this study should be kept in mind when interpreting the findings first we used rather broad retrospective questions to measure work and health histories which might not have captured the meaning of the work role in sufficient detail moreover several life history measures focus on the period before age 50 and therefore did not capture the years between age 50 and retirement it might be the case that the impact of midlife experiences cumulates during ones late career and that these latecareer experiences are more influential for shaping postretirement experiences in future studies it would be interesting to examine the role of both midand latecareer experiences to disentangle their relative importance for explaining postretirement adjustment second even though the retirees in the study sample form a highly diverse group in terms of earlier life experiences resources and retirement transition characteristics they were all employed at four organizations therefore the sample is not representative for dutch older workers third even though availability of information about the extent to which retirees miss workrelated aspects is an important strength of the data it should be noted that missing financial resources and social contacts were both assessed by singleitem measures for future research it is advisable to develop multiitem scales to measure the three adjustment dimensions examined in this study as well as other adjustment dimensions despite these limitations this study shows that adjustment to the loss of the work role is a multidimensional process embedded in the individual life course the findings of this study raise important issues for policy and practice for policymakers the findings point out that changing life course experiences might have important implications for retirement quality of future cohorts whereas the lives of dutch men and women born between 1931 and 1940 generally reflected the standard life course life courses destandardized among cohorts born after 1950 variation in behavior increased for example divorces became more common these developments might have important implications for the retirement experiences of future cohorts given that divorced retirees were found to be most likely to experience difficulties adjusting to the loss of the work role for retirement counseling the results highlight the importance of not solely focusing on the current situation of older individuals but to view retirement as an integral part of the individual life course

although the process of adjustment to retirement is often assumed to be related to experiences earlier in life quantitative empirical insights regarding these relationships are limited this study aims to improve our understanding of adjustment to the loss of the work role by conceptualizing retirement as a multidimensional process embedded in the individual life course design and methods analyses are based on panel data collected in 2001 20062007 and 2011 among dutch retirees n 1004 the extent to which retirees miss aspects of the work role moneyincome social contacts status is regressed on information about earlier life experiences resources and retirement transition characteristics results the incidence of adjustment difficulties varies across dimensions predictors differ as well a steep upward career path is associated with fewer financial adjustment difficulties but with more difficulties adjusting to the loss of status compared with continuously married retirees divorced retirees without a partner are more likely to miss the social dimensions of work and those who repartnered are more likely to miss financial resources the longer individuals are retired the less likely they are to miss workrelated social contacts implications changing life course experiences might have important consequences for retirement processes of future retirees

introduction humanitys awareness of the growth of dangers and risks in all spheres of life determines the search for ways of minimizing and preventing them the xxi century is marked by the problem of confrontation between the two worlds one is formed by nature without the participation and influence of man the other is an artificial world formed as the result of human activity modernity is associated with fundamental changes in the functioning of the artificial environment which separates man and begins to develop its own laws as a result the artificial is replacing the natural an important role in the invasion of the artificial is performed by consumption the special importance of studying consumption is emphasized in the report of the stiglitz commission which strongly recommends that in the assessment of socioeconomic development and progress the emphasis should be made on the measurement of production but on the assessment of wealth income and consumption in this regard the study of the characteristics of consumption and the identification of factors that determine their crisis dynamics become relevant the sustainable development project makes one take a fresh look at the causes of the crisis and look for ways out in the sphere of consumption the world community has identified social responsibility as the most influential lever on the path to sustainable development and provided its legal formalization through the international standards iso 26000 iso 14000 iso 90012000 the un global compact etc ukraine has committed itself to the implementation of sustainable development in ukrainian society social responsibility has not taken its proper place in the system of social relations and has not become a conscious and used norm and the need for it is growing rapidly in this context the relevance of the search for effective forms of social management on the social responsibility basis to consolidate social order is increasing the aim of the study is the analysis of socially responsible consumption as a possible option to overcome the crisis caused by the transformation of technology into a determining factor in systemic changes in modern society to achieve this goal it is necessary to perform the following research research tasks 1 analyze the essence and place of social responsibility in the system of public relations 2 consider the essence of the naturalartificial crisis in the context of ontology and the theory of dialectics 3 show the relationship between consumer lifestyle and technocratic society 4 assess the prospects for the use of socially responsible kinds of behavior in overcoming the naturalartificial crisis research methods the main provisions of the system of social responsibility and socially responsible relations were developed in the works of h jonas i panarin x lenk and others various aspects of the formation and manifestation of social responsibility are covered in the works of e giddens v windelband t parsons a close relationship between social cohesion and social responsibility is in the works of e durkheim the search for the most effective means of goaloriented behavior m weber t adorno j delgado k lorenz h marcuse m heidegger m horkheimer k jaspers laid the foundations for the crisis in the technocracy of modern civilization the unevenness of the processes of material and spiritual development the idea of technohumanitarian balance and the consideration of civilizational crises as its violation associated with the acceleration of scientific and technological progress is formulated in the works of v vinge r kurzweil a d panov a p nazaretyan and others a adler a gehlen h plesner and others find the roots of the crisis in human biological insufficiency for which social progress serves as compensation the constantly renewing diversity of the world of technology and its connection with natural and social problems requires reliance on the philosophical principle of complementarity which makes it possible to carry out methodological synthesis in the process of studying the phenomenon of technology the basis of the study is the ontological characteristics of technology given by m heidegger showing the possibilities of technology in the unity of man society and culture research results responsibility as a philosophical category defines the objectively necessary relationship between the individual and society on the basis of their mutual obligations which are realized in conscious and volitional behavior and activities regulatory mechanisms in a broad sense responsibility is one of the universal ethical regulators and principles of any social interaction and organization socially responsible relations are correlated with the processes of effective democracy which is represented by the selforganization of the citizens themselves their ability to make responsible consensus decisions and the logic of coordinated collective actions regarding the public good harmonization of the interests of different social groups social responsibility is a category determining the degree of free manifestation by a social subject of his duty and right to choose under specific conditions the best option relating to reality based on the progressive interests of society there are three most important foundationscharacteristics of social responsibility the social subject his freedom and its degree the social subject in this definition implies an individual a social community society and in the end humanity as a whole the object of social responsibility is various acts of activity and behavioral practices that are implemented in the system of social relations public awareness of the importance of social responsibility is the key to certainly expected achievements in this area due to the peculiarities of this category which is inherently multifaceted its understanding is not limited to any one definition or concept social responsibility penetrates the entire system of social relations characterizes a certain type of behavior and recreates the level of culture and moral qualities of a person and society the desire for a systematic vision of social responsibility and its manifestations necessitated the orientation of scientific research towards the simultaneous study of the features of the social responsibility of an individual society business and state applying to the natural and the artificial for the first time the ratio of artificial and natural as a philosophical problem arose in antiquity in particular aristotle defined some existing objects as those that exist by nature and others due to other reasons everything formed by nature has the beginning of motion and rest in itself on the contrary what is artificially formed does not have an innate impulse for change in antiquity the idea dominates according to which the natural is an ontological value and the artificial only as a derivative of it is secondary at the same time nature and space are divine animated and sacred in the middle ages the idea of the creature of nature prevails which loses the halo of divinity acting as a peculiarly understood product of god starting from the 15th century the idea of replacing shortlived natural nature with artificial nature becomes one of the fundamental components of technogenic civilization by the xx century the artificial world has become so significant influencing nature that mankind began to understand that the natural world must be protected there is no single technological complex on planet earth however within the framework of philosophical studies the artificial world is considered as a single object referring to the fact that the global level of some technogenic changes has been reached technogenic impact on nature proceeds in three directions direct technological modification of natural processes and systems for the purpose of their economic use вісник нау серія філософія культурологія 2022 № 1 indirect impact of the technogenic environment on the biosphere through climate transformation impact on living beings through a change in biospheric cycles and interactions caused by the extinction of other biological species the technosphere as a manifestation of the artificial expanding farther and farther steps on the natural and thereby displaces man himself an attack on nature in general is associated with an attack on the moral nature of man technocracy marks the beginning of the posthuman era in which there is less and less of man and nature human consciousness does not keep pace with progress the dangers of the technosphere are growing faster than man is getting smarter e tofflers work future shock describes a production cycle that establishes a cycle of deathrebirth accelerated renewal of things thanks to which fashion is created and its mobility is affirmed the standards for using things are changing towards onetime use or shortterm use and then being replaced by a newer model which gives rise to a throwaway culture a whole chapter is devoted to the issue of using a thing things the throwaway society in which he describes a new type of relationship with things that do not imply getting used to them shopaholism consumerism and throwing away the category of old which dominated in the traditional culture is being replaced by the category of new the new is precisely the permanently new the minimal new is the other at the moment of its appearance and the period of interaction with things becomes as short as possible and is increasingly signified only by the phase of familiarization hence there is the growth of the pathos of disposable things although their quality and their price are often not commensurate with a onetime appeal to them the phase of parting with things also undergoes similar changes if the period of getting used to a new environment is compressed in time then the period of weaning from the old conditions is also reduced j baudrillard states we are experiencing the time of things i want to say that we live in their rhythm and in accordance with their continuous sequence today we see how they are born improved and die while in all previous civilizations there were things tools or durable monuments that lived longer than generations of people on the one hand things reach moral faster than physical obsolescence which makes it impossible to become attached to a thing and on the other hand consumer products are often deliberately intended to be shortlived that physical aging occurs in a much shorter time than its counterparts it is often more profitable to replace a thing than to fix it therefore it makes more economic sense to produce cheap nonrepairable disposable products consumption also contributes to the further growth of production because the needs determine production direct functionality the high quality of a thing associated with it and accordingly its longterm use completely contradict the discourse of fashion and consumer culture and therefore only symbolic functionality is acceptable for this discourse quality is compensated by quantity and symbolic utility today the man thing relations are characterized by an everincreasing interest in the consumption of symbols and signs a kind of virtualization of a thing which is noted by many researchers of modern culture that interest in the thing which has been known for many centuries of human history is now being modified into an interest in the symbol of the thing if a thing of the past demonstrated status class affiliation or anything else of that kind today this function is not fixed in a thing the meaning can be anything including negative and the absence of meaning is also possible the thing turns into a text that according to the laws of postmodernism is not obliged to educate contain or appeal to any intelligible idea at all the essence of the sign and symbol conveyed by the thing can be understood only by the author of the idea or by some group associated with it the thing as a text is of interest in the light of the game process which includes fragments of texts from other cultures or subcultures it is no longer necessary for man to own a thing he only uses it not trying to keep it for a long time but changes it immediately as soon as a newer thing appears an illusion arises that the suffocation of traditional culture with its hoarding is being replaced in our world by the antisuffocation of free consumerism thus the destabilizationdegradation of the natural environment is only one side of the coin of the problem the other is the formation of an integrated environment of a new type this is evidenced by the data that the technosubstance in terms of annual mass turnover exceeds the biosubstance of land by 12 orders of magnitude and the energy capacities of technoprocesses have already caught up with geological ones in such conditions the adaptive apparatus of man is under double pressure and in our opinion we are talking not only about the tension of existing mechanisms but also about the need to develop new ones so if the expansion of classical industrial factors in the technosphere has been gradually unfolding for quite a long time then the modern rapid development greatly complicates the preservation of the natural and adaptation to the new technized reality in the sphere of the general public various forms of protest against consumerism are brewing further searches within the framework of this topic can be focused on the study of socially responsible attitudes in the individual and public consciousness as a type of social responsibility in order to introduce the principles of sociallyresponsible consumption into everyday life it is necessary to make a comprehensive effort for the whole society first of all it will be necessary to form socially responsible thinking for all participants the state business and citizens in this regard the study identified the main methods for the formation of sociallyresponsible consumption from the standpoint of these three levels in order to prevent an increase in the anthropogenic load on the environment the state must control the activities of economic entities and create the necessary conditions for the formation of socially responsible consumption regulation of the activities of companies by the state can be both voluntary and mandatory the main methods can be the following legal regulation development of national standards development of social advertising in order for a business to fully express itself as a supporter of socially responsible consumption it needs to raise standards in the industry review business models and processes by major manufacturers implement circular economy models and increase supply chain transparency for civil society the following are the main methods of forming socially responsible consumption downshifting freeganism anticonsumerism primitivism and enathism the ideas of rationalizing home space are becoming very popular minimizing things and the possibility of transforming them in order to increase functionality another option is to go into creativity allowing one to shift personal interests and not external relations with things the efforts of anticonsumer tendencies are absorbed by what these efforts are directed against the world of consumption appropriates the subversive movements of thought and action makes them serve its own purposes subjecting them to recoding commodification that is turning into a market commodity as a result of which the former subversiveness disappears from them it is able to neutralize not the social ideas and slogans themselves that call for specific actions but their image a symbol from which the ideological potential that was once inherent in them is eventually forced out using the example of the creation of a capsule wardrobe one can see how the legalization of anticonsumer ideas ends with a real consumer from the idea of limiting the number of things in the wardrobe this movement goes all the way to a clearly fixed set of clothing items with specified brands and terms of operation all of these features strictly correspond to the ideology of consumerism and the individual himself is deprived of the need for selfcriticism forming another element in the series of consumers who manifest latent consumerism disguised as anticonsumerism the same thing happens in the choice of styles so minimalism which seems to limit the number of things in the interior actually illustrates the same consumertype behavior having at its disposal clearly marked objects brands budget and other features for its implementation it is the illusion of antimaterialism that becomes a part of modern fashion a paradoxical situation arises where consumerism is hidden under the mask of nonattachment to things all this gives rise to a situation in the modern world that one would like to call antisuffocation because formally its requirements are met there is no getting used to the thing and the desire to possess fades into the background the modern technocratic is insatiable in consumerism therefore the forecasts of scientists about the coming ecological catastrophe are quite justified the united planet can seriously react to insane consumption in an attempt to attract the attention of a greedy human consumer who armed with the idea of anthropocentrism neglecting ecology and turning nature from a thinginitself into a thingexclusivelyforus ceased to be a reasonable person and began to feverishly use resources outstrip the viability of the ecosystem nature began to be presented as an area that resisted purposeful human activity and the tasks of science and technology were reduced to finding ways to overcome this resistance discussion permanent innovationism expressed in the cult of revolutionary continuity is extremely harmful since with it the new serves the development of culture and the sociosystem but their complete denial in favor of the invented the focus on progress should not be limited to itself it needs to have some kind of socially useful metagoal a supertask in relation to which progress is a means an instrument of achievement the correct formula is new is not for its sake but new is for society any innovations require an assessment in relation to themselves from the standpoint of the prospects that they are able to give to man and society the new should not destroy the old but improve or supplement it because any sociocultural development is limited by certain limits in this focus the way is being paved for social responsibility which is not associated with a destructive trend of cardinal destruction of the past culture and sociosystem but involves its systematic improvement it is necessary to move not forward to the progress of technology which turns into its intellectual moral environmental etc costs but upward movement toward the improvement of man society and culture according to the apt expression of v kutyrev if progress is not stopped and death is not avoided there is no need to push it but to rush it society is called to develop not to stand still but the process of development cannot be frozen by superconservatism nor given complete freedom by boundless innovation responsibility for the future is becoming one of the key conditions for modern people to preserve the future for future generations given the threat of possible environmental disasters gradually information about environmental degradation is becoming a more and more public concern and the issue of socially responsible consumption is becoming interesting and relevant not only for consumers but also for businesses and the state which provide goods and services to citizens socially responsible consumption is those actions and decisions on a purchase that are connected with problems of depletion of an ecological resource the transformation of the consumption model involves awareness of the environmental social and economic consequences of decisions made in the process of consumption the desire to eliminate or minimize any harmful effects associated with the consumption of certain goods and maximize any beneficial positive effects taking into account the requests of stakeholders and society as a whole when making appropriate decisions willingness to assume certain obligations and follow certain restrictions conclusion the modern relationship between man and the environment is in a state of extreme disequilibrium this is due both to the growth of loads on its natural part and to the hypertrophy of the technogenic component the challenge of our time is the harmonization of the development of the artificial world with the natural environment processuality flexibility omnipresence of modern technologies change the ways of production and ways of consumption socially responsible consumption involves the purchase use and disposal of products based on the desire of the consumer to minimize or eliminate any harmful consequences of his choice and to have the maximum beneficial effect on society socially responsible consumption is comprehensively formed by raising the level of responsible behavior of the state business and individuals м а абисова социальноответственное потребление в условиях обострения противостояния искусственного и естественного аннотация статья посвящена анализу социальноответственного потребления как вида социальной ответственности обусловленного бурным ростом техносферы те интеграции технологий в общество и культуру понятие «техносфера» отражает свойство техники не оставаться в виде локальных управляемых объектов но формировать целостную среду современное состояние техногенной цивилизации можно назвать кризисом изза вытеснения естественного искусственным техногенное общество как квазиприродное образование воспринимает нормы технической деятельности как естественный горизонт развития событий политика социальноответственного потребления противопоставленная действиям коммерческих корпораций преследующих финансовоэкономические цели за счет общественного благосостояния в частности в вопросах охраны окружающей среды социальной стратификации заявляет о себе как форма гражданского и политического действия ключевые слова искусственное естественное социальная ответственность социальноответственное потребление устойчивое развитие техногенная цивилизация м а абисова соціальновідповідальне споживання в умовах загострення протистояння штучного та природного вступ ххі століття позначене проблемою протистояння двох світів один створений природою інший штучний світ що утворився в результаті діяльності людини метою статті є аналіз соціальновідповідального споживання як можливого варіанту подолання кризи викликаної перетворенням технологій на один з визначальних факторів системних змін у сучасному суспільстві для реалізації даної мети необхідно вирішити такі дослідницькі завдання проаналізувати сутність і місце соціальної відповідальності в системі суспільних відносин розглянути сутність кризи природногоштучного з позиції теорії діалектики показати взаємозвязок споживацького способу життя та технократичного суспільства оцінити перспективи використання соціальновідповідальних видів поведінки для подолання кризи природногоштучного методологія дослідження різноманітність світу техніки що постійно оновлюється її звязок із природними та соціальними проблемами вимагає звернення до філософського принципу взаємодоповнюваності результати дослідження до хх століття формування штучного цілісного середовища призвело до дестабілізаціїдеградації природного середовища для впровадження принципів соціальновідповідального споживання у повсякденне життя необхідно докласти комплекс зусиль з боку держави бізнесу та громадянського суспільства регулювання державою діяльності компаній має відбуватися на добровільній та обовязковій основі за допомогою правового регулювання та розробки національних стандартів з метою переходу бізнесу на стандарти соціальновідповідальної діяльності необхідним видається підвищення стандартів в галузі виробництва та сфері надання послуг перегляд бізнесмоделей та процесів виробництва із зверненням до переваг впровадження циркулярної економіки для громадянського суспільства під впливом соціальної реклами мають посилюватися антиспоживчі тренди обговорення зосередженість на прогресі не має зазнавати абсолютизації потрібна суспільно корисна метаціль надзавдання по відношенню до яких прогрес виступає засобом знаряддям досягнення правильна формула це «нове не заради нового» а «нове для суспільства» висновки процесуальність гнучкість проникнення в усі сфери людської діяльності сучасних технологій змінюють способи виробництва та способи споживання соціальновідповідальне споживання передбачає купівлю використання та утилізацію продукції виходячи з бажання споживача мінімізувати або усунути будьякі шкідливі наслідки його вибору і максимально благотворно впливати на суспільство соціальновідповідальне споживання комплексно формується шляхом підвищення рівня відповідальної поведінки держави бізнесу та окремих осіб ключові слова штучне природне соціальна відповідальність соціальновідповідальне споживання сталий розвиток техногенна цивілізація

вступ в статті обґрунтовується теза що з одного боку правові інститути виконують конкретну законодавчоправову функцію з іншого боку сила закону може блокуватися з політичних економічних чи інших умовних причин у сучасному глобальному правовому соціумі сформувався загальний образ правових інститутів який як єдина модель «накладається» на інші існуючі в ньому моделі нібито «підганяючи» їх під себе «правовий інститут» як такий виконує свою класичну функцію як механізм та сукупність правил що регулюють ту чи іншу сферу діяльності як спеціальний закріплений у нормативноправових актах різного рівня порядок регулювання суспільних відносин заснований на встановлених та забезпечених державою правових засобах глобальний правовий інститут регулює суспільні відносини засновані на встановлених та забезпечених тим чи іншим обєднанням держав правових засобах метою даного дослідження є концептуалізація ключових детермінантів розвитку глобальних правових інститутів та експлікація даного терміна в рамках сучасного соціальнофілософського та філософськоправового дискурсу ключовим завданням стало осмислення феномену глобальних правових інститутів та його впливу на сучасний глобальний правовий соціум соціальнофілософський та філософськоправовий методологічні принципи дозволили розглянути глобальні правові інститути їхню структуру механізми формування соціальних звязків крізь призму сучасного суспільства людини культури релігії права виявити звязки глобальних правових інститутів з іншими явищами права зафіксувати когерентність сформульованих та кодифікованих правових норм з базовими ідеями та моральними цілями що лежать в їхній основі оновити понятійний апарат соціальної філософії та філософії права в частині трактування правових інститутів у результатах дослідження доведено що ключові детермінанти глобальних правових інститутів є відображенням глобальної системи права з точки зору її структури а також логіки її розвитку логічні звязки між структурними ланками глобальних правових інститутів встановлюються за умови створення найстійкішої глобальної наддержавної правової системи такий логічний звязок визначається характером обсягом якістю та змістом суспільних відносин на перший погляд опосередкованих правом у дискусії підтверджено що глобальні правові інститути можуть сформуватися на стику різних наднаціональних та наддержавних утворень обєднань спілок альянсів вони представлені як сукупність юридичних норм що регулюють відносини усередині цих утворень у висновках доведено що ключовими детермінантами глобальних правових інститутів є правове регулювання норм та протоколів через наявність множини глобальних несхожих правових систем несиметричність норм юридичної відповідальності де теоретична та практична моделі юридичної відповідальності часто не корелюють через складність конструкції цілісної глобальної правової системи

introduction groups of people who are systemically marginalised within a society have poorer health outcomes than those who have access to safe living conditions nonhazardous work a living wage and educational health and social welfare institutions these types of resources are frequently considered to be social determinants of health a term that broadly encompasses the conditions in which people are born grow develop live work and age importantly the constellation of sdh that disadvantages a specific groups health may also make its members unable or unwilling to engage in research residential mobility fear of arrest noncomprehension of a national language or a lack of transportation can all be barriers to optimal health and to research participation this has the potential to more deeply entrench health inequities as populations that go unstudied cannot benefit from interventions treatments and services tailored to their needs to build a comprehensive body of knowledge about how sdh operate within a specific social context researchers must begin by considering how various vulnerabilities and oppressions may affect peoples experiences of being recruited interviewed and retained in a study for example members of a population that have suffered threats of deportation may be wary of interacting with people from outside their community and thus be challenging to reach through standard recruitment and retention channels likewise a longstanding history of exploitation of lowresource communities by researchers who were not members of those communities could be another barrier to peoples willingness to participate wallerstein et al 2014 sudhinaraset ling et al 2017 such exploitation by outsiders can have a negative impact that reverberates far beyond the research study itself for example the disclosure of the infamous tuskegee study of untreated syphilis in the negro male conducted by the united states health service from 1932 to 1972 has been found to be correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men a local populations sense of distrust or wariness about exploitation can also arise in the context of communitybased organisations if they are perceived as being overly accountable to political funding sources or other outside interests if populations underrepresented in research choose to enrol in a study research or survey questions developed for mainstream populations may not resonate with them or adequately allow for their experiences which may lead to discomfort frustration or distress as well as a perception among community members that research is unhelpful a lack of consonance between a population and the questions being asked also could result in incomplete or poor quality data and potentially an investment of funds in research that yields few results of interest or improvements in population health under these circumstances the risk of further stigmatisation and negative labelling of communities through the research process is all too real and a problembased approach can create a pathologising lens for researchers that obfuscates the strengths of communities in this article we discuss the a crecer study which examines sdh among latino youth living in an agricultural community we undertook this study with the knowledge that factors which potentially make these youth vulnerable to poor health outcomes may also pose specific challenges to enrolling them as research participants we therefore understood that it was imperative from the outset of the study to develop methodological strategies that actively addressed these challenges in ways that were culturally responsive community engaged and inclusive as we set ourselves to this task we interpolated our own identities in order to be reflexive about how members of this community would see us as outsiders or different from them as well as our shared experiences and commonalities within this articles authorship team which was responsible for the design and leadership of the study two of us identify as mexican american and two as children of immigrants some of our families struggled to make ends meet during our childhoods including by working in the agricultural field economy while others of us had the privilege of financial security prior to attending college a few of us lived in neighbourhoods or attended schools that experienced elevated levels of teen pregnancy and violence none of us grew up in the community where we conducted our research although one author has lived and worked there for over 30 years and another was raised in a similar community in california in designing our approach we understood that the youth we sought to enrol in our study and their families would consider us to be outsiders and therefore our methodological strategies needed to address issues of building trust and rapport with this in mind we generated a series of questions about best practices for conducting research with rural latino youth that shaped our research development and implementation how can we best develop and strengthen community relationships and community engagement in the research what considerations are important when staffing our study and how can we best support staff to do this work how can we engage youths perspectives in this study how can we develop culturally appropriate research protocols below we present the methodological strategies developed in response to these questions and used in a crecer to recruit and retain a longitudinal cohort of 599 youth we begin with a review of the literature to situate our work methodologically within other efforts to engage marginalised and oppressed populations in health research as well as conceptually at the junction of adolescent health sdh and rural latino youth next we provide an overview of the study purpose and settings to contextualise the community in which we work we then detail our methodological strategies as they relate to our best practice questions we conclude by reflecting on our experiences undertaking this research including the importance of sustaining a focus on community strengths and implications of this process for future studies methodological approaches to engaging marginalised populations in health research research with members of marginalised populations has a long and troubled history that emphasises the importance of thoughtful engagement with such groups certain populations may be difficult to recruit and enrol in health studies because of wellfounded misgivings about the trustworthiness of researchers but others may be elusive because public acknowledgement of membership in the population is potentially threatening this frequently includes people who are at risk of arrest harassment or violence due to a specific activity or characteristic under these circumstances participating in research may take on additional risk either because the topic of the study identifies someone as having a vulnerable status or because being involved in a study could make someone easier to find or to prosecute if there were a breach of confidentiality multiple methodological approaches have been developed in epidemiologic research to grapple with such challenges respondentdriving sampling for example constitutes one strategy that engages participants through their trusted social networks a design that uses structured incentives and chainreferral methods to reach hidden populations as its name implies rds offers a recruitment strategy yet does not necessarily address issues of marginalisation or vulnerability at other stages of the research process another methodological approach that has been adopted for public health research is communitybased participatory research a defining feature of cbpr is the cultivation of inclusive partnerships with shared decisionmaking and ownership of the research process building trust and respect between researchers and communities is foundational to successful cbpr work yielding research that addresses locally identified needs recognises a communitys assets supports colearning between diverse partners and is positioned to address health disparities cbpr is particularly effective in informing the development of interventions that address sdh and cbpr methods have been applied to numerous public health issues with successful examples found in areas ranging from chemical exposure for nail salon workers to hepatitis b vaccination for research on adolescents youth participatory action research is a form of cbpr that aims to engage youth directly several ypar publications have focused on the opportunities for and challenges encountered in building empowerment and leadership development with youth as well as defining a feasible and actionable research agenda in this article we describe our approach to designing and implementing the a crecer study as guided by best practices in communityengaged research inspired by cbpr the processes of cbpr have been explicated in detail and there are manuals guiding the use of cbpr approaches however applications of the cbpr framework may vary across stages of the research and some research teams may not be equipped to fully adopt cbpr methods which can be intensive at all phases we recognise that we did not follow the cbpr framework to the extent necessary to exemplify this methodology in its fullest sense however through our awareness of our positionality as outsiders to the community and the concomitant need to build trust and rapport we understood the benefit of incorporating the principles of respect for community stakeholders and responsiveness to community needs despite increased use of communityengaged methods in research there are few examples in the literature outside of cbprspecific studies that explore how to establish multisectoral partnerships build trust and engagement among partners and advance a thoughtful research agenda that integrates the insights of local perspectives with research expertise our goal in this article is to elucidate our efforts in these domains before providing an overview of our study purpose and setting we situate our work conceptually within the literature on latino youth in agricultural communities adolescent health social determinants and rural populations the health of adolescents is strongly shaped by sdh including proximal sdh such as family education employment and peers as well as structural factors such as city ordinances local criminal justice policies and national legislation there is global and national recognition that the health of young people has generally been neglected leading to young adults surprisingly poor health in the words of the institute of medicine the lancet commission report on adolescent health and wellbeing highlights the importance of addressing inequalities in health and wellbeing in socially and economically marginalized adolescents including ethnic minorities among other groups eliminating health disparities in the united states constitutes a national goal reflected in healthy people 2020 and addressing sdh is a core strategy for achieving this goal the ability to improve adolescent health is limited by a lack of technical knowledge and capacity to intervene including a dearth of evidence regarding the effects of sdh on youth and a shortage of evidencebased interventions and policy the scarcity of research is most evident among the youth who are most affected by inequities including ethnic minorities lowincome youth and the children of immigrant parents latino youth living in rural areas lie at the intersection of these categories most of these youth grow up in immigrant families whether as immigrants themselves or as children of immigrants and frequently one or more members of these families is involved in lowpaid seasonal agricultural labour the existing research on latino youth has focused primarily on urban latino populations but the few studies that have focused on rural youth in the united states have reported similar or higher levels of risk behaviour particularly alcohol and other substance use as well as lower uptake of preventive sexual health services compared to urban youth these studies indicate a clear need for indepth longitudinal research focused specifically on rural latino youth while proximal individuallevel factors associated with risk behaviours may be similar among rural youth to those found in urban populations current intervention approaches do not address sdh specific to latino adolescents living in rural areas such as the influences of the agriculturebased economy and the dominance of mexican migration understanding these underlying contexts and how they might be contributing to health disparities is recognised as vital to achieving substantive improvements in health outcomes notably the centers for disease control and prevention has identified addressing urbanrural health disparities related to health care access as a national priority the relationships of structural and interpersonal factors in rural environments to poor health outcomes for latino adolescents therefore constitute a largely unexamined but vitally important research area however conducting rigorous research with rural youth presents numerous challenges that are common to working with other populations facing health disparities our goal in a crecer from a methodological perspective was to address these challenges by developing a set of best practices for engaging the local community and being inclusive in our approach to conducting rigorous research that would yield knowledge that was useful and actionable we turn now to the study purpose and setting followed by a discussion of our methodological strategies and innovations for developing and strengthening community relationships staffing the study engaging youths perspectives and developing culturally appropriate research protocols study purpose setting and sample a crecer was designed to examine the multilevel factors that influence latino adolescents wellbeing as well as the onset of youth violence and sexual health risks associated with teen childbearing the study which began in 2014 focuses on the transition from middle school to high school a critical developmental period thus examining trajectories through middle adolescence recruitment began in november 2015 and the full sample was enrolled by march 2017 data collection is ongoing with a cohort of 599 youth study participants complete a questionnaire at baseline and then every six months over the course of two years all study procedures including written consent provided by study participants were approved by the rti international institutional review board a crecer is being conducted in salinas california which offers a vibrant environment for a communityengaged study of the protective factors that influence rural latino adolescent trajectories salinas is a migration destination for agricultural sector employment and is home to multiple generations of immigrants eightynine per cent of salinas public middle school students identify as latino nearly all of mexican origin salinas has a strong history of community organising for farmworker rights engaged families and rich cultural ties however alongside these assets youth experience high rates of entrenched poverty gang exposure and teen childbearing a crecers approach to the cultivation of community partnerships study staffing engagement of youth perspectives and development of research protocols contributed to the successful recruitment of our targeted study sample figure 1 presents a diagram of enrolment efforts starting with recruitment of 1099 8th grade youth from the four middle schools that comprise the school district with which we partnered for this study youth were approached on school campuses by bilingual research staff members under the leadership of the project coordinator with input from youth advisers engaged during the formative research stage staff created a brief interactive pitch for the study that they could deliver in classrooms and to small groups of students in schoolyards during recruitment eligible youth were asked to provide contact information for a parent who could provide permission for them to enrol in the study the telephonebased verbal parent permission process was directed by a script that allowed for an interactive conversation with the study staff member initiating the permission process these conversations were held in english or spanish depending on the parents preferred language as depicted in figure 1 study staff successfully made contact with 870 of the 1081 households a parent gave permission for their child to participate in 92 per cent of cases the 600 youth who enrolled in the study did so with an average of 49 contact attempts from recruitment through enrolment as presented in table 1 the staff recruited a sample of youth that met the study objectives of balance between male and female youth geographic distribution of residence within the community and variation in sociodemographic indicators nearly all youth identified as latinx mostly of mexican origin half of participants had at least one parent employed as a farmworker 60 per cent resided in crowded housing conditions and 42 per cent had mothers who did not complete high school 1 percentages add to 100 as participants may have more than one origin given these multiple vulnerabilities we see the robust number of youth interested in study participation the willingness of their parents to permit children to be enrolled and the achievement of an ambitious sample target as evidence that our efforts to undertake best practices for communityengaged and inclusive research were well received we turn now to describing those efforts conducting research with rural latino youth a crecers approach as noted from the outset of a crecer we challenged ourselves to respond to a series of questions about best practices for conducting communityengaged and culturally inclusive research with latino youth living in salinas understanding our status as people who were not members of this community we firmly believed in the importance of undertaking research that respected community norms listened to community voices and addressed questions of community concern in the following sections we detail the methodological strategies and innovations we generated and implemented in our efforts to build trust and rapport throughout the design of the study development of the research protocols and recruitment of the study sample we begin with our approach to the first question how can we best develop and strengthen community relationships and community engagement in the research community relationships and engagement development of the proposal the a crecer study developed as a partnership between the principal investigator who is based in san francisco and the monterey county health departments youth violence prevention coordinator who has coordinated teen pregnancy prevention youth violence prevention and other prevention efforts in salinas for over 20 years through her work the yvpc has established relationships with diverse leaders and agencies working to improve adolescent health in the community in 2011 she learned of the pis research with latino youth in san francisco and invited her to present at the natividad medical center grand rounds this initial meeting led to interest in developing a collaborative research proposal that could examine the intersection of sexual health and youth violence in salinas over the subsequent 18 months the pi and yvpc established regular professional interactions exchanging research articles discussing the community environment in salinas and planning the grant proposal as a longtime and wellknown health department employee with extensive professional network ties in the community the yvpc was able to actively facilitate early support for the project locally and build connections between the pi and a diverse range of local leaders including identifying a local coinvestigator for the study at natividad medical center to inform the research design and refine the research questions in the grant proposal the pi and yvpc met to discuss potential study objectives and the types of community perspectives that could provide groundlevel insights into the core issues and concerns affecting youth in salinas in order to learn about those perspectives they decided to conduct a set of informational interviews with community stakeholders drawing on the yvpcs decades of work in salinas and strong relationships with community leaders and organisations they identified key individuals and groups including directors of youth leadership and gang prevention programs a middle school teacher former gang members working to stem gang involvement a local city council leader community health clinicians and social service providers when conducting the initial interviews they adopted an iterative strategy of asking the key informants to whom they spoke whom else they should approach to discuss the study in total they conducted 12 informational interviews some of these individuals joined the studys community advisory board and many agreed to support a crecer as partner organisations to facilitate parent engagement and local visibility the pi and yvpc also solicited youth input through a discussion with peer leaders at a local high school in addition to these joint meetings the yvpc helped to mobilise support with the school district the mayor the local congressman and the community alliance for safety and peace a coalition comprised of over 50 agencies working to reduce violence in salinas this process was crucial to the design of the study as the research questions and approach reflected ideas and reactions offered by the individuals interviewed most importantly the research concept resonated with community stakeholders and stimulated great interest in supporting an effort to generate highquality data to guide future prevention policies and programs many stakeholders discussed communitylevel influences on youths trajectories including gender and family norms housing instability and employment structures for farmworker families intergenerational gang involvement and differences in access to community resources by immigrant generations these factors informed our approach to identifying protective and risk factors in youths social and structural environments the a crecer grant proposal was first submitted to the national institutes of health in 2012 resubmitted in 2013 and funding commenced in august 2014 community relationships and engagement school districts and community stakeholders once a crecer funding began the pi and yvpc focused on strengthening partnerships with the school district and community stakeholders they jointly attended multiple meetings with school district administrators during which they presented the project emphasising how the study goals were aligned with those of the school district for supporting student success they also met with individual school site teams including principals counsellors and parent liaisons the process of soliciting input from a diverse set of community leaders at the proposal design stage established foundational relationships that supported the development of a crecers cab convened by the yvpc and the coi the cab has met quarterly since the inception of the study when recruiting members for the cab the yvpc and coi contacted a variety of colleagues working in youth development teen pregnancy and violence prevention who were well respected within the community and known to be credible and trusted among local groups tapping their networks accelerated development of the cab attracting engaged and enthusiastic members current cab membership mirrors the racial and ethnic demographics of salinas and includes parent representatives school representatives a grassroots organiser of women working in agriculture salinas service providers the local hospitals codirector of community medicine and teen radio coordinator of the local bilingual radio station among others the cab advises the study on outreach strategies to parents as well as recruitment and retention approaches for example cab members suggested the development of a website featuring the logos of member organisations in order to strengthen the perceived legitimacy of the study and deepen community connections subsequent feedback from participants parents indicated that these endorsements boosted a crecers credibility as a study that was genuinely invested in the local community in addition a crecer data are presented to the cab for input on interpretation and analysis which is a particularly important validity check for the members of our team who are not based in salinas to achieve language inclusivity at the meetings simultaneous translation in spanish is offered staffing the study communityengaged professional development in addition to valuing the importance of grounding research in community partnerships we asked ourselves what considerations are important when staffing our study and how can we best support staff to do this work a focal point of our approach to this question has been our commitment to employing young adults from the local community as research staff particularly because none of the senior staff members grew up in salinas and we felt it was important to include local voices in our daily work by bringing community members to the table as salaried employees encouraging dialogue and soliciting input we hoped to increase accountability of the research to the people it would ultimately affect furthermore it was congruent with our ultimate goal as a study seeking to support resilience and opportunities for youth to invest research funds in creating jobs that could provide exposure to career paths in public health research to current undergraduates and recent graduates from the community to maximise visibility a crecer job announcements were listed online posted on local community college and state university job websites sent to the youth collaborative of monterey county and disseminated by cab members in an effort to reach potential applicants who might not otherwise have considered working in research job descriptions emphasised the desirability of skills such as knowledge of local culture and ability to establish rapport with youth during the period from the study launch to enrolment of the full cohort a crecer employed a total of seven salinasbased staff members including five originally from the broader salinas valley and two from similar communities in california six of the seven members of the staff identified as latinx and all were bilingual in spanish and english five staff members had attended a local college or university for five staff members a crecer was their first job upon completion of an undergraduate or masters program as well as their first experience working in research extensive training in research methods was provided to the a crecer research staff inperson sessions facilitated by san franciscobased staff were valuable not only in terms of building capacity and skills among the newly hired junior members but also in providing opportunities for the junior members to share knowledge about youth in salinas with the more senior members and for team bonding trainings included topics such as ethics and adherence to institutional review board protocols effective recruitment techniques quantitative interview administration indepth qualitative interviewing adolescent development and health issues sdh research and how to provide facilitated referrals for distressed participants several presentations of local public health data by monterey county health department staff strengthened knowledge of adolescent health inequities trainings were ongoing and responsive to the needs of the junior research staff for example when staff members remarked that numerous participants were worried about firearm incidents that had taken place in town an adolescent health physician from the research team conducted a session on techniques for supporting youth exposed to violence and selfcare for staff working with vulnerable youth incorporating youths perspectives the question how can we engage youths perspectives in this study has been central to a crecer from its inception as a means of learning about youths perspectives early in the study we convened eight focus groups with youth recruited from participating middle schools as well as from salinas youth leadership programs recruitment for these groups was conducted using strategies developed with input from the principal or viceprincipal at each school as well as the cab information sessions held on campus at lunch offered students an opportunity to learn about a crecer sign up for a focus group and talk informally with members of the research staff to secure parental support for the focus groups we solicited input from local implementers of familybased prevention programs and met directly with parents during regularly scheduled parent meetings at each of the middle schools where the focus group recruitment was to be conducted at each parent group the study staff introduced a crecer and its objectives modelled a focus group discussion with the parents having them role play the activities that would be conducted with participants during the group discussed parent permission approaches solicited input on what parents saw as the greatest needs for youth in the community and offered an interactive educational session on adolescent health issues at a future date these presentations were either bilingual or conducted in spanish each presentation was led by one member of the san franciscobased team or the local coi and a bilingual and bicultural field coordinator who was from the salinas community a total of 42 youth participated in the eight focus groups which followed an innovative structure rather than posing questions to the entire group youth were engaged in a series of activities aimed at generating conversation in the first activity participants used stickers to rank their relative agreement or disagreement with statements about family gender and relationships they were then encouraged to discuss why and how strongly they agreed or disagreed with each statement in the second activity participants drew maps of their community with prompts to include their home school recreational areas and transportation methods and to indicate places where they felt safe and unsafe participants then presented their maps to the group indicating points of interest and providing further details focus group findings informed questionnaire development and recruitment strategies for example youths strong orientation towards family as their primary source of health guidance and modelling pathways to adulthood prompted us to expand the scope of measures related to family included in our questionnaires in response to requests from parents of focus group participants to have an opportunity to learn more about the research and to contribute to the design of the parent engagement and permission procedures for the cohort study the salinasbased coi led a meeting for eight parent leaders from two middle schools two of whom subsequently joined our cab we also convened a youth advisory board to provide guidance on study activities in addition to conducting activities to engage youth in understanding the purpose of the research the yab served to inform the development of the study name and logo through an art workshop the design of study flyers the development of recruitment messages that would resonate with youth and the development of the referral guide for youth services and activities in salinas that is distributed to all participants during their study visits development of culturally appropriate research protocols our final best practices question how can we develop culturally appropriate research protocols is of utmost importance to our team we aim to conduct rigorous research that will yield knowledge that is useful and actionable to those directly concerned with the health and wellbeing of youth in salinas and similar agricultural areas it is therefore tremendously important that youth and their parents feel comfortable with and preferably enthusiastic about participation in the study to this end the a crecer team actively solicited and incorporated information regarding local culture terminology and norms to inform recruitment and interviewing procedures for the cohort study we drew heavily on the knowledge and insights of the salinasbased staff members led by the project coordinator particularly regarding how to best approach youth and their parents about study participation staff framed the study as exploring what it is like to be a teen in salinas and encouraged students to consider participating as a way to share your voice and contribute to the community the staff also noticed that peer leaders could quickly set the tone for whether youth would express interest in study participation and they consciously adopted strategies of matching the tone of exuberant students generating a sense of shared enthusiasm while also telling students that they could join the study with friends and come to interview appointments together as recruitment proceeded the staff noted that they had developed ways of adjusting recruitment to different environments groups and even schools early on in their recruiting the salinasbased staff discerned that both youth and their parents had concerns about what was meant by a research interview realising that many people think of an interview in terms of what is seen on television news or talk shows the staff began proactively explaining the quantitative interview more concretely for example they described the survey as multiple choice and reiterated that youth could skip any questions they did not want to answer they also specified that the answers were entered directly into a computer which youth and parents alike found reassuring often telling staff that they had been concerned that youth would be asked to write down responses these explanations also helped parents understand a crecer as a research study as opposed to an afterschool program in addition the staff learned that parents were sometimes hesitant to enrol their children in a crecer because they feared negative consequences for their child if they were unable to bring him or her to an interview appointment the staff therefore made sure to explain to parents that children were never penalised for missing appointments they also clarified that parents did not need to stay on site during the interview recognising that many parents had multiple responsibilities and could not spare the time to wait these efforts to assuage parents concerns yielded not only higher numbers of enrolled study participants but also a sense of pride among students and their parents who began to see study participation as a way of contributing to the community and benefiting youth building on this perspective we partnered with local school officials to arrange for youth to receive community service hours for their participation in a crecer focus group findings also informed procedures for recruitment and obtaining parent permission for the cohort study based on parent feedback obtained through recruitment for the focus groups the staff developed a telephonebased verbal parent permission process that ensured parents had opportunities to talk privately by phone and also to meet staff in person either at our study office or at one of the five communitybased interview locations in advance of having their child enrol in the study concerns about literacy were also raised by youth during the focus groups which confirmed our decision to use audio computerassisted selfinterviewing for the more sensitive questions and staff emphasised during recruitment that youth were not required to read or write on their own in order to participate finally we made use of multiple opportunities to build legitimacy within the community for example on two occasions salinasbased staff members were interviewed by a teenled youth radio show that aired on a bilingual radio station as a means of raising awareness about the study and demonstrating engagement with the community discussion when conducting studies on sdh in communities that experience inequalities and marginalisation researchers must be mindful of how the same conditions that may shape health disparities may also affect whether and how community members engage with research we take a crecers ability to engage parents and school partners achieve enrolment targets and sustain high retention to date as indicators that our approach has been successful not only by research but also by community standards importantly this engagement has also helped us to ensure that our research focus is well aligned with parents and youths priorities and community objectives regarding the promotion of adolescent wellbeing while a crecer brings attention to challenges faced by youth in salinas and an evidence base for tailored solutions to address these challenges the study team has been cognisant of the potential for reinforcing a negative image of salinas through the study findings in focusing research on two of the most pressing public health problems facing salinas teens we have strived to also acknowledge the importance of understanding resilience among adolescents who are engaged in school volunteer in a community to which they feel attached and are connected to families with whom they share strong bonds it has been a priority of the a crecer team to be vigilant about slipping into a problembased characterisation of atrisk youth in a disadvantaged community and instead choosing to align with a growing movement to investigate what helps a community thrive building on the strengths of its residents and a proud cultural heritage collaboratively the research team has challenged itself to incorporate protective factors such as school connectedness resilience and a future orientation towards the measures of influences that lead to a positive trajectory this focus grew naturally out of the strong communityresearch linkages forged by intentional community engagement during the formative stages of the study this more balanced approach respects and nurtures growing community pride and has been welcomed by cab members yab members and local stakeholders our team is fully committed to the approach described in this article we recognise that such engagement requires time resources and a willingness of all parties to listen be transparent and remain openminded it has been important and meaningful in a crecer for the san franciscobased researchers to spend entire days in salinas in an effort to better understand the context in which the study takes place meet face to face with community partners and problemsolve on site with the local staff likewise the salinasbased research staff have worked evenings and weekends in order to maximise their ability to connect with parents teachers and other community members shared their observations and experiences in order to inform the aspects of the research that can be adapted to the local culture and maintained the research protocols that need to be standardised with equanimity and good humour within a study that focuses on rural latino youth many of whom contend with immigration acculturation poverty and other issues that could potentially affect health outcomes such efforts to create communitylevel trust and buyin are key conditions for the production of highquality data that can be used to support resources solutions and paths forward conclusion work that will meaningfully affect sdh must be conducted in ways that not only acknowledge community challenges but also recognise and build upon resilience taking this approach promotes a growing community awareness of the barriers resulting from sdh and the drive to address these factors to further the development of a safe and thriving community in the case of our research with rural latino youth building in the active participation of the actors in charge of the settings where adolescents live such as educators and parents was crucial indeed developing these community partnerships and working to maintain them through accountability and transparency helped expand the reach of our study to a greater number of residents thereby promoting community engagement and expediting participant recruitment likewise we found that by engaging local opinion leaders including youth early in the research process support for the study spread through multiple channels minimising the barriers that could have arisen for community members who feel wary of outsiders and instead prompting parents to come forward and enrol their children in what was perceived as a positive communityfocused activity despite their importance building community partnerships and providing avenues to hear the voices of a study population is not sufficient in order for research among vulnerable groups to be as relevant and ethical as possible community perspectives and expertise must be deeply integrated into the study itself two channels for this are research staff and protocols the heart and soul of a study by hiring young people from the local community and valuing and building their knowledge we hope not only to improve the quality of our current work but also to help train the next generation of scholars similarly by designing protocols that are culturally appropriate and respectful we aim to broaden the communitys understanding of research degree of comfort engaging with it and expectations that it should lead to solutions that will be feasible and effective in working towards these goals we hope that a crecer will live up to its namesake by providing opportunities not only to learn but for all of us involvedyouth community and researchers to grow

the health of adolescents perhaps more than in any other period of their life is shaped by the social determinants of health sdh the constellation of sdh that disadvantages a specific groups health may also make members of that population unable or unwilling to engage in health research to build a comprehensive body of knowledge about how sdh operate within a specific social context researchers must design studies that take into account how various vulnerabilities and oppressions may affect peoples experiences of being recruited interviewed and retained in a study in 2014 we initiated a prospective cohort study with latino youth declaration of conflicting interest the author s declare no potential conflicts of interest with respect to the research authorship andor publication of this article

introduction the life of this world is not concurrent often changing as well as social life this change can be a fundamental social shift as happened in the relationship between men and women the roles and status of the husband and wife in the family that society has accepted and believed in have changed and shifted the husband thought to be the leader can be replaced by his wife to lead the family this shift not only changes or even replaces the tradition that previously existed among the indicators of this shift is the emergence of the phenomenon of the household father or stay at home dad several studies have been conducted on husbands leadership including those seen from a gender perspective from a gender perspective leadership is not the husbands absolute right but the wife also has the opportunity to become a family leader husbands leadership is considered a product of a patriarchal culture that is not genderfair thus the concepts and manifestations of gender relations are dynamic and flexible considering the changing sociocultural conditions zamroni ishaq researched husband and wife leadership in the family from the point of view of classical and contemporary mufassir in his research he said that the husbands leadership over his wife is based on two theological matters meaning that it is an innate trait given by allah swt that one should not envy one another because each has been given their specialties other research is regarding the permissibility of wifes leadership in the family from a gender perspective meanwhile basyars research focused on the relationship between husband and wife in a review of islamic law and law number 1 of 1974 his study found that the husbands role as the head of the family has not changed while the wifes role has shifted because her role has increased in the public sphere meanwhile marta widyawati focuses her research on the impact of a shift in earning a living on the crisis of her husbands masculinity such as loss of independence selfconfidence courage assertiveness and emotional control muhammad amanuddin in his research emphasizes that the husbands leadership can be eroded if he does not carry out his obligations so to anticipate the husband must be able to carry out their obligations properly meanwhile chaula luthfia found multiple and unequal roles for a wife namely being a housewife and earning a living ikhma zurani in his research found that businessmens wives have the power to decide business and family financial affairs siti khoirotul ula discusses leadership in the family with the theory of mubilah the research shows a mutual relationship between husband and wife in carrying out their obligations so there is no dominant relationship between husband and wife meanwhile agus hermanto in his research criticized feminist thinking about the rights and obligations of husband and wife he concluded that what was put forward by feminists was not absolute but casuistic and the genuine concept of islam would bring problems if implemented correctly all of the research that has been described above has an object of study that is different from what the author will do this paper is focused on answering a question on what are the negative consequences of a shift in husbands leadership in the family on household goals method this qualitative research uses the descriptive analysis method the approach used is a normative and sociological legal research approach data was collected using a literature study technique then the data were analyzed using qualitative data analysis techniques studying reducing correcting tabulating categorizing interpreting and drawing conclusions results and discussion economic problems in the family often cause shifts in husbands leadership husbands in this case cannot earn a living while wives have the opportunity to work and even have a more significant income finally the husband decided to become a housewife according to psychologists a householder from a psychological perspective will feel that he is a man who has had bad luck for several reasons one of which is because he has just been fired from a job or has been ill for a long time in addition being a housewife creates pressure or being cornered frustrated and useless sometimes leading to suicide the wifes more money and career skyrocketed often trigger a fight the fame or success of a wife accompanied by a lot of money will intimidate the husband coupled with the arrogant attitude of the wife who feels she has a better career and a lot of income it often becomes a psychological problem for the husband when i finally met my inlaws my husband became embarrassed in addition to the psychological problems above household leadership will also be problematic husbands whose actual status and role as leaders in the household are questioned and their status is challenged carrying out the part of the households father as if he were a leader is considered illegitimate as a result the husband is no longer confident that he is a leader under these conditions it is challenging for the husband to be able to carry out his role and function as the head of the household on the other hand wives who work and pursue careers outside the home with large incomes seem to have a basis for legitimacy to be able to take over leadership status and determine the direction and decisions of the household in other words leadership status shifts from husband to wife or at least between husband and wife have the same and equal status when household leadership shifts or is problematic and does not function as it should it is certain that all rules and laws relating to the household will not be implemented properly there will be overlapping rights and obligations as well as noble and noble ideals from the household will not be achieved in other words the household will be a household that is not sakinah mawaddah wa rohmah another negative consequence is the lack of harmony in the relationship between husband and wife a wife who is busy with activities outside the home with all her problems and burdens at work often runs out of energy and energy to be able to serve her husband well not to mention that there are assignments out of town for days on end that the husbands needs cannot be served properly and optimally coupled with the problems faced that are not resolved at work and then brought home wives with tired conditions with a myriad of work problems tend to be emotional as a result the relationship with their husbands becomes less harmonious and they are always bickering it is not uncommon for quarrels to end in divorce research conducted by the international organization who in 2005 showed that the number of female heads of household has increased from year to year in the caribbean the number of female heads of household is latin america sub saharan africa central asia north africa west asia and south asia india even in central america as many of refugee families are supported by women this is confirmed by data from the central bureau of statistics in 1999 which stated that 132 of households in indonesia were headed by women the data presented above indicates that there has been a shift in the husbands leadership among some households this is indicated by the exchange and shift of roles between husband and wife the husband who previously had the role of earning a living now takes care of the domestic affairs of the house and vice versa the wife who previously carried out the domestic role at home carries out the role of the husband in earning a living this exchange of roles can eventually lead to a shift in the husbands leadership in some cases the father of the household the inability of the husband to meet the economic needs of the family is the reason someone decides to become a father of the household such is the case in tkw families where the role of the husband as the main breadwinner in family needs is replaced by the wife while the husband is in charge of taking care of the children and doing household chores another case is experienced by mr sri mahamat maaji a graduate of yogyakarta state university who has decided to switch roles with his wife since 2002 in order to maintain the continuity of family life while his wife has a career as an office employee functional structural theory according to the functional structural theory as proposed by parsons that the family will be in a state of harmony and balance if family institutions or institutions are able to maintain stability in the family members a family structure that can carry out its functions properly while maintaining the values and norms that are upheld by family members will create stability in the family itself parsons believes that there are several conditions that must be possessed by a social system namely first structured that is a system must be well organized and able to work harmoniously with other systems second there is support from other systems third it can meet the needs of the actors proportionally fourth create a participative atmosphere from the members fifth controlling negative behavior sixth being able to control conflicts that lead to chaos seventh there is language among the social systems that are important and also determine the pros and cons of social life in society is the family a good family will have a positive impact on the good social condition of the community on the other hand when a family has a problem it will have a negative impact on the social damage of the community the family as a system has established accepted norms and values when a family carries out its functions properly it means that the family adheres to the values norms and rules that apply however families who are unable to carry out their roles and functions properly will cause conflict friction and other negative impacts among the established values accepted in society especially muslims is regarding the husbands leadership status in the household the husbands leadership shift and its negative consequences the shift in husbands leadership that occurs amid some people is the impact of a change in the way of thinking among them especially regarding the relationship between husband and wife in the family they believe that family leadership is not the husbands prerogative but the wife also has the same rights and opportunities in addition the economy is also one factor that encourages exchanges and shifts in the role and status of leadership in the family a husband who for one reason or another cannot make a living and is replaced by his wife while he carries out his wifes domestic role this shift has negative social and psychological consequences for the family the failure or dysfunction of the role of the family institution causes this the powerlessness of family institutions in solving problems due to deviations committed by leaders and or family members from the status and roles that have been regulated and determined for a family to function optimally it must have a structure structure is an organized set of social relations involving members of a society or group a structural aspect in the family structure can function to unite families in one container there are three main things which are related to each other in the family structure which is 1 social status this can be breadwinners homemakers toddlers school children or teenagers 2 social function the role of parents in the family namely the instrumental role expected to be carried out by the husband or father and the emotional role usually held by a wife or mother figure this role has the function of fulfilling the love tenderness and affection needed by family members if there is a shift and division of functions that are not firm and clear it will disrupt family integrity and harmony functionalism theory seeks to explain how the system always functions according to the role that exists in society 3 social norms social norms are rules that describe how a person behaves in his social life as well as social functions social norms are standards of behavior expected by each actor the nuclear family like other social systems has characteristics in the form of role differentiation and a clear organizational structure b functional aspect functionality of the structure can be implemented if there are 1 role differentiation each family member should have a clear role to play 2 allocation of solidarity division of relationships between family members based on love closeness of relationship and strength 3 economic allocation distribution of goods and services within the family the division of tasks must also exist in the family financial sector especially in production distribution and consumption 4 political allocation the distribution of power allocation in the family these conditions will be fulfilled if each actor carries out his role following the provisions of the organization in which he is located based on the structuralfunctional theory above structure in the family is one of the most important things because of the importance of its existence it will affect the functioning of the family according to scholars such as zamakhsyari alusi and said hawa the husband is a leader for his wife in the family this husbands leadership is based on alquran surat annisa verse 34 and some hadiths of the prophet saw when the husband carries out his status role and function as a family leader while the wife and other family members carry out their respective status roles and functions harmony will grow amid the family also sakinah mawaddah wa rohmah will be realized it becomes a problem when there is a shift in status roles and functions especially in matters of family leadership the husbands leadership status is questioned and even sued because his wife makes a living for the family if this happens dysfunction can occur namely the husband is no longer confident in carrying out his status and functioning as a leader the husbands lack of selfconfidence can cause the roles and functions that should not be carried out this can result in overlapping roles and functions and impact other family members status roles and functions ritzer said that the family is a social system consisting of parts that are connected in a balanced unity changes in one will affect the changes in the other this shift in the husbands leadership can cause instability in the family system and impact the familys failure to carry out its functions namely socialization and affection one of the causes of failure in carrying out family functions is the existence of a particular situation in the family including because the wife works and longs for a higher position than the husband and the husband and wife often leave the house because they are busy outside similarly kartini conveyed that several cases of juvenile delinquency were caused by the failure of the mothers role as educator and protector in the family the shift in husbands leadership is a form of not working the division of roles properly amid the family which in the end has some negative consequences both psychologically the husband loses his selfconfidence and sociologically where the relationship between husband and wife becomes disharmonious which ultimately has an impact on reduced parental affection for children and conflict between husband and wife these negative consequences eventually lead to not achieving the households goals to the fullest there are several functions that a disharmonious family cannot carry out among others a socialization function it is the function of education namely educating children from childhood to form a noble personality in children however because of the busyness of their parents sometimes they are negligent in carrying it out and rely more on other parties in carrying it out b protection function the function of protection serves to protect all family members from various hazards that threaten both physically and psychologically c affective function the function of affection must be given by parents to children they will vent it elsewhere without warm communication between family members d recreation function the function of recreation is that the family must function as a place of entertainment for its family members however because it is rare to meet among family members this function does not work the shifting of the four family functions above is a factor causing the familys goals and aspirations to be not achieved one of them is the presence of juvenile delinquency in the family another negative consequence of the husbands shift in leadership is the less harmonious relationship between husband and wife the wife after work runs out of energy to serve her husband properly and optimally in addition another negative consequence is the opening of opportunities for infidelity husband and wife who are not harmonious and have no warmth at home seek escape outside plus meetings with other men that are so intense that location love occurs conclusion the shift in husbands leadership among several families is a social reality of indonesian society this has several consequences including giving birth to several adverse effects psychologically and sociologically so that the ideals and goals of household cannot be achieved optimally

this study aims to understand more deeply the shift in husbands leadership and its negative impact on the family this qualitative research uses the descriptive analysis method the approach used is a normative and sociological legal research approach data was collected using a literature study technique then the data were analyzed using qualitative data analysis techniques studying reducing correcting tabulating categorizing interpreting and drawing conclusions this study found that social changes caused a shift in the husbands leadership harming the family psychologically and sociologically

introduction the health of brazilian children has constantly and significantly improved in recent decades data from the 2010 census recorded that infant mortality in the first year of life had nearly halved in ten years in 2000 for every thousand live births 297 babies died before their first birthday while the figure in 2010 was 156 regarding anthropometric indices stunting decreased during the period between 2003 and 2009 from 157 to 97 among white children and from 205 to 117 among blacks this is an important achievement for the advancement of human capital investment as it is well known that early life conditions have persistent and profound impacts on an individuals later life in terms of chronic diseases education and wages the progress in maternal and child health that brazil is achieving is the result of important changes over the last three decades in several domains brazil has experienced major economic growth with an increase in gross national income per capita of 472 only between 2004 and2012 the financial gap between rich and poor has become less pronounced and cash transfer schemes have increased family income among the poorest groups from an educational point of view the major investment in elementary schooling during the 1990s has increased educational attainment among brazilian mothers in parallel brazil has experienced an important decline in its fertility rate the country has also seen great improvements in terms of urbanization specifically in terms of health policy in the late 1980s a threetiered healthcare system of private security social security and charitable institutions was replaced by a universal taxfunded national health system primary health care became the cornerstone of the system and the geographical targeting of care led to the setting up of family health teams in the neediest areas of the country moreover maternalchild health policies in brazil underwent profound change a vertical health program that started in the 1980s paism for the promotion of breastfeeding oral rehydration and immunizations as well as the implementation of many national and statewide programs have improved childrens health and nutrition despite all the progress the prevalence of stunting is much higher than in wellnourished populations indicating that there is still room for improvement moreover even if the brazilian case can be thought of as a successful example the speed of the improvement has not been uniform and important differences still remain on a geographical level differences between rural urban and metropolitan areas continue to exist which are mainly explained by the heterogeneity in sanitation and access to or quality of the health system despite convergence to a national standard level the prevalence of stunting has been historically much higher in the poorest regions than in the wealthier southeast also although the racial gap in nutritional indicators has clearly decreased white children still receive better nutrition than blacks while acknowledging regional and racial disparities the main focus of this paper is to study the importance of family structure as a source of inequalities in childrens health outcomes our hypothesis is that children raised by a lone mother are more likely to have lower heightforage zscores after controlling for other socioeconomic and demographic characteristics than children growing up with both parents several mechanisms may be at play lone mothers may suffer higher levels of stress because of the difficulties dealing with the role of sole carer and primary breadwinner at the same time lone mothers cannot count on the help and monitoring of a cohabiting partner similarly they may have more difficulties obtaining care for their children because of a smaller extended family all these mechanisms may explain the poorer health outcomes for children raised by a lone mother as far as we know this is the first time that family structure has been taken explicitly into account when analysing childrens health inequalities in the case of brazil if our hypothesis is confirmed our results have important implications both for social and health policy according to data from brazilian censuses the number of children under the age of 14 that did not live with their father multiplied almost fourfold from 1980 to 2010 indeed in brazil nearly 1 out of 5 children between 0 and 13 years of age were raised by a lone mother in 2010 historically brazil has had a high level of informal unions also it is common to have a child in each new union to fulfil the idea of having a proper family this being particularly true for men who leave their children from previous relationships with the mothers to this situation we can add the violent context of high male homicide and incarceration rates which increase the probability of women rearing their children alone the isolation of a causal effect between family structure and childrens health requires an econometric strategy that accounts for selection into marital status we estimate a treatmenteffects model that uses male preference for firstborn sons to instrument the probability of a woman becoming a single mother family economics literature has well established that firstborn children are more likely to cohabit with a father figure if they are boys than if they are girls assuming that the sex of a child is random and that there is no sexselection abortion in brazil the gender of the firstborn in a household allows us to implement an instrument variable strategy that to the best of our knowledge is used for the first time in the context of childrens health analysis our results indicate that children raised by a lone mother in brazil have a heightforage zscore that is 031 points lower than that of children of the same characteristics that cohabit with both parents these findings are robust to different specifications that control for socioeconomic and demographic characteristics moreover the number of children in the household below the age of 10 and the mothers lack of schooling are factors associated with lower heightforage zscores in turn the mothers height and bodymass index are positively related with childrens height our results confirm that family structure should not be overlooked when designing health policy in brazil lone motherhood may become a real challenge for future maternalchild health programs in brazil after this introduction the following section describes the acute consequences of malnutrition in early life section 3 discusses the relationship between childrens malnutrition and family structure according to previous literature section 4 describes the dataset used and presents some descriptives while section 5 details the econometric strategy section 6 contains our main results and section 7 concludes malnutrition in early life malnutrition is typically caused by a combination of inadequate food intake and infections that impair the bodys ability to absorb or assimilate food it encompasses stunting wasting and deficiencies of essential vitamins and minerals with obesity or overconsumption of specific nutrients as another form from an economic perspective infant nutritional status can be seen as the output of a health production function where nutrient intake is a very important input however in addition to that and to the particular genetic variation there are other relevant variables appropriate care household conditions parental education access to quality health care and living environment there are two commonly used anthropometric indicators for childrens nutritional status wasting and stunting which distinguish between shortterm and longterm physiological processes the first indicates a low weightforheight and reflects current nutritional problems the weight loss associated with wasting can be restored quickly under favourable conditions and is generally seen as a shortlived problem 1 the stunting index is measured by heightforage and shows childrens cumulative linear growth or a chronic restriction on their potential growth it thus reflects the childs present and past inadequate nutrition andor frequent illnesses expressing a longrun health condition and is not usually reversible the who recommends it as a reliable measure of overall social deprivation 2 these indicators are measured in terms of a standard deviation zscore which accounts for the difference between the value for an individual and the median value of the reference population divided by the same reference populations standard deviation extensive epidemiological literature has focused on the early childhood environment nutrition in particular and its relationship with health outcomes in adulthood3 it emphasizes that linear growth failure is largely confined to the intrauterine period and the first years of life and is caused by inadequate diet and frequent infections malnutrition in the early years of life may also cause later deficiencies in cognitive development there is some disagreement as to whether the effects of malnutrition on cognitive development are more acute when the child is a baby as dobbing argues or a toddler but there seems to be a consensus that the first two years are very important early growth failure will lead to reduced adult stature unless there is compensatory growth in childhood which is partly dependent on the extent of maturational delay that lengthens the growth period because maturational delays in lowincome and middleincome countries are usually shorter than 2 years only a small part of growth failure can be compensated individuals who remain in the setting where they developed childhood malnutrition tend to become short adults 4the epidemiological literature reveals that the nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome short maternal stature is a risk factor for caesarean delivery and low maternal bodymass index is associated with intrauterine growth restriction in the short term the results of maternalchild malnutrition are mortality morbidity and disability in the long term the consequences are adult size intellectual ability economic productivity reproductive performance and metabolic and cardiovascular diseases regarding academic achievement particularly in developing countries the economic literature has found that childhood malnutrition is a significant determinant of delayed enrolment and low test scores malnutrition in childhood can also undermine labour outcomes in adulthood because of the probability of low school attainment being greater for unhealthy children than for those who were wellnourished in the brazilian case machado showed that for children between 714 years old and from the northeast and southeast regions low heightforage status increases the chances of late entry into school the study by gomesneto et al uses data from a major education intervention program edurural which measured students health this program was designed to reduce low achievement and high dropout rates in these rural areas the authors studied the complementarities between health and educational attainmentcognitive proficiency of children and found that changes in nutritional status play an important role in explaining cognitive differences among children more recently gigante et al used a large cohort of data from all children born in the city of pelotas in 1982 with followups in adulthood to analyse various later health and economic outcomes this study confirms that heightforage predicts school or cognitive test performance in later life and stunting between 12 and 36 months of age predicted poorer cognitive performance andor lower school grades attained in middle childhood so the previous literature has reached a strong consensus on the acute consequences of malnutrition during the first years of life across the whole life cycle this paper assesses whether stunting can be partly explained by family structure in brazil 3 family structure and infant health a review studies that have analysed the impact of marriage on health systematically find a positive association between the two in general the literature indicates that married people live longer have fewer problems related to alcohol engage in fewer risky behaviours and have better mental health the literature has established that the marriagehealth relationship can be explained by selection causation or both5 according to the selection framework healthier people are more prone to marriage because they are more desirable in the marriage market in this case it is not possible to attest that marriage itself provides a better health condition so the advantages observed in the health status of married people only reflect selection on the other hand the causation alternative advocates that marriage does cause benefits to the health of the people involved this is known as the marriage protection hypothesis which sees marriage as a mechanism that protects peoples health through social channels as integration accomplishment of some social roles support financial resources and economies of scale and joint and full monitoring between spouses the most common view is that marriage leads to emotional support it is seen as an institution that gives a sense of meaning of responsibilitycommitment to others as well as closeness 6 it also works as a sign of fulfilment of an adult social role which together with parenthood reduces the chance of healthharmful and risktaking attitudes other factors include family incomewealth and economies of scale that may increase access to medical care and the purchase of better nourishment and housing despite the difficulties disentangling the influence of selection and protection studies that have dealt with the issue are consistent regarding a marriage premium they generally find that the association between marriage and health is a combination of both so marriage affects and is affected by its members health status consequently the positive results of marriage on health are also extended to the children living in twoparent families the monitoring mechanism is especially relevant when there are children in the household because they are treated as a collective good by both parents 7 in this case any opportunistic behaviour by one of the parents is avoided by the monitoring between them which may encourage both to invest in the common good theoretical models provide intuition for the empirical studies that have evaluated the effect of marriage on childrens health through specific inputs for example qualitytime of prenatal care nutrition andor abstention from tobacco alcohol or illegal substances during pregnancy the findings indicate that the quality of care during the prenatal period including the significance of the mothers nutrition is very important for ensuring that the infant is born in healthy conditions thus affecting the childs subsequent ability to accumulate human capital moreover despite the increased diversity of family arrangements women are still disproportionately the primary caregivers for children in brazil as a result women are more likely than men to be faced with the dual role when unmarried that of sole caregiver and primary breadwinner this situation affects access to resources and psychological wellbeing and must have an impact on the quality of care provided to children a mothers stress has a negative impact on her childs health not just in key periods such as pregnancy and breastfeeding but also during early childhood 8 regarding the fathers involvement some research suggests that it plays a role in linking family structure to children health outcomes married and cohabiting fathers are more likely to be involved with their children by virtue of proximity while men who are not married to or living with their childs mother find it harder to be involved and hence participate less besides when a union dissolves the fathers involvement drastically declines especially if the relationship ends when children are very young in general the literature suggests that fathers may have an impact on infant health by encouraging women to seek prenatal care and refrain from unhealthy behaviours such as smoking and consuming alcohol while pregnant misra et al have suggested that the fathers involvement may improve birth and infant health outcomes by reducing maternal stress the relevance of each aforesaid mechanism is difficult to evaluate since they depend on the interaction between family members 9 therefore no empirical study of the impact of family structure on childrens development has succeeded in isolating each mechanism a significant number of empirical studies have examined the potential effects of family structure on childrens development and these generally confirm the disadvantage of children from households led solely by women 10 most of the literature focuses on cognitive and educational factors as well as factors that are relevant during youth studies that specifically analyse the impact of family structure on childrens health indicate that unmarried mothers invest less in prenatal care and consequently their children have poorer indicators at birth thus their children are at a disadvantage to others in terms of prematurity birth weight and mortality however few of these studies have addressed a causal relationship the challenge for disentangling the effect of family structure on childrens outcomes resides in the difficulty finding exogenous variations in the mothers marital status ribar argues that in most studies the identification strategies used to address the issue of selectivity into marriage are unconvincing 11 one of the most common methods used is that of instrumental variables and it is usually found that exclusion restrictions reduce the association between family structure and wellbeing but do not eliminate the association such is the case with buckles and price who measure the effect of marriage on four child indicators low birth weight prematurity mortality in the first year of life and the apgar test they use a sample of siblings to show that accounting for selection with regard to observable and timeinvariant characteristics significantly reduces estimates of the marriage premium but the positive causal effect remains this paper uses the instrumental variable method to analyse the causality between family structure and childrens malnutrition by 8 see amato fomby and cherlin and wu for further studies that have documented the adverse associations of family instability and child outcomes 9 note for example that lonemothers may also be exposed to some degree of monitoring by other family members 10 for a literature review see ribar and siglerushton and mclanahan 11 it seems that the literature that analyses the impact of family structure on child outcomes address causality more often some examples are ermisch and francesconi finlay and neumark and craigie proposing a new exclusion restriction that has not been previously used for a similar research question data definitions and descriptives data is from the brazilian consumer expenditure survey relative to the 20082009 period the survey contains 190159 individuals from 55970 households and is representative of the population living in private households in brazil our working sample is restricted to all children under 60 months of age that are sons or daughters of the head of household whose mothers are between 20 and 44 years of age and did not have their child as teenagers this last restriction is imposed because we do not want to confound the effect of teenage biological immaturity with that related to lone motherhood moreover in the pof family ties are defined in relation to the head of household spouse partner child another relative or nonrelative such a survey structure allows us to link 893 of the infants in the sample to their mothers children classed as another relative or nonrelative cannot be linked to their mothers even if they are in the household 12 as explained above the 60 month threshold seems most appropriate when seeking to capture earlylife health in total 10072 records have been used the pof data contains anthropometric measures for all individuals as well as information on such characteristics as age race education position in the family availability of a private health insurance plan for each person in the family household income governmental cash transfers living conditions and geographic variables despite its importance the raw anthropometric data collected by the pof is of limited value as an indicator of malnutrition in its own right partly because weight and lengthheight depend on both age and gender so in order to assess the adequacy of a childs growth it is necessary to compare these indicators with their distribution in a healthy reference group and identify extreme or abnormal departures from the reference values 13 to do this the anthro software created by the world health organization was used which requires input of each infants sex age in months weight and lengthheight data 14 from this data zscores for heightforage have been calculated table 1 shows that the average heightforage zscore is zero with a standard deviation of 12 strickly speaking this means that our sample is not representative of all children under the age of 60 months in brazil however it is also true that about 5 of children in this age group do not live with their mothers so we are not missing as many motherchild links as it may seem also note that the restriction of mothers age is also related to survey structure limitations by only using the sample of women between 2044 we disregard the possibility of considering grandmothers that are rearing their teenage daughters child 13 a total of 101 observations were considered extreme cases and were deleted from the final analysis 14 anthro can be consulted at the web page this software also provides the who child growth standard measures for weightforage weightforheight and bodymass index for age since 2006 the who has used new curves to assess the growth and development of children around the world this new standard was obtained by combining longitudinal followups from birth to 24 months and a crosssectional survey of children aged 18 to 71 months the sample has information from 8440 healthy breastfed infants and young children from a wide variety of ethnic backgrounds and cultural settings 170 and a minimum and maximum value of 599 and 592 respectively indeed descriptives indicate that 112 of children in the sample suffer chronic malnutrition on the other hand 157 are obese regarding family structure a childs mother is considered to be a lone mother if none of the registered members of the household is her partner this means that the lone mother may be divorced separated never married or widowed as a matter of fact the pof data does not make it possible to distinguish the mothers marital status 15 in total 96 of the children in the sample cohabit with a lone mother as in many other parts of the world lone motherhood has become an increasing phenomenon in brazil as shown in graph 1 which uses data from the censuses from 1970 to 2010 to create a sample with the same characteristics as those explained above a thorough analysis of this trend goes beyond the scope of this paper but two explanations stand out in the case of brazil firstly the analysis by greene and rao indicates a squeeze in the brazilian marriage market driven by a decrease in mortality rates as on average men marry younger women the simple reduction of mortality in younger cohorts increases the supply of women in relation to men the result of this compression would be an increase in cohabitation with men going through various unions during their life cycle 16 secondly it is important to take into account how the brazilian context of violence also increases the probability of a woman having to raise her children alone each year the country loses approximately 45600 men lives due to homicides according to data from the ministry of health which particularly affects young men the same is true for incarceration rates the other rows in table 1 show summary statistics for the groups of variables that will be used as controls when modelling the effect of lone motherhood on childrens heightforage zscores other demographic factors childrens and mothers characteristics household economic status and regionalurbanization descriptives as for other demographic characteristics summary statistics indicate that there are between 1 and 4 children in each household under 60 months of age and that 43 of the children in the sample have at least a brother or sister between the ages of 5 and 10 and 24 between the ages of 11 and 15 regarding childrens characteristics 489 of the sample are girls 511 are black halfcaste or indigenous and on average they are 32 months old as for mothers characteristics mean age is 296 and mean age at birth is 274 mothers average height is 158 centimetres their bodymass index is 248 and they have been to school for an average of 8 years 4 of the mothers have never been to school and nearly 18 of them did not complete primary education at least two of the mothers characteristics are particularly important for the childrens health height and age at birth regarding mothers height extensive literature highlights its correlation with some reproductive outcomes taller mothers tend to have easier births heavier babies at birth fewer stillbirths and higher survival rates among their children thus the mothers height carries direct information on genetic inheritance and indirect information about her own past situations of malnutrition and poverty the information on the mothers age at birth is a measure of her biological maturity which is another relevant factor for the childs health outcomes finlay et al analyse the effect of the mothers age at first birth on infant mortality its anthropometric failure diarrhoea and anaemia using data from demographic and health surveys for 55 low and middleincome countries these authors found that the risk for the childs health is lower for women who have gave birth for the first time between the ages of 27 and 29 the risk of infant mortality in firstborn children from mothers below 27 and above 29 is higher although the effect is only statistically significant for women below the age of 18 the variables referring to household economic conditions are poverty status and being a bolsa família beneficiary poverty is defined using the same concept applied by the government cashtransfer program bolsa família which has been operating since 2003 this study uses the values that were established from june 2008 onwards families with an income per capita up to 30 usd are considered extremely poor and families with an income per capita above 30 usd but below 60 usd are considered poor here the sum of these two groups defines a poor family in the sample 165 of the children live in a poor family and 231 receive the cash transfer it is important to note that the bolsa família is a secondary indicator of household poverty but also works as a health input control its inclusion was necessary for two reasons first because of its conditionality regarding the health of children up to 7 years old which requires beneficiary families to monitor the vaccination card and make frequent visits to the doctor to followup the childrens growth and development this condition exposes all children whose families are beneficiaries to the same health input access to medical services 17 second the bolsa família and poverty status are both included because not every poor family receives this cash transfer in order to control for the level of urbanisation we also consider the variables piped water and paved street the first is used as an indicator of sanitation conditions and the second as a proxy for the public services that come with urbanization in the sample 878 of the children live in an area with piped water and 595 with a paved street as for regional characteristics the brazilian territory is divided into five areas most children live in the northeast region of the country followed by the southeast and south econometric strategy the simplest modelling strategy to capture the relationship between family structure and child malnutrition would be an ols regression accounting for changes in the outcome of interest according to a set of observable characteristics formally haz i β 0 β 1 singlemother i β 2 x i i being haz i the heightforage zscore as already explained above among nutritionists heightforage is a widely recognized index to identify malnutrition among economists it is the most useful indicator of a childs health and welfare in developing countries and is widely recognized as a good predictor of many laterlife outcomes moreover β 1 is the coefficient for lone motherhood which we expect to be negative thus indicating poorer health outcomes among children being raised by a single mother x i is the vector of explanatory variables and finally i is the usual white noise error term however a simple linear regression holds the assumption that the mothers marital status is an independent variable and that there is no correlation between the error term of the model that gives rise to the choice of mothers marital status and the error term in our equation of interest as a matter of fact there are various channels by which the mothers marital status may be thought of as endogenous and therefore the estimates from equation 1 are inconsistent as explained in the literature review people choose whether they will partner or not and with whom so marital status is a selectionintotreatment moreover there are unobservable factors related to mothers health that make an unhealthier woman more likely to be a single mother and which in turn affect childrens health if the error term in a model for becoming single mother is correlated with poor mothers health and the error term in equation is correlated with this the error terms are correlated in this case we have an omitted variable problem that yields biased ols estimates in order to account for the bias we fit an instrumental variables estimation a treatmenteffects model that will also restore consistency under the hypothesis of selection of unobservable factors this is achieved with at least one instrumental variable that must be correlated with marital status and at the same time uncorrelated with the childs heightforage zscore thus we are interested in fitting the model haz i β 0 β 1 singlemother i β 2 x i i out prenatal tests and monitor their health and the babys health singlemother i α 0 α 1 iv i u i where singlemother i 1 singlemother 0 ie mother is single separated divorced 0 otherwise and iv i is the instrumental variable that needs to assign exogenous variation to the relation between mothers marital status and childs heightforage expressed differently we need at least one variable that influences the probability of a woman becoming a single mother that at the same time exerts no influence on her childs heightforage zscores in this paper the instrumental variable is firstborn girl the family economics literature has shown the existence of a relationship between the probability of divorce or lone motherhood and the sex of the firstborn in a family dahl and moretti ananat and michaels bedard and deschênes and ayllón have shown for the united states that firstborns are less likely to cohabit with a father figure if they are girls in other words firstborn girls increase the probability of divorce or separation among natural parents and decrease the probability of their mother finding a new partner after dissolution of a partnership 18several hypotheses have been used to explain the association between partnership stability and firstborn males first it could be that men are gender biased and have a greater preference for raising boys than girls which would explain why they are more likely to cohabit with their male offspring second the role model hypothesis argues that fathers may believe that their sons are more in need of a male role model and that is why they are more likely to stay third the technological reasons or differential costs hypotheses assume that men could be more efficient at raising boys than girls so since it is easier for them they are more likely to cohabit with their male children this is similar to the idea that girls could be more costly in terms of money and time finally the compensatory behaviour hypothesis assumes that boys have more health problems and are harder to look after than girls so fathers are more likely to stay in the household to compensate we hypothesize that like in the united states firstborn girls are more likely to live without their father in brazil than children in families where a boy is born first indeed a simple regression probit with the dataset at hand confirmed that this is the case firstborn girls are more likely than boys to live with a lone mother we have confirmed these results with data from the five brazilian censuses from 1970 to 2010 extracted from the international integrated public use microdata series the significance level for the gender effect was even higher which is readily explained by the fact that the census contains a huge number of observations compared to the pof and therefore the gender effect can be more easily captured it is important to note that results from the simplest regression model indicated that firstborn girl has no influence on the heightforage zscore equation which allows us to implement an instrumental variables strategy to the best of our knowledge this is the first time that such an instrument has been used in the context of child health analyses motherss previously imposed age limitations help us to ensure that the child observed to be the eldest really is the mothers firstborn in brazil mean age at leaving home is above 20 so it is unlikely for the firstborn in a family to have already left the parental home while the mother has a child that is younger than 6 median spacing between children of the same mother below the age of 20 is 3 years according to census data from 2010 moreover we assume that child sex is random and that there is no sexselection abortion in brazil as confirmed by chiavegatto filho and kawachi empirical results table 2 shows the results of the treatmenteffects regression model the first row clearly indicates that controlling for other observable factors being raised by a single mother is associated with lower heightforage zscores or phrased differently with a higher probability of suffering malnutrition among children under the age of six in brazil the coefficient for lone mothers is statistically significant at 1 moreover postestimation results indicate that conditional on being in a lone mother household a childs expected heightforage zscore is 031 points lower than for children in households with both parents this is for example equivalent to the effect of being raised by a mother that never attended school the results of the second equation indicate the validity of the instrument variable used having a firstborn girl in the family increases the probability of a mother raising her children alone the wald test establishes that we can reject the hypothesis that the two error terms are uncorrelated moreover a likelihoodratio test of an overidentified treatmenteffects system of interest against a justidentified version indicated the validity of the instrument used indeed the firstborn girl dummy was not significant in the main outcome equation in any of the specifications we tried as for the other variables for family structure the number of children in a household up to 10 years of age is associated with lower heightforage zscores in the studied sample but not in the case of older siblings it is reasonable to believe that malnutrition is more prevalent in families with a large number of children since food needs to be shared among more members regarding the other explanatory variables we focus first on childrens characteristics being a female infant is positively related with higher heightforage zscores while being black halfcaste or indigenous does not have any explanatory power our results indicate that the nutritional racial gap is closing in brazil once controlling for the endogeneity of family structure childrens age is negatively associated with heightforage zscore which indicates that younger children are taller than older children the mothers characteristics offer some of the factors with the greatest explanatory power mothers height is associated with higher childrens heightforage zscores and the same is true for bodymass index both variables are keys in our specification as they control for the childs genetic code as for the mothers age at birth the older the mother was when she gave birth to the child the higher her childrens scores 19 this association slightly reverses at older ages following the usual invertedu shape 20 a mothers lack of schooling is another key variable for understanding childrens heightforage zscores in brazil compared to a child whose mother holds a university degree a child with a mother that never went to school has a zscore that is 030 points lower note that no differences are observed between mothers that went to school moreover children with an employed mother have higher than average heightforage zscores although the coefficient is only statistically significant at 10 household economic status was controlled by building a categorical variable that combined poverty status and receipt of bolsa família poor children in brazil that live in households that receive bolsa família are still suffering consequences for their health condition because their family cannot provide sufficient economic resources despite the bolsa familias success at fighting poverty in brazil poor children in beneficiary households have lower heightforage zscores compared to those not receiving the transfer 21 also household income per capita was considered but was not statistically meaningful 22 19 note that despite our initial hypothesis that taller women could have had better chances in the marriage market the variable mothers height was not statistically significant in explaining single motherhood 20 mothers age was not included in order to avoid multicollinearity problems 21 if households are no longer considered poor thanks to the bf transfer this would indicate major success of the program by not only helping families out of poverty but also their children out of malnutrition 22 we also tried to include household income quintiles but this made no difference to the results so they were left out of the final specification in terms of the level of urbanization the results show that living in an area with paved streets is positively related with higher heightforage zscores while piped water does not have any explanatory power as for regional characteristics and unlike the previous literature we do not find statistically meaningful differences across regions once controlling for other characteristics and the endogeneity of family structure other variables were included in the specification to test their importance for heightforage zscores but they do not yield statistically significant results and were left out of the final specification these include living in an urban area whether the child has a private insurance plan sewage disposal in the household mail delivery service dangerous location in the sense of being close to a dump sewer polluted river or a hill subject to sliding garbage service streetlighting and households perception of the quality of the health service note that the inclusion of none of these variables made no difference to the main results robustness checks one possible drawback of the estimation strategy presented above is the fact that for a certain number of children in the sample the explanatory variable girl in the main equation and firstborn girl in the auxiliary equation refer to the same child in order to confirm our results we have run the same specification but excluding firstborn children the results were very similar to those presented in table 2 lone motherhood is associated with lower heightforage zscores with a coefficient of 189 and statistically significant at 1 similarly firstborn girl is associated with lone motherhood with a level of significance of 3 and a coefficient of between 0169 these results confirm that our findings are not dependent on the childs order of birth and neither is the instrumental variable strategy 23 conclusions this paper has studied the causal relationship between family structure and childrens health conditions in brazil in particular we assessed whether lone motherhood has any influence on the heightforage of children under the age of 6 using data from the pesquisa de orçamentos familiares collected between 2008 and 2009 we find that children being raised by a lone mother have a heightforage zscore that is 031 points lower than that of children of similar characteristics that cohabit with both progenitors the results are robust to different model specifications and are the outcome of an instrumental variable econometric strategy that has been used for the first time in the context of child development analysis more precisely we use male preference for firstborn sons to instrument the probability of a woman becoming a single mother robustness checks also indicated that the results are not dependent on childrens birth order the mechanisms that help to understand the positive relationship between stunting and lone motherhood in brazil while controlling for other socioeconomic and demographic factors are difficult to disentangle the previous literature has indicated that lone mothers probably suffer higher levels of stress given the need to deal with the dual role of sole carer and primary breadwinner 24 stress may affect womens capacity to care for children and therefore child development may be jeopardised lone mothers also lack monitoring by a cohabiting partner that could for example dissuade her from healthharmful and risktaking attitudes with regard to the child finally women that raise their children on their own may have a smaller extended family and also fewer social relations and as a result may find it harder to seek or obtain help our findings indicate that lone motherhood should be a major concern for health policy design in brazil as in other parts of the world each year more and more children are being raised by a lone mother moreover our results are probably highly conservative as we have intentionally not considered teenage mothers in order not to confound biological immaturity with lone motherhood health policy designers in brazil should not only focus on the inequalities by region or race but should also shift their attention to the inequalities by family structure acknowledgments sara ayllón gratefully acknowledges financial support from spanish projects eco201021668c0302 eco201346516c41r and xrepp and natalia batista from fapesp and cnpq we wish to acknowledge the institute of geography and statistics for providing the census data that made this research possible and the minnesota population center for making it available to us

this paper studies the relationship between lone motherhood and childrens heightforage zscores in brazil in order to isolate the causal effect between family structure and childrens condition we estimate a treatmenteffects model that uses male preference for firstborn sons as opposed to firstborn daughters to instrument the probability of a woman becoming a single mother we find that children being raised by a lone mother have a heightforage zscore that is 031 points lower than that of children of similar characteristics that cohabit with both progenitors we argue that the increasing trend of lone motherhood in brazil should be treated as a major concern in health policy design

introduction discrimination against people with disabilities in the health care system for many people is stereotypically associated with inhumane conditions in psychiatric hospitals not so long ago such a situation was common in many countries of the world and lithuania is no exception in recent decades there has been a debate in health care practice for people with disabilities that there is already a shift from a medical model to a social model and new models are developed such as the human rights model which can be linked to the united nations convention on the rights of persons with disabilities on the other hand in many countries including lithuania the analysis of the situation of people with disabilities in the health care system in terms of discrimination is not carried out systematically and it can hardly be said that this topic is a priority in order to systematize the research conducted in lithuania on the analyzed topic i performed the analysis of scientific works in the scientific bases available to me such as academic search complete education source eric health sourceconsumer edition health source nursingacademic edition sage journals online sciencedirect socindex with full text springer link and google scholar since my research is focused on the situation in lithuania i first chose keywords in lithuanian narrowing the field of the research and searching for scientific articles reflecting discrimination against people with disabilities in the lithuanian health care system later i repeated the search using the same keywords but already in english i searched for articles in english that are related to discrimination against people with disabilities in the health care system in lithuania i have focused on research papers written over the last ten years i set myself the following tasks to find out to what extent the situation i am going to delve into is researched what are the quantitative indicators of scientific works what is the manifestation of discrimination against people with disabilities in the context of the health care system i also sought to predict the novelty and relevance of the article in both aspects of lithuanian science and practice i have not found a single scientific monograph in the last decade i have found eight doctoral dissertations related to my field of research only one of the dissertationsthe doctoral thesis by ruškė in its philosophical approach is closest to the interpretation of my research data and the perception of the formation of findings in her research the author revealed the peculiarities of constructing the dignity of persons with disabilities through consciousnessraising strategies the analysis of scientific articles has highlighted two topics in a broad sense that are related to discrimination against people with disabilities in the health care system issues of capacity and related legal regulation are analyzed in the articles by juodkaitė presents the model of supported decisionmaking as a tool and form of socialization of people with psychosocial disabilities analyses the aspects of its applicability in lithuania pūraitėandrikienė analyses the problematic aspects of the institute of incapacity established in lithuanian legal acts zaturskis and kiaunytė investigate how the incapacity of a person with a mental disability is constructed and what dilemmas the social worker involved in the process faces from the aspect of human rights the articles of ruškus presenting the united nations convention on the rights of persons with disabilities as a phenomenon influencing the social concept of the world including lithuania are significant the united nations convention on the rights of persons with disabilities proclaims a fundamentally new approach obliging countries to develop such legislation that persons with disabilities receive such support that does not stimulate old or new forms of discrimination but creates particular conditions for the participation of persons with disabilities in education health culture the labour market and other sectors and organizations of society to make it a working norm and a particular aspiration ruškus actualizes the concept of inclusive equality overcoming otherness as a resource including changing the situation from the aspect of human rights ruškus presents the possibilities of the community in his article pūras analyses how human rights are observed in medical practice many of the aforementioned researchers articles and other scientific works are devoted to the rights of people with mental disabilities or intellectual disabilities and their family members to a dignified life including health care in other works by pūras the rights of people with intellectual or mental disabilities are analyzed in international contexts in relation to historical cultural economic and other environments revealing their impact and analyzing the opportunities for change the state of the publics right to health in lithuania is assessed as insufficiently ensured in the article by čelkis the works of šumskiene˙ and her coauthors proving and explaining the facts of multidimensional discrimination against women with disabilities in the health system is directly related to the field of my research the issues of legal regulation in a disability situation are discussed by krikščiūnas and gudžinskienė špokienė emphasizes the importance of solidarity in medicine viluckienė delves into the change in the concept of disability in medical sociology the links between social policy and the health of people with mental disabilities are analyzed by mikutavičiene˙ and guščinskienč the link between discrimination and models of assistance provided is analyzed in several scientific works materials and methods the study of scientific works conducted allows us to assume that there is little research on discrimination against people with disabilities in lithuania in the aspect of the health care system in this context the questions naturally arose what is the situation of people with disabilities in the health care system in lithuania are they discriminated against if discrimination against people with disabilities persists what is its manifestation these and other similar questions reflect the scientific problem of the article to answer these questions i analyzed the data of the research experiences needs and challenges of people with disabilities their relatives and professionals providing assistance to people with disabilities in the lithuanian health care system during the research applying life history methodology 8 interviews were taken from each of 30 people with disabilities from 30 of their relatives moreover 5 interviews from each of 50 professionals providing support to people with disabilities in the health care system all over lithuania i define the ontological perspective of research as the perception formed by postpositivism that one truth and one reality cannot be achieved from the viewpoint of the epistemological perspective i define interactive ethnography as the approach namely on the basis of which research data were collected first of all i associate the methodological perspective of the research not with the purified method but with the disclosure of the logic of the research the collection of research data was organized by abandoning the preconstruction and the research participant was followed great attention was paid to research ethics both by introducing the research participants with the research and ensuring their anonymity and by respecting the research participant as a personality his or her wellbeing and feelings and later the selection and interpretation of the research data the data analysis procedure and process complement the methodological perspective thematic analysis as a method of data processing and interpretation was chosen for its flexibility the possibility for the researchers to think in their own way nondogmatically exposing the findings and leaving room for the expression of the readers perception and critical attitude in this article in order to answer the questions raised the data are analyzed only from the aspect of discrimination results disability discrimination the analysis of the episodes of the narratives allowed to distinguish three objects of the subtopic prejudgement about the persons abilities other rules services to a particular person are not provided the object of the subtopic prejudgement about the persons possibilities is characterized by the multidimensional expression however on the other hand despite different situations circumstances and other factors the preconceived opinion usually of one or another persona doctor another professionalabout the physical mental professional or other possibilities of a person with a disability dominates for example in lithuania in many sanatoriums and spas pools are adapted for people with disabilities but it happens that due to a prejudgement about the persons abilities they are not allowed there there are various arguments the very fact of not allowing a person is motivated that the person does not have an accompanying person to supervise him or her for security reasons that not everything is adapted here but nothing more although the administration of the sanatorium itself informs and confirms during the investigation that it has everything and everything there is adapted a lift to the pool shower rooms for people with mobility disabilities the applicant herself has indicated that she has visited this sanatorium before and in that pool maybe not everything is perfect but it was enough to meet the needs the object of the subtopic other rules is related to the creation of different rules in the same sanatoriums or spa centers sanatorium managers decide not to allow a particular person to use their services in the analyzed cases it was found that not only other rules for people with mobility disabilities are created but a rule for a particular person is created the semantics of the cases also reveal how much effort is needed to ensure that the person and the professionals assisting the person prove that the exclusive decision not to admit the person to the pool is discriminatory findings the expression of the subtopic prohibition of discrimination on the grounds of disability is related to prejudgement about the persons abilities other rules not provided services to a particular person having examined the expression of the subtopic i can state that the relevance of the subtopic prohibition of discrimination on the grounds of disability and the necessity to change the situation in the lithuanian health care system does not raise any doubts disregard of the rights will and wishes of a person with a disability after the complete inductive analysis of the expression of objects the subtopic disregard of the rights will and wishes of a person with a disability was divided into three semantic objects the discussed treatment plan is not followed the basic needs of the person are not met due attention is not paid in an emergency situation a mother who lives with her daughter with a mental disability tells that when her daughters health deteriorated she had to receive hospital treatment where the discussed treatment plan was not followed the family lives in a town that did not have a hospital therefore it was necessary to receive hospital treatment in the city hospital which is 60 kms away the mother discussed the plan of tests and treatment with the doctors but it was not followed when she called them she would find out that nothing was done when she went there it was the same again and again the mother had to look for doctors ask to pay attention to her daughter and her illness the mother felt that she and her child were being discriminated against the narrative context allows us to conclude that the mother tends to justify and understand the doctors in her opinion that they are good but very busy on the other hand telling about her experience in an even bigger city the mother states that it is completely different there we called that doctor from the city x he says i dont want to traumatize that child you see there are wards without handles i will ask for you to be admitted to that easier unit well so we were admitted they increased that dose well and now we have not been to the hospital with these medicines for 7 years she got married and gave birth to a baby so i have met very great people the expression of the mothers wellbeing when the doctor does not follow the discussed treatment plan does not arrive at the agreed time ignores the mothers requests and observations allows to assign the analyzed object to the subtopic disregard of the rights will and wishes of a person with a disability and treat as discriminatory the expression of disregard of the rights will and wishes of a person with a disability is reflected by the object of the subtopic the basic needs of the person are not met as can be seen from the episode selected for analysis an elderly person with a disability and diabetes is admitted to the hospitals admissions department where he spends more than eight hours during that time no one took care of the person and have him receive a meal although he offered to pay there are various circumstances a weekend tired workers on the one hand but on the other handan old sick person with a disability and diabetes not meeting basic needs is also encountered in caring for a relative because what they prescribe is obviously not enough but she sometimes brings a packet of diapers from that red cross society there may not be every month but sometimes its every month and we need to buy them less because in practice we need diapers three pieces a day at night its necessary and during the day it depends the expression of disregard of the rights will and wishes of a person with a disability is reflected by the object of the subtopic due attention is not paid in an emergency situation a young woman with multiple sclerosis says she felt bad and called a friend the woman does not remember the situation and she relies on a friends story a friend took the woman to the admissions department where the womans doctor was on duty who was surprised by why she had come here and understood the reason for her arrival as a desire to stay at the hospital the doctor showed no desire to delve into the womans wellbeing the friend was surprised but asked for some injection of medication at least to sit and when she recovers they will go home when the friend was asking the doctor the woman started having seizures the woman then received all the necessary help the woman says that such a reluctance to delve into the persons state of health is common as is the saying that it is not that bad with you why are you rushing to that hospital the same woman remembers another episode related to her critical health condition when the tests were very bad the options of treatment with medications were exhausted and she had to return home from the doctor in complete uncertainty and you know you come home you know neither what medicine is nor what prognosis is and if they had spoken to you humanly at least and you dont know here they talked to you or not to you they did not look into your eyes they look at the papers and simply talk to you like this a2 findings the expression of the semantic objects of the subtopic disregard of the rights will and wishes of a person with a disability is related to the objects of the subtopicthe discussed treatment plan is not followed the basic needs of the person are not met due attention is not paid in an emergency situation which proves discrimination against people with disabilities in the health care system elimination of the discrimination against people with disabilities in health care the semantics of the title of the subtopic elimination of discrimination against people with disabilities in the health care system could cover the whole topic discrimination in this case the possibilities of elimination are delved into after the complete inductive analysis of the expression of objects the subtopic elimination of the discrimination against people with disabilities in health care was divided into four semantic objects rehabilitation treatment is not prescribed you get medication and dont look for other problems for yourselves any more a walking diagnosis not a person stuffed with loads of medicine the titles of the three semantic objects are short quotes from the peoples narratives the abstraction was rejected because these quotes reflect the semantics of the object in a much more visual way than a generalizing statement the object rehabilitation treatment is not prescribed of the expression of the subtopic is found in the contexts of various conversations it can be stated that rehabilitation treatment is relevant in many topics subtopics and contexts of conversations in general rehabilitation treatment the dominant semantics of the narratives is challenging to access in one womans narrative we see that a woman with a mobility disability was ignored by a family doctor when she wanted rehabilitation procedures or treatment in a sanatorium the family doctor did not prescribe it and her reasoning for not prescribing was very subjective the woman found a way outshe began to address the head of the outpatient clinic directly she then received treatment the subjective and discriminatory approach to the rehabilitation process is revealed in an episode of a professional physiotherapists narrative if it is a young person of working age then professionals should focus all their efforts on them invest as much as possible in them so that they can benefit society pay taxes work not be as i say dependent and feel helpless physical rehabilitation alone is not enough and they still need to be like all other people to integrate into work to attend some events so i would suggest that young people be given special attention and not only work but also the time should be invested in them and rehabilitation should start immediately and be prescribed on a regular basis maybe older people also need rehabilitation im not saying anything about it but maybe it should beturned a little differently although it is not explicitly stated that the rehabilitation of older people is unnecessary various discriminatory clauses can be deduced from the context maybe it should be turned a little differently on the other hand such episodes of narratives where rehabilitation is given unexpectedly to the person himself or herself at the initiative of the doctor are rare but still encountered and there was a doctor she came to me and she is such a nice doctor insanely nice for some reason she came to me and started massaging me she put her hands to my back and started massaging just for no reason and says lord how constrained you are you need massages an accidental meeting with a doctor creates preconditions for a persons rehabilitation treatment and by exploring the context of the narrative we learn that the woman forgets back pain for several years another object of the expression of the subtopic which is related to discrimination and which should be eliminated in the health care system is medical professionals indifference the performance of formal duties you get medication and dont look for other problems for yourselves anymore the woman who survived the accident does not remember anything however her parents still feel hurt when she with multiple sclerosis and lost memory was taken to a doctor for consultation according to the parents they were very worried about their daughter and sought help but the doctor did not communicate with them prescribed medication and said why are you going here you get medication and dont look for other problems for you i would relate the semantics of the object of the subtopic a walking diagnosis not a person to the dissociation of medical professionals and the patients pursuit of empathy … she looked at me and she well you wont get those medications here then you will get in the wheelchair again and she kind of talks to herself we can prescribe one experimental medicine here but i dont know maybe in a week maybe in two you could die and im sitting chm here and i don t know what or where i realized only two things if i dont get medication it will be bad i can agree on a new medication but i can die from this episode of the narrative some may see a violation of ethics and others may perceive the situation as the doctors efforts or the patients hopeless health however the context of the whole narrative leads to the conclusion that the patient as an individual is discriminated against the statements of the narrative such as she was sitting talking to herself we can prescribe one experimental medicine here but i do not know maybe in a week maybe in two you could die allow us to state that the doctor does not care about the person sitting in front of her as a human being with her feelings and experiences it is highly unlikely that the doctor would say such words to her close person another object revealing the expression of the subtopic elimination of discrimination against people with disabilities in health care is stuffed with loads of medicine a professional who works in a nursing home says people with alzheimers are in her opinion unduly suppressed by medicine to keep them quiet so that no more staff are needed to care for them the professional says that the amount of medication administered is such that people become involuntary apathetic like dolls after researching the narrative episode the data obtained show that because of medicine people become immobile apathetic like dolls in a relatives narrative there is a similar expression of the data well sure when she was taken to the hospital they would give her such medicine what i didnt like it made her very sleepy when i came there i could hardly talk to her it seemed she was sleeping they would say that its such treatment yes they said it has to be so but well in the city x it wasnt so aar 7 the mother was anxious about why her daughter was almost asleep she would ask the doctors and hear an unjustified answer that it is such treatment however a long history of treating her daughter allows her mother to compare such treatment with treatment in a big city where her daughter not only was not suppressed by medicine but a psychologist was working with her she also received another alternative treatment she was taken out for a walk etc analyzing the subtopic elimination of discrimination against people with disabilities in health care it was difficult to find an example of the expression of the elimination of discrimination the narratives in which the revealed situations prove the necessity of elimination dominated i managed to find one warm and sincere story of a young professional that illustrates that it is possible to see a human being in a person with any diagnosis and communicate with him or her as with an equal i was very attached to such a little old woman with alzheimers she was called laura so its even a pity to remember somehow really we communicated very well and i was attached to her and now its even a pity to remember well that i dont work and simply its interesting how shes doing actually really i myself i would just find free time and would just go would go to her to talk to her the first time even when i went to her i was scared and i didnt even understand she tells me they brought me here they brought me here she says they brought me here from home and i didnt understand whats happened to her why she was saying that and she forgot herself why she came here so in fact she also has alzheimers herself but by herself everything by herself its great to communicate with her and you can talk about everything with her at that moment maybe she wont remember something maybe she wont remember that she had a meal now but she will talk to you like a human being the young worker felt the warmth from a woman with alzheimers as evidenced by the semantics of this episode but she will talk to you like a human being not the professional will talk to the woman but the woman with the professional the context of the research suggests that the professional was exposed to severe working conditions a predatory environment and the communication with the woman with alzheimers allowed her to feel like a valuable specialist to see the meaning of her work findings after examining the expression of the object the highlighted properties of the object allow us to assume that people with disabilities in the health care system are primarily faced with insufficient and limited rehabilitation treatment formal assistance when medicines are prescribed without seeing a person when medical professionals do not want to delve into the persons psychological wellbeing or psychosocial problems when no alternative treatment is given first of all i would relate the elimination of discrimination against people with disabilities in health care to these findings of the research legal capacity is violated having analyzed the expression of the subtopic legal capacity is violated i distinguished two elements the recognized legal incapacity results in poor quality medical care the forcible inclusion in the process of establishing legal capacity these elements not only describe the object of the subtopic but also reveal the impact on discrimination the object of the subtopic the recognized legal incapacity results in poor quality medical care is illustrated by the narrative when a doctor while filling in the documents noticed a record in the medical history about a persons disability and incapacity and decided that the person should be transported to a psychiatric hospital a person with an intellectual or mental disability has been declared legally incapacitated and had a caregiver his relative this means that this person with a disability had a health problem very sharp pains in the abdominal cavity internal organs the relative went to the emergency department of one of the cities of our country together with the patient in an ambulance the doctors seemed to start filling in the documents and saw that the disability had been diagnosed in the medical history incapacity due to a mental disability and they immediately told that this person needed to be taken to a psychiatric hospital because of an exacerbation of his illness because he is shouting in the hospital the caregiver tried to argue that he has pains not an exacerbation of the mental illness nothing to do with the illness but the doctors were unyielding they put him into an ambulance and sent him to a psychiatric hospital probably the patient was probably given sedatives to make him calm according to the caregivers testimony the patient and his pains were not given much attention just treat mental illnesses but not relieve existing pains a few days later the hospital applied to the court for involuntary treatment for the court to issue a permit the court granted this request from the hospital that due to an exacerbation of the disease the persons treatment was necessary and when he was discharged from the psychiatric hospital in the words of the caregiver when they went to the city hospital the patient was diagnosed with a rib fracture of course the caregiver could not answer when those ribs of the patient were broken before or after going to a psychiatric hospital which in fact could have been the cause of the pain with which he complained so in this case we recommended that they apply to the ministry because of the patients violated rights for it to carry out an investigation in that case distinguishing the elements of the narrative and the description of the data suggest that the person possibly due to his legal incapacity and diagnosed disability did not receive quality medical care however he was sufficiently actively and persistently represented by a courtappointed caregiver the person was admitted to a psychiatric hospital due to pain and when he was discharged from the psychiatric hospital in the words of the caregiver when they went to the city hospital the patient was diagnosed with a rib fracture the caregiver appealed to a state institution which also got actively involved in representing the persons rights trying to make people draw conclusions from this situation and make decisions that do not discriminate against persons with legal incapacity the state institution appealed to the ministry of health to consider whether it would not be better to have psychiatric wards in general hospitals instead of separate psychiatric hospitals however the elements of the narrative such as the psychiatric hospital strongly opposed and argued that if the necessary importance of complex treatment arose the hospital would bring doctors to the hospital or the hospital itself would take care of taking the patients to the treatment institution and medical care would be provided allows us to assume that the system is difficult to reform more than that the institutional interests are above the interests of the individual another object of the subtopicthe forcible inclusion in the process of establishing legal capacityis related to the object the recognized legal incapacity results in poor quality medical care a person with difficulty walking who has a physical disability says that due to a conflict in the family he was involved in the process of determining incapacity due to various circumstances according to him the daughter wrote the application the court was on the next day and after the court he was immediately taken to a psychiatric hospital the person spent two weeks in a psychiatric hospital they examined him there observed him he was kept guarded in his words it was more terrible in the hospital than in prison after examining the persons health the person was invited to a commission where he was heard the commission was interested in the situation in the family the person was not declared incapacitated and he was discharged from the hospital to home although he had a disability had difficulty walking was not brought to the psychiatric hospital voluntarily he had to return home by himself according to the person sitting on a bench at the bus station he felt badthe heart apparently couldnt stand it an ambulance took him out of the bus station and the person was lying in the hospital this episode is also not directly related to discrimination in the health care system on the contrary the health care system acquitted the person did not recognize him as incapacitated however the humiliating process of determining incapacity itself indifference when discharging from hospital discriminates against a person findings the expression of the objects the recognized legal incapacity results in poor quality medical care the forcible inclusion in the process of establishing the legal capacity of the subtopic revealed during the research proves that the persons right to legal capacity equally with other persons in all spheres of life in the health care system is violated and it is discriminatory prohibition of torture and cruel and degrading treatment having conducted the analysis of the expression of the subtopic prohibition of torture and cruel and degrading treatment i distinguished three objects kicked and called a penguin doctors indifference is accepted as humiliation ignoring as humiliation the title of the first object is a mothers words which i could abstract with the concepts of bullying or degrading behavior however as i have already mentioned it is important for me that the title of the object reflects the semantics by that i aim to make the reader realize that the situation requires change the title of the objectkicked and called a penguinhas a much stronger message within it than for example degrading behavior other titles of the objects of the subtopicdoctors indifference is accepted as humiliation ignoring as humiliationthey could also be not distinguished and integrated into the subtopic however i see different meanings in them ignoring is a deliberately constructed behavior while the causes and circumstances of indifference may be different the episode of the kickeds narrative of the object called a penguin of the subtopic is one of the most revealing cruel and humiliating behaviors that gives if not physical then deep spiritual suffering to both the mother and her child from my subjective point of view eliminating the narratives that reflect the history of people with disabilities in the health care system it is one of the most revealing episodes how a child and a mother who are in the situation of disability are tortured nowadays well there was probably a medical professional there we went to the room already for the disability group im sorry… maybe i would have dressed her somehow differently but since already in such a month i bought a blue winter hat well its such white blue such a white fur inside the shoes also suit the hat the shoes like this the fur is here my daughter sat down like that and i sat down here a medical professional a woman is sitting she took that card threw it there and i tell her it will be hard to untie those shoes the daughter does not understand what is going on here the doctor says untie those shoes already in such a tone i just leaned over to untie she came up you dont untie well i think ok i wont untie i sat down she came up i dont lie at all because i dont have the reason to lie came up and kicked her feet i see the man is sitting there was sitting he didnt even raise his head it was probably a medical professional there too they were all there afraid of her they were sitting and no one was reacting they dont see they dont even want to see stand up she is sitting the penguin is sitting here and i understood that she didnt like clothing that i dressed her the penguin came and is sitting here go she didnt go anywhere as she was sitting and did not go she bowed her head… and it was scary for me that i couldnt protect her however after that i went out i gathered all my strength i called i say im still in your outpatient clinic now i say ill call the tv now i say her surname is so and so in writing i say you dont think im going out now i say it was very hard for me however i say i have to gather all my strength if i dont defend my child shes not a medical professional an uncultured woman will not kick my child in my presence so i say i am getting terrified of what is happening to those people with disabilities who do not have parents at home who are closed in this house so they are also kicked like this when my child is kicked in my presence in the mothers presence this case could be considered accidental but the mothers statements 1 allows us to assume that this is a systemic situation such cruelty of professionals traumatizes a person leaves longterm grievances and consequences on the other hand it differs from the narratives that reflect the history of health care in peoples ability to fight against such discrimination and it was scary for me that i couldnt protect her but after that i went out i gathered all my strength i called if i dont defend my child the analysis of the narrative of the object doctors indifference is accepted as humiliation shows that the doctors treatment of the patient has discriminatory features humiliates the patient as a personality such an expression of medical professionals indifference when people with disabilities and their relatives feel humiliated is often found in narratives peoples stories that doctors dont delve into the situation a cold this cold is because of old age no one here will cure you aar 2 you can use any drops that you want nothing will help you anymore aar 21are a reality these days ignoring as a phenomenon is somewhat less common in narratives but its mani festation is obvious one accepts it as cruel and degrading behavior that causes a lot of psychological suffering a woman says that when she came to visit her father who has a mobility disability she found him distressed agitated talking in whispers because the ward doctor a neurologist had punished them he discharged the man who said that the treatment did not help anyway home the same day and punished the whole ward saying that he would not come to them for three days 1 … the man is sitting there was sitting he didnt even raise his head it was probably a medical professional there too they were all there afraid of her they were sitting and no one was reacting they dont see they dont even want to see i am getting terrified of what is happening to those people with disabilities who do not have parents at home who are closed in this house so they are also kicked like this when my child is kicked in my presence in the mothers presence the woman states my dad said agitated that he hadnt slept all night and kept repeatingso they are not going to treat me now it was so difficult for me to get into the hospital and now everything is in vain aar 23 as can be seen from the other circumstances of the narrative the patient received treatment but both father and daughter felt humiliated because they had little to do with the conflict but were taught that the doctors decisions are nonnegotiable during the research the distinguished objects kicked and called a penguin doctors indifference is accepted as humiliation ignoring as the humiliation of the subtopic torture and cruel and degrading treatment and the distinguished features related to the objectsphysical and psychological torture of a person with longterm consequences indifference as a form of patient humiliation ignoring causing psychological suffering etcshow that there is a lack of systemic solutions in the health care system conclusion in the aspect of discrimination it has been established that in the lithuanian health care system the facts have been found that people with disabilities are discriminated against because of their disability people with hearing impairments do not even have a theoretical opportunity to take a driving test because the family doctor does not send them to a specialist doctor for a checkup persons with a certain mobility disability even though they had a certificate required for sanatorium treatment were additionally referred to a paid consultation of a sanatorium doctor who made a decision whether a person can attend the pool or not it can be stated that exceptional rules have been created for people with mobility disabilities the fact of discrimination against one person also became clear the managers of the sanatorium decided not to allow the use of their services to a particular client with a mobility disability the rights will and wishes of a person with a disability are disregarded the discussed treatment plan is not followed the basic needs of the person are not met due attention is not paid in an emergency situation there is no expression of the facts of the elimination of discrimination against people with disabilities in the health care system the manifestation of discrimination is evident in the situation of rehabilitation treatment in case of a difficult health condition there are frequent facts about the overuse of medications from the experiences of both professionals and relatives the expression of legal capacity equally with other persons in all spheres of life in the health care system is also negative there are facts discovered that the recognized legal incapacity results in poor quality medical care and the forcible inclusion of a person with a disability in the process of establishing legal capacity the provision of the convention on the prohibition of torture and cruel and degrading treatment is violated a professional kicks a child and calls her a penguin people with disabilities accept the doctors indifference and ignorance as humiliation

in recent decades there has been a debate in health care practice for people with disabilities that there is already a shift from a medical model to a social model and new models are developed such as the human rights model which can be linked to the united nations convention on the rights of persons with disabilities on the other hand in many countries including lithuania the analysis of the situation of people with disabilities in the health care system in terms of discrimination is not carried out systematically and it can hardly be said that this topic is a priority the scientific study has revealed that this is the case in this context the questions naturally arose what is the situation of people with disabilities in the health care system in lithuania are they discriminated against if discrimination against people with disabilities persists what is its manifestation these and other similar questions reflect the scientific problem of the article answering these questions requires obtaining the data of the research needs and challenges of people with disabilities their relatives and professionals assisting people with disabilities in the lithuanian health care system were analyzed which were processed referring to the principles of thematic analysis the findings of the research prove the multidimensional expression of discrimination against people with disabilities in lithuanias healthcare system

introduction covid19 is an infectious disease caused by sarscov2 which mainly affects the functioning of the pulmonary system 1 current evidence shows that the covid19 pandemic has a much higher mortality rate in older adults due to morbidities and bad lifestyle associated with aging 2 factors associated with increased risk of mortality in covid19 include comorbidities related to aging such as obesity insulin resistance and cardiovascular disorders and individuals especially older adults are at risk of having lower functional capacity and physical activity levels 3 4 5 which makes them more vulnerable to the infection 24 during periods of social isolation and physical distancing for a pandemic coping strategies and safety measures that promote wellbeing and improve or maintain the general state of health should be performed and encouraged among the general population to mitigate the negative impacts of the disease 6 the covid19 pandemic has had an unprecedented impact on the global health economy and functioning of societies 7 latin american countries with a high level of social and economic inequality have experienced worse effects of the pandemic for example são paulo brazil has a high population density and great disparity in demographic and epidemiological profiles social and economic levels and accessibility to health services and protection and safety measures such as the use of face masks 8 therefore understanding the sociodemographic variables and adherence to mask use is essential to auxiliary health decisions by public and health authorities to minimize the effects and negative consequences of the covid19 pandemic on public health 9 the assessment of sociodemographic variables determines the impact of population diversity on the effects of the pandemic 10 and how choices regarding safety security measures and adherence could affect the consequences and outcomes in the field of public health it is known that a populations profile and social characteristics can impact safety measures hygiene social distance outcomes and possible changes in timing of pandemics 11 due to the risk and characteristics of the professional practice and health literacy it is quite plausible that health professionals because of their frequent contact with the public are more sensitive regarding adherence to safety measures 12 moreover the physical and social distancing use of face masks and eye protection devices in public and health care facilities are needed for the public and health professionals to control covid19 transmission 13 however in lowincome countries like brazil the lack of literacy and access to health care the spread of fake news among the general population and the lack of proper management by the government can make a difference in the results and outcomes of such complex health scenarios 14 unfortunately this is what we observed in brazil during the covid19 pandemic brazil has been one of the countries with the worst management of the public health crisis it is on the brink of a progressive social and economic collapse thus studies that aim to check the populations sociodemographic profile and the choices related to security and protective measures during a pandemic are essential to make more precise decisions based on technical and scientific knowledge an onlinebased crosssectional study involving 12 bangladeshi residents 64 years of age recruited via social media investigated the influence of factors related to perception knowledge attitudes and practices regarding covid19 and found that the factors that impact perception and choices were female sex older age higher education higher family income and urban area residence 15 a crosssectional survey conducted by telephone or mobile phone with older individuals living in the state of minas gerais brazil showed that older individuals were knowledgeable and had good health literacy regarding covid19 but those that did not implement all the preventive measures were older adult male individuals living by themselves with a low educational level and they are more vulnerable to covid19 16 importantly individuals 60 years and older are more vulnerable to covid19 and the use of face masks is a protective safety and health care measure to decrease the risk and spread of infection 13 in addition older people have a higher peak viral load and especially those with comorbidities have higher mortality rates related to covid19 than young people this would be associated with chronic inflammation present in older people who are frail which could allow a more effective action from sarscov2 leading to serious infectionrelated complications 17 currently epidemiologists emphasize that the use of face masks covering the mouth and nose effectively stops airborne infections in general health and government officials followed the world health organization recommendations and in some cases forced the population to wear face masks in public places however in some countries like brazil there is a low rate of health literacy among government officials at all levels research shows that using the right type of face mask according to location and profession protects and reduces the infection risk 18 our aim is to present the sociodemographic and economic profile and health features and compare the individual determinants of face mask use during the covid19 outbreak among younger and older brazilian people procedures participants were invited to answer the questionnaire voluntarily through posts made on social media and whatsapp using a standard text that publicized the study and drew attention to the importance of understanding the behavior of the population in relation to covid19 which could provide subsidies to implement awareness actions reducing the spread of the disease a link to the informed consent form was provided to each participant upon consent and agreement to voluntary participation the participants were directed to the mandatory study questions the questionnaire was developed by the researchers corrected and adjusted by a panel of health experts including a professional statistician made available on the online platform google forms and disseminated through social networks the online questionnaire 19 was composed of 14 closedended questions about the following variables age sex origin marital status religion family income education presence of signs or symptoms or confirmed diagnosis of covid19 and occupation as a health professional in addition multiplechoice questions about covid19 included the following knowledge about the forms of transmission of covid19 risk groups signs and symptoms and what to do if they were present preventive measures to be taken in case of traveling and information on popular beliefs regarding the prevention transmission and treatment of covid19 statistical analysis for the descriptive analysis of categorical variables frequency and percentage were calculated for continuous variables mean sd median minimum and maximum were calculated to compare the variables of interest chisquare and likelihood ratio test were used a significance level of 5 was used the data were analyzed using spss version 19 results our sample consisted of the adult brazilian population from different states of brazil acre alagoas amapá amazonas bahia ceará distrito federal espírito santo goiás maranhão mato grosso mato grosso do sul minas gerais pará paraíba paraná pernambuco piauí rio de janeiro rio grande do norte rio grande do sul rondônia roraima santa catarina são paulo sergipe and tocantins the majority of participants were from são paulo table 1 shows that most of the 2673 individuals in the study were aged ≤59 years were female were from the city of são paulo were married were catholic had a monthly family income of 4 to 7 minimum wages in r and had completed or were currently doing postgraduate studies in addition 618 were not health workers 844 did not show symptoms of covid19 and 974 had no confirmed diagnosis of the disease the studied age groups were not homogeneous regarding the following variables sex brazil region marital status religion total family income professional type and health characteristics and status table 2 compares the profiles of participants with regard to the use of masks between the groups in terms of sex education level occupation as a health worker and presence of signs and symptoms or a confirmed diagnosis of covid19 on the use of masks there were significant differences in sex level of education and occupation as a health professional females health professionals and those with a higher level of education adhered to the use of masks more than others vancini et al jmir aging xsl • fo renderx discussion principal findings the main aims of this study were to describe the sociodemographic variables determine the profiles of individuals compliant to the use of face masks and compare them between younger and older people the majority of the 2378 participants in the group aged ≤59 years were women were living in the southeast region and had postgraduate degrees in the case of the 295 individuals aged ≥60 years the majority were women were living in the southeast region and had completed or were still completing higher education in addition the majority of participants in both groups have been using face masks this was significantly influenced by sex level of education and whether the participant was a health professional or not this study has two major findings nearly 30 to 40 of the participants were health professionals and 80 to 90 were from são paulo that is people who have good health literacy and educational level and those who are living in regions with the highest socioeconomic level in brazil bambra et al 20 reported that social economic demographic differences and inequalities and lack of access to health care have implications in any pandemic recorded in history including covid19 dowd et al 9 pointed out that understanding the profile of sociodemographic variables are important for all governments to rapidly make policies to mitigate the negative effects of the covid19 pandemic through sociodemographic studies it was possible to verify that the most serious cases and deaths were prevalent among older adults and those with comorbidities this is important information for health care systems worldwide hence tracing the sociodemographic profile of different populations worldwide to outline short medium and longterm positive coping strategies to help mitigate the covid19 pandemic will help decrease inequalities in access to social and health services for future generations it is interesting to note that hospitalizations and mortality are higher in men than in women and that men are more inclined to smoke and thus have the potential for poorer respiratory outcomes in covid19 infection 21 regarding the use of face masks in general the majority of the participants in this study both the general population and health professionals reported adherence to this measure during the course of the covid19 pandemic the factors that significantly influenced this relevant control measure were sex level of education and whether the participant is a health professional or not we highlight three clinical trials but only one of them is directly related to the use of facial masks as a central measure to control the spread of covid19 infection bundgaard et al 22 conducted a nonblind randomized controlled trial to investigate whether the use of facial masks could reduce the risk of sarscov2 infection they included adults without previously confirmed covid19 or symptoms suggestive of covid19 who spent more than 3 hours a day outside the home with exposure to other people the authors concluded that the use of a face mask could be a protective factor for the user against sarscov2 infection however more evidence is needed through robust clinical trials to provide consistent scientific evidence for recommendations from health authorities worldwide and in the future liang et al 23 through a metaanalysis concluded that the use of masks is an auxiliary method and measure of health and prevention in relation to the outbreak of covid19 and highlighted that these protective health measures are impacted by the level of knowledge and health literacy 24 and different beliefs moral values and even conditions of access to health final considerations in this study women health workers and people with a higher level of education had greater adherence in relation to the use of masks a potential correlation was found between gender where there was a higher incidence of disease in men and there has been a globally observed shorter life expectancy in men as compared to women 25 determining sociodemographic profiles and identifying the factors that favored the use of face masks especially in são paulo does not reflect the actual scenario in brazil which is a country with many social inequalities but provides subsidies to study other regions from the same point of view which can assist in facing the current scenario and future health crises study limitations and practical applications this study has limitations using social media to collect the data may have influenced the study sample as many participants are health workers and living in the state of são paulo the most economically developed region in brazil nevertheless we were able to gather an expressive sample in view of the results of our study we believe that the implementation of health care policies aimed at certain age groups such as older adults and populations for example men and people who are not health professionals can increase the compliance to disease prevention measures for example the use of face masks since these populations are heterogeneous from the health care point of view other limitations were the absence of some items in our questionnaire regarding family size the type of mask used evaluation of the proportion of infected men and women and a larger sample of people 60 years or older one of the difficulties of our study was to obtain a larger sample of older participants our expectation was to have a more equalized sample size between younger and older groups which was not possible it is necessary to understand why older adults tend to answer questionnaires less than younger people despite the massive dissemination of the instrument to this audience finally we did not include questions regarding the smoking habits and alcohol consumption of younger and older people these are factors that can impact the general health status and outcome of a covid19 infection in cases of abuse and excessive or constant use despite this these are areas of study that need to be further explored and may be the focus of future studies finally education actions carried out by health workers for health promotion and disease prevention can be stimulated and carried out increasing the health literacy of the population which will provide individualized and effective actions authors contributions rlv lcn and crvc conceptualized the study rlv lcn cabl msa rgs ptn bk lhvp mcbtl reab and crvc designed the methodology the formal analysis was done by rlv lcn and crvc the investigation was done by rlv lcn cabl msa rgs ptn bk lhvp mcbtl reab and crvc the data was curated by rlv lcn and crvc the original draft was prepared by rlv lcn cabl msa rgs ptn bk lhvp mcbtl reab and crvc rlv lcn cabl msa rgs ptn bk lhvp mcbtl reab and crvc reviewed and edited the paper rlv lcn cabl msa rgs ptn bk lhvp mcbtl reab and crvc contributed toward visualization crvc supervised the study rlv lcn and crvc contributed toward project administration all authors have read and agreed to the published version of the manuscript conflicts of interest none declared

background sociodemographic variables may impact decision making regarding safety measures the use and selection of adequate face masks is a safety and health measure that could help minimize the spread of covid19 infection objective this study aims to examine sociodemographic variables and factors relating to covid19 that could impact decision making or the choice to use or not use face masks in the prevention and care of a possible covid19 infection among a large sample of younger and older brazilian people methods an online survey composed of 14 closedended questions about sociodemographic variables and covid19 was used a total of 2673 participants consisted of brazilian people aged ≥18 years from different states of brazil and were grouped according to age ≤59 years and ≥60 years to compare the variables of interest associated with wearing a face mask or not chisquare and likelihood ratio tests were used with p 05 being significant results most of the participants in both groups were women from the southeast region who had postgraduate degrees approximately 61 14522378 of individuals aged ≤59 years and 678 200295 of those aged ≥60 years were not health professionals in the group aged ≤59 years 834 19832378 did not show covid19 signs and symptoms and 973 23142378 were not diagnosed with covid19 in the older adult group 925 273295 did not show signs and symptoms of covid19 and 983 290295 were not diagnosed with the disease the majority of the participants in both groups reported using face masks and their decision to use face masks was influenced by the level of education and their occupation as a health professional conclusions younger and older adults have worn face masks during the covid19 outbreak it is difficult to measure how much of a positive impact this attitude habit and behavior could have on the degree of infection and spread of the disease however it can be a positive indicator of adherence to the populations security and safety measures during the pandemic

introduction while a growing corpus of literature regarding the stress suffered by caretakers for people living with dementia already exists very little data is available regarding this subject among romanian caretakers objectives this crosssectional study aims to compensate for this by assessing a small sample of caretakers through the use of selfreporting questionnaires for subjective feelings of stress and burden methods responders filled and online survey containing miscellaneous sociodemographic questions and the kingston caregiver stress scale along with the caregiver health assessment self questionnaire results were collected and analysed in spss for subsequent correlations results the majority of caretakers are women and 86 of responders are offering their care at home emphasizing pervasive gender roles and lack of availability or accessibility of social services for the plwd in romanian society three thirds of caregivers were children of pldw more than half of responders had kcss scores that suggested severe stress while less than 9 related only mild stress most responders related social aspects of their lives as most affected by their caregiver status conclusions while in line with most other findings and limited in scope and means by its methodology this study offers a quick snapshot on the subjective levels of stress affecting caretakers of romanian plwd and can lead towards further points of inquiry on the matter in the romanian population disclosure of interest none declared epv0527 exploring the paradigm of depressive disorders through an evolutionary and biopsychosocial lens t ochi1 a j loonen 1 g g simutkin2 n a bokhan 2 a n kornetov3 and s a ivanova 2 introduction depression can be considered to be a common psychological response to adversity or loss from which an individual may recover quickly based on a natural resilience mechanism in major depressive disorder however we see that biopsychosocial factors exist that can prevent this natural resilience mechanism from taking effect objectives to investigate neurotransmitter pathways linked with antidepressant response genetic epidemiological studies and a literature assessment of biopsychosocial factors were conducted methods newly admitted patients with a depressive episode according to the criteria of icd10 who had not been on antidepressant medication for at least 6 months were recruited more than half the patients have never been treated with antidepressant medication during their entire life the patients depression was of at least moderate severity as measured by the hamiltons depression rating scale to determine the effect of adrenergic pathway genes to antidepressant response the outcome was measured by the difference in hamd17 score between entry and two weeks of treatment after two and four weeks of treatment and entry and four weeks of treatment multiple linear regression was conducted to identify the independent factor associated with δhamd17 between the three time periods including age sex depression diagnosis type of antidepressant taken and selected snps literature assesement utilised a snowball technique building on prior literature reviews conducted the selection of included literature was determined by the authors results the tomosk cohort was mainly women with less than 20 of patient being male the cohort was dynamic thus the number of participants involved in each investigation varied most patients took ssris specifically sertraline paroxetine escitalopram fluoxetine and fluvoxamine comparing the medication taken δhamd17 was significantly more improved in participants taking tricyclic antidepressants at 0 2 weeks and 0 4 weeks from our literature assesment we determined that targeted therapy can undermine the influence of biopsychosocial factors and allow natural resilience to bring depression to an end many mental activities is not exclusively individual but depends on the sociocultural context as people are part of a community conclusions depressive disorders can be understood as a rather habitual dysregulation of human behavior which unlike normal behavior is not limited by natural resilience in time and severity our investigations looked at polymorphisms impacting serotonergic dopaminergic and adrenergic neurotransmissions and enzymes

21 cases of bipolar disorder 21 cases of schizophrenia two cases of chronic hallucinatory psychosis and 3 cases of delusional psychosis fortythree patients were fit to continue working 133 patients were fit with restrictions and twentysix were unfitted to work a professional reclassification was recommended for 37 patients in positions with a lower mental load one employee suffering from advanced schizophrenia was offered early retirement on grounds of disability permanent unfitness was pronounced in 116 of cases conclusions the impact of mental disorders on cognitive abilities can be so significant as to result in temporary or permanent unfitness for work however the decision of medical fitness for work for the same psychiatric pathology may vary from one individual to another and from one workstation to another

introduction refugees face many difficulties in their lives and settling in a new and markedly different environment can be an added difficulty for many of them these difficulties may lead to poor psychosocial adjustment and emotional problems in refugees who often embody significantly higher mental health problems than other populations in general as elsewhere refugees in australia have lower levels of personal wellbeing than other migrant groups this is particularly so for newly arrived refugees and more so for women who are often culturally displaced socially isolated and have ambivalent feelings about their future this acculturative stress is likely to result in depression among refugees for any individual having to relocate to another social setting necessitates extensive adjustment which often leads to changes in health status as well as disruptions to family connection and social network this is more marked among refugees who have experienced violence and civil conflict in their homeland for many refugees resettlement can be very daunting it has been suggested that the resettlement process that refugees go through can have more negative impact on health and wellbeing than their premigration situations doi 101093heaprodav015 nevertheless there are factors which have helped to protect refugees during their settlement processes in particular social support from peers and their own ability to cope according to mulvaneyday et al social support provided by unrelated close friends has shown a positive influence on the physical and mental health of refugees social support can help to alleviate some of the difficulties associated with resettlement in a new environment we contend that one aspect of social support for refugees is being part of a peer support group in this paper we discuss the experiences of refugee women who participated in the peer support programme for newly arrived refugee women in melbourne australia our project adopted a twopronged approach to establishing peer support networks among refugee women from similar communities peer support training enabled the participants to meet discuss issues and consequently establish communicative relationships within the peer group additionally the women were given access to a free mobile phone research has shown that mobile phone access can act as a health promotion tool in this study participants were provided with a free mobile phone and free unlimited calls within the peer support group numbers and to limited set of local and overseas numbers for a 12month period to augment the peer group relationships as well as relationships with a small number of people and institutions external to the peer group peer support group as social support and health enhancing strategy theoretical framework in this article peer support is perceived as a subset of social support in which the relationships are formed between individuals who are similar to each other peer support has received much attention within the mental health area it has been defined as social emotional support frequently coupled with instrumental support that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change this concept is clearly relevant to our project which attempt to use peer support group to enhance the health and wellbeing of refugee women in the case of the refugee situation emotional physical and tangible support which is offered by peers who are also refugees can lead to desired personal and social changes within their communities peer support embodies active ingredients which enhance positive health and wellbeing among group members peer support groups which provide a channel for individuals to periodically meet to address commonly shared concerns and problems have resulted in social support among group members which has in turn led to the improvement of quality of life of those involved within peer support groups empathy sharing support and assistance are often offered as such feelings of social isolation can be overcome schutt and rogers put it clearly that peer support provides resources for effective functioning and a foundation for coping with stress and loss additionally a peer support group has been seen as the principal ingredient of the empowerment process peer support programmes not only increase social support they can also promote empowerment among group members peer support makes the most of the ability of peers to contribute to the situations and needs of others in the group as well as their potential for influential relationships with others in our study we based our research within the peer support framework discussed earlier the peer support group training sessions and the provision of a free mobile phone offer a means through which meaningful empowerment processes could eventuate here we emphasise the empowerment that become materialised at the individual level and we refer to this as personal empowerment according to chamberlin this personal empowerment is a multidimensional concept which embodies the feeling of being part of a group and promotes positive self and the conquering of personal difficulties within the refugee context peer support could empower individuals to find ways to overcome difficulties in their new homeland additionally we contend that participation in peer support group can be perceived as healthpromoting behaviour within the health behaviour framework it is assumed that by participating in peer support group people will receive benefits of some kind for example participants may perceive that being a group member would assist them with difficulties in life additionally it will entitle them to some support that will help them fight against isolation and difficulties in their everyday life as such participation in peer support group training can be seen as a healthpromoting behaviour with the expectation that support from others may follow peer support group activities our project the peer support group activities ran for 12 months different groups have different start times but the whole programme started in 2010 and ended in 2012 participants attended weekly peer support training sessions for the first 6 weeks and five bimonthly sessions group composition and timings were guided by participant preference resulting in 9 groups with 915 members the women practised swapping time where for 35 min they took turns in the roles of talker and listener the themes for each session were selected using a strengthbased assets model designed to direct the womens attention to the positives in their lives these themes included the following something good something new goals and aspirations educational successes personal pride and other topics that were defined by circumstances of the time the group sessions ended with a wholegroup discussion during which each woman shared a thought feeling or anecdote with the rest of the group the importance of confidentiality was stressed to the participants from the start of the programme and this helped to establish trust as an expected group norm the women were presented with certificates of participation at the end of the fifth and the last session in the third training session each woman was given a mobile phone with the following unlimited freecall numbers on speed dial • intragroup numbers peer support group members from the same community • landline numbers home landline and four participantchosen australian landline or overseas numbers from selected countries and • service numbers telephone interpreter service four participantchosen service provider numbers and two members of the research team who facilitated the peer support groups a special agreement was established with the phone service provider that enabled the free calls to be provided cheaply the phone calls made by the women were recorded automatically in a call log that captured the time duration and destination of the calls only outgoing calls could be logged as it was not possible to log incoming calls the intragroup numbers linked people within their heritage culture as the australian landline and overseas numbers were selected by the participant they were predominantly numbers of close friends or relatives of the participants and therefore classified as numbers associated with the participants heritage culture the third set of numbers provided the participants with links to the host culture these were the tis four selected service providers including schools clinics and hospitals and the two researcher facilitators it should be noted that there were some women who did not attend all the training sessions and some who along the way stopped using their phones however no one actually gave the phone back and wanted to be taken out of the programme in our qualitative component we did include women who made very few calls compared with their colleagues methodology this paper is based on the qualitative component of our project that examines the roles of peer support and mobile phoneenhanced communication in the settlement experience of refugee women living in melbourne australia a full project has been reported elsewhere initially potential participants were invited by the afghan burmese and sudanese community leaders to an information session where the study was explained questions answered and participant information sheets and informed consent forms in both english and the community languages distributed a snowball sampling technique was also used where the first group of participants invited people they had relationships with to join the programme this recruitment process helped to elicit moral approval and practical assistance from heritage culture gatekeepers husbands or adult children who had the capacity to influence the womens participation in our full study 111 women were recruited 44 from the south sudanese 31 from the afghan and 36 from the burmese communities the mean length of stay in australia are 288 4 419 and 681 years for the burmese 1 burmese 2 afghan and sudanese communities respectively within the consent form were questions that asked participants for yesno responses to questions requesting participation consent to an interview interviewees were selected from those responding yes to an interview thus the number of participants who took part in the study component on which this paper is based was not determined by saturation all of these participants also agreed to being audiotaped where possible women selected for interview were approached directly to invite participation where language was a barrier participation was invited through the relevant interpreter at the end of the programme 29 participants were interviewed invitations to participate in an interview were based on the womens mean calls per week and mean call duration each cultural group was proportionally represented interviews were conducted by the second and third authors took place in participants homes lasted 6090 min and were recorded after participant consent apart from three participants who were proficient in english all interviews were assisted by a professional interpreter questions explored the womens programme experiences the changes in their lives and relationships and the significance of their call patterns the data were analysed using thematic analysis this method of data analysis aims to identify analyse and report patterns or themes within qualitative data initially we performed open coding where codes were first developed and named then axial coding was applied which was used to develop the final themes within the data this was done by reorganising the codes that we had developed from the data during open coding in new ways by making connections between categories and subcategories this resulted in themes which were used to explain the lived experiences of the participants the emerging themes are presented in the findings section three transcripts were initially coded by two authors who are qualitative researchers and differences in coding discussed and resolved subsequently for all other interview transcripts uncertainty about assigning codes to specific pieces of text was resolved jointly by the two researchers ethics approval for the project was granted by the faculty human ethics committee la trobe university in presenting the narratives of the women we adopted the use of fictitious names in order to preserve their confidentiality for ease of reading we also minimally edited the verbatim quotes to make them more grammatically correct findings to most of the women in our study participating in peer training sessions and having access to a mobile phone made a huge difference to their lives there are several major themes that emerged from the study creation of social networks enhancement of wellbeing and provision of empowering experiences creation of social networks social networks were created through the programme that was developed for our study the peer support training sessions and the access to a mobile phone allowed the women more connections with others as well as strengthen their own personalsocial networks cultivating new social network for most women the programme provided an opportunity for them to meet other women in their community most often however social networks between the women were increased due to the effect of group sessions many women suggested that having only a mobile phone would not create the network and that it was only through group sessions that such networks developed however other women remarked on the benefit of both having access to a mobile phone and participating in peer group session trainings meeting others in a group setting and having their mobile numbers and a means to make connection enabled them to connect with others if it wasn′t for this telephone i wouldn′t know because that person she doesn′t even know my other mobile number that i made at the group so if it wasn′t this group i wouldn′t have met the person since the women had more opportunities to connect with others in the community their lives were changed for me i can say there is a change in my life because i met other people that i don′t know before i don′t talk to before but now they are part of our community and i get to know them better creating strong links within the networks the peer support programme and access to a free mobile phone also created stronger relationships among group members we particularly noted this relationship within the sudanese community between the older women and the young women who had no parents in australia often refugee children and young people have lost their parents through war and escape attempts in these stronger relationships the older women acted as a mother for these young women it is because of this programme we sort of become close we have become close to these young woman already and they are treated as our daughters some of them they don′t have their mom here so we play their role now and we practice it a lot because of this social isolation is common among refugees and some women claimed that they did not have any friends prior to the programme which helped to create a closer connection between the women in the community for those who might have seen or known each other beforehand the programme provided an opportunity for them to form a closer relationship thus links between individuals as well as community became strengthened having access to a mobile phone and being connected to others in the community allowed the women to strengthen ties with members of their cultural community and participate more fully in it this is an essential aspect of resettlement for many refugees including the women in our study access to a mobile phone enabled the women to connect with family members who were left behind in their home country this is crucial for refugees who feel a strong need to be in contact with their family members who live far away from them for many women the free mobile phone from the programme arrived at the right time enhancement of wellbeing repeatedly newly arrived refugees and migrants endured many burdens particularly emotional burdens and yet they had few that they could rely on however our programme helped to increase the wellbeing among the women in the study it not only offered a sense of happiness but also lessened social isolation among the participants increasing sense of happiness participating in the peer support group programme and having access to a mobile phone augmented a sense of happiness among the women some women even suggested that the day they commenced the programme was a beautiful day for them the women also talked about feeling happy to be able to meet others in the peer support training sessions this sense of happiness took away the worries that most women had in their life to the extent that some women declared that they have become a free person access to a mobile phone allowed the women to be connected with their family members at times when they had to be outside their home for an appointment or a class this helped to lessen their anxiety about those who are left at home particularly their young children importantly it became apparent that the phones facilitated mutual emotional support among the women when i call my friends i share all my feelings with them and i take all of my stories my concerns and my worries out of my chest so it makes me feel much better the women talked about the complexity of their lives as refugees and remarked on the value of the phone as a tool to harness the peer resources in response to their emotional needs reduction of social isolation as the programme allowed the women to connect to others this diminished their sense of isolation refugee women who were mothers in particular tend to feel more isolated in their new homeland for the women in our study although they had children in their lives things were not the same as they were back in their homeland children tended to have a separate life due to school or work and seldom had time for their mothers this led to feelings of isolation among these women however having access to a mobile phone allowed the women to call others and talk instead of not having any meaningful activity to do this also led to feelings of happiness among the women now having this number having this mobile i call my friends you know i call my children even in america and i′m here if it wasn′t this telephone i would be just watching television you know i don′t even understand what they are saying just the picture but now this telephone has kept us laugh we call each other and we talk and you laugh we make joke on the phone and we laugh and you know the more you laugh the happier you are it has brought us back some memories some of the things that we used to do back home increasing social support due to the increased social interaction between individuals through the programme social support between group members was created repeatedly the women spoke about the emotional support that they received from others in the group the women also received tangible support from group members through knowing each other and through the use of mobile phones importantly the mobile phone and access to peer group members on their phone on speed dial took on lifesaving significance for some women once i was at tafe and doing english classes i suddenly didn′t feel well i got stomachache and the teacher had to call ambulance i couldn′t call my husband but because of this phone i called one of my friends i asked her to let my husband know that i was not feeling well and i was taken to the hospital so at that time i found out how important this telephone was otherwise he wouldn′t know peer support embodies both receiving and giving support to others around practical support the women became aware of not only their own but other womens needs and availed themselves to support others in their network provision of empowering experiences our programme provided several empowering experiences to the women in the study many women had not had any opportunity to own technology such as a mobile phone or computer in their own country having access to new technology such as a mobile phone was an empowering experience for these women the women felt proud of themselves for having knowledge about and skills to use a mobile phone additionally what the women learnt from the peer support training programme empowered them to acquire further skills or learn more about other issues which would become valuable for their lives in a new living environment the programme assisted the women with the acquisition of english language and provided more opportunities to practice english the women believed that the connection that they had created through the peer training sessions and the freecall mobile phone gave them an opportunity to be an informed individual who would have better knowledge about things around them they became more confident about travelling to places outside their home or community which led to feelings of empowerment and selfcapability among the women we got this phone and we contact each other and then we go everywhere we know so many places so that has improved it life we know so many places and we can go everywhere now access to mobile phones also made things easier for the women mobile phones enabled the women to settle into australia with better ease for example it increased their ease of obtaining essential ingredients for cooking the mobile phone also allowed the participants to connect with healthcare providers more efficiently for women who were mothers the mobile phone allowed them to deal with emergencies that might arise regarding the health and wellbeing of their children who were at schools i have been in trouble many times you know with my children sometimes there is an accident and they call me to let me know that it happened and that i needed to come or they were going to send the child to the hospital one of the children got sick in school so they called me and i couldn′t call them back because i didn′t have the credit so i went to school and when i went to pick up the kids all these incidents already passed they told me what happened and i felt that where was i when i was needed but now with this one mobile phone everything is there immediately if anything happens come now i will be able to because i have the means to call them back discussion in this article we have focused our attention on the unique aspects of our programme that helped to enhance the health and wellbeing and ease the settlement process of many recently resettled refugee women it has been suggested that participating in peer support groups provides beneficial effects to group members the findings of our project support this notion however our project also reveals that it was the combination of participation in a peer support group programme and access to a freecall mobile phone that provided the best effect on the wellbeing of our participants who were isolated and faced multiple complexities in life refugees roth and craneross and schutt and rogers have suggested that there may be some special features that enforce the positive effects of peer support group we content that the special feature of free mobile phone access contributes to this positivity the mobile phone is not only a unifying medium for information exchange but also a social amenity and a means for increased economic opportunities for individuals in a study of mobile phone use by immigrants from guineabissau in lisbon portugal johnson observed that mobile phones are widely used to facilitate relationships within the heritage culture in lisbon importantly it has been evidenced that the mobile phone can function as a health promotion tool this has been witnessed in our study for example reconnection is an important part of recovering from trauma and difficulties for the women in our study having access to a freecall mobile phone allowed them to reconnect with others and family members as well as their traditional ways of life this helped the women to feel less worried and isolated although some women had their own mobile phone prior to participating in our study our data showed that the freecall element of our mobile phone was important for them due to their low income they frequently ran out of credit in their own mobile phone mobile phone calls are expensive and as most of them are on a prepaid plan they simply could not afford to make the kind of calls they had made in our programme they referred to the phone we provided as the magic phone because it had unlimited credit although some participants said that they were disturbed by unwanted calls at inconvenient times the benefits of having access to a free mobile phone outweighed this drawback in our study peer support is viewed as a subset of social support in which relationships are formed between individuals who are similar to each other the initial training was undertaken in peer groups but the provision and receipt of social support extended into the broader community in our study peer support training enabled the participants to establish communicative relationships among participants from the same communities whilst the mobile phones augmented the peer group relationships and relationships with a small number of people and institutions external to the peer group our study builds on the role of peer support in refugee resettlement by adding a reliable communication channel that enables social network development which in turn influences the acculturation journey of refugee women in the following sections we discuss several salient issues emerging from our study ngum chi watts 2012benza and liamputtong 2014 most migrant and refugee women have to deal with multiple stresses associated with relocation and social adjustment when settling into a new homeland for refugees who have to deal with multiple difficulties isolation can be a compounding factor which make their life situations worse as a result of participation in peer support trainings as wallerstein suggests social isolation may be diminished and this led to the improvement of health and wellbeing among the women in our study in an online support group research conducted by van udenkraan et al the participants strongly experienced what the authors termed as enhanced social wellbeing participation in a support group resulted in increased social contacts as well as decreased loneliness our results similarly showed this enhanced social wellbeing as participation in peer support groups helped to reduce isolation and loneliness among the women additionally the social support helped the women to feel that they were not dealing with lifes challenges alone we contend that the support that the women received from their peer support group is crucial to their health and wellbeing and allowed them to deal with their vulnerabilities in a new homeland additionally peer support enhances empowerment among individuals in the group through learning and sharing during the peer support training and communicating on their mobile phones the women in our study cultivated a sense of their own abilities and had an opportunity to reinforce connections with others this helped to transform their lived experiences from being socially isolated individuals to being part of a larger community this we believe is the personal empowerment process for the women in our study although peer support emphasises individual strengths it simultaneously moves towards autonomy as well as community building thus peer support can be empowering for both individuals and their communities wallerstein suggests that participation in a community and a sense of community belonging has consistently been seen as a predictor of health and wellbeing wang and hu similarly contend that a sense of community and social support received from others in the community can have a protective health effect on individuals this is apparent in our study having a sense of community connection not only reduced the participants sense of isolation but also helped them to settle in their new homeland with greater ease research has shown that for most refugees and immigrants a sense of belonging to ones ethnic community is crucial for the health and wellbeing among these vulnerable people empowerment wallerstein suggests is a social protective factor which can also be seen as a health enhancing strategy this is clearly seen from our findings many women suggested that the connections and knowledge they had cultivated from the programme made them feel brave and safe enough to get out of their community and to do things that they previously had no opportunity or courage to do this has created the feeling of empowerment and selfcapability among the women the connections that were cultivated through the programme allowed the women to perform tasks which are more health promoting for example having a chat and obtaining advice from others in conclusion our programme provided evidence that appropriate peer support strategies can be incorporated into programmes designed to assist refugees with health and wellbeing enhancement as well as acculturation and resettlement needs we argue that mobile phone technology is ubiquitous and the issues are about making access possible for specific population groups and identifying the uses that are most important to members of particular population groups our programme has shown that by tapping on community resources to ameliorate personal or resettlement issues the burden on service providers could be reduced the findings of this study also offer a model for future research and health promotion programmes regarding people from other refugee backgrounds within australia or elsewhere peer support and health enhancement we have shown in this paper that participation in peer support group is a healthpromoting behaviour as kafaar et al theorize by participating in peer support group individuals will receive some kinds of benefits such as assistance for dealing with difficulties in life and combating against isolation peer support according to mead et al is a system of gaining and bestowing assistance it is operated within the principles of respect and shared responsibility among group members peer support is also about having empathetic appreciation of the situations of others through shared experiences when individuals in the group sense that they have shared experiences with others a connection is created peer support bestows a sense of connection belonging and community which frequently falls short among marginalised individuals and this clearly is the situation of refugees particularly those who are newly arrived including the women in our study clearly these are healthpromoting behaviours resulting from having access to peer support groups peer support is a form of social support which functions both at the individual as well as community levels as social support theory suggests support is reciprocal the women in our study gave help to others as well as received it when needed this was particularly so among older women who provided support to young women with no parents living in melbourne this support was essential for young people who have experienced loss and grief and for successful settling into a new life social support provided by the older women enhanced a sense of belonging and security among the younger women several authors have theorised that giving and receiving social support can be healthpromoting behaviours the support that one receives from social ties can act as a buffer against health difficulties barnes and aguilar argue that being part of a community offers an important sense of belongingness and social identity it also promotes an opportunity for the creation of social bonding resulting in increased social support and improvement of emotional wellbeing among individuals this was evident from our findings additionally the women in our study emphasized the practical support they received and provided to other peers in their social group peer support was developed into a complex system that benefitted not only the women but also the community the women became aware of not only their own but other womens needs and availed themselves to support their friends peer support and social wellbeing refugees and immigrants tend to face social isolation in their new homeland and this is particularly marked for recently arrived individuals in our study social isolation which was experienced by all was particularly pertinent for women who are mothers liamputtong 2006

in this article we discuss qualitative findings basing on the experiences of refugee women living in melbourne australia who participated in a peer support training programme and received a free mobile phone we pay attention to social support as a health enhancing strategy and empowerment that occurred among the participants participation in peer support groups and access to a mobile phone were beneficial for the women peer support functioned as social support among group members the programme allowed the women to be connected to their families and the wider communities and assisted them to access health care and other settlement aspects with greater ease it also increased personal empowerment among the women our programme shows that by tapping on community resources to ameliorate personal or resettlement issues the burden on service providers can be reduced our findings also offer a model for future research and programmes regarding refugee people elsewhere

introduction social exclusion is a dynamic procedural multidimensional and relational social phenomenon which makes it possible to understand poverty and its consequences on the moral dependence of families without work 1 among these characteristics multidimensionality makes social exclusion a phenomenon compatible with the operational framework of composite indicators this framework offers a set of methods that make it possible to simplify the representation of complex social phenomena and assist decision makers in the elaboration of public policies 23 however no method of constructing composite social indicators is exempt from shortcomings the normalization weighting and aggregation of the subindicators particular to each method impact the composite indicator scores 4 5 6 these different scores result in uncertainties in the position of the observations in the ranking and the strength of the link between the composite indicator and the conceptually most significant variables of the multidimensional social phenomenon 2 therefore it is impossible to determine in advance which method to use to construct a stable composite social indicator that captures the concept of the multidimensional phenomenon furthermore a method that offers a satisfactory solution to represent the social exclusion of a city may not present the same performance in another city as social exclusion is a social phenomenon dependent on space 7 this research aims to map social exclusion through a decision framework that allows for the identification of the methods that construct a stable composite indicator that captures the concept of the multidimensional phenomenon for this the stability and capacity of six methods used to represent the social exclusion of eight cities were analyzed the results of this analysis contribute to the literature in six different ways first it offers a decision framework for choosing a method to construct a composite social indicator second it shows to what extent geographic space matters in defining the method used to construct a composite social indicator third it identifies the bestperforming method regarding stability and linkage with the conceptually most significant variables of the multidimensional phenomenon fourth it reveals which methods perform poorly and should be avoided fifth it indicates which mathematical properties favor the representation of composite social phenomena sixth the research contributes to the debate of social phenomena from a geographical perspective and public policies since the results have great potential for appropriation by public policy managers literature review 21 multidimensional social exclusion poverty and social exclusion are disadvantages resulting from income inequality unemployment material deprivation and access to social and political activities 8 social exclusion in particular overlaps with the poverty concept and implies the total or partial removal of individuals from current social systems compromising social participation 9 and wellbeing 10 social scientists understand social exclusion as a comprehensive concept of a multidimensional nature including income housing transportation citizenship 11 and other indicators on the one hand the scope and multidimensionality of social exclusion allow for its representation from different perspectives for example social exclusion can be represented with an emphasis on the perspectives of health 12 transport 1314 children 1516 and later life 17 on the other hand the scope and multidimensionality of social exclusion make it challenging to develop a universal theoretical framework that allows for comparisons since the dimensions and indicators used in social exclusion measures are very different as shown below dimensions transportation 13 housing 10 sociodemographics and transport 18 economic social and political dimensions 11 economic social political and cultural dimensions 9 and demographic socioeconomic and environmental dimensions 12 indicators income distribution monetary poverty health labor housing conditions and material deprivation 8 socioeconomics education connectedness housing and health services 16 poverty education unemployment social security and the family situation 12 and physical conditions public transport services education opportunity employment opportunity medical care opportunity food opportunity and commercial opportunity 13 in addition to the lack of a universal theoretical framework to represent social exclusion the operationalization of the social exclusion concept has long been associated with several problems 11 in particular these problems reflect the flaws and limitations of the composite indicator construction methods 2 there are several methods for building composite indicators 19 with the choice of the method being a subjective decision which is reflected in a variety of methodological approaches for example it is possible to cite composite indicators of social exclusion constructed through simple additive weighting methods 15 principal component analyses 121320 benefitofthedoubt approaches 14 machinelearning approaches 17 and multicriteria methods there is a consensus in the literature about the failures and limitations of the methods of constructing composite indicators despite this the quality of the multidimensional representation of social exclusion has been superficially explored in particular works concerned with the quality of composite indicators of social exclusion focus exclusively on the external validity of the construct 1721 therefore these works ignore or disregard the importance of constructing a stable composite indicator in which variations in the way of normalizing weighting and aggregating the subindicators do not generate significant fluctuations in the scores 5 this research explores this gap and seeks to answer the following question which methods construct a stable composite indicator that captures the concept of multidimensional social exclusion methods for constructing composite indicators from a geographic perspective phenomena such as poverty social exclusion social vulnerability wellbeing and inequality have two characteristics in common dependence on geographic space 7 22 23 24 25 and a multidimensional nature 10 26 27 28 29 30 the search for the literature of interest to this research was based on these two characteristics and was carried out with the following criteria articles published in the web of science in the geography category with the term composite indicator in the abstract and published in the last five years fourteen research papers met these criteria and the method used to construct the composite indicator was identified in ten the most frequently used method was the simple additive weighting method saw has two main advantages the simplicity of operation and flexibility in choosing the weighting scheme for subindicators for example it is possible to operationalize saw with equal weights 31 32 33 or with participatory weights 3435 another widespread method with the advantage of the datadriven weighting of subindicators is the principal component analysis 36 methods such as the stochastic multiattribute acceptability analysis 37 and the geographic weighted principal component analysis 38 are less frequent but together with the benefitofthedoubt 39 have the advantage of considering spatial heterogeneity finally ordered weighted averaging is a sophisticated method that allows for the consideration of spatial heterogeneity the noncompensation between subindicators of poor and aboveaverage performance and the emphasis of the positive or negative aspects of the multidimensional phenomenon 40 even though this list of methods is representative it disregards one of the most popular methods in the composite indicator literature 19 the technique for order preferences by similarity to ideal solutions taking these aspects into account this paper evaluates the performance of six methods saw with equal weights or sawew saw with participatory weights or sawpw principal component analysis benefitofthedoubt ordered weighted averaging and topsis sawew consists of aggregating normalized subindicators with equal weights attributing equal weights is especially advantageous when causal relationships are unknown or when experts disagree on the relative importance of subindicators in the multidimensional phenomenon concept 2 sawpw considers that the subindicators have different levels of relative importance in the concept of the multidimensional phenomenon this method considers experts opinions in the weight definition which is especially advantageous when the experts know about the phenomenon and the geographic units 41 owa also considers decision makers participation in constructing the composite indicator the method aggregates the normalized subindicators ordered by performance and weighted with a value of 0 or 1 the owa corresponds to sawew when all subindicators are weighted with a value of 1 in turn weighting the five highestperforming subindicators with a value of zero corresponds to an emphasis on the negative aspects of social exclusion and noncompensation between the subindicators of poor and aboveaverage performance 42 this weighting is also advantageous because it considers spatial heterogeneity the weighting of subindicators with a value of 0 or 1 is performed based on the subindicators performance causing the aggregate subindicators to change from one spatial unit to another pca involves the datadriven weighting of subindicators constructing a composite indicator that retains most of the variance of the original data additionally the weights do not vary across geographic units and are free from subjectivities and judgment biases 43 these characteristics make pca an advantageous method when comparability is a critical attribute of the analysis and when specialists do not have knowledge about all the spatial units involved bod also involves the datadriven weighting of the subindicators however the weights are defined based on the performance of the subindicator in each spatial unit thus bod constructs a composite indicator that considers spatial heterogeneity as the subindicators weights vary from one spatial unit to another this weighting scheme highlights each spatial units positive aspects and is considered advantageous for avoiding disputes about the weighting scheme adopted in constructing a composite indicator 44 topsis consists of implementing a function that normalizes the subindicators based on their distance to the best and worst scores the socalled positive and negative ideal solutions the method uses the compensatory aggregation approach and offers flexibility in adopting the weighting scheme 2145 this flexibility is advantageous because it allows for the weighting of subindicators using the equal weights datadriven and participatory schemes this set of methods covers the most relevant mathematical properties in constructing composite indicators the sawew and topsis weight subindicators with equal weights the latter uses a normalization function that considers the distance of scores for a positive and negative ideal solution the sawpw and the owa weight the subindicators based on expert opinion with the second considering spatial heterogeneity and noncompensatory aggregation the pca and the bod weight the subindicators statistically the former retains as much of the original information in the composite indicator the latter emphasizes the positive aspects of each spatial unit by assigning greater weights to the higher performance indicators the question is as follows which of these mathematical properties constructs a more stable composite indicator that captures the concept of social exclusion materials and methods the development of this research is associated with a project named mapping and analyzing territorial inequalities in mediumsized cities in the interior of paraná brazil this project aims to understand the processes of social exclusion poverty and inequalities in the face of the growing appreciation of the territorial dimension in analyzing public policies especially social policies 46 study area mediumsized cities of the state of paraná brazil cities were selected due to their importance in territorial development and because they present very different realities that need to be analyzed from their internal dynamics 46 figure 1 shows the location of eight midsized cities in the state of paraná brazil used as a reference in this study study area mediumsized cities of the state of paraná brazil cities were selected due to their importance in territorial development and because they present very different realities that need to be analyzed from their internal dynamics 46 figure 1 shows the location of eight midsized cities in the state of paraná brazil used as a reference in this study according to the last brazilian census recorded in 2010 the midsized cities analyzed in this research have more than 100 thousand and less than 1 million inhabitants 47 census tracts are the geographical reference unit for constructing the composite indicator of social exclusion census tracts are the smallest units for aggregating demographic census data and comprise between 200 and 250 households 47 the number of census tracts varies with population size across the eight midsized cities apucarana 113 rattlesnake 418 foz do iguaçu 320 guarapuava 182 londrina 770 maringá 483 ponta grossa 398 and toledo 109 theoretical framework multidimensional social exclusion subindicators the theoretical framework used in this research is based on the methodology developed by the center for studies and mapping of social exclusion for public policies 48 this framework has the advantages of using a consolidated methodology the availability of subindicator data and information obtained from specialists on the relative importance of subindicators in the social exclusion concept five dimensions of social exclusion are addressed in this framework economic dimension influences the other dimensions consisting of indicators with a greater availability of data ease of access and levels of stratification educational dimension the main element of mobility in social conditions today given the relationship between levels of education and income demographic dimension socially excluded people have a lower life expectancy than average due to higher infant mortality and fertility rates environmental dimension more privileged populations seek to occupy more wooded areas to avoid the thermal discomfort resulting from the densification of buildings in cities household dimension connects all previous dimensions to urban space and reflects them in the housing and neighborhood conditions figure 2 presents the five dimensions and the fifteen subindicators of the theoretical framework of social exclusion used in constructing the composite indicators as well as the direction of the relationship of each subindicator with social exclusion according to the last brazilian census recorded in 2010 the midsized cities analyzed in this research have more than 100 thousand and less than 1 million inhabitants 47 census tracts are the geographical reference unit for constructing the composite indicator of social exclusion census tracts are the smallest units for aggregating demographic census data and comprise between 200 and 250 households 47 the number of census tracts varies with population size across the eight midsized cities apucarana 113 rattlesnake 418 foz do iguaçu 320 guarapuava 182 londrina 770 maringá 483 ponta grossa 398 and toledo 109 theoretical framework multidimensional social exclusion subindicators the theoretical framework used in this research is based on the methodology developed by the center for studies and mapping of social exclusion for public policies 48 this framework has the advantages of using a consolidated methodology the availability of subindicator data and information obtained from specialists on the relative importance of subindicators in the social exclusion concept five dimensions of social exclusion are addressed in this framework economic dimension influences the other dimensions consisting of indicators with a greater availability of data ease of access and levels of stratification educational dimension the main element of mobility in social conditions today given the relationship between levels of education and income demographic dimension socially excluded people have a lower life expectancy than average due to higher infant mortality and fertility rates environmental dimension more privileged populations seek to occupy more wooded areas to avoid the thermal discomfort resulting from the densification of buildings in cities household dimension connects all previous dimensions to urban space and reflects them in the housing and neighborhood conditions operational framework construction and performance analysis of composite indicato the theoretical framework presented in section 32 was operationalized using t methods detailed in section 2 saw with equal weights or sawew saw participatory weights or sawpw principal component analysis be ofthedoubt ordered weighted averaging and topsis then two criteria were applied to evaluate the performance of the composite in tors linkage with external variables and stability the link with external variables allows for the verification of the relationship composite indicator with conceptually significant variables in the concept of the mu mensional phenomenon 2 studies on social phenomena such as social exclusion u stand that income is the conceptually most significant variable 1 therefore a soci clusion composite indicator captures the concept of the multidimensional phenom when its scores are similar to those of the income variable this similarity is usually fied by the correlation coefficient between the composite indicator and the external v ble 4 in particular the spearman correlation coefficient indicates how much the co site indicator captures the multidimensional phenomenon even in the presence of ou or for data without normal distribution 49 the strength of the link between the co site indicator and the income variable indicated by the spearman correlation coeffi is based on the rule of thumb by 50 as follows r 03 insignificant 03 r 05 w 05 r 07 moderate 07 r 09 strong and r 09 very strong another way to verify the similarity between the composite indicator scores an come is by calculating the mahalanobis distance the mahalanobis distance is a biv outlier detection approach that allows for identifying the geographic areas with soci clusion scores incompatible with the external variable 35 this research uses the pr tion of bivariate outliers obtained through the mahalanobis distance as a second me of the composite indicators capacity to capture social exclusion correctly the second performance analysis is associated with constructing a composite in tor with a stable structure 24 it requires verifying the levels of uncertainty produc changes in normalizing weighting and aggregating the subindicators 5 in th search the uncertainty analysis is adapted to verify the stability of the composite ind operational framework construction and performance analysis of composite indicators the theoretical framework presented in section 32 was operationalized using the six methods detailed in section 2 saw with equal weights or sawew saw with participatory weights or sawpw principal component analysis benefitofthedoubt ordered weighted averaging and topsis then two criteria were applied to evaluate the performance of the composite indicators linkage with external variables and stability the link with external variables allows for the verification of the relationship of the composite indicator with conceptually significant variables in the concept of the multidimensional phenomenon 2 studies on social phenomena such as social exclusion understand that income is the conceptually most significant variable 1 therefore a social exclusion composite indicator captures the concept of the multidimensional phenomenon when its scores are similar to those of the income variable this similarity is usually verified by the correlation coefficient between the composite indicator and the external variable 4 in particular the spearman correlation coefficient indicates how much the composite indicator captures the multidimensional phenomenon even in the presence of outliers or for data without normal distribution 49 the strength of the link between the composite indicator and the income variable indicated by the spearman correlation coefficient is based on the rule of thumb by 50 as follows r 03 insignificant 03 r 05 weak 05 r 07 moderate 07 r 09 strong and r 09 very strong another way to verify the similarity between the composite indicator scores and income is by calculating the mahalanobis distance the mahalanobis distance is a bivariate outlier detection approach that allows for identifying the geographic areas with social exclusion scores incompatible with the external variable 35 this research uses the proportion of bivariate outliers obtained through the mahalanobis distance as a second measure of the composite indicators capacity to capture social exclusion correctly the second performance analysis is associated with constructing a composite indicator with a stable structure 24 it requires verifying the levels of uncertainty produced by changes in normalizing weighting and aggregating the subindicators 5 in this research the uncertainty analysis is adapted to verify the stability of the composite indicator construction method in other words the research verifies how much the results obtained by one method vary concerning the results obtained by the other methods in particular two uncertainty analyses were performed the first uncertainty analysis shows the proportion of the general variation in the census tracts position in the social exclusion ranking the second uncertainty analysis shows the variation in the social exclusion scores a summary of the researchs operational framework is illustrated in figure 3 construction method in other words the research verifies how much the results obtained by one method vary concerning the results obtained by the other methods in particular two uncertainty analyses were performed the first uncertainty analysis shows the proportion of the general variation in the census tracts position in the social exclusion ranking the second uncertainty analysis shows the variation in the social exclusion scores a summary of the researchs operational framework is illustrated in figure 3 in short the development of the research boils down to five steps first data are collected on the fifteen subindicators of social exclusion for each of the eight selected cities second six composite indicators of social exclusion are constructed for each city using the selected methods third the correlations between the composite indicator and income and the proportion of outliers are verified as a measure of external validity fourth variations in the scores and ranks are verified as a measure of the stability of the composite indicators fifth the methods that build stable composite indicators and that capture the concept of multidimensional social exclusion are identified results and analysis table 1 makes it possible to compare the performances of the composite indicators constructed by the six methods in capturing the conceptually most significant variable of social exclusion income in short seventythree percent of the composite indicators are moderately or strongly correlated with the income variable in short the development of the research boils down to five steps first data are collected on the fifteen subindicators of social exclusion for each of the eight selected cities second six composite indicators of social exclusion are constructed for each city using the selected methods third the correlations between the composite indicator and income and the proportion of outliers are verified as a measure of external validity fourth variations in the scores and ranks are verified as a measure of the stability of the composite indicators fifth the methods that build stable composite indicators and that capture the concept of multidimensional social exclusion are identified results and analysis table 1 makes it possible to compare the performances of the composite indicators constructed by the six methods in capturing the conceptually most significant variable of social exclusion income in short seventythree percent of the composite indicators are moderately or strongly correlated with the income variable bod is the method that presented the largest proportion of weak correlations with the income variable in four cities cibod was weakly correlated with the income variable moderate strong or very strong correlations were observed in all cities for the composite indicators constructed by the sawpw and pca methods seven cities showed moderate strong or very strong correlations between the composite indicators constructed by topsis and the income variable six cities achieved moderate strong or very strong correlations between the income variable and the composite indicators constructed by the sawew and sawowa methods the results in table 2 show that none of the methods has more than 10 of social exclusion scores incompatible with income the difference in the percentage of bivariate outliers among the six analyzed methods is only 1 this low difference indicates that no method stands out positively or negatively regarding the number of census tracts with income scores incompatible with the composite social exclusion indicator scores the scores of the composite indicators constructed by the owa and bod methods are the most compatible with the census tracts income both methods present an average of 626 of outliers the pca composite indicator scores show the highest percentage of outliers with income an average of 679 the general average of bivariate outliers is 6 indicating that the percentage of census tracts with social exclusion scores incompatible with income is low these low percentages of outliers suggest that the social exclusion scores of census tracts are highly compatible with income regardless of the method used the low percentage of census tracts with social exclusion scores incompatible with income does not overlap with the low correlation between the composite indicators constructed by the bod method with income therefore the link between the income variable exclusion and the composite indicator suggests that only bod may not be an adequate method to represent the social exclusion concept the uncertainty analysis reinforces the suggestion that bod should be avoided table 3 reveals an average change of 24 in the census tracts position in the social exclusion ranking when the bod method is applied to construct the composite indicator this percentage is on average 18 for the composite indicators constructed by pca and topsis the composite indicators constructed by sawew sawpw and owa are more stable with less than a 15 change in the position of the census tract in the ranking of social exclusion the uncertainty associated with the different ways of normalizing weighting and aggregating the subindicators of each method is lower in the composite indicators constructed by the sawew method the composite indicators constructed by the pca and topsis methods are 13 times more unstable than those constructed by sawew sawpw and sawowa the bod method constructs the most unstable composite indicator among the methods studied the position of the census tracts in the ranking of social exclusion obtained using the bod method can vary by 24 up or down concerning the average position obtained using the other methods the uncertainty analysis associated with the variation in the scores presented in table 4 reinforces these results it indicates that the primary sources of uncertainty are associated with datadriven weighting and normalization using the distance function on average the social exclusion composite indicator scores change by 042 when the bod method is applied to construct the composite indicator the pca and tospis methods also show significant instability the social exclusion scores change by more than 020 on the composite indicators constructed by pca and topsis these results indicate that the weights obtained from the data and by distance normalization generate more instability in the composite indicator than the noncompensatory aggregation the weights obtained from expert opinion and the equal weights an analysis of tables 14 makes it possible to identify which methods construct the composite indicators with the best performance in terms of stability and connection with the conceptually most significant variable in the concept of social exclusion in guarapuava the noncompensatory aggregation of the subindicators the emphasis on subindicators of poorer performance and the consideration of spatial heterogeneity contribute to a better representation of social exclusion the social exclusion composite indicator constructed by owa strongly correlates with income and presents only 44 of outliers the average change in the position of the census tracts in the social exclusion ranking is 12 up or down and the average change in the social exclusion scores is on average 017 a visualization of these results is presented in figure 4 outliers the average change in the position of the census tracts in the social exclusion ranking is 12 up or down and the average change in the social exclusion scores is on average 017 a visualization of these results is presented in figure 4 weighting the subindicators with equal weights and aggregating them by the average results provide a better representation of social exclusion in cascavel foz do iguaçu and maringá the sawew method constructs the most stable composite indicators of social exclusion in these cities the variation in the position of the census tracts in the weighting the subindicators with equal weights and aggregating them by the average results provide a better representation of social exclusion in cascavel foz do iguaçu and maringá the sawew method constructs the most stable composite indicators of social exclusion in these cities the variation in the position of the census tracts in the ranking of social exclusion is 132 times lower than the average of the other methods the scores vary 136 times less than the average of the two other methods the composite indicators of the social exclusion of cascavel foz do iguaçu and maringá present the lowest percentage of bivariate outliers among the methods analyzed the correlations of the composite indicator with income exceed 050 in all cities a summary of the results is displayed in figures 567 weighting the subindicators with equal weights and aggregating them by the av age results provide a better representation of social exclusion in cascavel foz do igua and maringá the sawew method constructs the most stable composite indicators social exclusion in these cities the variation in the position of the census tracts in t ranking of social exclusion is 132 times lower than the average of the other methods t scores vary 136 times less than the average of the two other methods the composite dicators of the social exclusion of cascavel foz do iguaçu and maringá present the low percentage of bivariate outliers among the methods analyzed the correlations of the co posite indicator with income exceed 050 in all cities a summary of the results is display in figures 567 the sawew method allows for the construction of stable composite indicators that capture the concept of social exclusion in six of the eight cities the method fails to capture the concept of social exclusion in the cities of londrina and ponta grossa these results suggest that assigning equal weights to subindicators does not deteriorate the composite indicators capacity to capture the concept of the multidimensional phenomenon furthermore the results indicate that a method of simple execution and understanding by public managers offers a good representation of multidimensional social phenomena the sawew method allows for the construction of stable composite indicators that capture the concept of social exclusion in six of the eight cities the method fails to capture the concept of social exclusion in the cities of londrina and ponta grossa these results suggest that assigning equal weights to subindicators does not deteriorate the composite indicators capacity to capture the concept of the multidimensional phenomenon furthermore the results indicate that a method of simple execution and understanding by public managers offers a good representation of multidimensional social phenomena sawpw is the method that constructs the most stable composite indicators that best capture the concept of social exclusion in the cities of apucarana londrina ponta grossa and toledo the weights obtained from expert opinions favor the representation of social exclusion in these four cities however the performance of the composite indicator constructed by the sawpw method is significantly superior in apucarana and toledo when compared to that in londrina and ponta grossa as shown in figures 891011 sawpw is the method that constructs the most stable composite indicators that best capture the concept of social exclusion in the cities of apucarana londrina ponta grossa and toledo the weights obtained from expert opinions favor the representation of social exclusion in these four cities however the performance of the composite indicator constructed by the sawpw method is significantly superior in apucarana and toledo when compared to that in londrina and ponta grossa as shown in figures 891011 the correlation of the composite indicator with income is 132 and 130 times lower in londrina and ponta grossa than the average for apucarana and toledo the variation in the position of the census tract in the social exclusion ranking is 225 and 133 times higher in londrina and ponta grossa than the average for apucarana and toledo even so the sawpw method better represents social exclusion in londrina and ponta grossa than the other methods ponta grossa presents the worst performance in the linking of the composite indicator with the conceptually most significant variable of social exclusion the average correlation between the composite indicators and the income variable is 050 the composite indicators constructed by sawew and owa show an insignificant correlation with the income variable the correlation of the composite indicator with income is 132 and 130 times lower in londrina and ponta grossa than the average for apucarana and toledo the variation in the position of the census tract in the social exclusion ranking is 225 and 133 times higher in londrina and ponta grossa than the average for apucarana and toledo even the correlation with income and the variation in the scores of the eight composite indicators constructed for londrina are worse than the results for the other cities the variation in the position of the census tracts in the ranking of social exclusion is worse in londrina than the average of the other cities when using five of the six methods only the composite indicators constructed by sawpw pca and topsis moderately or strongly capture the concept of social exclusion in londrina and ponta grossa however the sawpw method is a more stable composite indicator than the pca and topsis methods in the two cities in londrina the position of the census tracts in the ranking varies 150 times less in the composite indicator constructed by the sawpw method than in that constructed by the pca or topsis methods the social exclusion scores vary 168 times less in the composite indicator constructed by the sawpw method than in that constructed by the pca or topsis methods in ponta grossa the composite indicator constructed by the sawpw method is 131 and 164 more stable than that constructed by pca and topsis concerning the ranking position and score variations these results indicate that space matters in defining the method used to construct the composite indicator sawew and sawpw perform the best in representing social exclusion in 88 of cities however the performance of these methods varies between cities and the sawew method fails to represent the multidimensional phenomenon in two cities discussion of the results this research addresses a topic of great interest among researchers in the composite indicators field the influence of geographic space on the measurement of multidimensional social phenomena 7 the research results reveal that multidimensionality and spatial dependence on social phenomena such as social exclusion prevent the determination of a fully reliable method for their measurement for example a method that provides a satisfactory solution for representing social exclusion in one city may not perform as well in another these results enrich the current literature on the impact of space and the construction methods of composite indicators on the representation of the multidimensional phenomenon on the one hand the research results confirm that space matters in the representation of social exclusion 2223 on the other hand the research results add to the literature that the representation of social exclusion is also directly influenced by the construction method of the composite indicator in this respect the research offers a valuable contribution to identifying which method offers the best representation of the multidimensional phenomenon as current studies 1721 focus exclusively on externally validating the composite indicator of social exclusion the results also show that the composite indicators stability and capacity used to capture the concept of the multidimensional phenomenon vary according to the method and space at this point it is possible to connect two understandings sedimented in the literature and to conclude that the flaws and limitations of composite indicator construction methods are spacedependent this connection reinforces the importance of a decision framework that allows for the identification of the most suitable methods to construct stable composite indicators that capture the concept of multidimensional social phenomena the application of the decision framework shows that widely used methods in the construction of composite indicators of social exclusion such as pca 121320 and bod 1439 perform poorly and should be avoided composite indicators constructed using subjective weighting offer better representations of social exclusion than those constructed using datadriven weighting this result contributes to the discussion about the problem of the incompatibility of weights obtained endogenously with the relative importance of the subindicators in the concept of the phenomenon 3643 conclusions analyzing the composite indicators constructed by the six methods for each of the eight cities provides evidence to reach eight conclusions first it confirms the current argument in the literature that there is no perfect method to construct a composite indicator 251 second popular methods such as bod that consider spatial heterogeneity through the individualized weighting of the subindicators of the best performance of each spatial unit show poor results and should be used with caution third sophisticated methods such as owa that combine noncompensatory aggregation spatial heterogeneity and the emphasis of the positive or negative aspects of the phenomenon do not guarantee better results fourth methods that are simple to implement and easy to understand by public managers such as sawew and sawpw offer satisfactory results in most cases fifth datadriven weighting through the bod and pca methods is a critical source of uncertainty for composite indicators reinforcing the argument that the weights of the subindicators obtained through this weighting scheme are not necessarily compatible with the concept of the multidimensional phenomenon 3643 sixth weighting the subindicators based on expert opinion improves the performance of composite indicators which capture the concept of the multidimensional phenomenon in 100 of cases seventh the weighting of subindicators with equal weights using saw and topsis constructs composite indicators that capture the concept of social exclusion in 81 of cases indicating that space also matters in considering therelative importance of the subindicator in the multidimensional phenomenon eighth normalization by distance improves the capacity of composite indicators of social exclusion to capture income however it increases the percentage of bivariate outliers and the instability of composite indicators from these conclusions it is possible to point out the following research contributions first researchers can identify methods that build stable and reliable composite indicators in a context in which space matters through a fourcriteria decision framework two the performance of the composite indicator in terms of stability and ability to capture the concept of social exclusion varies from city to city supporting the argument that geographic space matters in representing multidimensional social phenomena third considering the opinion of experts on the relative importance of subindicators makes it possible to construct more stable composite indicators that always capture the concept of the multidimensional phenomenon fourth composite indicators constructed using datadriven weighting methods show unsatisfactory results in particular the pca method constructs composite indicators that are not very stable while bod constructs composite indicators that do not capture the concept of the multidimensional phenomenon in 75 of cities fifth the mathematical properties that most favor the representation of composite social phenomena are participatory and equal weights weighting noncompensatory aggregation and normalization using the maxmin and distance functions sixth the geographic perspective is a critical property for the debate on social phenomena so the framework developed in this research has great potential for appropriation by public managers in the planning and development of public policies in short geographic space matters in the methods definition making it impossible to indicate a priori which method to use to construct a composite indicator some methods generate more consistent results than others indicating the need to compare the performance of at least two methods with different weighting properties considering that the research results are based on two validations exploring new ways to validate the composite indicators is desirable it is suggested to expand the number of validations and consider composite indicators of social exclusion constructed from satellite images and google street view images another limitation to be considered in future research is comparing scores from different cities the social exclusion scores obtained in this research are not comparable between cities insofar as the maximum and minimum values used in normalization are specific to each city additionally it may be useful in future work to evaluate the frameworks responsiveness to other theoretical frameworks for example constructs that consider threshold levels for the subindicators the results of this research have important policy implications related to the fight against social exclusion and poverty as space matters and influences the performance of the methods to construct stable composite indicators urban planners and managers must experiment with these methods to search for the bestfitting alternative moreover it is also advisable to confront statistical outcomes with local urban characteristics including occupation history physical conditions land use patterns and social and economic structures to elaborate customized policies grounded in reality data availability statement the data used in the analyzes are available at martinuci os machado amc libório mp data for timeinspace analysis of multidimensional phenomena mendeley data v4 doi1017632m3y4jncvch4

this research proposes a decision framework that allows for the identification of the most suitable methods to construct stable composite indicators that capture the concept of multidimensional social phenomena this decision framework is applied to discover which method among six best represents the social exclusion of eight mediumsized brazilian cities the results indicate that space is important in the definition and performance of the method and ease methods to apply present the best performance however one of them fails to capture the concept of the multidimensional phenomenon in two cities the research makes six important contributions to the literature first it offers a decision framework for choosing the bestfit method to construct a composite social indicator second it shows to what extent geographic space matters in defining the bestfit method third it identifies the bestfit method regarding stability and linkage with the conceptually most significant indicator of social exclusion fourth it reveals the methods to be avoided given their poor performance fifth it indicates the mathematical properties that best represent composite social phenomena sixth it illuminates the debate on social exclusion from a geographical and public policy perspective

background alcohol use among college students is problematic globally but little is known about the extent to which various measures such as campus alcohol policy and education deter excessive student drinking in the context of south korea transition to college is often associated with an escalation in binge drinking one investigation reported that approximately 712 of students consume at least four to five standard drinks per drinking session 1 in the united states although binge drinking rates have decreased over time 3040 of adults consume four to five standard drinks per drinking session 2 while in europe around 60 of men and 41 of women between the ages of 18 to 23 binge drink regularly 3 considering that there are numerous negative consequences of college binge drinking including violence date rape accidents and academic problems 4 more research on prevention efforts is necessary rates of student alcohol use have been shown to vary between schools even when individuallevel characteristics such as gender race and ethnicity 5 have been adjusted for there are also multiple arealevel characteristics such as peer drinking norms 6 wealth and entertainment of the neighborhood surrounding the campus 7 and alcohol outlet density 89 that previous studies have associated with student drinking the national institute on alcohol abuse and alcoholism has identified the following environmentalfocused strategies for decreasing college binge drinking 1 retaining the minimum legal drinking age of 21 2 enforcing the mlda 3 increasing taxes on alcohol 4 retaining a ban on sunday alcohol sales and 5 enacting bans on happy hours and other price promotions although such policies are enacted at the state or local level when colleges partner with other organizations or coalitions to implement or retain such policies reductions in risky alcohol use and related problems among students are possible 10 previous studies in the international literature have also shown that certain policy interventions influence student alcohol consumption whilst policies vary among institutions emerging evidence indicates that policymakers should target both individual and environmental strategies to reduce excessive alcohol consumption and binge drinking among students typical environmental policies include campus alcohol bans bans for minors no alcohol use at college events prohibition of beer kegs and alcohol displays on campus 11 and limitations on maximum number of drinks purchasable per student 12 in one study students attending schools with a ban on alcohol use were up to 30 less likely to engage in binge drinking 13 attending colleges that restrict high volume sales or target underage drinking has been associated with lower rates of alcoholinvolved driving while substancefree residence halls have been associated with reduced alcoholrelated problems 14 regulating excessive alcohol use through distance and accessbased interventions that reduce the average distance between a college and outlet or the number of outlets in a county have also been effective in decreasing excessive alcohol consumption 15 banning alcohol advertisements and kegs on campus and enforcing deterrence policies more strictly have been associated with decreased alcohol consumption 16 recent studies have also found that while campaigns to drink responsibly are ineffective for heavy drinkers strategic campaigns that promote responsible drinking may be effective among mild and moderate drinkers 17 however in 2008 nelson and colleagues found that 23 of colleges in the united states were not employing any recommended strategies to reduce alcoholrelated harm while 45 were only employing a single recommended strategy such as 1 interventions challenging alcohol expectancies 2 restrictions on alcohol retail outlet density 3 enforcement of laws to prevent alcoholimpaired driving andor 4 responsible beverage service policies in social and commercial settings 18 overall limited research has been done to assess the association between selfreported campus alcohol policy and education experience on alcohol consumption among college students on the individual level alcohol education programs especially those directed towards individuals that typically use alcohol at higher rates have shown to be effective in some studies 19 ultimately according to a study of 734 college administrators most institutions in the united states continue to offer some type of alcohol education program despite their limited success in combination with restrictive environmental policies that reduce student access to alcohol 11 although alcohol policies have been enacted to prevent and reduce harmful drinking of college students limited research has been done to assess the association between type of campus alcohol policy and student alcohol consumption from a multilevel model approach therefore the present study focuses on examining the association between perceived college alcohol policy and student drinking while controlling for both individuallevel and collegelevel characteristics methods study sample and data in the 2017 national statistics published by the korean educational development institute on college students we found that 1951940 students are enrolled in 356 colleges in south korea thus we stratified a proportionately representative sample of undergraduate students from 54 4year colleges and 28 liberal arts colleges students in these colleges were further stratified according to sex year level major gpa pocket money smoking status stress level depressive thoughts suicidal thoughts and number of clubsorganizations in total 5000 students completed the survey instrument the response rate was 687 with the total number of approached participants being 7278 a financial incentive of 10000 korean won was given to each participant upon completion of the 14page survey instrument of these students we excluded 10 students who had missing data for their major and gpa and 211 students who had missing data for questions related to the auditc for a final study sample of 4592 college students more information regarding the survey have been published in previous studies 2021 data was collected via facetoface surveys with students questions were mainly about student drinking behavior health sociodemographic characteristics and thoughts on campusalcohol policy whenever possible the instrument included alcoholrelated questions that had been previously used in other international national or largescale epidemiological studies including the harvard college alcohol study 14 the korea national health and nutrition examination survey 22 and the korea youth risk behavior webbased survey 23 collegelevel information such as number of students faculty and staff were found on the korean educational development institute website which provides basic information about all registered colleges in the country a standard drink was defined as the amount of alcohol contained in one glass of alcohol drink equivalent to1 shot of soju 1 glass of bottled beer 23 of a canned beer 12 glass of draft beer 12 bowl of makgeolli 12 glass of wine 1 glass of whiskey 1 shot of cheongju 1 shot of herbal liquor 1 shot of fruit wine or a 35 glass of mixed liquor in accordance with the standards of the korea centers for disease control prevention our survey instrument followed the guidelines of the institutional review board of yonsei universitys college of medicine all procedures were performed in accordance with the ethical standards of the declaration of helsinki informed consent was obtained from all individual participants included in the survey in written form data collectors were trained about the surveys ethical standards regarding privacy anonymity and confidentiality by our research team and collaborators from gallup korea each question of the questionnaire was required to be administered privately to students in a facetoface manner at a quiet enclosed space on campus such as a café or lecture room the survey contained no identifying values that could link the information to the participant making it completely impossible for researchers to identify specific participants measures outcome variable alcohol intake measured through the alcohol use disorders identification testconsumption was selected as the outcome variable the auditc is an abbreviated 3item measure consisting of the first three questions from the fulllength audit questionnaire the auditc assesses alcohol consumption over the past year and can help identify persons who are hazardous drinkers or have active alcohol use disorders items are scaled and summed to create a total score higher auditc scores indicate greater alcohol consumption generally the higher the audit score the more likely the patients drinking is affecting his or her safety among korean men a score of 4 or more is considered positive optimal for identifying hazardous drinking or active alcohol use disorders whilst a score of 3 or more is considered positive among korean women 24 perceived type of campus alcohol policy perceived type of campus alcohol policy was measured via individual answers to the question what is your universitys campus alcohol policy response options were as follows unaware of campus alcohol policy bans all drinking on campus bans minors from drinking on campus occasionally allows drinking on campus at certain locationsduring events allows drinking in outdoor spaces and allows drinking in all areas students could only select one answer based on their knowledge of their schools campus alcohol policy multiple choice options were unavailable alcohol education experience alcohol education experience was measured via individual answers to the question in the past 12 months how many times have you encountered or taken part in the following alcohol prevention activities at you university response options were as follows attended alcohol prevention programs lectures or training received a mail or brochure on alcohol prevention saw posters or promotion materials on alcohol prevention and participated in a moderation campaign on campus individuals were able to select their response on the following frequency scale never once twice 3 times 4 or more times the sum of these responses was recategorized into a new variable alcohol education experience and individuals were classified into the following categories none 12 times 34 times more than 5 times statistical analysis in order to examine the study participants general characteristics chisquare tests were performed to compare differences between groups to examine the association between perceived type of campus alcohol policy and alcohol education experience with alcohol consumption multilevel linear regression analysis was employed both arealevel characteristics with respect to each college campus and individuallevel characteristics were controlled for in the mixed model the beta values used in this model indicate the nonstandardized regression coefficient which signifies how much the mean of the dependent variable changes given a oneunit shift in the independent variable kendalls taub correlation coefficient was used to measure the relationship between our variables of interest and auditc the simultaneous relationship between type of campus alcohol policy and alcohol education experience frequency on auditc was determined through subgroup analyses by running the linear regression analysis on the sample when stratified by sex the calculated pvalues in this study were considered significant if lower than 005 all analyses were performed using sas software version 94 results table 3 shows the general characteristics of the study sample three thousand five hundred ninetysix students reported to being unaware of campus alcohol policy followed by 704 students reporting to college bans all drinking on campus 85 students reporting to college bans minors from drinking on campus 201 students reporting to college occasionally allows drinking on campus at certain locationsduring events 148 students reporting to college allows drinking in outdoor spaces and 69 students reporting to college allows drinking in all areas students who perceived that their campuses allow drinking in outdoor spaces or all areas had the highest auditc scores kendalls correlations showed that auditc was positively correlated with both perceived policy type and education experience kendalls correlations also showed that auditc was positively correlated with both perceived policy type and education experience considering that small correlation coefficients can be highly significant in large sample sizes and a kendall correlation is equal to 2π times the inverse sine of the pearson correlation 25 these correlation coefficient values may represent significant associations table 4 shows the results of the multilevel regression analysis performed to investigate the association between various factors and auditc score among our study sample compared to students unaware of campus alcohol policy students whose campuses allow drinking in outdoor spaces or allow drinking in all areas on campus had higher auditc scores even when arealevel characteristics including college type number of students number of faculty members number of workersadministrators and college region were controlled for alcohol education experience was not a predictor of reduced alcohol consumption females scored lower on the auditc than males as did seniors relative to freshmen students in the lowest gpa bracket scored higher on the auditc than students in the highest gpa bracket past smokers and students who reported to currently smoking had higher auditc scores compared to those reporting to not smoking as did students participating in two or more clubsorganizations relative to no clubsorganizations for males allowing alcohol consumption in outdoor spaces or in all areas resulted in more alcohol consumption for females allowing alcohol consumption in all areas resulted in more alcohol consumption receiving alcohol education 12 times or 34 times were not associated with higher auditc which was in alignment with the existing body of literature discussion our results suggest an association between selfreported campus alcohol policy and student alcohol consumption relative to students unaware of campus alcohol policy students who believe that their college allows drinking in outdoor spaces or all areas may consume higher amounts of alcohol than their peers such findings are in alignment with previous studies that have found that students drink more on school grounds when they perceive lax policy enforcement by college officials 26 interestingly alcohol education experience pertaining to alcohol prevention programs through lectures mail brochures posters promotion materials or moderation campaigns was not a significant predictor of decreased alcohol consumption among students in our investigation and only affected female students who had received alcohol education more than five times in their college years alcohol education programs have had mixed results when it comes to college interventions online and or offline alcohol education courses for college students have been both successful 27 and unsuccessful 162829 in mitigating alcoholrelated highrisk behaviors among student populations what is clear is that while educational experiences may have no effect among all college students among students who violate campus alcohol policies andor engage in highrisk drinking behaviors alcohol education or counseling is an effective measure in preventing alcohol misuse 30 furthermore as emphasized by kellyweeder and colleagues integrating educational interventions with environmental approaches can increase program effectiveness 17 our findings also show specific sociodemographic groups that should be particularly targeted when establishing campus alcohol policies males freshmen students with low gpa students receiving high amounts of pocket money current and past smokers and students in two or more clubsorganizations findings from major college alcohol investigations including the harvard college alcohol study have already noted these vulnerable populations as seen in the 1993 1997 1999 and 2001 harvard college alcohol study males students under the age of 21 students with academic problems related to alcohol such as missing class andor getting behind in school work 13 and smokers have all been associated with consuming more amounts of alcohol than other subpopulations 4 likewise previous studies have found that students who are more active in school activities such as clubsorganizations 31 or university athletics drink more and find alcohol problematic on campus 15 a difference between previous studies and our study is that in the context of year level students in south korea have the highest auditc scores in their freshman year whereas students in international studies mostly consume high amounts of alcohol during their sophomore and junior years 3133233 this phenomenon may be particular to south korea students in south korea have been noted to consume the most amount of alcohol in their freshman year at various orientation andor freshmen events where juniors and seniors pressure incoming students to drink 1 similar trends were also found among some asian countries like china 32 and taiwan 34 where alcohol use was greatest among 1st year students however in most european countries like france 33 belgium colombia ireland and poland 34 age andor year of study were not associated with binge drinking and associated drinking behaviors our study has a number of limitations first our study is crosssectional in design and therefore it is difficult to make causal inferences about the effect of campus alcohol policy type or education experience on alcohol consumption the data is based on selfreported answers and the question about campus alcohol policy may be ambiguous as only single choice answers were possible furthermore the group size is too small to meaningfully interpret trends especially because being unaware of campus alcohol policy does not mean full prohibition or liberalization future investigations should attempt to overcome these limitations through the survey instrument and design second there are not enough previous studies with regard to a nationally representative sample of koreans when it comes to measuring type of campus alcohol policyeducation experience and its effect on drinking behavior of college students it is difficult to see whether the values we calculated are similar to that of the statistics found in previous studies especially for the college students age group similarly all alcohol education experiences ranging from lectures to campaigns were given equal weights in our analysis because our survey instrument measured these experiences together however certain activities may have a greater impact on drinking behavior than others future studies should take this factor into account and attempt to give weights to these experiences or measure them separately as individual effects furthermore various sampling biases may have emerged from our surveying methods because college students in south korea drink large amounts of alcohol relative to adults different patterns are likely to emerge in adult populations likewise a small number of christian colleges that were originally in our sample declined our request for participation because of their teetotalism principles and thus had to be replaced with nonchristian colleges because of the facetoface method that we employed for accuracy of obtaining responses to complicated questions there may have been response biases relative to social desirability the majority of questions in our survey instrument required students to think about their drinking behaviors in the last 12 months or so which likely resulted in recall bias finally although we included numerous lifestyle covariates as potential confounders the limited nature and number of questions in our instrument as well as information publicly available regarding each college campus made it difficult for other confounding variables relative to health sociodemographics geneenvironment environment and lifestyle to be measured and controlled for despite these limitations our study also has several strengths few studies have measured the effect of environmental and educational campus alcohol policies on drinking behavior for a nationally representative sample of college students in south korea especially with a multilevel statistical model which controls for macrorelated characteristics our findings not only show which subgroups are at higher risk of consuming dangerous amounts of alcohol but show that alcohol education experience is effective only when done frequently and in combination with environmental deterrence policies among certain subgroups conclusion in conclusion this study emphasizes the importance of prohibiting alcohol consumption in open public college spaces if only to prevent highrisk students from perceiving that college alcohol policies are lax while alcohol policies and educational programs may be limited in impacting the drinking behaviors of all college students it is undeniable that college alcohol policy is associated with student drinking behavior it is especially important for schools to have nonjudgmental and supportive mechanisms that help students with alcoholrelated fig 1 subgroup analysis of the association between perceived alcohol policy and education experience by sex problems andor auds 35 according to blanco and colleagues roughly 20 of college students meet the criteria for an aud 6 thus college educators and administrators should be aware that relative to students unaware of their schools campus alcohol policy students who believe that their college allows drinking in outdoor spaces or all areas may consume higher amounts of alcohol than their peers authors contributions sso and yjj made substantial contributions to analysis and interpretation of the data sso was involved in drafting the manuscript and revising it critically for important intellectual content sij was in charge of revising the manuscript and giving final approval of the version to be published ec park conceived designed and directed this study all authors participated sufficiently in the work and take public responsibility for appropriate portions of the content all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background campus alcohol policy has been associated with student alcohol consumption in numerous studies however more information is required to assess the extent to which school policy affects student drinking behavior especially when both individuallevel sociodemographic characteristics of students and arealevel characteristics of college campuses are controlled for thus this paper explores the association between campus alcohol policy and student alcohol consumption among a nationally representative sample of college students in south korea while controlling for both individual and arealevel characteristicswe surveyed and analyzed the data of 4592 students from 82 colleges multilevel hierarchical linear modeling was used to identify the association between campus alcohol policy and alcohol consumption levels measured via the auditc alcohol use disorders identification test consumption controlled individuallevel characteristics included sex year level major gpa grade point average pocket money smoking status stress level depressive thoughts suicidal thoughts and number of clubsorganizations controlled arealevel characteristics included college type number of students number of faculty members number of workersadministrators and region results compared to students unaware of their schools campus alcohol policy students who selfreported that their campuses allow drinking in outdoor spaces β 0755 p 0010 or in all areas β 0820 p 0044 had higher auditc scores students attending schools with a large number of students males freshmen students with low gpa students with high amounts of pocket money and smokers also had higher alcohol consumption scores relative to their peers alcohol education experience in the form of lectures mail andor campaigns were not associated with student alcohol consumption levels conclusion our results suggest an association between selfreported campus alcohol policy and student alcohol consumption college educators and administrators must be aware that relative to students unaware of their schools campus alcohol policy students at colleges that allow drinking in outdoor spaces or all areas consume higher amounts of alcohol than their peers even when arealevel factors are controlled for

introduction lawrence 1 listen up yeah this is simon hes got a project he wants to talk to you lot about unknown who lawrence simon the guy i told you about listen up simon um thanks for coming in basically im a student doing social work at university and i want to do some research with a group of you on what its like for a young man growing up in st pauls today when i say i want to do it with you i mean im looking for maybe half a dozen maybe all of you to become researchers with me i dont just want to interview you or whatever youd actually be researching your own lives if that makes sense unknown oh okay how much simon hold up ill train and pay you a oneoff amount but you need to sign up for twelve weeks of group sessions where well just hang and talk about issues you raise then well do whatever you want with what we learn we can make a music video do photography or a film whatever you want whatever that is will be yours not mine i just want to record the group sessions we do each week for my research and work with you to make something thats useful for the community and for you guys it would be like three hours a week for twelve weeks thats the basic commitment im looking for after that you get paid and if we havent finished you can carry on if you want or leave no pressure no questions you can leave anytime you like but if you go earlier than the twelve weeks then obviously you wont get the full amount jermaine si i have a question so how much we gettin paid for this simon £100 but look over twelve weeks at three to five hours a week thats only like £4 an hour but its all ive got in the budget you also get skills in research or whatever interests you so if you want to make a film or do music ill arrange for you to get trained up in that too if i can so like you can get a lot out of this if you put in i hope that by doing this together we might come to see things differently i dont know anythings possible i guess jacob look yeah you dont need these lot lets just me and you work on it si and you just pay me the others share 1 all names have been changed marcel its a good opportunity you lot dont do nothing anyways so you should sign up you might learn something you need to be motivated though that is have a motive to action in this paper we offer a critical reflexive analysis of a participatory action research project undertaken with seven young men aged 1524 in the innercity neighbourhood of st pauls bristol a provincial english city of around half a million people animated by benign intent and a genuine attempt to build a collaborative enquiry we will surface some of the different ways ideological control was nonetheless exerted interand intrapersonally specifically we will explore how par as a particular participatory social research approach exerts control over meaning in practice and in the process administers and recycles feelings of failure and marginalisation among participants including the professional researcher so that this description might deliver some realworld utility beyond postmodern descriptions of power position and identity we conclude by considering what actionable knowledge our analysis contains for the practice of participatory social research the project in question was my 2 doctoral fieldwork and took place over the eighteenmonth period immediately prior to august 2011 when rioting young people took to the streets of several english metropolitan cores including st pauls a small and diverse neighbourhood of around three and a half thousand people located immediately adjacent the citys central shopping mall and retail concourses st pauls was and remains one of the most youthful and ethnically diverse neighbourhoods in the city and also one of the most disadvantaged across a range of indices ranking at the time of the fieldwork 284 out of 32482 super output areas3 in england i decided to work through a participatory action research method and ethic with young men living in the area with the intention of producing a highly situated ethnographic account of urban marginality and the increasingly consumerist identities of youth masculinity social class and race in the inner city i wanted to understand the worldview of a demographic of young people statistically overrepresented as adults in the acute mental health and criminal justice systems and in contrast to the service cultures of the education social care and health systems i had experienced in my professional life which examined the issue of differential access and outcomes for black boys and men through a biomedical and observational lens i wanted to subject the issue to a poststructural analysis drawn from a participatory and political epistemology put another way i wanted to engage with the social economic and political context of my coparticipants and offer a challenge to the prevailing and enduring locus of mental health as residing inside the individual my hypothesis was that such an approach was morally imperative under circumstances of social exclusion because it returned the value of the research process to my coparticipants and i also supposed both that the ethical issues of beneficence and justice inherent to fieldwork would be best realised in this way and that such a research process would deliver an emancipatory outcome of some kind for my coparticipants john oneill once wrote that the privatisation of meaning… is a principal source of social control in a liberal society my intention for this research was that its processes resocialise the meaning my coparticipants gave to their lives and structures of feeling where so often these young identities and lives are problematised and pathologised by the state and commodified by the market i was keen that the voices of my coparticipants should destabilise the assumed purpose and role of public services their real life encounters exposing the different ways in which power is administered and experienced intraand interpersonally briefly the most important theoretical influences on my research and practice at this point were multidisciplinary and critically engaged phenomenology provided my philosophical instincts with a language that simultaneously rejected the mindbody dualism of cartesian science and legitimised experience as evidence the disciplines of liberation psychology and critical pedagogy built on this foundation offering me an epistemological frame that i embraced for its politics and provocation as much as its method postmodern critical theory was generally important but the reflexive ethnography advocated and practiced by behar bourgois and belmonte was especially influential in encouraging me to consider and make visible my own positionality in the same postmodern current critical childhood studies and theories of children and young peoples participation were also contributing influences not least becauseat the timethe voices and perspectives of young black working class men were almost entirely absent from this literature to find them i looked to a body of sociology concerned for issues of social exclusion race and class in the british inner city and in particular to an ethnographic monograph of st pauls written a generation earlier endless pressure the data presented in this paper come from the transcripts of our taped friday night group discussions in a small local community flat in st pauls between june and december 2010 a much longer period than the twelve weeks i originally set aside and anticipated in fact because of the way the recruitment and research had unfolded i was still a weekly visitor to the neighbourhood throughout the spring and summer of the following year my eventual withdrawal was prompted by the rioting that gripped several english metropolitan areas including st pauls in august 2011 which mobilised elements of its youth to overrun and smash parts of the nearby retail mall the additional period was largely spent trying to encourage the completion of a short film my coparticipants had wanted to make but because our relationships deepened over these months it also contributed to a more nuanced understanding of their lives on my part the young men i recruited to the project were offered training skills and accreditation in film making as well as an individual stipend of £100 for their twelve weeks participation in the project our critical reflexive analysis in this paper centres on a heated exchange in the group that brought to a head my decision some months earlier to offer this oneoff stipend we have chosen this extract over others that might also have provided fertile territory for the same themes because it is an opportunity to lay bare an inconvenient truth about participatory research that too much of what is personally uncomfortable and challenging to our identities as researchers is often tidied out of the final presentation when in reality as olesen nordentoft observe we can only learn from what we are doing as researchers and facilitators if we dare to explore sensitive incidents and gain insight into what is at stake in dialogical reflexive processes the stipend the extract that follows was informed and preceded during the week by a dramatic split in the group i had booked a local production company to visit us at the community flat to help with the film making process providing support and equipment training and skills to the group as they scripted and shot their idea for a short documentary film the group comprising ashley jermaine tyreese ledley lawrence marcel andtrigga 17 ashley you didnt show up at all this week you did fuck all what have you done for this project tell me jermaine i been here every week simon cmon mate every week really i was here every week i was about the only one who was here every week jermaine most weeks then tyreese you dont say nothing though even when you was here fucking sleeping through most of it simon look yeah i never ever wanted this to happen where we got to this place i thought offering you a few quid to participate would make things fairer im committed to writing up what weve done and getting something out of this a qualification and stuff i wanted you all to get something out of it too but it was difficult because half the time people didnt turn up or fell asleep or fucked about so now what do we do i was going to just pay everyone regardless tonight and ask if anyone wanted to carry on meeting and working together but hardly anyone turned up last week to film and i gotta tell you that pissed me off cos we spent nearly £2k for him to come down here and work with you on your film ashley how much simon yeah his time and crew and equipment costs money and he gave a lot of it away for free still ashley fuck man i didnt know that look all im ledley yes 4 a fool the exchange above and the session around it were highly charged and full of strong feelingsanger embarrassment confusion fear anxietythat moved in a complicated pattern that was sometimes adversarial and dominating and sometimes highly participatory and selforganising the embodied and expressed feelings involvedwhich are only partially captured by the textare an important site of information in any critical reflexive analysis since they speak to a group process and embodied experience that might otherwise get lost beneath the noise of multiple and competing voices that the stipend should elicit such strong feelings might reasonably supply evidence of it being a poor ethical decision to include one and yet some years later and even through a critical reflexive lens the outcome remains more complicated to judge than that i had made my mind up some time before the fieldwork started to offer the stipend in return for participation in the project i had wrestled with the ethical implications of this and had no satisfactory answer to the objection that it might act as an inducement in fact as the period of engagement and recruitment wore on i confess i ended up hoping that it would induce participation however i also saw compelling ethical reasons for offering something material to participants when i was in position to do so because my studentship included a small budget to support fieldwork costs i was looking for coresearchers in a place of enduring and multiple material disadvantages and i was asking for an investment of time and labour in a supposedly horizontal project the fruits of which were likely to increase my own status and prospects through award of a phd it was i thought an appropriate acknowledgment of the lived concerns priorities and material reality of my coparticipants while the money was not initially intended as an inducement to participate i nonetheless found myself increasingly wielding it as such as the weeks wore on or at least to induce participation in particular ways consistent with my understanding of participatory research and my identity as a researcher each week the group meetings were undermined and interrupted by my coparticipants absence routinised lateness and their ability to sleep through much of our time together just as frequent were the silences apparent boredom and incessant messing about rarely was any proposed fieldwork actioned between our meetings and even the best sessions contained within them less than an hour of reflective generative dialogue and planning through all this i was often left feeling frustrated and deskilled confronted by strong feelings of failure that my efforts were not good practice and that the project was in some ways confirming stereotypes rather than challenging them the stipend soon began to show subtly in my conversations with the group in the form of a joke or a gentle reminder that was also undeniably a language of compliance and control through which i aimed to corral and mobilise this came to a climax in the excerpt above despite the ongoing challenges of attendance punctuality and participation i was keen not to withhold payment for worry this might herald a complete breakdown in our accumulated trust even though i badly wanted to in the case of jermaine and ledley who were entirely absent at least half the time by this stage i was simply happy to be rid of the money and hoped that enough interpersonal work had been done that the group would want to continue to meet and finish our enquiry together as it turned out ashley and tyreese were very keen to discuss the ethics of my decision because of this the exchange delivered a rare dialogic moment in our time together it was a conflict but it felt horizontal and participatory as i was for a time submerged beneath feelings and agencystronger than my ownabout the value of the stipend beyond its monetary worth and about the issue of collective accountability and fairness its supposed to be a group thing and two of us didnt do nothing in the moment the feelings were raw but only because they were honest and this emotion achieved a genuinely catalysing and galvanising effect clarifying purpose commitment and expectations for my part and contrary to my expectations i actually got more respect from the group when i sounded pissed off at the money we had already wasted than when i didnt just propose to give it away like a mug when it came this respect was a relief but only because it gave me permission to acknowledge the frustration i had experienced and administered in much more subtle ways over the preceding weeks because it is certainly true that while i was holding the money i was also in fact nourishing a particular process of subjectification that meant my coparticipants were required to conform to a position in the group that was more or less consistent with my beliefs about what a valid successful participatory action research project contained by way of outputs and outcomes an unacknowledged academic research identity was present that remained to my embarrassment hidden in plain sight throughout for it was not at all obvious to me that my commitment to realising emancipatory research of the kind described by my textbooks and embodied by my own personal search for legitimacy could ever become an ideological project seeking to control the process and privatise its meaning selfevidently i thought i was trying to effect the very opposite of this outcome the consequences of this unacknowledged identity and my adherence to its structure of thought in practice was an occasionally oppressive reliance on the kinds of technical skills and personal and intellectual faculties privileged by it for my coparticipants these qualities were either very badly wounded perhaps by earlier formal experiences of scholastic failure and exclusion or suffocated by the effects of the local moral economy articulated by street culture which was suspicious of and often hostile towards behaviours inconsistent with the local image and story of black masculinity much of what i sought from my coparticipants as the correct research behaviour was coded in street culture as white the move towards me risked exclusion from the group and accusationstypically delivered using humourof betrayal or washout as the group would know and call it under these conditions the stipend became a potent symbol not only of the research identity that i was affecting but also of the embodied and expressed dispositions manners and symbols of my adulthood my whiteness and my middleclass identity at various times these dispositions became positional techniques and effects of power that unintentionally but too frequently revealed and poked at the wounds of my coparticipants one example was my assumption which became an insistence that there should be a social action output a thing that we could point to as evidence of the validity and success of our enquiry and a demonstrable disruption of the story of failure the group had assigned to st pauls another was my asking the group one evening to write down questions for the interviews they hoped to carry out which had the effect of humiliating jermaine whose lack of functional literacy was exposed and exacerbated by the clumsiness of my noticing and the groups laughter at his exposurenotwithstanding their own limitations in the same area throughout our time together i would have considered my efforts to be grounded in an ongoing spirit and practice of critical reflexivity so it is no easy thing to acknowledge that some internal assumptions escaped my interrogation and bled out into the research process eventually time and distance from both the field and the text revealed a deeper level of insight than i was capable of in the moment and immediate aftermath my opening analysis at the time located my failure of the methodological form as speaking to a deficit in representation of young socially excluded men in the available literature on par and a romantic idealisation of emancipatory research born in another time only more recently have i been able to connect with a deeper layer of assumptions i was still even in my initial analysis holding onto about the meaning and identity of academic research and by extension myself as its student critical encounters jermaine i think what we say anyway they already have planned anyway so it aint gonna really matter this is just a cover up we care but our thoughts dont really count criticalreflexive analysis here is concerned with the ways in which power is distributed and moves through a participatory research setting in particular the embodied intraand interpersonal aspects of this movement critical reflexivity is really the only route to engaging effectively with the situated contextual and contingent operation of powerknowledge particularly that produced by a process of group enquiry and sensemaking that claims to be highly participatory and emancipatory this is because b eing attentive to powerknowledge relations makes it possible to recognise reproductions of cultural norms and how such norms constantly mould our relations interpretations and categorisations put more simply reflexivity in research processes is needed because existing power differences between participants may generate tendencies to reenact the same social norms that we set out to challenge bourdieus theories of doxa and habitus offer real descriptive and explanatory value in the reflexive effort at this point bourdieu views power as culturally capitalised and constantly recycled and relegitimised through the dialectical interplay of agency and structurehabitusthe socialised norms and tendencies that guide our behaviour and thinkingis thus the way society becomes deposited in persons in the form of lasting dispositions or trained capacities and structured propensities to think feel and act in determinant ways context and environment are key influences on habitus and in this sense the container for the enquiry paris a field in which we as participants both wielded and experienced power in an ongoing dynamic bourdieus related concept of doxa allows us to move towards a fuller description of the ways in which my identity as a researcher obscured research itself as a contested and ideologically privileged site for bourdieu doxa is an adherence to relations of order which because they structure inseparably both the real world and the thought world are accepted as selfevident the analysis of power expressed by these two concepts can help the collaborative researcher unpack the ways in which we can and do resist particular forms of power and domination in one field and collude with them in another the particular discourse i was busy administering represented only one side of the dialectical struggle and one voice in the dialogic story the other side was variously expressed and enacted by my coparticipants as agents of a local street culture partially constructed from a repurposed image and story about them told from above there was no cultural capital to be earned by my coparticipants expressing feelings of vulnerability among their peers in fact street culture rewarded interpersonal presentations that flowed in precisely the opposite direction habitusbased inequalities that found normative expression in values like swagga an embodied disposition that aesthetically extended to both the particular brand and relative newness of ones clothes while asserting ones individuality independence selfreliance and consequently dignity our research space flickered into life for only three hours each week it was simply too temporary and fragile to nourish a countercultural challenge to the reality produced outside it every day consequently when they did get going our group discussions were for many weeks filled with cautious generalisations and thirdperson voices and our social action project was stymied by a culture of selfreliance that meant individuals were keen to work alone and were reluctant to lead assume collective responsibilities and even adopt a specific role within the group effort whilst par trades on its capacity to deploy multiple and diverse methodologies many of them purposefully nonscholastic this feature alone does not overcome the kind of deficit in personal and collective confidence which profound intergenerational social and economic exclusion will eventually produce for example consider the inheritance of a racist discourse internalised and embodied that black men dont do intellectual work local street culture as its dialectical antithesis had reclaimed this discourse as a site of personal resistance and dignity ascribing status and respect to young men who moulded their selfhood to its racialised image of hyperheterosexuality physicality selfreliance and certain expressions of creativity like musicality and entrepreneurialism confidence and selfworth were made possible in and by this identity but only on these narrow terms this dialectical call and response whereby through cultural practices of opposition individuals shape the oppression that larger forces impose upon them might have been at the centre of our enquiry but it was also in the room with us wacquant describes this dialectic as the objective divisions that pattern social space and the subjective visions that people acquire of their position and extant possibilities in it for example the extract below reveals how staying out of trouble thinking ahead talking posh or doing stuff black people dont do is regulated by street culture through the outgroup accusation and image of wash out in our penultimate session some weeks after the stipend had been discussed and distributed tyreese said to the group that he was going to miss meeting every friday night its good to just chill and talk it dont ever happen normally i like it in the room in the moment i missed it but much later his statement on the meaning of our time together finally penetrated the academic research doxa and came into view a moment i caught only when i named the guilt i felt reading it backan embodied clue as to the divergence my own priorities had represented and delivered in the project confronted by tyreeses words i was finally able to recognise and consider that a participatory ethic in these circumstances of exclusion had demanded a radical repositioning of research and not as i had tried to effect a repositioning of my coparticipants ashley this consequently perhaps one of the reasons we often seemed stuck in the reflective side of the par cycle was because reflecting may have been the most meaningful purpose and outcome of the enquiry to the participants in this an alternative image and practice of social research emerges bottomup one that assimilates storytelling testimonial and the remembering and naming of cultural experiences and knowledge in this repositioned form of enquiry a group of young men whose members have suffered from diminished senses of themselves by virtue of racism and classism could use the temporary and fragile research space to nurture a shared understanding of themselves according to tandon this is an image of participatory enquiry with an ancient heritage a history of ordinary people working together to understand their world most often orally or through the arts rather than by formal research outputs because of this form such efforts have been largely unrecognized and delegitimized by those producing knowledge at the dominant centres of societies conclusion sayin people in st pauls is good or bad isnt breaking it down enough people can be good and bad listen yeah say if my family aint got no money to eat and i go out a rob some guy for money to feed my family am i good or bad like whats more important feeding my family or not being seen as bad by you by way of a conclusion we wish to briefly consider some of the more actionable insights that fall from this experience and analysis to do this we must begin with a necessary provocation in order to lift the paper out of a preoccupation with itself and a continued collusion with the very academic research doxa weve attempted to describe and decentre because while we have been especially keen to embrace critical reflexivity we are nonetheless concerned for the ways a selfconscious presentation risks denying and prioritising the suffering delivered into the lives of our young coparticipants the anthropologist philippe bourgois describes this as the profoundly elitist tendencies of many postmodernist approaches deconstructionist politics usually confine themselves to hermetically sealed academic discourses on the poetics of social interaction or on cliches devoted to exploring the relationship between self and other although postmodern ethnographers often claim to be subversive their contestation of authority focuses on hyperliterate critiques of form through evocative vocabularies playful syntaxes and polyphonous voices rather than on engaging with tangible daily struggles postmodern debates titillate alienated suburbanized intellectuals they are completely out of touch with the urgent social crises of the inner city i walked away from st pauls each friday night knowing that jermaine was going home to care for his depressed mother that ashleys mother was exhausted from working double shifts and struggling to find the rent that month that lawrence was in mourning for a friend who had killed himself by hanging in the local park and that sol was now in hiding for fear of his life after being accused of a stabbing i also learned that ashley gave the stipend to his mother to help her make the rent that tyreese gave his to a younger brother for a school science trip and that jermaine used his to take some driving lessons on his way to a hopedfor driving job these tangible actions and what they tell us about the realities and priorities of the material world my coparticipants negotiated daily are important considerations in any ethical judgment about my choices the offer of the stipend or indeed my coparticipants in their early ideas for the short film my coparticipants wanted to invite those outside their neighbourhood to consider a less binary judgment of their lives and the choices their environment delivered to them people can be good and bad in this same spirit we think they also invite the wouldbe collaborative researcher to embrace bothand thinking my coparticipants lived lives filled with love joy and growth as well as want violence and suffering they were at times frustrating and flawed as was i and each member could be morally sophisticated in their thinking and appraisal of me and the world around them as could i the offer of a stipend acted as an inducement to participate in the project and given the material difference it made to my coparticipants options it was the right thing to do finally one can work in a critically reflexive way that decentres truth and still say something about a material world that is everyday and tangible in its injustices a foundational piece of learning from this experience is that the collaborative social researcher cannot hope to engineer another reality where knowledge and power relations will be fixed and can be planned for nor should they be seduced by the neatly rendered research writeup characteristic of an academic research identity that confers sequential order and clear methodological form but that is not representative of actual experience as collaborative researchers we must guard against the creation of coherence singularity and closure where there was none and avoid creating a cosy camaraderie with the reader in an ultimately conservative and uncritical rendering of the status quo collaborative research is messy often contingent rarely emancipatory and always underpinned by intraand interpersonal conflict critical reflexivity is a basic requirement in this context simply because there are no guarantees for what happens in a process of this kind finally if as professional researchers we aim to work in places of significant social exclusion and contribute to a socialisation of meaning that restores to knowledge its value as the basis of community then we may have to reconsider our minimum expectations of what must be done for an enquiry to count as research for as much as this represents a challenge to our ways of working and capacity for selfreflection and critical insight it is also a challenge to the professional identity of the academic researcher

title participating in social exclusion a reflexive account of collaborative research and researcher identities in the field type article url doi doi date 2020 citation newitt simon and thomas nigel patrick orcid iconorcid 0000000253109144 2020 participating in social exclusion a reflexive account of collaborative research and researcher identities in the field action research

introduction peerbased interventions are a feature of prison health services and there is an established literature around peer education and to a lesser extent peer support in the contexts of incarceration given the high prevalence of poor physical and mental health in the prison population combined with exposure to risk factors detrimental to health both prior to and within the prison setting interventions delivered by inmates for inmates offer a means to reduce risk factors and improve health for this population devilly et al summarized the value of peer programs in terms of benefits to inmates from accessing credible sources of knowledge and positive role modelling benefits to peer educators gained through their role and organizational benefits including increased service capacity as well as the contribution to maintenance of good order in the prison there are a wide range of peer programs in this heterogeneous field of practice a survey conducted in england and wales by the prison reform trust in 2002 found that around 7 of inmates were engaged in some form of peer support since then there has been an increase in the applications for peer programs the evidence base has grown with a small number of reviews on the effectiveness of peer education and also international comparisons of service provision more recently a large mixed method systematic review conducted by the authors assessed the effectiveness and costeffectiveness of peer interventions in prison settings this systematic review uncovered a diverse range of peer interventions including both peer education and peer support as well as other types of peer program there was considerable variation in terms of intervention mode health topic type of setting target population and in some cases theoretical models treating the included studies as a homogenous whole would have undermined the validity of the conclusions therefore a typology of prisonbased peer interventions accompanied by working definitions was developed in order to group interventions so that data synthesis could take place the typology may have wider application in building the knowledge base for correctional health care because it provides a framework for understanding peer programs their similarities and distinguishing features the aim of this paper is to present the typology describe how it was developed and discuss its application and value in differentiating types of peer intervention the paper starts first with a brief introduction on the concepts of peer education and peer support what is a peer intervention peer interventions are based on the principle of homophily and therefore seek to utilize social and communicative processes occurring between those who have similar demographic characteristics or sets of experiences for the purpose of achieving health or social goals the social influence of peers forms the basis for development of therapeutic or affirmative relationships that enable health promotion prevention or care activities to proceed more effectively with a given target population reach is a key concept as network membership offers opportunities to connect with underserved and marginalized communities peer education and peer support are normally distinguished from each other on the basis of different aims emphasis and also different traditions peer education has been defined as a process of education and information sharing occurring between individuals from the same age group or from similar social backgrounds various theoretical perspectives have been offered to justify peer education turner and shepherd listed social learning theory social innoculation theory role theory differential association theory subculture theories and communication of innovations theory in health promotion there has been a strong critique of peer education in terms of poor application of theory to intervention design and evaluation and lack of definitional clarity over the term peer there have been questions about whose agendas are being served when peer education is used in an instrumental rather than empowering fashion a point also made in the context of peer education in prisons peer support concerns different forms of support provided and received by those who share similar attributes or types of experience dennis in a key conceptual paper on peer support in health care contexts built on this definition to argue that peer support involves emotional support informational support in terms of advice and feedback and appraisal support facilitating selfevaluation and problemsolving these facets of support are then applied to help the recipient cope with actual or anticipated stressors dennis went on to argue that peer support can lead to better health due to the direct effects of improved social relationships on wellbeing through buffering mechanisms that enhance coping skills or through the mediating effects of building selfefficacy and positive reinforcement of positive behaviors in a realist review of communitybased peer support harris et al concluded that homophily matching individuals on the basis of shared characteristics is insufficient as peer support interventions work best when they promote social interaction that builds trust and bonds in groups and when they give autonomy to peer supporters in how tailored advice and support is delivered many of the generalized theories of peer education and support have been applied in the prison literature however three points can be made regarding this unique setting first peer identities based on shared experience or mutual history of incarceration have been given as a result of coercion not choice unlike in civil society where group identities may be hidden or negotiated incarceration brings a sharp distinction between inmates and prison staff second although peer interventions can reduce barriers to advice and support for inmates ross drawing on goffmans notion of the total institution argued that inmates lack of agency and resistance to authority can make the delivery of health promotion more difficult as health becomes a battleground where tensions over power and control surface third peer support can occur through informal networks of prisoners and be a valuable source of assistance without use of formal interventions collica argued that prosocial networks can not only help with adaption to prison life but also provide a sense of community that may extend on release conversely informal peer networks may support risky behaviors through distribution of contraband such as drugs or result in some inmates being socially isolated or bullied developing a typology for peer interventions as discussed above the typology was developed as a framework for categorizing formal interventions as part of a systematic review of the effectiveness and costeffectiveness of peer interventions in prison settings the study used standard systematic review methodology to undertake systematic searching then to select appraise and review a total of 57 quantitative qualitative and mixed method studies reporting health outcomes from peer interventions and one costeffectiveness study results from the review are reported elsewhere where a full list of included studies can be found one of the challenges in the review process was dealing with a heterogeneous group of studies that covered diverse intervention types prison contexts and health topics it was clear that aggregating all the intervention modes as peerbased would fail to distinguish critical differences in methods but at the same time an overly cautious approach to grouping interventions would limit the extent to which evidence could be synthesized therefore it was decided to draw up an initial categorization framework for intervention modes these modes would represent the general approach and orientation of interventions and additionally describe the primary role of the peer worker it was recognized that peer interventions might use multiple methods such as health promotion campaigns counselling or advice within an overall model discussion with the advisory and steering groups highlighted the utility of being able to group similar models during the process of synthesis this was in preference to an alternative grouping of health topics as many interventions aimed at improving general health and reported a range of health and social outcomes an initial scan of background literature did not identify any existing typologies of peerbased interventions in prisons although some literature included relevant definitions and also descriptions of types of program found in practice a framework developed from an earlier systematic scoping study on communitybased lay health worker roles did not provide a sufficiently comprehensive framework to categorize peer interventions within the prison setting a new typology of peerbased interventions was therefore developed using existing theoretical and empirical literature until there was a complete set of definitions for intervention modes covering the included studies in the review the analytical approach drew on qualitative thematic analysis techniques in that initial categories were developed from the literature and refined until the final typology provided the best fit to explain the interventions as reported in the included studies a staged approach to analysis was adopted i identification of relevant background literature this included key papers providing discussion of theoretical or conceptual issues around the nature of peer interventions theoretical papers offering classifications of peer education and peer support and publications with description of peer programs in practice most of these papers were identified through the review process during initial scoping searches and through contact with experts ii all included studies in the review had information extracted on intervention mode setting and population as part of the review process data extraction records indicated where publications contained thick descriptions or definitions of the intervention and also where studies identified the application of a theoretical model iii preliminary definitions of types of intervention were then developed using both background literature and descriptions found in included studies some additional literature was identified from reference lists where required for example a definition of peer mentoring was sourced through the reference list of an evaluation of a peer mentoring scheme iv an iterative process of comparing definitions with reported intervention modes in the included studies was undertaken until the best fit was obtained some codes were merged at this stage or defined as subcategories for example specific models of peer support where individual studies could not be easily categorized a brief description of the intervention was given v information on the application of the intervention mode in prison settings was added to the typology to ensure that relevant aspects of program delivery and social context were not lost vi the final stage was applying the typology of definitions in coding and grouping studies for the process of review and synthesis both the final typology and the categorization of included studies were agreed by all members of the review team a typology of peer interventions in prison settings the peer education prisonbased peer education involves communication education and skills development occurring between prisoners with the aim of increasing knowledge and awareness or effecting behavior change this extends the definition of peer education used by milburn a number of publications discussed theoretical justifications for peer education in prisons in relation to social influence and reinforcement of positive social norms through peerbased social networks risk reduction was a theme around hiv prevention with recognition of the value of prisoners experiential knowledge of risk behaviors both inside and outside prison in the context where functional access to health care in prison might be good outreach activities were reinterpreted as accessing lay networks to overcome low literacy and social exclusion and improving the credibility of information in the face of resistance to professional advice the reach of the peer intervention could extend beyond the immediate target group as transmission of health messages might occur between prisons as prisoners moved and potentially further afield to families peer support prisonbased peer support involves peer support workers providing either social or emotional support or practical assistance to other prisoners in line with other forms of peer support in healthcare contexts most of the prison peer interventions identified in the review involved peer support delivered on a onetoone basis in response to prisoner needs or through informal social networks in contrast a minority of peer support interventions involved group work such as selfhelp groups on substance misuse while the basis for most prison peer support is forming supportive relationships in the context of stressors created by the experience of incarceration roles can encompass counselling listening befriending carrying out domestic duties for other prisoners liaison with prison staff translation providing basic information and signposting to other services a range of peer support interventions involving the provision of emotional support to alleviate stress were identified the review found two programs used a similar model specifically targeted at suicide and selfharm prevention the listener scheme and sams the listener scheme is a prison suicide prevention scheme that has been widely adopted in adult prisons in england and wales and in 2006 there were an estimated 1400 listeners the samaritans a national mental health charity select train and supervise volunteers who then provide confidential emotional support to fellow prisoners who are experiencing distress the review found two other interventions that were focused on the alleviation and prevention of mental distress the peer support training program canada was implemented across a number of womens prisons and was described as being based on a holistic womencentered approach to health care that aimed to be culturally sensitive and to develop the womens autonomy and self esteem on prisoner volunteers in us prison hospices was identified in the review prison hospices were described as being based on a concept of providing a decent prison which entailed maintaining terminally ill prisoners humanity and dignity prison hospice volunteers worked within a wider multidisciplinary team to provide companionship practical assistance and social and emotional support to terminally ill patients the review found that theoretical justifications for peer support related to the buffering effect against stressors and the mitigation of mental health risks associated with incarceration and the removal of the prisoner from their normal social networks many of the interventions also combined emotional support with instrumental support that is practical assistance and care for example insiders and prison hospice care peer mentoring the process of mentoring describes a relationship between two individuals one of whom acts as a role model and supports the personal or professional development of a mentee peer mentoring in a prison setting involves the establishment of affirmative relationships between individual prisoners and exprisoners usually with the primary purpose of guiding personal development and supporting successful transition through release there is an established literature on peer mentoring in the criminal justice system where interventions are primarily focused on social goals such as resettlement social inclusion and prevention of reoffending the review identified a small number of scotland involved exprisoners or those with history of addictions as life coaches who met prisoners in the prison setting and also outside the gate to allow some continuity of support bridging roles bridging roles occur where lay health workers act as cultural connectors in improving access to information support and health services for underserved communities in the review two distinct interventions were identified where peer workers acted as cultural connectors and where signposting to other services was a major component both interventions also had a strong element of informational peer support and were explicitly focused on reducing inequalities prison health trainers worked with other prisoners to motivate and support them to adopt positive health behaviors for example healthy eating or better stress management and provided information on other health services the role was adapted from a public health initiative introduced over a decade ago in england to reduce inequalities by recruiting lay health workers from disadvantaged areas to support individuals around health behavior change prison health trainers received formal training on health promotion communication skills and mental health adapted from a standardized competency framework like the wider health trainer service a major objective was increasing the skills qualifications and employability of those who took on a peer worker role the peer advisors program also a uk initiative was focused on housing advice within prison and also during and after release peer workers assessed housing needs of new prisoners or those due for release helped with accommodation and welfare payments and signposted to other sources of help like health trainers there was a formal qualification and a focus on the personal development and postrelease employment of the peer workers other peer models the review confirmed that this field of practice is diverse with peer interventions being adapted to a range of contexts and populations it was not possible to categorize four interventions because they had very distinctive components or deviated from existing models in significant ways that were assumed to affect the way the intervention worked for example the alternatives to violence project used a specific cascade training model that involved peer education combined with prisoner involvement in project management structures another study reported on the peer counsellor role as one component of a formal substance abuse treatment program linked to spiritual care two interventions one focused on harm reduction and the other on suicide prevention had some similarities to peer education and peer support interventions respectively but the roles described were not sufficiently aligned to justify grouping them with existing models peer observers in the suicide prevention initiative watched prisoners who were at risk of suicide but did not take on the more active peer support aspects of listeners a moldovan harm reduction program had a single focus on improving access to health resources using prisoners to distribute condoms needle exchange supplies and information booklets it was possible informal peer education occurred alongside the distribution activities but this was not the focus of the intervention therefore it could not be categorized as peer education discussion peerbased interventions are complex interventions with a number of interrelated components relating to the selection preparation and supervision of peer workers their subsequent roles in care or prevention and the nature of interactions with the target population the typology presented here provides a framework for categorizing interventions reported in an international literature and describing where possible their main features and theoretical underpinnings it cannot be viewed as a comprehensive classification or taxonomy nonetheless the typology does provide a means of distinguishing different intervention modes within a transparent framework related to the prison setting this builds on earlier work published more than a decade ago that described existing models in practice while a previous systematic review highlighted the role of peer education the typology describes four major intervention modes that utilize the social influence brought by peers prison is evidently a unique setting but peer education and peer support draw on a set of justifications and principles of design that have a long history in health promotion and healthcare contexts similarly prison peer mentoring fits within a wider field of mentoring what appears critical in the context of correctional health care is the significance of peer identity for a population that is marginalized and experiencing barriers to good health justifications for peer education relate less to traditional notions of reach but to credibility and tacit knowledge and for peer support the ability to empathize with those experiencing stressors generated by incarceration this mirrors the conclusions of harris et al that effective communitybased peer support requires peers to share experiential knowledge as equals and to form social groups and bonds a further issue is limits to confidentiality which vary depending on legal jurisdiction and may affect the application of peer mentoring in the usa there are clear guidelines on privacy through the hipaa privacy rule which means it may be unsuitable for nonmedical professionals to be involved in the support or management of prisoners with specific health conditions for fear of breaching individuals health status in other countries peer workers may be able to speak confidentially with other prisoners but may face pressure from staff to disclose the nature of their contact limitations the typology was developed from a systematic review of quantitative qualitative and mixed methods studies as a heuristic tool to help categorize studies so appropriate synthesis could occur the systematic review process included systematic searching and selection and nonevaluative studies were excluded due to the focus on effectiveness this meant that additional literature had to be sourced to build the typology and this literature was not selected in a systematic fashion more in the manner of purposive sampling to gain further illumination where gaps in descriptions existed a nonlinear iterative approach to literature searching is advocated by finfgeldconnett johnson for qualitative reviews that build knowledge or generate theory as opposed to assessing effectiveness the final typology was refined through to an inductive process of defining checking and sorting until saturation was reached and categorizations stood the typology was developed from the 57 included studies in the main effectiveness review it is likely that a scoping review that took a more inclusive approach to searching and study selection would have uncovered further types of peer intervention in prison settings the majority of interventions described in the typology worked with male adult prisoners and more research is needed to examine the application of peer programs for young offenders and female inmates the research team were keen to gather grey literature through contacts with experts and practitioner networks in the uk as there was an assumption that some interventions would not be reported in the formal academic literature grey literature can broaden evidence sources however it can also be context specific and it was not possible to extend that search into other countries contact with international networks would have generated additional interventions as this is a heterogeneous field of practice there is undoubtedly scope for more international comparisons about interventions and practice the sampling bias towards uk and also north american peer interventions is a major limitation of the typology there are a number of potential explanations for the geographical spread and dominance of certain types of interventions which could affect transferability and generalizability whether and how peer interventions are implemented will reflect differences in legal systems between countries differences in penal policy types of institutions and the demographics of prison populations and differences in the practice of correctional health care and the organization of health systems more broadly despite similarities between several uk and nonuk peer support interventions it cannot be assumed that specific programs presented in this paper are widely implemented an international task force on suicide prevention in prisons compared eight countries and found marked differences in policy and practice as to whether peer programs were used the typology may also reflect publication bias including country or language bias as well as variations in research capacity and funding between countries that influence whether intervention studies are undertaken overall more research would be needed to test the transferability of the typology particularly within countries and settings not well represented in the prison literature potential applications by defining the main features and identifying underpinning theories of different peer intervention modes the typology offers a platform for further research and theory development this is a diverse field of practice and interventions need disaggregating if conclusions are to be drawn about their effectiveness and appropriateness bravata et al identify the development of standardized definitions of concepts as a core strategy to deal with a broadbased literature where detailed accounts of intervention components were reported as was the case with some of the peer education programs aimed at hivaids prevention this allowed for meaningful evidence synthesis between interventions conversely many studies did not report in detail how interventions worked and fewer still used any explicit theoretical models the typology provides the basis for developing more sophisticated logic models argue that there need to be many more opportunities for prisoners to undertake active citizenship roles such as peer support that might be of benefit to them and others conclusion the typology presented in this paper provides a framework to map and understand the range of peer interventions in prison settings and the major modes peer education peer support bridging roles and peer mentoring this typology was developed as a part of a systematic review and although it is not a definitive list of peer intervention types a number of specific models from north america and from the uk are identified it is important to recognize the heterogeneity of peerbased approaches not only is there a spread of health topics from mental health issues through to communicable diseases there are also differences in intervention design modes of delivery and theoretical underpinnings one conclusion of this paper is that aggregating peer approaches as a single method is not justified and over simplifies what is evidently a rich and diverse set of practices in health care and prevention the sifunda s reddy p s braithwaite r stephens t bhengu s ruiter r a van den borne b the effectiveness of a peerled hivaids and sti health education intervention for prison inmates in south africa health education behavior35 494508 doi 1011771090198106294894 sirdifield c bevan l calverley m mitchell l craven j brooker c a guide to implementing the new futures health trainer role across the criminal justice system lincoln university of lincoln 2 studies uk

peer interventions delivered for prisoners by prisoners offer a means to improve health and reduce risk factors for this population the variety of peer programs poses challenges for synthesizing evidence this paper presents a typology developed as part of a systematic review of peer interventions in prison settings peer interventions are grouped into four modes peer education peer support peer mentoring and bridging roles with the addition of a number of specific interventions identified through the review process the paper discusses the different modes of peer delivery with reference to a wider health promotion literature on the value of social influence and support in conclusion the typology offers a framework for developing the evidence base across a diverse field of practice in correctional health care

introduction in many countries covid19 national lockdowns have been the most profound deep reaching and significant public health interventions within living memory fig 1 provides a logic model describing a highlevel overview of lockdown as a complex public health intervention it shows a range of key contextual elements important to understanding the situation in which lockdown has taken place and it shows the central problem that initial lockdown was intended to resolve ie exponential transmission of it also highlights the complexity of lockdown as a public health intervention with multiple interdependent components cumulatively working through varied and intersecting mechanisms to elicit a range of intended and unintended positive and negative changes within scotland it is clear that the initial national lockdown intervention succeeded in relation to its primary goal of reducing the exponential transmission of covid19 and achieving its intended positive health outcomes similarly as had been anticipated lockdowns have led to unintended and negative health consequences for example there is emerging evidence concerning the amplification of preexisting health inequalities 1 2 3 both overall 45 and in subpopulation specific groups 6 groups those experiencing socioeconomic disadvantage and the unemployed evidence also suggests a worsening of mental health in adults 78 and children 9 along with increases in loneliness and isolation 10 11 12 broader impacts on family functioning 13 loss of economic productivity 14 and education 15 including the gendered burden of home schooling have also been reported 16 in contrast to the emerging evidence of the unintended negative effects of a national lockdown here we report emerging evidence concerning unintended positive changes taking a salutogenic approach which focuses on the factors that support and promote health during stressful conditions 17 we examine the positive adaptation and growth experienced by some individuals using crosssectional data from an online survey the key objective of the current study is to examine the social patterning of the positive effects of lockdown across a range of domains given the large corpus of work concerning the role of structural social factors such as poverty racism gender and age in explaining health and illness we hypothesised that our findings would be shaped by these classic determinants of health method participants and procedure data collection took place for 23 days from 20 th may 2020 to 12 june 2020 spanning the 9 th to the 12th week of national lockdown in scotland this national lockdown period was part of the ukwide national lockdown that commenced in march 2020 the advice during national lockdown was to stay at home and people were told to work from home wherever possible and to only leave their homes for essential purposes these essential purposes included leaving home for food shopping for medical purposes or to provide care for a vulnerable person people were also allowed to leave home for one form of exercise each day the target population of the survey was adults aged 18 years or older currently residing in scotland who were interested in sharing their experience of positive change participants were primarily recruited through social media advertisements on facebook and twitter which directed participants to the online survey on qualtrics all materials and procedures were approved by the ethics committee of the university of strathclyde and all participants gave informed consent the present sample comprised 3342 participants participant characteristics are shown in table 1 measures sociodemographic and health variables participants provided sociodemographic and health data on the following variables gender age relationship status ethnicity education annual household income employment status overall health risk status for covid19 eg aged 70 or have an underlying health condition and covid19 diagnosis positive changes we measured positive changes using an expanded version of the positive events subscale of the epidemicpandemic impacts inventory 18 we utilised 21 items to assess positive changes that participants may have experienced across a number of domains the measure that we utilised can be found via the projects open science framework page participants were asked since social distancing restrictions were introduced what has changed for you with the response options of yes no or not applicable across each domain example items included more appreciative of things usually taken for granted improved relationships with family and friends and increase in exercise or physical activity a positive score for each participant was computed by scoring 1 for a yes and zero for no on the 21 questions a total score was computed which comprised of the sum of the yes responses for each participant this was then converted to a percentage score by dividing the total score by the sum of yes and no responses nas were removed from the analysis since individuals could not increase their score by responding to a question which did not apply to them a higher percentage positive score indicated a greater proportion of positive changes the scale was found to have good internal consistency in the current study statistical analysis exploratory univariate analysis taking each sociodemographic factor in turn was performed to determine which factors were associated with the positive change scores between group scores were analysed using ttests or anova factors independently associated with positive change were then determined using a multiple regression model with stepwise variable selection in which variables are sequentially entered into the model all analyses were done using minitab at a 5 significance level results descriptive statistics the sample characteristics are shown in table 1 in addition a graph of the distribution of positive change scores is shown in fig 2 scores ranged from 0100 with a mean of 472 table 2 presents the proportions of people reporting yes no or not applicable at the item level of the positive change measure from this it can be seen that the positive changes that were most commonly reported were being more appreciative of things usually taken for granted more time doing enjoyable things more time in nature or being outdoors paid more attention to personal health increase in exercise or physical activity and more quality time with partner or spouse positive change analysis univariate analyses were used to identify factors significantly associated with positive change with postanova comparisons where appropriate table 3 shows the results females reported significantly higher levels of positive change than males in relation to age we found that there was evidence of a difference in the mean positive change score between the age categories with the older age group demonstrating the lowest level of positive change and significantly lower than those aged 1824 similarly there was evidence of significant differences in the mean scores across each of the relationship status groups with those married or living with their partner exhibiting the highest level of positive change those in the employed group had higher levels of positive change than those in the inactive and unemployed groups when considering ethnicity there was no evidence of a difference in positive change scores when comparing white and nonwhite participants similarly for education there was no evidence of a difference between the groups in terms of their positive change scores for household income there was no significant differences in positive change scores across the groups however there is a notable trend with positive change score increasing with increasing household income levels in relation to health there was a significant effect of selfreported health with those who reported their health to be very poor having the lowest level of positive change and significantly lower compared to each of the other groups in addition those that reported being at higherrisk of contracting covid19 had a significantly lower positive change score than those not at highrisk finally there was no evidence of any difference in positive change scores based on covid19 diagnosis multivariate analysis utilising stepwise regression showed that age gender relationship status and selfreported health were all significantly associated with positive change when considering the coefficients it is shown that males reported a positive change score that was 61 lower than females the older age group had a positive change score that was 75 lower than the younger age group in terms of relationship status those who were married or living with a partner had a score than was 3 higher than those who were single when examining selfreported health those who were in very poor health had a positive change score that was 245 lower than those in poor health and 294 lower than those in very good health discussion the present study is the first to explore the social patterning of positive changes experienced during covid19 national lockdown referring back to fig 1 there is clear evidence that unintended positive change has taken place as a result of lockdown at least for some groups of the population the important role of time was highlighted in the positive changes that had been made by the majority of the sample lockdown seems to have afforded people with more time to spend on activities they value for example the majority of the sample reported that they had been able to spend more quality time with their partner in addition participants reported that they had been able to spend more time doing enjoyable things spend more time in nature or the outdoors and increase their physical activity lockdown also seems to have provided participants with the time to reflect and the majority of participants reported that they were now more appreciative of things usually taken for granted however we found evidence of differences in the amount of positive change people had experienced based on sociodemographic and health variables those groups with higher levels of positive change were females those from younger age groups people who were married or living with their partner those who were employed and those reporting better health the phrase we are all in this together has been used both domestically and internationally throughout the pandemic to highlight the sense that covid19 is uniting us in shared experiences however there is a growing evidence base on the inequalities associated with covid19 our findings fit within this emerging literature and point to the fact that while some groups were able to take advantage of lockdown as an unexpected opportunity to make positive changes in their lives other groups were not similar findings on the inequalities associated with adverse experiences during lockdown have been reported 3 with the experience of more adverse events being related to socioeconomic position in addition research on the experience of adverse mental health during covid19 has also shown the frequency of abuse selfharm and thoughts of suicideselfharm to be higher among women bame groups those who were unemployed and those in poorer physical health 5 complementing this work we also find that the experience of making positive changes in lockdown is shaped by many of these key sociodemographic factors together these findings indicate the enduring nature of health inequalities and evoke key concepts from complex adaptive systems perspectives within public health 1920 despite the enormity of structural and social change that the national lockdown brought there appears to be no sense of reaching a tipping point in which the selforganising system that drives inequalities was radically disrupted or dramatically changed in fact emerging evidence suggests the opposite there is clear evidence of negative feedback loops ensuring the system returned to stasis reiterating inequalities along very familiar lines across a broad range of outcomes for example covid19 related morbidity and mortality in addition to positive and negative psychosocial change we believe that our study is the first to report on the social patterning of positive changes during a period of covid19 national lockdown the study also has the strength of a large sample size and the inclusion of a wide range of sociodemographic factors however there are limitations most notably as our participants were primarily recruited from social media our sample is not nationally representative of the scottish population in particular in comparison to scottish census data it is clear that we have an overrepresentation of female participants and those educated to university level however the sample has a good age distribution and the ethnicity and household income levels of the sample is broadly reflective of the scottish population a further consideration relating to recruitment via social media is that we may have reached a different type of participant than if we had been able to employ more traditional recruitment methods however as the study was conducted during national lockdown we were restricted in the recruitment methods that were available in addition the sampling method employed was purposive participants responded to study adverts which asked them to share the positive changes they had made during lockdown we used this sampling strategy deliberately as we wanted to recruit participants who had experienced positive change in order for us to examine the processes behind these positive experiences however the amount of positive change being reported by participants in our study may not be typical of the experiences of the general population in addition the study is crosssectional in nature and so provides only a snapshot of the positive changes people were experiencing at a particular stage of the lockdown and cannot at this stage provide data on whether these positive changes were maintained over time it is also important to consider the that the positive changes experienced by participants within the context of a national lockdown in scotland may be different from the positive changes that people living in other national lockdown contexts experienced as noted above time was central to many of the positive changes that people made national lockdowns across the board are likely to have afforded many people more time as time commitments such as commuting and many forms of socialising were removed this extra time is likely to have provided many people with an opportunity to reflect and as noted by the participants in our study to be more appreciative of things usually taken for granted in this regard our findings are likely to be applicable to other national lockdown contexts however they may differ from national lockdown contexts where stricter restrictions were imposed on time outdoors and time allowed for exercise within the national lockdown in scotland people were allowed to leave their homes for exercise and many of our participants noted that they had been able to spend more time in nature and had increased their physical activity levels indeed recent research has reported that moderatetovigorous physical activity levels increased during the national lockdown in scotland 21 these types of positive change would not have been possible in countries with stricter national lockdowns where people were not allowed to leave their homes for exercise conclusion the present study reports preliminary evidence relating to the social patterning of selfreported positive change during lockdown the data reported here are part of the larger mixedmethods catalyst project which seeks to understand how people have initiated and maintained positive change across a number of domains during lockdown and as restrictions have been eased the aim is to share this learning through intervention development work in order to facilitate positive health change in others from the results of the current study we can see that there are subpopulations and communities where it may be particularly important to target these interventions in order to provide opportunities for health change amongst those who may benefit most all data files are available from the open science framework doiorg1017605osfionwh48

multiple studies have highlighted the negative impact of covid19 and its particular effects on vulnerable subpopulations complementing this work here we report on the social patterning of selfreported positive changes experienced during covid19 national lockdown in scotlandthe catalyst study collected data from 3342 adults in scotland during weeks 912 of a national lockdown using a crosssectional design participants completed an online questionnaire providing data on key sociodemographic and health variables and completed a measure of positive change the positive change measure spanned diverse domains eg more quality time with family developing new hobbies more physical activity and better quality of sleep we used univariate analysis and stepwise regression to examine the contribution of a range of sociodemographic factors eg age gender ethnicity educational attainment and employment status in explaining positive changethere were clear sociodemographic differences across positive change scores those reporting higher levels of positive change were female from younger age groups married or living with their partner employed and in better healthoverall our results highlight the social patterning of positive changes during lockdown in scotland these findings begin to illuminate the complexity of the unanticipated effects of national lockdown and will be used to support future intervention development work sharing lessons learned from lockdown to increase positive health change amongst those who may benefit

note on transliteration there is considerable confusion about the transliteration of arabic names many people whose arabic names are mentioned in this paper are known in englishlanguage publications by names with selfchosen spellings when applicable selfchosen transliterations will be used while placing between brackets the spelling according to the ijmes transliteration system western and coptic names spelled in arabic should not be transliterated and are provided in their common spellings introduction the paper discusses how interreligious dialogue can be reached through both study and friendship the paper aims to answer the following questions how can we expand our own social bubble see the world from different perspectives and contribute to interreligious dialogue in social relations and daily life how did this experience influence religious engagement and activities of the author to this end the paper combines a literature review with the authors personal narrative of events that changed his perspectives on truth and spirituality making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue in the netherlands israel egypt and the middle east more generally the author grew up in a conservative christian reformed family in the netherlands in a deeply pillarised dutch society and experienced its depillarisation a personal tutor encouraged a life of involvement with different religious communities and meeting with leading religious leaders and scholars this encouragement motivated the author to work in mutual understanding and reporting about interreligious tensions while always remaining independent of religious and political leadership these experiences impacted his personal search from a pietistic orthodox reformed christianity to intellectual curiosity in christianity judaism and islam which influenced his spiritual development in all three religions an orthodoxy attempts to address social and political issues while holding on to revealed truths with claims to the one and only truth resulting in seeking protection in ones own social bubble with the possibility that this can develop into fanatism and violence many people tend to seek protection in social bubbles with clear cultural or religious boundaries between us and them believing that we are right and they are wrong and considerable time and energy within these structures is spent on providing a relatively safe space for those with shared outlooks solidifying shared identities and providing respite from the challenges of the exterior world building bridges of cooperation needs genuine friendships across the boundaries of these social bubbles intercultural friendships are prerequisites for interreligious dialogue that in turn are fundamental to reducing intergroup conflict fear and prejudice the first part of the paper discusses the dutch context and focuses on the reformed church tradition in the netherlands including the orthodox christelijke gereformeerde kerken in which personal piety and ethics play a big role and the author grew up the gereformeerde kerken in nederland and vrije universiteit amsterdam founded in respectively 1886 and 1890 by rev dr a kuyper in opposition to liberalism became overwhelming liberal over time with theologian harry kuitert as a major exponent of liberal theology and philosopher sander griffioen as an exponent of orthodox reformed thinking both teaching at the free university amsterdam kuitert his student goud writes was combative in not wanting to accept handeddown truths from previous generations without searching and believed his faith had to be based on openness personal convictions and experiences which made him depart from traditional truths insights and teachings which clashed with the proponents of orthodoxy due to different presuppositions human logic versus human logic with divine inspiration griffioen has been a lifelong member of the vereniging voor calvinistische wijsbegeerte which influenced many christian thinkers opposing religious liberalism liberalism changed the traditional notions of personal piety secular philosophies including nationalism came up and merged in religious societies with personal religious convictions creating new boundaries to the other after an overview of debates in the netherlands the debates between orthodoxy and liberalism in israel and egypt are discussed since these are the countries the author lived most of his life and engaged in local debates that involved judaism christianity and islam in his personal account the author explains how political events social changes including the debate between orthodoxy and liberalism and experiences of interreligious engagement in the netherlands israel and egypt have exerted an impact on interreligious dialogue both literature and personal experiences demonstrate that debates are often clouded by advocacy and selfdefensive stances which complicate the road towards mutual understanding in the conclusion the author explains what lessons have been learned social bubbles the balancing act between the search for protection and dialogue cultural differences help us to distinguish between us and them which is the basic characteristic of a social bubble culture kuitert writes can be described as a way of life that people share with others both spiritual and material that developed in time and place religion is part of culture that seeks the anchoring of religious certainties that explain human experiences like joy fear and pain that all humans share and in religious universities with a focus on strengthening the faith of one religion this includes christian theological universities worldwide but also such a venerable institute as alazhar the main centre for teaching islam in egypt with a strong international focus since one finds here muslim students from all over the world within the christian language we find a multitude of differences anglican archbishop rowan williams writes that the overarching unity of all christians is that they all interact with canonical texts that are compiled in the bible either through reading it or having the text read and explained to them all christians interpret these texts within their historical and cultural context resulting in different ways of interaction shaping patterns of worship teaching and ethical discourse in the same vein we see a multitude of differences in the jewish and islamic languages the term fundamentalism is problematic since both the media and politicians have in the case of islam associated fundamentalism with such labels as extremism violence and terrorism such labels are associated to ideological biases catholic sufiislam expert giuseppe scattolin states arguing that historical facts always need to precede ideological arguments a first requirement in dialogue is using the same terms for the same realities across religions both orthodox and fundamentalists kuitert explains believe their scriptures are revealed by god and believe they know what gods will for humanity is larson and shady bring in the category of religious exclusivists those who believe that their religion is the only way to god orthodox believers are usually exclusivists but are often able to present their faith in humility and make practical compromises without giving up basic tenets of faith fundamentalists however resist religious change refusing to compromise because compromises mean relativity orthodoxy can change their desire to stick to the truth of their forefathers is not immune to changes that have become unavoidable with migration and modernised communication making our world increasingly diverse and interconnected with religious identities that are continuously in flux fundamentalism has a definite negative connotation in the west australian muslim scholar sayed khatab explains this is very different for islam since knowing the fundamentals of ones religion is honoured several scholars describe islamic fundamentalism as a combination of islamic devotion and political activism often linked to revivalism in the light of western political and cultural dominance muslim fundamentalists believe religion is flexible and has something to offer all generations khatab explains that islamic fundamentalism is not necessarily radical or reactionary and in no way does it inherently lead to violence and terrorism khatabs definition of fundamentalism matches kuiterts definition of orthodoxy while khatabs concept of reactionary matches fundamentalism this paper will therefore speak about islamic orthodoxy or conservatism instead of fundamentalism unless a refusal of compromising is at play also extremism and terrorism need to be explained dutch historian and terrorism expert beatrice de graaf explains terrorism as the outcome of seeing life as a struggle between good and evil with extremists seeing themselves in the centre of that struggle to influence history acceptance of difference between adherents of different religions and within religions cannot be separated from building friendships beyond our social bubbles and is a prerequisite for interreligious dialogue the goal of interreligious dialogue is to become theologically bilingual understanding the language of another faith community in the broadest sense this includes understanding people with both orthodox and liberal views religious convictions of the other need to be taken seriously which means that we have to accept that civil life includes various religions and beliefs anna wilson senior program coordinator at collegepoint highlights three essential virtues for effective interfaith engagement receptive humility reflective commitment and imaginative empathy receptive humility means acknowledging the limitations of our own religious views this can be difficult when it comes to doctrinal beliefs and is a challenge for anyone convinced of the absolute and final truth of ones own convictions seeing that we often seek fault in others religious beliefs and instead should engage in open questions is the beginning of humility in reflective commitment we need to put all beliefs on the table and apply socratic scrutiny and rigorous critical thinking it should be possible to admire an aspect of another religious tradition without weakening our commitment to our own receptivity may lead us to change own views and assumptions in imaginative empathy we learn intellectually about another religion and its adherents as well as display a willingness and make sincere efforts to penetrate into the religious mindset of the other and understand the other from within we need to understand before we criticize and when we criticize we need to be informed critique should be rooted in factual truth the virtues of humility reflective communication and imaginative empathy can only mature in the context of facetoface encounters and budding relationships with real religious others american astronomer carl edward sagan adds that we only can understand the social reality around us through a set of successive approximations continuous research into our own recent or more distant past can improve our selfknowledge in opening our social bubbles we should take both factual truths and faith seriously which is the opposite of avoidance reducing all traditions to their lowest common denominator of shared values is such a strategy many strong believers in a particular religion believe that interfaith dialogue creates a risk for participants but this does not need to be the case amber hacker of interfaith youth core argues another major misconception is that many people engaged in interreligious dialogue believe religious exclusivists should be excluded but they too should be invited to participate since exclusivist beliefs can still be held with humility and an awareness of ones own fallibility griffioen states that dialogue only can succeed if interlocutors are able to depend on each others sincerity and the integrity of each others convictions in dialogue he writes we also need to be able to talk about inconsistencies and contradictions in the precious convictions we hold we need to be able to see things we believe to be evident but that belongs to the category of presuppositions mcneal provides a model for interfaith engagement based on jewish philosopher martin buber and croatian theologian miroslav volf and calls this inclusion respect for interpersonal and intellectual boundaries promoting a shared reality where all partners in the dialogue seek to understand each others position even if they do not entirely agree with it we best come to understand ourselves in dialogical relationship with the other inclusive dialogue is described as the effort to seek to break down boundaries and develop deep relationships with other people and with things that others have created such as texts and works of art it greatly helps if people of different faiths experience mutual events every religious believer should be able to share his or her own truth and understand other peoples efforts to interpret their scriptures the person engaged in dialogue should be able to both learn and teach which results in genuine friendships that provide the most concrete and reciprocal experience of inclusion martin buber made a sincere effort to practice the inclusive approach in the dialogue between jews and arabs who dispute the right to the holy land on foundationally different views buber does not present a theory for how to evaluate the truth of competing views nor does he argue that the truth of ones view is irrelevant he however argues that in friendship we do not seek to impose our ideas on others including our religious beliefs in this process of dialogue we should be able to become an advocate for the other in his fight against religious prejudice this includes islamophobia that is often fuelled by inaccurate representations of what it means to be a practicing muslim if a person has had no meaningful interaction with muslims heshe may easily succumb to inflammatory antimuslim sentiment one may add antisemitism and other efforts to provide a distorted view of people different from us the authors of from bubble to bridge are working with university students college years are a critical time for examining deeper faith as the intellectual life of the student is also maturing openness to pluralism and diversity needs to result for a christian in an ecumenical orientation learners view humble authentic and appropriately selfrevealing teachers and facilitators as trustworthy when difficult topics are encountered we need to look first at what we have in common fear ignorance and misunderstanding are too often leading to isolationist policies hateful speech and even violence interreligious dialogue will inspire us to be good neighbours by replacing fear with empathy and love the split of the dutch reformed bubble orthodox and liberal do social bubbles provide protection the orthodox reformed believed so but saw their part in society shrinking often blaming people with liberal theological views for causing secularisation religious liberals in turn believed the orthodox were to be blamed for holding on to certainties that violate science and human reasoning and saw this as a major reason for people leaving the church we will see how this worked out in the struggle between the orthodox and liberals in the netherlands griffioen defines faith as a commitment to religion true faith griffioen argues is given by god and lives in us as the new testament says religion leaves human freedom in place it is always possible to say no this definition is related to griffioens faith in the bible as inspired by god griffioens views are in line with classical reformed faith while kuitert came to see all religions as a human construct i have chosen to contrast reformed orthodoxy with the theologically liberal views of kuitert because both are clear about their presuppositions furthermore kuitert was highly influential he used his life after his pension in 1989 to search into what faith really is using scientific knowledge and logic as his primary tools to separate facts from imagination in the past many believers he found blurred these two domains logic however teaches us that we should treat imagination and reality as two distinct domains the growing resistance of kuitert to orthodoxy and vice versa cannot be explained without a brief history of the dutch reformed tradition that stems from the nederduitsgereformeerde kerk formed in 1579 as a state church during the war of independence from catholic spain that became known as the tachtigjarige oorlog and became the dominant provider of collective morality in the netherlands the dutch reformed church accepted the belgic confession of 1561 that states in article 36 that the governments task is to promote church services and remove and destroy false religions 1 this confession is until today part of the confessional documents of the different reformed churches in the netherlands it is even referred to in article 1 of the program of principles of the staatkundig gereformeerde partij formed in 1918 the dutch reformed church was deeply influenced by the theology of john calvin who desired a theocracy cooperation between the church and government without government interference in issues of faith of the church 2 during the 18th century enlightenment period ideas about human autonomy observing the world with our senses and independent scientific reasoning without belief in the moral codes provided by god through revelation were promoted resulting in fierce reformed resistance to these new ideas yet the republic abolished the state church in 1795 that was renamed nederlandse hervormde kerk the influence of the reformed church on public affairs further declined with the constitution of 1848 and the restoration of the roman catholic hierarchy in 1853 the church had not only lost influence over the state but also faced divisions between liberal and orthodox streams resulting in multiple splits and unifications since the 19th century that gradually reduced the orthodox stream despite all efforts to keep the faith to a ever declining minority in 1834 the first conservative secession from the netherlands reformed church took place the secession of 1886 led by rev dr abraham kuyper was the largest taking with him around 10 of the members of the netherlands reformed church resulting in the formation of the gereformeerde kerken in nederland some of the secessionists of 1834 joined kuypers church while others remained independent and in 1892 formed the more conservative christelijke gereformeerde kerken the church secessions in the netherlands became because of the large numbers of people following them a mobilising force for political action in 1879 kuyper formed the antirevolutionary party to oppose the dominant liberal politics of his days the name antirevolutionary expressed resistance against ni dieu ni maitre the motif of the french revolution kuyper also established the free university amsterdam schools and other organisations on a reformed basis which aimed at creating safe places or bubbles that greatly reduced contacts with people outside their circle which created the reformed pillar in which members of all reformed churches cooperated the catholic pillar developed in the 1890s when they clashed with the liberals over government funding for religious schools in which they found an ally in the arp in 1904 a catholic party was founded political cooperation with the catholics along with other issues split the arp in 1908 and resulted in the more conservative christelijk historische unie the second breakaway with conservative members from both arp and chu resulted in 1918 in the staunchly conservative sgp party the system that developed became known as verzuiling zuilen were the names given to extensive networks of similarminded organisations with broad claims on the identity of their members members of a pillar placed a strong emphasis on relations within the own group resulting in a sharply separate life and worldviews that resulted in reformed catholic socialist and neutral pillars kuyper developed the concept of societal soevereiniteit in eigen kring with each sphere or sector responsible for its own activity area the created order includes the family and communities for education worship and many other areas of life the state should not interfere in these spheres but focus on public justice these ideas were further developed in the vereniging voor calvinistische wijsbegeerte that was founded in 1935 in 1947 the society established a foundation for the maintenance of endowed chairs in calvinistische wijsbegeerte in 1995 renamed reformatorische wijsbegeerte at different dutch universities reformed philosophy rejects the thought that humans can discover the truth through human efforts alone it needs gods revelation calvinist philosophy was popular in the circles of the arp and other groups that stemmed from this calvinist political approach pillarisation was firmly established before the second world war but the war the holocaust the establishment of the state of israel and the cold war marked major changes in american and western european thinking with the american support for rebuilding europe also came american cultural influences around 1900 practically all citizens in the netherlands belonged to a church this was still the case in 1945 but decline set in after the war in 1966 67 of dutch citizens considered themselves to be members of a church this percentage has dropped to 30 in 2012 changes are not only about reduced church membership but people no longer seeing guidance in christian moral values in 1979 43 of respondents to research titled opnieuw god in nederland saw no connections between their most important values and the christian faith the remainder of the people questioned believed their christian faith contributed to a larger or smaller extent to the values they believed to be important or they did not know bart wallet describes the processes of verzuiling and depillarisation as a historical phenomenon in the netherlands that explains the demise of the privileged position of organised religion as the main provider of collective morality billy graham witnessed the decline of organised religion in the netherlands and in 1954 and1955 organised evangelisation campaigns attracting tens of thousands of people other american evangelists also visited the netherlands witnessed the changing cultural climate in europe and wished to stem the tide religious influences did not go one way abraham kuypers political and theological views and the philosophers of the society for calvinist philosophy had a significant impact on the reformed community in the usa and canada that in 1967 founded the institute for christian studies in the kuyperian stream of the reformed tradition 3 all churches were searching to match old church traditions with science and logic creating a wide diversity in responses in 1953 the christian reformed synod appointed bj oosterhoff as professor of the old testament he published several studies that were interpreted by the conservative wing of the christian reformed churches for relativising the authority of revealed scripture and giving in to the spirit of the age oosterhoff and fellow professors at the christian reformed theological university in apeldoorn engaged in a balancing act to maintain unity in the church at the same time evangelism campaigns led to the beginning of a new conservative christian bubble at the one hand the formation of evangelical churches that attracted members from the traditional reformed churches while on the other hand orthodox reformed church members created new organisations to protect adherence to the 16th17th confession documents of the dutch reformed church in 1966 the magazine bewaar het pand was established around this magazine a group with the same name was formed the name refers to the admonition of the apostle pauls first letter to timothy 6 2021 timothy guard what has been entrusted to your care read the church turn away from godless chatter and the opposing ideas of what is falsely called knowledge which some have professed and in so doing have departed from the faith not science but teaching from the bible infallible and divine without allowing text criticism to play a role needs to have prevalence since this will protect the church from heresy and liberalism member churches are held to decisions of the synod members of bewaar het pand opposed allowing local churches to appoint women in positions of teaching and leadership in the church which created deep divisions in the church and a balancing act between the most conservative wing in the church and more liberalminded churches to maintain unity 4 other churches saw similar developments but this did not stop the demise of organised religion which greatly impacted the leading christian democratic parties the arp chu and katholieke volks partij that had dominated politics in the first half of the 20th century they saw their electorate rapidly dwindle in a very short period in the elections of 1965 these three parties obtained 76 seats in the parliament of 150 seats this dropped to 69 in 1967 58 in 1971 and 48 in 1972 the decline continued after the merger with only 15 seats in 2021 the netherlands transformed from a christian society to a mostly secular society in orthodox reformed circles one can describe this as a decline of almost biblical proportions the dutch reformed split into two main camps seeking protection in newly established conservative organisations while others sought hope in religious liberalism many believed in cooperation between protestants and catholics which resulted in 1980 in the arp chu and kvp merging into the christen democratisch appèl the arp believed their members would be able to contribute with their reformed vision on politics in the new party a substantial number of orthodox members opposed the direction party leadership chose and in 1975 formed the reformatorische politieke federatie founding members of the rpf accused the cda of not resisting the spirit of that time the split throughout the reformed ranks was profound more conservative members of the reformed churches turned to one of the many organisations in the evangelical movement where people believed in the revitalisation of religion based on orthodox religious notions while the depillarisation in the orthodox reformed churches was slower because of a strong focus on personal principles once orthodox reformed organisations such as the nederlandse christelijke radio vereniging established in 1924 as a conservative reformed radio broadcaster were impacted by liberal christian views criticism of the ncrv resulted in 1967 in the formation of the evangelische omroep which aimed to form a bulwark in the fight against secularisation and provide the good news of the bible to the widest audience possible but it yet had to obtain government recognition founders including former roman catholic priest turned conservative reformed pastor herman hegger were greatly inspired by the campaigns of billy graham and other american preachers and saw ecumenism as a threat to the message of jesus christ and the foundation of the state of israel in 1948 as a fulfilment of biblical prophecies and prelude to the return of the messiah the 1967 sixday war between israel egypt jordan and syria that resulted in bringing large areas under israeli control were interpreted as gods hand in history a similar dissatisfaction was seen with the dutch daily trouw established in 1943 as a reformed newspaper resisting nazi ideology in line with the political ideals of the arp but beginning in the 1970s the publication embraced depillarisation rev jan hendrik velema widely recognised as the most influential christian reformed theologian after the second world war and sometimes nicknamed the pope deplored the departure of trouw and arp from their initial conservative reformed roots and in october 1968 established koers that was entirely focused on orthodox reformed views velema joined the eo in 1968 and played a major role in providing the eo with sufficient members that were needed for government recognition the resistance to the liberal developments at trouw provided in 1971 the impulse to form the reformatorisch dagblad a conservative reformed daily newspaper the founders wanted to halt the secularisation in their own circles which was praised by jh and his brother wh velema jp versteeg and other leading theologians of the christian reformed churches van tillo describes the developments leading to the formation of the eo and rd as the rise of restorative or restorationist societal impulses the term restorative indicates a wish to return to the old order it is also possible to speak in more positive terms of a religious renewal and political activism reaching a new high griffioen served between 1976 and 1979 at the institute for christian studies in toronto canada between 1979 and 1991 as professor of calvinist philosophy at leiden university and between 2002 until his retirement in 2006 as professor for intercultural philosophy at the free university amsterdam griffioen argues in line with kuypers souvereignty sphere that a pluralist ethos is inherently impossible and hence the multicultural society is best described as a society with directional diversity in which rival traditions pursue recognition when challenged different ways of life are under pressure to provide selfjustifications when these ways of life are not provoked the choice of a direction is likely to be more a matter of habit than of articulated claims argumentation is by nature divisive because it is bound to stir up dormant differences that may result in dissolving society into an archipelago of islands an image griffioen borrowed from lyotard and kant orthodox reformed and evangelical christians realized that they needed to strengthen mutual ties in 2000 the rfp merged with the gereformeerd politiek verbond and formed the christenunie conservative in ethical issues and progressive in social and ecological issues the merger capped thirty years of development toward a new orthodox reformed pillar in society harry kuitert grew up in an orthodox family and became throughout the years a major exponent of liberal theology grew up in a deeply pillarised society aimed at protecting reformed orthodoxy he not only witnessed the process of depillarisation but also played a major role in this and opposed repillarisation as it was formed by the eo and other orthodox reformed institutions kuitert challenged christian orthodoxy in a way that no dutch reformed theologian before him had done he wrote numerous bestselling theological books in which he presented information that was known to theologians but not thought over in a way that was accessible to a wider audience he responded to questions in lectures about his books and in thousands of letters it was his method to seek the debate and initiate the thinking process with others during this process kuitert further developed his views in an interview with gerritjan kleinjan on his 90th birthday in the dutch daily trouw he says all books i have written over time are records of a search each time a step further i did not know where i would end up a search is only a search if you do not know where it ends otherwise it is not sincere searching dutch remonstrant theologian eginhard meijering lector of the history of theology at leiden university and since 1980 a member of the prestigious royal netherlands academy of arts and sciences wrote that anyone who wants to understand the changes in theological views in the netherlands must read the books of harry kuitert he described kuiterts book of 2005 as the end of a development that distanced him from traditional christian faith but sees him also as a scholar who challenges christians to think about what matters in christian faith goud states that kuitert meant a great deal to believers and nonbelievers of his and subsequent generations to be fully free to believe or not believe without the guilt of not believing what they were told to believe dutch protestant and catholic theologians elected kuitert in 2004 as the 7th most influential theologian in the 20th century no dutch protestant theologian since abraham kuyper sold as many books as kuitert delpher a digital archive of dutch newspapers shows some 4000 articles referring to kuitert in dutch media between 1990 and 1996 delpher is incomplete for later years but the number of references in the given period is staggering kuiterts doubts started early in his career in 1968 he publicly challenged the literal understanding of the creation story in genesis and called this a myth to which netherlands reformed pastor g visee responded in 1969 with an apologetic booklet verstaat prof kuitert wat hij leest when we told you about the coming of our lord jesus christ in power but we were eyewitnesses of his majesty visee refused historical criticism of the bible since neither jesus nor the apostles doubted its historical validity what matters is that they preached the salvation of god pp 16 66 arguments between kuitert and christian orthodoxy came to a peak in the years following his retirement in 1989 in 1994 kuitert concluded in zeker weten that since evolution is based on the survival of the fittest we can no longer maintain that god has a plan for our world discarding the concepts of seeing gods hand in history divine revelation or inspiration dear to christian orthodoxy there are many conflicting revelations whose human origins can be traced they may have value for the believers of a faith tradition but since it is a matter of faith only it is not providing us with historically reliable information for the world we live in kuitert argues that factual beliefs beliefs in religious scriptures that claim to be grounded in history need to be tested and if these turn out to be incorrect we need to review our conceptions of faith when a large part of the factual beliefs of a religious worldview are undermined and religions claim that accepting impossible things are the pinnacle of piety then believers drop out maintaining displays of faith that are not in line with reality causes one to live in two separate worlds the only way to overcome living in two worlds is through accepting that displays of faith are put into words by people in a particular time and culture in which they have formulated their religious certainties and why kuitert notes substantial similarities among the abrahamic religions judaism christianity and islam in all three god is a transcendent personal god god is one is the creator who maintains his creation and rules everything that happens happens according to his will humanity is not subjected to fate or gods that contradict each other the creator is a righteous judge who also shows mercy it is possible to communicate with him within these broad similarities there are also numerous differences not least because all three religions also claim their books were revealed by god and therefore have special status differences not only exist between these three religions but also within each of these religions since kuitert expressed in zeker weten his faith in a mystical experience with god his book was appreciated by many in the conservative flank in the church in jesus the legacy of christianity kuitert critiques the orthodoxy for their faith in the historicity of the gospels which he sees as stories of faith giving meaning to jesus death but he also realizes that human beings tell stories because they have meaning for the person telling them the role of science is to provide facts and leave the subjective meanings to the believers kuitert is certain jesus lived preached and was crucified but does not believe in the virgin birth and miracles including the physical resurrection of jesus faith in resurrection is in his view in 1998 believing that friendship with god is eternal which will not end with death a key fact to kuitert was that jesus was jewish adhered to the jewish faith and criticised the people of his days but not judaism since a jew cannot see himself as the son of god in the trinitarian understanding jesus cannot have seen himself as such kuiterts arguments shattered one by one key orthodox notions of faith it is impossible to speak about the world of god without metaphors the language of faith in judaism christianity and islam consists from a to z of metaphors metaphors can be misused or become a trap because interpretations are given that were not intended by the original users dogmas are equally human since it is possible to see how dogmas follow the piety of past generations and once a dogma has been established piety has to adjust to dogma all dogmatic expressions treasured so much in orthodoxy need to be seen in culture and time but since they are part of our history they cannot be removed but they can be reinterpreted piety described by kuitert as devotion dedication and veneration should be respected fighting piety is denial of what someone experiences and that kills each form of communication we have to accept what people feel that is the necessary basis for talks whereby we do not need to agree kuitert argues in favour of more selfcriticism the realisation of the relativity of faith that in his view can go together with faith he argues that all people are gods people regardless of what faith they adhere to that leaves space for relations with believers of other religions kuitert also believes churches have responded in a wrong way to secularisation which many church leaders described in terms as unhinged autonomy and degradation of society such denunciations however do not help believers need to realise that religions are linked to morality and philosophies that have been built on those of previous generations such as the influence of the ethical philosophy of the stoa in the apostle pauls letters faith needs to move people kuitert writes since if it does not move me it is not part of myself maintaining something as true is insufficient faith that moves but is not linked to truth is also insufficient the apostle paul says when he writes about love in 1 corinthians 13 faith that moved kuitert is found in matthew 25 seeing the face of god in people in need and seeing in the new testament a call to unite humanity through abolishing ethnic and cultural borders kuitert sees the church as a place for social contacts providing people with security pastoral care and dignity to make them dedicated and trust leaving the church is not leaving christianity which has deeply permeated europe throughout its history but the church should still pass on faith to next generations since christian faith will not survive without institutions in later books kuitert discarded space for a personal experience with god pronk sees the tipping point in his theology in his book over religie aan de liefhebbers onder haar beoefenaars kuitert searches for the origin of religion in human history and now believes that first there were humans then religion gods and god our images of god are the product of human imagination which makes knowing god beyond our human ability in 2005 kuitert goes again a step further in expressing doubts in hetzelfde anders zien het christelijk geloof als verbeelding in 2006 he however still left the possibility open that one can feel secure in gods hand the enlightenment separated fact and fiction which kuitert took to its limits in his book alles behalve kennis kuitert defines knowledge as anything in our physical world that we know for certain and cannot be denied without being exposed if we do not know we should not speculate the practice of science consists of eliminating what is not true and establishing what is kuitert relegates anything that is not proven factually true to the area of imagination theology has its place but as a continuous process of giving meaning to a continuously changing world which is an entirely human phenomenon and differs from religion to religion kuitert saw his work as taking church goers out of the house of bondage since religions prescribe what you can and should do in the name of god in kuiterts view no one can speak in the name of god the concept house of bondage is a biblical metaphor used for the people of israel in egypt prior to the exodus to the promised land kuitert was averse to absolute truths but appreciated religion as a search for wisdom as his appreciation for augustine showed since he did not present theology as science but as sapienta a way of living pronk has seen kuiterts correspondence with thousands of people and noted that despite repeated orthodox criticism he was ready to correspond with anyone including rev herman j hegger who believed the bible was gods word their correspondence became cold and culminated on 25 october 2006 in an open letter of hegger to kuitert in the dutch daily trouw in which he argued that intuition comes before knowledge and leads to god who is in heggers view the only purpose and sense who provides humanity with hope hegger asked kuitert how he can be certain that he will not be judged by god kuitert responded that hegger can have his intuition but not impose his intuitions as if these were absolute truths on others that is an effort to rule over someone elses faith hegger kuitert concluded should stop threatening people with the judgement of god kuiterts lifelong search for the secret of faith with the tools of science historical research and logic and the responses from his opponents resulted in the loss of faith in religious authorities and certainty about a life hereafter kuitert undermined the foundations of orthodoxy resulting in orthodox criticism meijering criticised kuiterts hetzelfde anders zien for turning faith into humanism which makes the proclamation of the church irrelevant meijering opposes fundamentalism but feels closer to orthodoxy than to kuitert in believing in a world hereafter and god revealing himself through history including jesus christ christians meijering believes should not change the faith tradition as handed down but a debate about the foundations of the christian faith is needed the key difference between kuitert other liberal thinkers and orthodoxy is in rejecting or accepting the concept of revelation seeing gods hand in history and by extension seeing the bible as the revealed word of god through which god speaks to humans knowledge of god orthodox believers argue cannot be obtained through rational thinking only but also needs feeling leading christian reformed theologian willem hendrik velema explained that belief in god requires that people study the bible to understand what god is communicating to us humans today engage in prayer and allow god to speak to us in our lives internal spirituality is dependent on knowing that god loves us this faith should permeate our lives and is evidenced by how we live meijering agrees that we cannot proof revelation but states that we also cannot discard it certain beliefs could be a scientific possibility not a scientific certainty meijering accepts the evolution theory but is convinced that our world is not an accidental product of an inevitable process but created by god with a purpose even if we see god through images we remain sinful people who may know they can trust in gods grace life is already a sign of living in the kingdom of god the test for our acts should be the neighbour who needs us jesus meijering writes preached that anyone who wanted to enter the kingdom of god had to convert making believers responsible for their behaviour including care for life on earth and fighting injustice radical orthodoxy developed by james k a smith and others in opposition to religious liberalism on the insights of the dutch reformational tradition of abraham kuyper and the society for calvinist philosophy and summarised by amos yong believes that it is not possible to separate faith and reason since no nation exists without an ideology that leads to the question of how dialogue can proceed on traditionspecific terms is dialogue between persons who do not share the same presuppositions possible how can we consider the encounter of the diversity of religions in our time kuitert considered these questions and responded that truths of religions through revelations do not work since then that religion is always right yong points to contradictions between different beliefs constructions that in themselves seem reasonable but in comparison seem to be a paradox this observation matches kuiterts definition of religion yong however goes further and states that since beliefs and practices are intertwined religious traditions are effectively shielded from immanent critiques attempted by outsiders smith resists the blurring of the lines between the church and the world yong sympathises with smith but also believes no theological vision exists that can successfully answer all questions revelation only can be understood as knowledge of god that has been mediated through the created order it comes down to the human experience of the encounter with god the testimony to the wondrous works of god can be received only through a multitude of voices which all provide a perspective that needs to be discerned amidst by and through the community of faith yong states that the work of the holy spirit sets the church not individual churches apart from other communities he admits the practices of the historical church are messy and that the lines between the church and the world can never be hard and fast in actuality identities are never pure and there is no absolute other but any authentic encounter and dialogical encounter will always be with those who have been brought near by the spirit in this encounter christians can bear witness to the coming of the kingdom of god that will deabsolutise all human claims in the end yong believes this approach opens the opportunity to engage in immanent critiques of other faith traditions and makes it possible that we are transformed through our encounter with those in other faiths the orthodox contribution to the interfaith encounter includes apologetics defending the faith against the polemics of others but christian apologetics must speak truthfully about rather than bear false witness against religious others yong recognises that believers of other religions have their quest for truth interfaith encounters may influence and impact the lives of others but there should also be every expectation that authentic interfaith interaction will result in personal transformation as well interfaith dialogue will inform christian thinking theologically by indepth reflection on and with those in other faiths theology by and for the church in the twentyfirst century cannot proceed in isolation as if others were absent interesting is sander griffioens observation that one of the central themes of his tutor jpa mekkes was that gods revelation comes to all humankind and subjects every dimension of culture to a radical critique griffioen focused in his most recent book on good and evil in our world and believes the good cannot be separated from a giver griffioen does not make any reference to kuitert in his book and when asked responds that kuiterts statement that religion is a human construct is trivial if you do not ask where the speaking about god originated that is divine inspiration griffioen does not believe in a literal sixday creation period and does not find this relevant in describing god as the creator of our world 5 kuiterts growing conviction of faith as a human construct and as a consequence of the absence of absolute truths created a distance to his protestantse kerk in nederland formed in 2004 following a merger of the vast majority of the netherlands reformed church the vast majority of the reformed churches in the netherlands kuitert was born into and the evangelischlutherse kerk in het koninkrijk der nederlanden theologian lieke a werkman who earned her phd with kuitert saw in 2004 in him a deeply religious human being but deplores he had lost confidence in the church as an institute people need a social structure it helps them and does good to the world through for example diaconal work kuitert had an insufficient eye for this yet in 2006 kuitert still saw a need for the church as an institute in his later work he sees no problem in people abandoning church in an interview in 2014 he criticised how the concept of church was conceived and put into practice and believed this had to digress in an enslavement of souls kuiterts last books amounted to agnosticism not knowing god exists or not and with this discarding the experience of faith within established institutions which went for many too far werkman argued that kuitert was too convinced in the rationality of his own thoughts which made him conclude that speaking about god was not only human but only imagination and projection how do you know werkman asks kuiterts work results in humility in speaking about god but for werkman does not need to lead to a farewell of god dutch jesuit priest hans van leeuwen sj blamed kuitert for his focus on human weaknesses in the search for god but not seeing the experience of faith people who undergo a touch that is possible because humans have a natural sense of god nobody has ever seen god but what humans try to put in words reflects their sense of god heino falcke awardwinning professor of radio astronomy and astroparticle physics believes in god humans are trying to create an image of god but the universe arouses curiosity and teaches humans humility humans may become the conductor of gods blessings the ebbing of faith made pope francis who of course did not mention kuitert assure an audience of priests seminarians and pastoral workers that good pastoral ministry is possible if we are able to live as the lord has commanded us in the love that is the gift of his spirit that is a focus on living a christian life that had been undermined by a rationality that for committed christians had been taken too far liberal critique of orthodoxy is profound but orthodox responses show that science and logic do not have all the answers revelation turned out to be a key concept to protect orthodoxy not only in reformed and catholic christianity but also in judaism coptic orthodoxy and islam orthodox rabbi moshe peleg does not question gods hand in scripture either and sees the torah and rabbinic literature as tools for life an aid to humanity to face the big questions in life 6 muslim scholar muhammad abulaylah argued in a book used at azhar university that god speaking through the quran and islam should not be questioned kuiterts books demonstrate the human origin of religions that involved various political influences providing us with canonical scriptures tradition and dogmas in which facts and imagination have been mixed aiming at girding desired codes of conduct the orthodox defence in turning to revelation to substantiate believed factual claims that violate science and historical critical research alienated many people and turned kuitert into a leading figure taking reformed christians out of their house of bondage dutch history shows the orthodox reformed have long been a political force to be reckoned with the decline of faith after the second world war greatly reduced the appeal of christian democratic political parties which in turn impacted policies that were intended to support faithbased policies the discussions between kuitert and his critics show that religion cannot depend on the search of factual truths and logic only real faith in the words of wh velema allowing god to speak in our lives is based on personal experience that moves people and determines how people live discussions about religion orthodoxy and politics took a very different turn in judaism and israel judaism and israel religion as a political factor unlike the orthodox reformed who saw their influence dwindle in the netherlands orthodox jews saw their influence both religiously and politically grow in israel leading to a deeply polarised israeli society the current state of israel and messianism are deeply intertwined the israeli success in the june 1967 war boosted messianic views to an unprecedented height making many christians and jews believe modern israel is the revival of ancient israel in biblical times messianism took various forms but all resulting in support for israel the dispensationalists among american evangelicals promoting a literal or straightforward reading of biblical prophecies that minimise allegorical or spiritualized interpretations interpret jesus prophecy that jerusalem will be trampled by gentiles until the times of the gentiles are fulfilled as a sign that israel will embrace jesus as their messiah before his second coming to earth israels victory in 1967 was also widely celebrated by american jews who collected over usd one hundred million in support for israel the elated responses made israels eloquent minister of foreign affairs abba eban publish his widely popular my people the story of the jews underscoring the link between ancient and modern israel in which zionism plays a major role jewish orthodoxy has long been divided over mixing faith with politics which changed over time this paper will present the views of an orthodox opponent to mixing faith and politics with jewish support for evangelical messianism since that was politically opportune in the advancement of zionism jerusalembased orthodox rabbi lion wagenaar 8 born in germany and surviving auschwitz expressed his opposition to the euphoria following the june 1967 war in correspondence with german author helmut spehl 9 between august 1967 and february 1970 wagenaar believes zionism violates the basic tenets of jewish faith judaism as a faith forbids to set up a jewish state as a political entity until apocryphal times the return to jewish statehood always has been godcentred never a political design that humans had to carry out god is just but zionism and the state of israel were founded on and continue to promote myths political and military means that violate old testament principles of justice being jewish is not based on a blood band but on faith a mindset of living holy the jewish people were chosen to be a nation of holiness bringing the nations to the faith in one god with wagenaar there is no convergence between christian orthodoxy and jewish orthodoxy he criticises the apostle paul for diverting from judaism since he placed the focus on faith instead of living according to gods requirements wagenaar would have most likely agreed with most of kuiterts views in his book about jesus but not his later views on religion in general wagenaar criticises western political double standards and sees the jewish state as a christian creation since christian nations wanted the jewish state and provided substantial support the muslim world did not drive out jews but the christian world did wagenaars criticism also concerns lies of israeli politicians such as the claim that israel is the only hope for jews in need zionists lured arab jews to israel because israel needed them wagenaar does not call for the dismantling of the state of israel but his views show a deep resentment of linking faith with politics where wagenaar displays knowledge of jewish and palestinian history billy graham does not in his 1970 film his land calvin college scholar bert devries found his film full of unproven assumptions such as that the founding of the state of israel was literally foretold by the biblical prophets and that the creation of israel is an important step in gods timetable a step that brings us closer to the return of christ claims do not have to be accurate to have impact and impact it had on evangelical christians in the usa who believed that rallying to the support of israel would bring the second arrival of jesus christ closer the 1967 war showed graham god was on israels side the identification of prophecy with modern israel and the silence about israels history between ancient and modern israel resulted in devries views in a dangerously slanted portrayal of israel that justified conquering land and that arab claims on palestine are not worth mentioning the american jewish committee saw the film would be able to rally support for israel and helped make grahams film an international success billy graham became the leading evangelical supporter of israel through the mid1970s in later years graham was taken over by a host of other evangelists and pastors who advocated evangelical christian zionism 46 supporting israel became responding to gods will a view that greatly impacted churches in the netherlands it is at this point needed to present jewish and christian messianism in a historical context and see how this intersected in the late 19th century with the secular political zionism of theodor herzl that led to the establishment of the state of israel and influenced modernday jewish orthodoxy robert eisenman describes the events leading up to the messianic movement that followed jesus of nazareth who was preaching the kingdom of god jesus crucifixion by the romans was a shock to his followers and was interpreted in the context of messianic beliefs the destruction of jerusalem and the second jewish temple in 70 ce and grecoroman philosophies in the first centuries ce which deeply influenced the formation of the christian church that further departed from judaism which will be described under the section of egypt both eisenman and kuitert describe the departure from judaism to an extent that made wagenaar state that islam is closer to judaism than christianity messianic movements presenting followers with hope for a utopian world have come up throughout history but none was as impactful as the one around shabbetai z evi who lived in the ottoman empire in a period of jewish humiliation and persecution in a society that was deeply religious old eschatological visions were mixed with new elements z evis messianism even had an impact on jews and christian millenarian circles in the netherlands england and germany many jews sold houses and property to journey to the holy land when the ottoman sultan authorised his arrest and z evi converted under pressure to islam z evi was presented as a tragic but still legitimate redeemer hundreds of jews followed him in converting to islam but most did not after this death it was speculated that he had been the suffering messiah rather than the final redeemer it took years for jewish orthodoxy to regain control shabbateanism only finally disintegrated in the early 19th century both eisenman and scholem demonstrate that religious developments always need to be studied in the context of time and location which made kuitert question the orthodox belief in gods hand in history with the enlightenment absolute trust in religion greatly reduced secular ideologies including nationalism arose in the west the souvereign nationstate became the objective to strife for nationalism has often been interwoven with religious predicates the nation as a holy entity service and even death for the nation have been elevated to the level of sacrifice and martyrdom impacting zionism in the same period european powers conquered land from a greatly weakened ottoman empire and encouraged ethnic and religious groups to break away from their empire and form their own nation states starting with european guarantees for greek independence in 1830 woodrow wilson the american president from 1913 to 1921 argued that the principle of selfdetermination should be rigidly applied with every nation having the right to establish its own state the reduced trust in traditional religion led to religious liberalism that resulted in various forms of orthodox resistance including the orthodox reformed and evangelical restorationism which is the belief christians should try to emulate the life of the apostolic early church since this would be a purer and more ancient form of the christianity restorationists were calling for and willing to sponsor the emigration of jews to palestine as a precondition for the second coming of jesus christ while simultaneously seeking to convert them to christianity gershon shafir writes the political elite in europe came to see religion as a tool to increase their influence in the ottoman empire russians became the patrons of the orthodox and the french of the catholics but since the protestant numbers were small and the british wanted to gain a foothold in palestine the narrative of a jewish return to palestine was encouraged to justify their ambitions long before vague jewish messianic aspirations became a concrete zionist project and long before jewish voices proclaimed jews to be a nation rather than a religious group cohen describes the zionist labour movement from its earliest days that initially saw itself building a revolutionary class as the agent of national liberation for the jewish people early zionists in line with the nationalist beliefs in their days came to see the hebrew language as a critical element of cultural authenticity linking modern zionists to the jews in antiquity the first zionist congress in basel linked the call for a jewish national home in palestine to israel in antiquity encouraging jews to settle here under the influence of eastern european jewish orthodoxy religious convictions gradually became more important forming religious zionism during the first world war the british government tried to obtain support from both arabs and jews resulting in an exchange of letters in 19151916 promising arab independence in return for an arab revolt against the ottomans and in the balfour declaration a national home for the jewish people in palestine using the religious narrative of the jewish return to palestine to safeguard british imperial interests in the middle east after the pending demise of the ottoman empire the promotion of the religious narrative ignores anything that does not fit that narrative such as debates about possible largescale conversions to judaism in 8th10th century khazaria north of the caucasus first suggested by german orientalist karl neumann and later further researched since that undermines the claim of a direct line between the inhabitants of ancient israel and jews with roots in russia following the ottoman defeat palestine became a british mandate and the narrative of jews returning to their homeland was promoted with success emigration increased land acquisitions mostly from large absent landowners led to clashes with local palestinians that in turn resulted in discussions about and proposals for partition david bengurion at the time the executive head of the world zionist organisation and chairman of the jewish agency in mandate palestine proclaimed israeli independence on 14 may 1948 in accordance with the 1947 united nations partition plan the arab league was opposed to the un plan and the establishment of israel several arab countries invaded israel one day after the declaration of independence which was immediately de facto recognised by the usa other countries followed israeli independence was followed by a massive exodus of palestinians the war ended in an armistice with a border beyond the lines drawn in the un partition plan orthodox chief rabbi isaac herzog boycotted the declaration of independence he wanted a jewish state with jewish religious laws and had worked for years on a constitution for the new state based on biblical laws and believing in israel as a theocracy the secular leadership at the time however did not want israel to be controlled by religious laws between 1948 and 1967 successive labour governments focused on strengthening israel not fearing military confrontations with their arab neighbours and in 1956 joined great britain and france in an attack on egypt following egypts nationalisation of the suez canal benefiting israeli military developments in the same period israel made all efforts to stimulate jewish emigration to israel knowing well that this would strengthen their hold on the land a major turning point was the sixday war in 1967 israel marched into jordanianheld east jerusalem and allowed soldiers and the orthodox to pray at the surviving western wall of the second jewish temple the westbank gaza sinai and the golan heights were taken the rapid occupation of areas that once were part of ancient israel strengthened a messianic stream in judaism and christianity and created openings for political islamism in the arab world the war deeply intensified the israelipalestinian conflict this is sigal samuel writes not a story of how religion drives conflict but how conflict impacts religion the war reverberated in the netherlands resulting in massive support for israel in particular in orthodox reformed churches leading to discussions about gods promises for israel and what this meant for the church in the netherlands the war also resulted in 1969 in the establishment of the nederlands palestina komite which saw the israeli conquest of arab lands as a colonial occupation in 1973 egypt and syria tried to regain lost land in the october war their initial success resulted in an israeli nuclear alert which made president nixon order on the same day an american airlift to replace all of israels material losses only this support enabled israel to push back egyptian and syrian armies oilproducing arab nations responded with an oil boycott of proisrael countries including the usa and the netherlands in november 1977 during the tenure of menachem begin as the head of the government egyptian president anwar alsadat unexpectedly visited jerusalem resulting in peace negotiations and peace with egypt in september 1978 begin prior to the foundation of israel the leader of the zionist militant group irgun was the first likud politician who became prime minister his ascension to power indicated the growing strength of jewish nationalism and orthodoxy which greatly impacted the nonjewish inhabitants of israel in 1994 british author william dalrymple travelled around the arab world and israel documenting a diminishing christianity during the war of independence around 55000 christian and 650000 muslim palestinians fled or were driven from their homes in 1922 around 52 of the population of jerusalem was christian reduced to under 25 in 1994 armenian bishop hagop said his community had not received one single building permit since 1967 israelis changed the old city into a jewish city christian ruins including the ruins of the biggest monasteries ever discovered in the middle east have been looted and covered under soil but the ruins of the tomb of a 15th century rabbi and ancient synagogues were preserved dalrymple notes that probably on no other site on earth the distant past is so politicised as in israel referring to a statement of israeli archaeologist shulamit giva who accused israeli biblical archaeology of being a tool in the hands of the zionist movement attempting to find a connection between ancient israel and modern israel dalrymple refers to the early ottoman period in jerusalem when interreligious interaction was abundant and unimaginable today dalrymples sad account was made before religious nationalists further strengthened efforts to judaize east jerusalem and palestinian areas israeli egyptian jordanian american and european leaders knew the 1996 elections between israeli prime minister shimon peres and his opponent benyamin netanyahu would be crucial for the region peres received international support during an international summit in sharm elsheikh egypt on 13 march 1996 yet netanyahu was elected with a very narrow margin until today israeli politics has been dominated by netanyahu who in december 2022 formed israels most religious nationalistic government since israel was founded israel defines itself as democratic and jewish palestinian mp ahmad tibi prefers to formulate this differently democratic for israeli jews and jewish for israeli palestinians the influence of the secular labour party greatly declined ultra orthodoxy has grown tremendously largely because orthodox women give birth to an average of close to seven children three times as many as with secular jews in 2023 the ultraorthodox make up close to 14 percent of the population and are expected to grow in the coming decades to 30 to 40 percent they live in their own bubble in their own quarters with their own schools where religious education dominates their outlook the ultraorthodox that are critical of israel and zionism still exist but have lost much of their influence the younger generation of orthodox accepted the idea of a greater biblical israel jewish colonists in palestinian territories that were occupied in 1967 many of whom are orthodox are today represented in the israeli government they see the palestinian population in these areas as an error and want to divert greater sums of money to further colonisation israeli historian yuval harari warns that israel is a regional military power with nuclear arms ruled by a government consisting of extremists that openly disseminate racist views and expansionist objectives that can set the entire region ablaze egypt christian and muslim orthodoxy in both the netherlands and israel we see the orthodoxy attempting to steer politics in line with their belief system while protecting their belief systems through providing education within their own social bubbles depillarisation has crushed many of the institutions that aimed at protecting orthodoxy in the netherlands the orthodox bubble in israel on the contrary is growing developments in egypt differ markedly from the netherlands and israel since egypt is both profoundly religious and impacted by both christianity and islam in their search to find and preserve religious truth the coptic orthodox church has been the main christian denomination throughout egypts history the small protestant and catholic churches attribute their roots mostly to western influences since the 19th century religion was hijacked in the 20th century for political purposes either through the islamist slogan islam is the solution or islamophobe claims in the west that present slanted descriptions of nonmuslims in islamic societies as evidence of islams intolerance the section will provide examples of modern islamophobic writers who frequently refer to a religious past in egypt that their audience in the west is mostly uninformed about with western scholars warning of their simplified narratives that serve political objectives following this overview the main events that shaped the coptic orthodox belief system that was completed before islam entered egypt in the 7th century will be described in the 19th and 20th centuries egypt became deeply influenced by the west both the coptic orthodox church and islam experienced religious revival strengthening conservative religious sentiments in society egypt has been ruled by autocratic regimes since 1952 that until the revolution of 25 january 2011 have used machiavellian methods to use or oppose religious sentiments when it suited them after 2013 when islamists were removed from power successive governments tried to reduce the influence of politically motivated revivalist islam as much as possible various modern authors such as bat yeor attributed the decline of christianity throughout the ages to an almost continuous persecution of islam through a system of culture and religious laws contemporary political activists copts and noncopts living in the west present a very dark picture of christian life in egypt paul marshall writes about egypts endangered christians magdy khalil about the ordeal of arab christians and other authors attribute blame to radical political islam several conservative private think tanks such as the gatestone institute claim muslims persecute christians their objective is to report on various subjects including threats to the united states events in the middle east and their possible consequences for the usa 10 philip jenkins deplores many people have an insufficient eye for how religious change happens and do not see that globalisation encounters with other faiths and the dilemma of living under hostile regimes were also issues christians in the past have grappled with some muslim regimes have been inconceivably brutal others mild and accommodating that diversity suggests jenkins notes that persecution and violence are not inherent in the faith of islam but are related to circumstances in particular times and places one needs to ask why some native churches disappeared and others like the church in egypt survived looking only at islam is insufficient to some extent also decisions taken by churches themselves determined whether they died or lived the coptic orthodox church in egypt better adapted to the changes than churches in north africa jenkins attributes this to its network of monasteries and villages churches in addition egypt was spared many of the conflicts that were fought between different rulers and dynasties while government control was weak in upper egypt which left christians largely to their own internal rule rachel scott notes that modern relations between copts and muslims are linked to global conflicts and tensions she warns against the tendency in the west to see islam or islamists as a monolithic bloc assuming the divinely revealed law cannot be changed and hence that islamic tradition is fixed such beliefs hamper discussions islamists as all religious people do engage with the foundational texts of their religion muslims do this with the quran hadith h adīth and islamic jurisprudence that are used to legitimise and understand current realities these responses come also within the same islamist movement with considerable diversity the invention of tradition is an ongoing process and is affected when rapid transformation undermines social patterns scotts thesis illustrates the complex ways in which islamic tradition is modified reinterpreted and changed in response to the circumstances of the moment their organisations are made up of members with different views and agendas policy statements can reflect which group has gained the upper hand jenkins and scotts observations contrast starkly with authors like bat yeor marshall khalil and ibrahim and coptic solidarity which show views on muslimchristian relations that are never far away from political convictions rev dr andrea zaki stephanous notes that religion and politics are intricately intertwined in the arab world contrasting greatly with countries such as the netherlands and israel that have been deeply influenced by the enlightenment in separating religion and state and viewing the role of religion in society although the orthodox in israel are making efforts to increase the influence of religion these contrasts make egypt a great example for a study about the complexities in muslimchristian relations throughout the ages that are relevant for our understanding of interreligious dialogue today the first three centuries of christianity are known in the egyptian church as the era of persecution unlike the popular view today these persecutions were more periodical outbursts of persecution that gave the coptic orthodox church many of its martyrs roman persecution ended with the emperor constantine who used christians to tip the balance of power in his favour during a civil war against other contenders of the throne constantine found a highly divided christianity two major groups were the arians stressing gods unity at the expense of the notion of the trinity and the orthodox who stressed the notions of the deity of christ and the trinity statements eusebius of caesarea attributed in his biography about the emperor to constantine like seeing a distinction between the father and the son indicate sympathies with some arian beliefs eusebius was an orthodox bishop and for a while advisor of the emperor who called for the council of nicaea since it was in constantines political interest to see the uniting of christians who saw god as the ruler of the cosmos and earth and the emperor as his representative on earth which gave him powers no roman emperor in the third century hadremarkably the representative of god who was not interested in spreading the gospel beyond the borders of his empire arianism was defeated at the council of nicaea but never fully disappeared the decisions made at this council influenced to a large extent how the church developed in later centuries interestingly islam presents a view of jesus that was and is much closer to arianism than trinitarian christology the political interest in supporting the missionary dimensions of christianity and later islam only developed in later centuries the arab conquest of egypt 639642 ce was a watershed moment for egypt they called the mostly christian inhabitants qibt a name derived from the greek aegyptus which became our word copt mariz tadros calls the usage of the name copt of significant sociopolitical importance which was underlined by an egyptian ambassador in the netherlands who at the opening of an exhibition of icons stated that he was proud to be a muslim copt signifying that both muslims and christians in egypt are egyptian the arabs brought islam to egypt egypts christians had no idea of what religion this was but they rapidly noticed that the major differences between their orthodox christian faith and this new religion was in how they viewed jesus a prophet with a special status very different from their notions of the deity of christ and the trinity as has been reflected in early debates between egypts christians and muslims islam can be seen as a further development of arianism growing further away from christianity with early muslim rulers stressing their differences from the orthodox faith that was held in the byzantine empire the continuity and differences between these three religions as well as the claim all three make on the divine inspiration of their canon make it interesting to study the origin and further historical developments of islam the focus of western and some muslim scholars of religion on the historical critical method of research however is not appreciated by many muslim scholars eildert mulder presented the draft of his book review of a book of emilio platti de koran herontdekt to azhar scholar h assan muh ammad wajīh who does not believe all outcomes of the historical method and referred to muhammad abulaylahs book alqur ān alkarīm min almanz ūr alistishrāqī dirāsa naqdiya wa tah līliya aliflāmmīm zalik alkitābu lā rayba fīhi hudān lilmuttaqīn the critique of orthodox muslim scholars on rationalist approaches to the study of divine scriptures appears to be similar to those of orthodox christians and jews regardless of their denomination the focus on a rationalist approach of religion was uncommon during most of egypts history since the arrival of islam egypt despite periods of interreligious tensions also never saw muslimchristian relations degenerate into a sectarian civil war makaris book is a testimony of the lessons of history that can help to address tensions copts experienced a period of religious revival during the fatimid period until caliph alhakim made an end of this with an intensity and brutality that was one of the worst in egyptian history and saw a large drop in the number of copts as many converted to islam christianity was long a force to be reckoned with in the muslim world until as late as the eleventh century asia was the home of at least onethird of the worlds christians with africa perhaps home to 10 percent during the twelfth and thirteenth centuries christians in the middle east experienced a widespread cultural renaissance history is showing ups and downs for local christians but throughout history the number of christians also declined philippe fargues andyoussef courbage provide in christians and jews under islam an insight into the demographic changes that took place in previous centuries interestingly the percentage of christians slightly grew during the 19th century but declined after the first world war mostly due to instability and regional conflicts the percentage of christians has been stirring intense political debate since copts have been disputing the credibility of the data presented by egypts central agency for public mobilization and statistics the last nationwide census dates to 1986 and indicated that copts made up 56 percent of the population expatriate activists claimed the copts constituted between 15 and 25 percent of the egyptian population elsässer notes the desire to build a case that would shock into action a western audience seemed to tend toward exaggeration simplification and selective perception while serious research uniformly concluded that the capmas figure must be fairly accurate the huge differences in presenting coptic population figures did not exist at the coptic congress in 1911 coptic representatives then demanded more significant representation based on taxes paid muslims organised a counter congress and argued that the copts sought power disproportionate to their numerical size in the nation which they nevertheless obtained from egyptian nationalist leader saad zaghloul to foster unity between muslims and christians to push the british colonialists out of the country copts remained prominent in egyptian politics until the 1952 coup détat of gamal abdel nasser from this moment their political influence greatly declined while voices of discrimination accompanied by substantially higher population claims increased since pope shenouda was elected in 1971 coptic counternarratives to the dominant national unity discourse gained prominence pope shenouda was more assertive than his predecessors and did not hesitate to challenge the president publicly about issues he felt the government had responded inadequately to issues concerning coptic christians pope shenoudas assertiveness coincided in the 1970s with the establishment of the american coptic association their campaigns for coptic rights with increasing the alleged coptic proportion to 20 never providing any evidence 11 alkiraza the official coptic orthodox church magazine edited by pope shenouda adopted a similar claim in 1977 in 2002 metropolitan bishoi bīsh ūy the influential secretary of the holy synod stated president mubarak spoke some time ago about 10 percent of the population so lets keep that number as a guideline in 2008 pope shenouda publicly claimed copts made up 15 percent of the population it is plausible to attribute the differences between capmas counting and church estimates to the the inconsistency of position a term coined by egyptian sociologist and human rights activist saad eddin ibrahim which links claims of higher coptic population percentages with claims about inequality from the moment their political influence declined which did not match their economic influence ibrahim noted that copts earn on average 30 more than muslims discrepancies lead to tensions islamists believe copts exaggerate their number in a bid for disproportionate power while copts in turn believe muslims deflate their numbers to undermine their presence and weight in the country the capmas stopped recording religion in the censuses since these debates gave them a headache in 2012 extensive research was carried out to investigate christian claims resulting in an estimate between 5 and 6 percent french demographer philippe fargues contributed to this report and disagrees with researchers who call capmas figures estimates their figures may have a margin of error he said but it is still based on counting the estimates christians provided are mostly politically motivated guesses tadros argues the government has data and blames the government for lack of transparency in releasing credible data the failure to release available data adds fuel to the fire of rumour and suspicion a lebanese christian scholar opined in 2015 at a conference at vienna university that one should not dispute christian population estimates since all arabs exaggerate inflated population claims and claims of persecution or discrimination often go hand in hand indicating political objectives as scott earlier noticed which need more digging into muslimchristian relations in egypts contemporary history just as in the netherlands egypts orthodox christians resisted religious liberalism since this came up in the 19th century and called for revivals in line with the bible and at times tradition so also muslims did the difference however is that european orthodox christian responses addressed european liberalism nineteenthcentury coptic orthodox and muslim responses had to address western liberalism that colonial powers had brought to their countries with efforts to undermine the ottoman empire as is obvious in the writings of sayyid jamāl aldīn alafghānī who referred to muslim religious scriptures in seeking answers to western encroachments on the muslim world the collapse of the ottoman empire in the first world war was followed by western dominance over protectorates that were predominantly muslim islamic thinkers responded to these political changes not rejecting modernity but calling for liberty social justice equality and solidarity with the fall of communism the focus point of world politics became islam which led to various responses some of them militant in 1952 colonel gamal abdel nasser jamāl abd alnās ir removed the deeply unpopular king with his cabinet that depended to a large extent on the political power of both muslim and coptic landlords the land reform that followed destroyed the basis of the 2000 wealthiest landlords who could otherwise have challenged the regime nassers principal opponents during his reign were the muslim brothers making them the prime targets of political arrests and subjecting them to political sadism during 1961 and1966 he initiated a socialist transformation the muslim brotherhood radicalised in this period as exemplified in the writings of their ideologue sayyid qut b who developed a strong manichean approach in creating a sharp distinction between good and evil unbelief also of muslims and belief a true muslim qut b argued is committed to the establishment of an islamic order and state nasser who saw his writings as an attack on the regime had him arrested and executed his works however live on in islamist circles and became the basis of even more radical thoughts after nassers death in 1970 president anwar alsadat gradually released islamists from prison and used them to dismantle the secularleftist powerbase of his predecessor in an effort to impose a new economic policy resulting nadia ramsis farah explained in a transition crisis in november 1971 pope shenouda had become the head of the coptic orthodox church his predecessors avoided confrontations with the state but pope shenouda a theologically conservative leader with a history in the revivalist coptic sunday school movement was more assertive and thought to voice the copts political demands muslimchristian clashes started in 1972 with the burning of a small building in khanka north of cairo that the pope had turned into a church without having a license such clashes had not been seen during pope shenoudas and sadats predecessors president sadat requested dr jamal alutayfi the deputy speaker of parliament and confidant to the president to form a factfinding committee to investigate what happened alutayfis committee detected an oversensitivity of muslim and christian religious leaders regarding publications about religious subjects and highlighted three key issues that repeatedly led to sectarian tensions the licensing of church buildings missionary activities and censorship of the publication of religious books alutayfis report and recommendations were excellent and repeatedly referred to in egyptian media as the very points that needed to be addressed but most recommendations were not implemented human rights activist saad eddin ibrahim wrote 36 years later if they had been implemented many sectarian incidents in the following years could have been avoided coptic writers at the time frantically argued for a secular order in which a plural society could developan allegiance to the nation not to a religion their voices drowned in the increasing polarising voices islamic groups strengthened their influence on university campuses and in january 1977 clashed with coptic christians in upper egypt they were trying to pressure the government into accepting the literal application of islamic law which was strongly opposed by pope shenouda clashes escalated in the following years in may 1980 the government proposed a constitutional amendment to make the sharia the source of legislation farah describes this amendment as the worst blow in muslimchristian relations during his reign sadat thought to silence pope shenouda by accusing him publicly of initiating and intensifying religious strife which did intensify more strife culminating in june 1981 in the arrest of around 1500 people including islamists political activists and intellectuals of all colours as well as 120 christians including 8 bishops and 24 priests pope shenouda was put under house arrest in the monastery of bīsh ūy not long after sadat and bishop samuel then head of the committee of bishops that had temporarily replaced pope shenouda were killed by muslim militants during a military parade on 6 october 1981 the tensions had interrupted the dominant pattern of the christian communitys survival that through the ages had been based on fostering relationships with muslim rulers sadats successor hosni mubarak gradually released leaders imprisoned by sadat in january 1984 pope shenoudas monastic arrest was lifted allowing him to preside over the coptic orthodox christmas celebration on january 6 the policies of nasser and sadat had contributed to the increase in islamic political violence but also factors outside egypt played a major role western dominance of which israel is seen as an extension and western military adventures in the muslim world are widely resisted and contribute to growing extremism an excellent example is usama binladens interest in jihad that was triggered by the soviet invasion of afghanistan in 1979 his movement could develop thanks to the support of the usa saudi arabia egypt and pakistan for his fight against the russians in 19861989 not only western politics but also islamic theology and ideology are important factors in the process of radicalisation binladens alqaida attracted many egyptians using the intellectual framework known as salafism pietistic in focus but sharing much of the rejectionist worldview of the jihadis with a widespread antipathy toward communication and contact with nonsalafis and nonmuslims alqaida and other radical movements borrowed ideas from earlier islamic movements capitalising on social economic and political constraints in the muslim world seeing their ideology and activities as a defence of islam in doing so they used selected religious narratives from the past and gave these new but perverted interpretations many of the audiences they reach out to khatab concludes are unable to distinguish between truth and ideological propaganda khatab believes jihadism can be eradicated at its roots through defining the nature of the conflict and providing support to the mainstream islamic community in struggling against it we should distinguish here between salafism and the muslim brotherhood where salafism is pietistic and tends to be nonpolitical when they are politically weak this enabled them to grow in local village mosques all over the country the muslim brotherhood is political activist and more pragmatic without tampering with their basic ideology the government and church established in the 1980s some cautious contacts with the muslim brotherhood some of the younger and more impatient members joined the militant aljamā a alislāmīyyah and jihadist movements and in the 1980s and 1990s attacked police christians and sometimes tourists with the purpose of harming egypts tourism industryall in hopes of pressuring the egyptian government to apply the sharia more strictly after the november 1997 terrorism attack in luxor killing 58 tourists the egyptian government cracked down on islamic militancy the government was unable to address widespread poverty and left social care largely in the hands of muslim and christian religious organisations including the muslim brotherhood which improved their public image the egyptian government was walking a tightrope expanding jewish settlements in occupied palestinian areas the palestinian intifādah with harsh israeli responses and the usaled invasion of iraq had strengthened islamist and antiwestern sentiments sectarian tensions came back coptic researcher peter e makari describing the mubarak period is convinced that we should not interpret these as a clash between the west and the east or between christianity and islam but rather between what he calls more conservative and extreme elements in all religions that adopt exclusivist claims and intolerant attitudes toward the other and other adherents of religions who seek reconciliation peace and justice for all the terminology used by makari reflects a possible liberal bias in linking conservatism with extreme elements and intolerant attitudes as opposed to the liberal approach of openness to all emigration substantially increased with the muslimchristian clashes in the 1970s and has continued ever since christian emigration is related to economic factors escaping sectarian violence fear for a country that is dominated by an islamist philosophy and a more secured life in the west just before the egyptian revolution of 2011 coptic businessman mounir ghabbour munīr ghabb ūr published with ahmed osman a book expressing fear for a disappearance of christians from the middle east linking this to islamism not long after publication various arab countries were plagued with revolutions and civil war in which islamists played a dominant role that indeed spurred christian emigration ghabbour and osmans book confirms the thesis of makari that clashes were not between christians and muslims but related to efforts of islamists to turn egypt and other countries into states with a greater role for islam in the public domain andrea zaki stephanous view of political islam is in line with ghabbour and osman he however adds the perils of israel for egypts christians since also israel blurred the lines between religion and politics providing justifications for militant islamists to create an islamic state with similar blurred lines the foundation of the state of israel claiming justification of land appropriations on old testament prophecies and the doctrine of land and covenant of god with his people resulted in many egyptians seeing the book as legitimising war crimes and murder for the sake of his chosen people with theological disputes within egypts churches tadros describes the increase of sectarian violence against christians bahais and muslim sufis between 2008 and 2011 that alongside huge discrepancies between the rich and poor fraudulent elections and police brutalities to suppress opposition became some of the catalysts for the january 25 revolution in 2011 the weeks following the uprising showed the highest degree of national unity between muslims and christians since the egyptian revolution against british occupation in 1919 christians hoped that the country could change to an inclusive democracy distinct from a majoritarian rule tadros writes the revolution or uprising led to the removal of president hosni mubarak and a political settlement between the army and the muslim brotherhood the strongest political entity at the time to facilitate a fairly smooth accession to political power while the army would receive impunity from accountability during the sadat years islamists pushed article ii of the constitution stating that the sharia is the main source of legislation that was insufficient for them in later years they argued for a stricter application of the sharia this makes the july 2011 poll of fāt ima alzanātī and muh ammad alghazālī into what egyptian respondents found of maintaining amending or annulling article ii of the constitution of great interest only onethird of the respondents had heard of article ii unawareness of a key article that had been the focus of many public discussions since the 1970s of muslims who knew of this article the overwhelming majority wanted to keep this while the overwhelming proportion of christians would rather let go of this article the next indicator was the parliamentary elections in 20112012 registering a higher voter turnout than any of the previous elections since nassers coup détat in 1952 parties that were outspoken islamist obtained 653 of the votes the third indicator is the first round of the 2012 presidential elections during which islamists candidates obtained 4326 of the vote during the second round an army officer ran against muslim brotherhood candidate muhammad morsi m ūrsī who won although disputed the elections primarily because many egyptians did not want a president with a military background the data show a large percentage of floating voters with a rapidly declining support for islamists during the first months cooperation between islamists and nonislamists appeared to be possible resulting for example in october in a multiparty delegation with islamists and their fiercest ideological opponents to the netherlands coptic orthodox pope tawadros ii took office on 18 november 2012 major sectarian clashes had not yet taken place these developments made tadros publish copts at the crossroads the challenges of building inclusive democracy in egypt with a preface dated january 15 expressing hope for a new era this was not a blind hope tadros noted for example that many copts did not trust a brotherhood rule resulting in emigration although the numbers are disputed tensions built up with debates on a new constitution islamists pushed through a new constitution with a strong islamist character nonislamists opposed which led george masīh a member of the constitutional assembly explained to rapidly escalating tensions between islamists and nonislamists ultimately resulting in massive demonstrations and the removal of president morsi it is obvious that the alsīsī government wants to push back islamism in july 2015 the president gave a landmark speech about the need to renew the religious discourse and linked this to counterterrorism reducing islamism also comes with reducing poverty in the past providing islamists with a fertile soil but this turned out to be far more difficult than changing the religious discourse the percentage of egyptians living under the poverty line increased from 278 in 2015to 325 in 2018 in february 2021 president alsīsī sparked a storm among conservative muslims when he instructed verses from the quran and sayings from the hadith be struck from textbooks changes become visible in religious education at egyptian schools emphasising religions common denominators and tolerance the struggle for the religious soul of egyptians is over a century old and will not rapidly disappear in conclusion religious developments cannot be discussed in isolation from political and social circumstances the impact of organised religion as the main provider of collective morality greatly reduced in the netherlands despite orthodox efforts to hold their ground israel started as a predominantly secular country and became more orthodox which also gained increasing political power that includes hardcore radicals islamism in egypt grew in number and radicalism since the nasser years which is to a large extent related to poverty education suppression and frustrations about efforts of western powers to change the islamic world according to their agenda there are no indications that the direction of religious adherence in each of these three countries will change any time soon which makes interreligious dialogue of paramount importance to reduce division and religious motivated violence expanding my bubble through travel and friendships in this section my personal narrative begins i travelled to places and met with leading religious academic and political leaders of all denominational backgrounds that my parents could only vaguely have imagined from news or movies on tv this was a major part of my formation i was raised in a christian reformed family during a period in which the old reformed pillar crumbled and many orthodox reformed including my parents sought salvation in a new orthodox reformed pillar my family belonged to church of rev jh velema i attended his catechism classes where traditional reformed faith was reinforced we believed that what we were taught was the norm and that all other beliefs were deviations from the truth this did not mean that other people were bad but they lacked knowledge of the truth and that necessitated evangelism and missionary work to bring them to the truth israels victory in the june 1967 war created in our reformed bubble a euphoria that was seen as the hand of god restoring israel which was a sign that the arrival of the messiah was nearby the newly founded eo played a major role in this euphoria presenting ancient and modern israel as the people of god my parents were among their first members and promoted membership to anyone in their reformed christian circle my father corresponded with and supported former catholic priest rev hj hegger who represented all the values that were important to my father an anticatholic conservative reformed pastor who became one of the leading founders of eo and a leading opponent to liberalism my father liked heggers critique on kuitert without having read any of his books i started a newspaper collection about dutch media reporting about israel which i maintained until after the october war in 1973 the collection shows an arabisraeli conflict with a decisively proisrael bias characteristic of dutch media reporting at the time the october war made me believe israel needed support that belief brought me in 1974 to israel where i further dug into faith issues meeting jews and palestinians my discovery of christian palestinians led to traveling around the arab world and discovering ancient churches that struggle with the phenomenon of emigration culminating in settling with my family in egypt in 1994 focusing on muslimchristian relations i will describe how i continuously tried to make sense of conflicting opinions and beliefs through actively looking for people who were explicit exponents of such conflicting beliefs and befriending them bit by bit my initial beliefs shattered my bubble expanded meeting a great variety of different believers christians jews and muslims both orthodox and liberal with people living their faith in sincerity and others using religion to justify certain behaviour to achieve certain interests my initial convictions turned out to be naïve i no longer see good and evil as spiritual powers outside us but the consequence of choices we make that may positively or negatively affect others friendships resulted in asking more questions and more study and confronting friends with newly developed views which brought me to the limits of what one can believe in good faith and what not my initial focus on israel changed many members from my church had been called to missionary work others had been called to serve christian media or otherwise serve the kingdom of god and i felt the call to work for peacebuilding in december 1974 i became the leading founder of the werkgroep middenoosten which became a vehicle to meet interesting people on topics of interest such as prof oosterhoff the choice of the name showed a wider interest than israel alone in 1975 i travelled overland to israel with the intention to meet as many middle eastern christians as possible in istanbul antakya syria and jordan a new fascinating ancient world had opened to me in israel i met with orthodox jewish rabbi cj auwendijk in metula on the border with lebanon he was armed with a riffle to protect himself and the area from marauding palestinians but also spoke about peace and gods promise of land to the jews zionism was gods hand in history and palestinians he believed would have to accept that i also met with palestinianarabchristianisraeli greek catholic priest elias chacour shaq ūr who also spoke about peace yet addressing numerous injustices against palestinians both in the past and contemporarily it seemed that gods hand in history was used to justify a turn in history that was favourable to one particular group willem van t spijker professor of church history at the christian reformed theological university saw my interest in israel and arab christianity and advised me in 1976 to contact retired dutch diplomat daniel van der meulen since he was a committed reformed christian had a great interest in arab christianity and believed in muslimchristian dialogue van der meulen had served between 1915 and 1948 in the netherlands indies and saudi arabia and had an impressive network of leaders in the arab world van der meulen became the advisor of the middle east study group and encouraged me to travel more and meet more people i discussed the various study options with daniel van der meulen and given my interest in the position of christians in the muslim world i chose development sociology at leiden university traveling and meeting people captivated me in september 1976 i travelled over land to athens and took the boat to alexandria i had no idea that my time on the ferry would open opportunities to meet with other youth coptic evangelical youth adel soliman safangy invited me to stay with his family in alexandria young muslim medhat ismail midh at ismā īl invited me to stay with his family in cairo both families became friends adel later emigrated to canada as so many educated young copts have done my first time in a muslim family happened to be during ramadan it was a humanising experience enjoying joys and sorrows together the muslim was no longer an abstract entity but had obtained a human face in cairo i found a spiritual home in the anglican church met with christian missionaries some focused on reaching out to the african refugee community while others believed they had to reach out to muslims i understood their motives although that was not the path i saw for my life egyptians i met were yearning for peace not out of love for israel but with a widespread awareness that more wars would be disastrous for the country i appreciated this sentiment that strengthened my desire to play a role in peacebuilding van der meulen introduced me to egyptian sociologist dr elsayid yassin alsayyid yāsīn who between 1975 and 1995 was head of the influential alahram institute of strategic studies alahram newspaper in 2017 described him as one of the most prominent and influential writers on egyptian politics in the years prior to the 2011 revolution that visit was eye opening yassin instructed a researcher at his centre to give me a first introduction to egyptian society and politics van der meulen also introduced me to dr piet dirksen a dutch scholar at the time teaching old testament at the evangelical theological seminary in cairo who gave me an introduction to egyptian christianity in 19761977 i spent a year in israel first in nes ammim israel established in 1963 to foster ties between christians and jews and later kibbutz ramat hashovet established on socialist grounds i used my time in israel to meet with many different people advocating dialogue and used information and connections to advocate peace building and dialogue through the werkgroep middenoosten at leiden university i pursued any subject i could find in the line of my interest including islam comparative religion and middle eastern studies seeking dialogue and christian commitment went hand in hand i was active in church and the christian student group ichthus and followed lectures in reformational philosophy with prof dr sander griffioen addressing questions about the relation between science and faith my work for the middle east study group continued during my entire studies my professors encouraged this engagement and i was offered space at our faculty to host speakers and debates in november 1977 months after i started my study president anwar alsadat alsādāt made his historic visit to jerusalem i was elated and visited the egyptian embassy where deputy ambassador muh ammad alghat rīfī was open to meetings and questions and provided me with information about the peace process that sadats visit had initiated the camp david accords followed in 1978 and the israeliegyptian peace was signed in 1979 during my student days i became a member of the antirevolutionaire jongerenstudieclubs the political youth movement of the reformed arp believing in political idealism rooted in christian convictions i rapidly became a member of the foreign affairs committee in which i was for years the middle east expert i came to know several members of parliament and saw the process of political negotiations about the merger between three confessional parties arp the chu and the kvp into the centrist christian democratic appeal and believed after initial hesitations this should make it possible for people leaning to the left and right to cooperate i was taught that the realisation of the current state of israel was prophesied in the old testament or torah this belief was reinforced by the eo and numerous christian proisrael advocates and groups in the summer of 1981 i went to israel with the purpose of speaking with jews and christians about these biblical promises and learned about different interpretations of the scriptures that mixed with political interests i visited egypt every single year after my first visit mingled with egyptian youth both muslim and christian mostly stayed with egyptian families and found the country its history and its people fascinating in 1981 i found a divided nation with islamists clashing with christians who expressed deep mistrust of their intentions and met with coptic orthodox bishop samuel who asked me how these muslimchristian tensions were reported in the west i was impressed by the bishops sincere wishes to live in harmony with muslims in egypt a few weeks later on october 6 bishop samuel was killed with president alsadat when they watched the annual military parade i was devastated the slayings made me more determined to focus on dialogue another defining moment was the turkish military coup détat in 1980 which heralded a new exodus of syrian orthodox and armenians from eastern turkey to istanbul and europe bert dorenbos director of eo from 1974 to 1987 was at the time deeply concerned about antichristian discrimination and persecution in eastern turkey and around 1981turkey and around 1982 formed a committee to study and publicise the plight of armenian and syrian orthodox christians in eastern turkey his aim was political pressuring dutch politicians to facilitate the arrival and acceptance of christians from eastern turkey in the netherlands one of the members of this committee was dirkjan groot founding director of dorcas a christian ministry established in 1980 that supports projects that uplift disadvantaged christians around the world i was asked to become the lead researcher for this committee since i was already known in various churches in the netherlands for my work on christians in the middle east and was politically active in the cdja i contacted numerous organisations and experts including henk glimmerveen a leading human rights activist and authority on this subject at the time i believed in providing humanitarian support but had growing misgivings about the prejudices i found within my christian friends about muslims and islam i saw the influences of politics in both turkey and the netherlands on religion and i no longer accepted to attribute the tensions in turkey only to muslims or islam in 19821983 i spent an academic year on a field study of small farmers in a small muslim village near fariskur damietta dumiyāt which interrupted the work of our committee i was used to attending church every sunday in cairo i had met with coptic orthodox bishop musa consecrated in 1980 as the first bishop of youth who told me of father boulos alhadidi b ūlus alhadīdī in damietta and decided to attend weekly services in his church in a city with only a small number of christians regular meetings at his home about faith fascinated me because the orthodox teaching was biblebased just as i had been taught in my christian reformed church father boulos explanation that bible and tradition go hand in hand made sense to me i found the history of the church in egypt going back to the early church after jesus life on earth fascinating i have met with many young christians wanting to leave egypt and each time they explained that they would have insufficient opportunities to advance in life if they remained in egypt many also did not want to stay in a country where public life is fully dominated by islam emigration motives were mostly economical since descending from a christian loweror middleclass family often would not help them to create a better life in egypt where being part of a welltodo family helps to advance in life sadly for many youths the only way to migrate to the west was through claiming persecution and applying for asylum resulting in numerous claims that were either exaggerated or not true but it often worked in the west where many people did not trust islam many christian persecution stories that i later investigated were deeply impacted by this mechanism i met with dutch jesuit priest henk van ruijven sj who invited me for visits to different places in egypt where the catholic church was active including minia minyā and introduced me to his fellow brother frans berkemeijer sj a strong advocate of dialogue and coptic catholic bishop antonios naguib najīb of minia the bishop later became patriarch and cardinal and always remained supportive of the dialogue work i carried out in later years fr henk treasured personal friendships regardless of someones religious or denominational affiliation and showed that the needs of muslims and christians were not much different both suffered from poor economic conditions poor education and poor medical circumstances fr henk was concerned with individual people showed compassion irrespective of their beliefs he helped me a lot to gain an understanding for egypt and egyptians during this study year copts spoke a lot about the house arrest of pope shenouda iii in 1981 i befriended dr george habib bibawi h abīb bibāwī professor of church history at the coptic orthodox seminary who was close to fr matta almaskin mattā almiskīn an influential church reformer in these days bibawi accused pope shenouda of being ignorant of early church teachings and accused him of heresy bibawi told me during these days that it was better pope shenouda had been removed from power since he saw him as a firebrand who had used his position to push president alsadat into concessions for the church but by doing so had not only alienated the president but also ruffled the feathers of many muslims which in his view was a major cause of the escalations into bloody collisions between muslims and christians i felt sympathy for the positions of fr matta almaskin and dr bibawi who argued for less political activism on the part of the head of their church and more separation between church and state since that would reduce tensions in society however i did not want to hear only stories critical of pope shenoudas handling of churchstate relations but to gather a different point of view i was told that in the uk an anglican priest by the name of fr dr john watson had become extremely active in advocating for the release of pope shenouda and i decided to visit him after my return to the netherlands watson was adamant that no government should interfere in the internal policies of any church and thus pope shenoudas monastic arrest was an anathema to him watson was an excellent and critical writer and used his access to the archbishop of canterbury to advocate for the release of pope shenouda making him much loved by the copts in the uk and the usa we too became friends and frequently exchanged views about the church in egypt i tried to reconcile the opposing views about pope shenouda watson was an excellent sparring partner for this after my return to the netherlands i picked up work with the committee that resulted in a 205page report on christian minorities from eastern turkey and was presented to the dutch parliament on 14 february 1984 work on the report made eo director dorenbos instruct producer pee koelewijn to make a film about the last armenians in anatolia turkey with the intent to use this to lobby in parliament to accept more christian refugees from turkey i was unhappy about this production since i believed relevant context was left out for the sake of advocacy while the eo focused on persecution claims i wanted to investigate opportunities to support the remaining syrian orthodox continue in their traditional homeland my report to parliament was greatly appreciated by syrian orthodox bishop julius yeshu çiçek since 1979 archbishop of central europe for my wish to seek support for the church in tur abdin he showed less interest he once explained to henk glimmerveen and me how he was growing his diocese by encouraging syrian orthodox to leave turkey for settlement in europe i found this to be a selfish attitude which damaged the tur abdin church since his encouragements contributed to the dwindling of the local church my involvement with christians from turkey made me write my masters thesis under the supervision of prof griffioen about factors leading up to the armenian genocide in 1915 taking the lives of around 15 million people i studied the growth of nationalism among armenians turks and other nations in the multireligious and multilinguistic ottoman empire with foreign powers stirring up nationalist sentiments that aimed at weakening or destroying the ottoman empire both nationalist armenians and nationalist turks wanted to create national states dominated by one religious group both claiming many of the same territories this conflict had little to do with religious convictions but rather with ethnicity tied to language and culture and so breaking away from the ottoman empire armenian nationalists were in the majority deeply secular not showing much interest in living a pious christian life but used the label of christianity for a decisively political purpose my earlier experiences and thesis had altered my outlook on christianity in the muslim world placing me in opposition to forms of nationalist ideologies in which ethnicity linguistic identity and religious heritage were fused to an extent that clashes with people with different nationalist and religious identities became inevitable my studies at leiden university had broadening my view of the world in which i had grown up my interest was to contribute to the perseverance of the church in the arab world and this continuation of the christian presence needed in my opinion dialogue education and development not only for christians in the arab world but for all my study made me focus on empirical facts intellectual trends and the social relations between people including the historical political cultural religious and economic aspects of societies as well as social change regardless of whether facts and analysis were convenient for particular groups or in line with prevalent convictions after i graduated in 1984 i went for dutch interchurch aid to tur abdin in southeastern turkey to describe the position of the local syrian orthodox church and make inquiries on what could be done to help the church remain in tur abdin i was welcomed by syrian orthodox bishop timotheos samuel aktash in the fifthcentury monastery of mor gabriel i loved to see the monks the school with dedicated young syrian orthodox students participating in the liturgy the bishop took me to beautiful villages with ancient churches it deeply struck me that the bishop lamented the efforts of bishop çiçek to encourage syrian orthodox from tur abdin to move to europe since this destroyed centuriesold local communities the bishop had convinced me that if this community would disappear that also their monasteries and churches would crumble 12 dutch interchurch aid supported the bishops views and funded a second visit leading me to syrian orthodox bishop yohanna ibrahim y ūh annā ibrāhīm of aleppo andhh patriarch mor ignatius zakka i iwas in damascus who both deeply deplored the departure of syrian orthodox from tur abdin and supported efforts for a development project dutch interchurch aid was unable to obtain the needed funding but the visits provided much information on the demographic decline of the syrian orthodox in tur abdin bishop aktash did not give up and was able to find other support churches monasteries and houses have been renovated development projects were initiated and pilgrimages to the heartland of the syrian orthodox church in turkey are made which kept the local church alive 13 bishop yohanna ibrahim later spoke at the apostolaat oosterse kerken in tilburg a catholic organisation creating understanding for eastern orthodox churches and argued that the future of the syrian orthodox church lay in the middle east not in europe nor north america the syrian orthodox who had emigrated to canada in the decades prior to the second world war had disappeared in canadian society through mixed marriages and secularism the current syrian orthodox church in most western countries consists mostly of firstand secondgeneration immigrants with practically all priests coming from tur abdin and syria since europe and north america had become highly secularised he did not believe the number of people being called to the priesthood would greatly increase in the west orthodox clergy in the west are making all efforts to maintain their communities but it will not be easy in the overwhelmingly muslim arab world however christians are maintaining their own identity and culture in a region where they have been present since the early days of christianity syria and other arab countries in the 1980s were ruled by authoritarian rulers who accepted religious diversity as long this would not challenge their rule no one could have expected at that time that the egyptian revolution of january 2011 would be followed by an uprising of sunni muslims against the alawidominated rule in syria syrian christians became major victims in this civil war since they had supported the alawi rule bishop yohanna was a true shepherd for his people and did not want to flee the violence of the civil war i met the bishop again in 2012 at the opening of the king abdullah bin abdulaziz international centre for interreligious and intercultural dialogue in vienna austria he believed he was still able and was obliged to talk with different warring parties to protect his own community as far as possible bishop yohanna was not naïve but followed what he believed was necessary for his church in aleppo bishop yohanna disappeared in 2013 while traveling with greek orthodox metropolitan boulos yazigi b ūlus yāzigī of aleppo to latakia to negotiate the release of two kidnapped priests no one knows which group kidnapped them on the road from aleppo to latakia no one heard from them after this kidnapping it is widely presumed they were killed but nothing is certain the destruction of syria is a tragedy but i do not think blaming islam for the killings of christians is right instead this is a political conflict that uses religion to mobilise communities and justify violence i am convinced that any religion can be used to encourage people to do good but at the same time to commit horrendous crimes exposure to the views of syrian orthodox and later other christian leaders in the middle east made me realize that i had to be cautious with claims of discrimination and persecution made by christian migrants from the middle east and i understood that i should always verify such claims with information obtained from local leaders during my study year in egypt i had spoken to people about returning to egypt for work with coptic development projects through the bishopric of ecumenical and social services i met with bishops athanasius and marcos but things were to change president mubarak released pope shenouda from his monastic arrest who in turn relieved bishop athanasius of his position and consecrated bishop serapion as the head of bless who discontinued the talks for my position at his bishopric bishop athanasius had been one of the committeeoffive who ruled the coptic orthodox church after president anwar alsadat had sent pope shenouda in exile to the monastery of bishoi which was seen by pope shenouda as disloyalty it was years before the two church leaders were reconciled with this change it was impossible to obtain a position at bless in this period i asked the church council of the christian reformed church of leiden for permission to become a member of the coptic orthodox church in egypt since i had become deeply impressed by the church many of its bishops priests and members i was not intending to leave the christian reformed churches but wanted to be a member of both churches one in the netherlands and another in egypt it took months of discussions in both egypt and the netherlands coptic orthodox metropolitan bishoi of damietta spoke about rebaptism while i argued in line with my upbringing that there is only one baptism i spoke about the procedures with dr isaac fanous fān ūs the famous iconographer of the coptic orthodox church who introduced me to fr antonios amīn of the st marcos church in cleopatra heliopolis cairo fr antonios asked for a letter from the christian reformed church of leiden stating that i was baptised with water in the name of the father son and holy spirit by an ordained minister who was ordained through the laying on of hands and a prayer to receive the holy spirit i travelled to the netherlands met with the church council and rev gerard den hertog and obtained the needed letter fr antonios went with this letter to the coptic orthodox cathedral in abassiya abāssiya cairo to ask permission to accept me as a member of the coptic orthodox church which they did but i had to receive the holy mairun since this had not been administered to me in the christian reformed church fr antonios anointed me with the holy mairun at the baptismal in his church witnessed by my dutch friend eildert mulder after which he led the liturgy and preached about conversion in fact being a baptism bishop musa was informed about this procedure approved of it and gave me the name brother cornelis there was no coptic orthodox church in the netherlands at the time and becoming a member of both churches did not come up in discussion in egypt with the establishment of the coptic orthodox church in the netherlands in 1985 however some members claimed that a dual membership of two different churches in one country was not possible bishop marcos of france the first european to be consecrated bishop in the coptic orthodox church 14 knew of my dual membership and asked me to join monastic life seeing in me a potential successor to his bishopric in france we both knew only pope shenouda could make that decision but since most members in his diocese were nonegyptian it would be hard for an egyptian to succeed him i appreciated his trust in me but declined i had come to see myself as ecumenical being a link between the coptic orthodox church and people coming from different traditions but not in the position of a cleric i had applied in october 1986 for the position of director of the christelijke emigratie centrale most members of the board were affiliated with the antirevolutionary party and after the merger with two other christian parties to the cda were actively involved in this political party reformed arp politician wil albeda had played a major role in the formation of the cda and believed during his term as minister of social affairs in 19771981 that providing emigration consultancy based on religion belonged to the past during my tenure as the last director of the christian emigration centre i carried out several tasks providing potential dutch emigrants with information advice and referrals to relevant institutions about and in different emigration countries working on my international church network for emigration initiating exchanges with young people from dutch emigrant communities abroad starting a program to facilitate the emigration of refugees building relationships with different embassies i used my contacts with journalists for media publications lobbied with other dutch emigration centres at the dutch parliament began documenting the history of the christian emigration centre in a book and arranged for the archives of the christian emigration centre to be transferred to the historisch documentatiecentrum at the free university amsterdam instead of the centre simply being abolished we reached a compromise with the ministry of social affairs to merge the four emigration centres in 1991 in the nederlands migratie institute with the added task of remigration of migrant workers who wanted to return voluntarily to their home countries i suggested to set up the stichting dienstverlening emigratie nederland providing paid emigration services to make it selfsustainable and became its director starting on 1 january 1994 the netherlands migration institute abolished its emigration consultancy activities and thereafter only focused on remigration it was hard work but my interest in contributing to dialogue in egypt had the overhand working in egypt addressing politically motivated images of muslimchristian relations during my time in the dutch emigration service i frequently travelled to egypt and promoted in the netherlands knowledge about the church in egypt and seeking support for egypts poorest christians during my travels i came to know sawsan we married in egypt in 1988 after which she came to the netherlands where we got three children in the summer of 1994 jos m strengholt a wellknown dutch freelance correspondent for different christian media in egypt since 1988 asked me if i could take over his function since he would leave egypt i liked the idea of working for christian media since that would enable me to focus on the position of christians in egypt and surrounding countries and engage in dialogue with the purpose of playing a role in reducing christians leaving egypt and the arab world i believed at the time this opportunity to return to egypt was a call of god the editors of the eo tros television radio broadcasting foundation and rd jos worked for told me they did not want a time lapse between his departure and my arrival i would have to be in egypt by 1 october 1994 this afforded me very little preparation time indeed my announcement to resign as director of the netherlands emigration foundation came as a shock to the board and staff the experience with emigration consultancy political lobby work and fundraising turned out to be an excellent preparation for the uncertainties i would later face in egypt i also worked with the katholiek weekblad news network international and christianity today in the usa the focus of my media reporting was on christians living in a predominantly muslim society it became a period of growing dissatisfaction with american coptic political activists attributing social ills and tensions to islam and muslims that found its way in many western christian organisations and media and fuelled islamophobia fr a few years after my family had moved to egypt the eo decided to end work with correspondents in the arab world working for them was my main source of income which led to a financially difficult period that prompted me to look for other sources of income during this period dirkjan groot of dorcas asked me if i would investigate the persecution of christians in egypt and report back to dorcas as this would help dorcas conduct a fundraiser for persecuted christians in egypt dorcas would pay for this work i asked if i would be permitted to write about the wider context and show nuances but dirkjan did not want nuance because that would not help his advocacy and fundraising activities i declined in 1995 the dutch christian organisation open doors asked me to investigate the stories of christian human rights lawyer morris sadek maurice s ādiq about christian girls in egypt being kidnapped by muslims and being forced to convert to islam initial relations with morris sadek were good and his stories sounded convincing but as time elapsed i learned that s adek met in most cases with fathers and brothers of converted girls in his office in shubra cairo and never made the effort to visit families on location to discover the various factors that led to conversions i spent over one year working on this report i wanted to understand the facts and learned through lots of interviews and discussing results with church leaders how complex reasons leading to conversions can be gradually i discovered that for morris sadek truth was subordinate to his belief that no christian should ever convert to islam and when this happened it always had to be the result of muslim pressure or deception i was surprised that coptic activists just like sadek were not at all interested in any background information but continued in their belief that screaming murder would be the best way to stop or at least reduce the number of conversions to islam taking place my wife sawsan played a significant role in this research helping me to understand stories told in the wider egyptian cultural context and receiving people for interviews at home open doors introduced me in 1996 to fieldstead and company the organisation of the wealthy ahmanson family founded in orange county california usa they had been funding news network international before it collapsed and were interested in my work on conversions of christian girls in egypt to islam roberta green ahmanson told me she wanted to replace news network international which had a focus on religious freedom in general by a new organisation that would exclusively focus on persecution of christians this became the start of compass direct cofunded by both fieldstead and company and open doors i did not agree with the exclusive focus on the persecution of christians the ahmansons were citing sources of christian persecution based on information provided by coptic activists and in the media while i was speaking from personal experiences and research in egypt that did not match those sources despite our differences the ahmansons and their staff remained extremely courteous much of their information at this time came from dr paul marshall who had previously worked with dr griffioen at the institute for christian studies in toronto where marshall was still based marshall at that time was working with lela gilbert on his book their blood cries out the untold story of persecution against christians fieldstead and company provided a supportive environment for marshalls work the book dealing with many different countries including egypt was mainly based on the work of advocacy organisations media reporting and advocates and experts from around the world that told a particular narrative about christians and persecution but not fieldwork marshall had at the time never visited egypt and thus his sources about egypt were all second hand the book became a best seller and a source of information for many people after visiting orange county the ahmansons flew me to washington dc where they had arranged my stay in the willard intercontinental hotel near capitol hill and the white house and arranged meetings with some congressional staffers about preparations in the house of representatives for what later became the international religious freedom act just as my contact person at open doors had done before i left for the usa inquiries were made if i could testify in congress about the persecution of christians in egypt however those responsible first needed to be sure i would present a view in agreement with their perspective i was well received but i was not comfortable with their line of thinking in lobbying for the international religious freedom act after i had returned to egypt i expressed reservations about this act in various articles in my estimation a significant number of individuals and organizations involved with lobbying on behalf of the international religious freedom act were at least partially driven by a christian missionary agenda as a christian i did not oppose christian mission work but i believed that it was important to provide a balanced view of the complex situations faced by christian minorities in the middle east later in 1996 i met with open doors founder anne van der bijl and told him that of course i wanted to support persecuted christians and advocate human rights but believed this had to be in the context of a better understanding of muslimchristian relations including systematically following egyptian media reporting about christians in egypt engaging with muslims and learn of their views about christians which later turned into a database anne van der bijl welcomed my aspirations and described this work as gods calling for me lutheran pastor and scholar of coptic church history otto meinardus used to visit egypt regularly to maintain his connections with coptic orthodox church leaders and collect data for new articles and books during each visit i helped him as he gave me great insights into understanding the egyptian church and its traditions beliefs that i initially thought were certainties began to waver he showed me how traditions were not as fixed as i initially believed but changed over the generations under the influence of interests struggles or other factors meinardus explained the difference between popular faith and official faith popular faith tends to be syncretistic one can see this for example in egypt in the similarities between the celebration of saints in the coptic orthodox church and muslim sufis official faith however is what is taught by the clergy or other experts in a particular religion and is shielded by canonical religious texts part of coptic orthodox faith is the widespread belief in miracles some have been officially sanctioned such as the miraculous displacement of the muqattam mountains during the reign of pope abraham other miracle stories belong to the realm of popular faith such as the apparition of the blessed virgin in 1997 in shentena alhagar which lasted a few weeks and attracted about 150000 people at that time my wife and i were among them i could not believe the light flashes we saw were apparitions of the holy virgin as local people believed this experience made me more cautious of miracle stories religious images are not harmless in tensions between christians and muslims religious images can develop into a stream of poisonous lies embellishments and accusations often published in the western press that i have resisted since i arrived in egypt in 1994 that resistance also resulted in threats of those who had created those images i have had numerous discussions with clergy and scholars about the coptic orthodox sunday school movement a revival that began in the 1930s and was much opposed by the orthodox bishops of the time reformers knew they only could change the church from within through monastic life reformers became monks later bishops and with pope shenouda the first sunday school reformer had become pope which resulted in consecrating bishops in line with his thoughts each time an old bishop had passed away reformers also clashed as we have seen in literature between fr matta almaskin and pope shenouda neither of the parties thought of either leaving the church or expelling the other party from church which is related to the principle of accepting authority since authority comes from god in 1999 i was asked to write a chapter for a book about the coptic orthodox holy family tradition it enabled me to delve into the traditions of this ancient church and showed how stories of an ancient and more recent past are created and become relevant in the lives of people who believe in them it became a confrontation between actual historical facts and wishful thinking and a desired to offer local christians something to hold unto some bishops including bishop dimitrius of malawi insisted that jesus had actually visited specific locations in egypt while other bishops did not deny the tradition but their faith was not tied to the belief that this tradition presented historical facts bishop dimitrius repeated statements claiming certainty where i saw none created in me more and more doubts about absolute truths income from journalism had severely dropped yet i stubbornly refused to give up the mission i had started in june 2000 economic problems and extreme work pressures led me to a severe form of pulmonary embolism that brought me very close to death with my wife wishing return to the netherlands yet after recovery i was asked to teach mass communication at the american university in cairo which gave new hope that i could continue my mission kerk in actie gave an extra push to remain working in egypt helping us to form an egyptian ngo and a company fostering mutual intercultural and interreligious understanding through building a database in egypt not long after german ngos missio and misereor joined in supporting this work various reports i worked on showed how social problems cultural factors such as honour and shame weak government policies but also religion contributed to the complex relationships and tensions between muslims and christians gradually i became convinced that there is no good or bad to understand how interreligious tensions can grow and develop we must instead pay attention to events and understand the interconnection between social and political factors the book about the coptic orthodox holy family tradition brought me in december 2002 in contact with dr willem kuiper at the time assistant professor of medieval dutch literature at the university of amsterdam who had found a reference to de goede hof in der leken spiegel an encyclopaedia written by jan van boendale but was uncertain about its location in egypt i recognised in the description the garden around the tree of the holy family in mattariya once part of the ancient city of heliopolis and today part of northern cairo kuiper used my information for his article about de goede hof kuiper explained that in understanding the development of christianity in europe we need to understand that in late antiquity and medieval times texts are not descriptive in the sense that they describe an actual truth but normative they describe a higher truth whereby older and wellknown texts served as models to steer an intended reception reading these text as actual truths as has been done by orthodox believers since the reformation is resulting in gross misunderstandings literature both worldly and spiritual is not of all times but tied to time and place 15 kuipers approach helped me in understanding debates about christianmuslim relations since orthodox christian and muslim believers so often refer back to their own textual heritage the bible quran and other holy books i came to understand as scriptures that are written by people who saw gods hand in personal experiences and circumstances around them the texts interact with human feelings such as love anger fear and hope that are perennial authors have been influenced by literature preceding them even though we may no longer have access to many of these texts from antiquity and the beliefs and circumstances of their times scriptural texts were also often influenced by the political circumstances that shaped their context this suggests that what is written in the holy books is partly related to time and place and partly is wisdom literature that helps us deal with various issues that arise in daily life our book on the holy family led me to the study of egyptian locations mentioned in the bible in 20072008 egyptologist dr lutfy sherif lut fī sharīf drew my attention to the book canaan and israel in ancient times redford showed that biblical history and the historicalarchaeological records often do not match this did not match with my faith of god inspiring the various bible authors if the text was divinely inspired how could it contain texts that were in violation with the historicalarchaeological records not all people i came in contact with agreed to my changing views on scriptures american editor rick anderson took the text of the bible as absolutely true and the infallible word of god at the time i corresponded with dr larry levine an orthodox jew teaching mathematics at stevens institute of technology new york both believed that god is a god of miracles if the archaeological and historical records do not match with the text then the text is right and we must seek for explanations that leave no doubt to the historical accuracy of the text i came from a similar faith tradition but the ease of various religious leaders to manipulate factual truths led me to stop believing in the absolute certainties that so many orthodox had taught my focus shifted from discussions of increasingly elusive certainties to a focus on living together another way to address misunderstandings that can evolve into tensions is to listen to the wisdom we find in other religions and cultures egyptian philosopher and former minister hamdi zaqzouq h amdī zaqz ūq whom i have met on several occasions stated that since we live in a very diverse world it is of paramount importance that we can relate to others who are different from us and compared humanity to sailors on a ship we must cooperate in order to sail the ship into a safe harbour humanity must cooperate if we want to keep earth inhabitable for our children and grandchildren since 1997 my wife and i have worked on building a database about the role of religion in egyptian society resulting in the foundation of centre for intercultural dialogue and translation company in 2005 this attracted the attention of prof andreas van agt prime minister of the netherlands 19771982 who visited egypt in 2006 and lectured at different universities and the lions club about dialogue met with egypts minister of foreign affairs and the head of the arab league and each time underlining the importance of intercultural and interreligious dialogue the european funded anna lindh foundation financed improvements to our database with a network with similar minded organisations in europe and the arab world which was launched by hrh prince elhassan bint alāl in amman jordan 2008 who describe the database as a vector for change in 2007 the egyptian ngo centre for arabwest understanding was founded by leading representatives of all churches and the azhar as well as a number of influential scholars and media representatives 16 and became the vehicle of student internships egyptian and nonegyptian muslim christian secular or whatever religion students adhered to between 2008 and 2022 cawu hosted 427 student interns who contributed in various ways for periods ranging from one to twelve months to interreligious dialogue that was reflected in numerous reports in the arabwest report database that my successor dr matthew anderson in 2022 renamed dialogue across borders emerging perspective on intercultural and interreligious relations cawus contribution has been unique in that it has maintained good relations with all egyptian religious institutions while remaining independent of each until 2011 cawu was probably the only egyptian organisation with such a wide diversity of leading religious representatives this changed with the formation of the bayt alayla after a terrible bomb attack on worshippers of the two saints church in alexandria on 1 january 2011 that claimed the lives of 23 people and injured 97 people each of the churches and alazhar that participate in bayt alayla has its own dialogue activities either selffunded or through own fundraising representatives represent their religious institution and are bound by the beliefs and policies of their institutions that makes bayt alayla different from cawu bayt alayla has grown out to be a major and influential centre for interreligious dialogue in egypt sadly bay alayla is not well known outside egypt egypt experienced great instability in the years 20112014 when islamists were striving for power and later pushed into the margins this period made them visible and accessible which gave us unique opportunities to interview also radical jihadi salafis and in 2014 we even had the spokesperson of binladens alqaida visit our office and meet with our students he wanted to talk and i had prepared our students ask why questions but do not engage in argumentations about what in his statements is true or not these radical islamists presented islam as the victim of western powers these meetings were lessons to us but of course we should not expect change in one meeting but every opportunity to meet people radically different from us should be taken in 2020 egyptian student intern nour saad a graduate of the deutsche evangelische oberschule and student in germany interned at cawu resulting in a paper of religious education at the deo during which students in the last two school years follow cooperative religious education whereby christian students learn to understand the religious language of muslim students and vice versa when this initiative started egyptian educational authorities responded with hesitation in 2020 the ministry of education announced the introduction of subject of ethics and principles in egyptian schools this is clear proof nour saad concludes that progress in the field of interreligious education in egypt is made which gives hope for the future conclusions the research question we sought to answer with this paper concerns how we can contribute to interreligious dialogue by seeing the world from different points of view at the same time the paper tried to explain how this has influenced my faith in the context of the differences between religious orthodoxy and religious liberalism intertwined with political influences in dutch israeli and egyptian cultures deeply influenced by abrahamic beliefs since world war ii american evangelical influences aimed to strengthen orthodox christianity in the netherlands and egypt as well as the state of israel believing that this was gods will often merging with islamophobic prejudices the paper argues that interreligious dialogue should not only concern members of different religions but also orthodox and religious liberalism the paper concludes that deeply held beliefs about ones own truth are linked to an absence of awareness of the broader historical context the positions of the parties involved and their beliefs understanding that these are not static but dynamic and constantly changing over time both literature and personal narratives show a strong intertwining of religion and politics through ideologically driven institutions and media that aim to promote the interests of their own social bubble with associated stories and myths the conclusion is that interreligious dialogue should strive to separate myth from factual truth which is far from easy because of the various interests involved evidence in the literature and personal narratives also show peoples personal social bubbles can expand through personal friendships across religious borders in which personal faith can be questioned the personal narrative adds the importance of having one or more longterm personal mentors in interreligious dialogue providing guidance connections and encouragements a pluralist attitude can contribute to promoting the common good that in turn needs interreligious dialogue to build bridges of understanding and create social and political solidarity that is needed to address worldencompassing issues that keep our earth inhabitable for our children and grandchildren there is also a need to offer students opportunities to expand their understanding of different religious beliefs with tutors who can introduce them to widely different believers living in circumstances that contrast with their own experiences the student interns the author has worked with were given the opportunity to actively engage in activities and share their experiences with others through contributions to the arabwest reportdialogue across borders database further research could be conducted on separating myth from factual truth in reporting about interreligious relations the interaction between religion and politics and other authentic dialogue experiences how can a better understanding of the relationship between religion and politics be communicated to committed orthodox jews and muslims and temper the religious angle in the political conflict between israel and palestinians how often do serious approaches to interreligious dialogue lead to a more liberal understanding of faith what other factors may play a role in such an outcome why do some people retain their original beliefs more or less data availability statement all data are publicly accessible email correspondence referenced in this paper is stored in the database of dialogue across borders

this paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles in which members draw clear boundaries between us and them differences between social groups can culminate in a struggle between good and evil that can escalate into tension and violence preventing tensions and conflicts requires respect for differences willingness to engage in dialogue and a sound understanding of what religion is and the historical processes that have determined its development distinguishing between empirical facts and images to which believers adhere because the author is a dutch sociologist turned journalist from a conservative christian family involved in interreligious dialogue in the netherlands israel and egypt the literature review presents contemporary religious developments in all three countries the literature review is flanked by the authors personal narrative on the events that changed his views on truth and spirituality making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue

introduction the sustainable development goals were introduced by the united nations in 2015 with the objective of eradicating poverty and reducing inequality by 2030 in china a significant developmental disparity exists between urban and rural areas the report of the 20th national congress of the communist party of china identified the advancement of balanced regional development and urbanrural integration as a crucial step toward facilitating highquality growth although traditional economic models have favored urban areas over rural regions owing to their abundance of resources and higher productivity levels 1 the digital age has presented opportunities for rural communities to leverage technology and drive innovation transformation and growth within the digital economy 2 examining the impact of internet development on urbanrural consumption inequality can shed light on the role and potential of the internet in reducing these economic disparities and achieving sustainable development consumption inequality closely mirrors income inequality often to a greater extent than indicated by overall reported expenditures 34 economists typically focus on individuals utility function which pertains to consumption and leisure rather than income 5 the consumption gap provides a distinct indication of welfare disparities among socioeconomic groups compared with the income gap 6 it reflects the imbalanced distribution of consumption resources capabilities and opportunities influenced by individual differences in abilities as well as disparities in resources and opportunities 7 empirical evidence based on data from the urban household survey suggests that consumption inequality in urban china has increased by 67 during the sample period surpassing the original figure of 36 reported by raw data the disparity in consumption was more pronounced in the central and western regions which played a pivotal role in driving up consumption inequality 8 expenditure inequality exhibits a greater magnitude in china compared with india whereas income inequality is less pronounced these variations can be attributed to differences in population demographics with china being more urbanized and having smaller household sizes as well as divergences in conditional income distributions based on the achieved educational level of the household head 9 information and communication technologies particularly the internet have been considered essential in facilitating market access reducing transaction costs and augmenting income for a significant proportion of individuals residing in developing nations since the beginning of the century 10 internet accessibility has a positive impact on poverty reduction with greater benefits seen in the rural sector for reducing extreme income and multidimensional poverty compared with urban areas 11 digital inclusive finance based on the internet can effectively narrow the per capita disposable income gap between urban and rural areas 12 although the internet presents a potential solution for mitigating health disparities ameliorating income inequality promoting healthier lifestyles and mitigating depression the existence of a digital divide among rural residents elderly individuals and lowincome populations highlights the urgent need for redress 13 the digital divide can be observed across multiple levels including intercountry interregional and sociodemographic groups 14 15 16 17 researchers have shifted their focus from the firstlevel digital divide of internet access to the secondlevel digital divide which refers to the soft gap caused by differences in communication literacy and levels of internet use 18 in other words uniform availability and proficiency in icts are not evenly distributed across different consumer segments 19 the internet has facilitated the digital transformation of the economy and has had a significant impact on social development for example the digital economy can effectively drive household consumption with a more pronounced impact on urban residents than rural residents 20 digital economic development has also significantly contributed to enhancing the economic structure and material wellbeing of the elderly population 21 certain studies suggest that digital finance has the potential to mitigate consumption inequality by boosting household trickledown consumption particularly among lowincome groups moreover the level of digital financial development within a county is positively correlated with the amount of trickledown consumption in chinese households 2223 recent research has focused on the invertedushaped relationship between the development of the digital economy and the urbanrural consumption gap 24 however contrasting findings have been reported in other studies on the basis of the data from the china family panel studies covering 155 counties between 2010 and 2016 internet penetration may cause an increase in consumption inequality additionally higher education and a certain threshold of internet penetration can mitigate the negative effects of the internet 25 previous research has conducted comprehensive investigations into the correlation between internetrelated content and consumption as well as its inequality however most studies focus only on the inequality of food or energy consumption while failing to comprehensively analyze the causes and shifts in the urbanrural consumption gap 26 27 28 this leaves room for debate first the impact of internetrelated content on consumption inequality remains a contentious issue second most studies fail to account for nonlinear relationships third many empirical studies use provincial panels leading to imprecise findings therefore this study aims to explore the impact of internet development on urbanrural consumption inequality as well as the potential influencing mechanisms the remainder of the paper is structured as follows first drawing on a comprehensive literature review we propose four research hypotheses and the corresponding theoretical framework to examine the impact of internet development on urbanrural consumption inequality second we employ panel data of prefecturelevel cities or above from 2016 to 2019 to empirically examine the aforementioned hypotheses as well as conduct robustness tests and heterogeneity analyses third we summarize and analyze the findings and providing corresponding recommendations theoretical analysis and research hypothesis the development and application of the internet have strengthened the interconnectedness between urban and rural areas resulting in improved factor allocation upgraded industrial structure and impacted income distribution the widespread use of the internet has the potential to greatly enhance the consumer structure of individuals 2930 it is expected that the internet will serve as a significant impetus in dismantling the urbanrural dual structure and unleashing consumption potential for both urban and rural residents however the existence of a digital divide among rural residents elderly individuals and lowincome populations has resulted in new disparities in opportunities and impeded equitable access to the advantages of digital resources 31 this may potentially exacerbate consumption inequality between urban and rural areas owing to the objective fact of uneven development between urban and rural areas and the difference in the ability of urban and rural residents to use the internet the above digital dividend and digital divide may have different manifestations in different stages of development therefore we posit hypothesis 1 hypothesis 1 the impact of internet development on urbanrural consumption inequality exhibits a nonlinear relationship china faces the objective reality of imbalanced regional economic development and the urbanrural dual structure 31 these factors contribute to a significant digital divide between the eastern middle and western regions of china as well as between cities and urban and rural areas urbanization as a crucial driver for chinas leapfrog development is closely linked to the distribution of income between urban and rural areas and consumption inequality urban areas as important spatial carriers for economic activities also provide essential infrastructure and talent support for the growth of the internet in general a higher level of urbanization corresponds to a smaller digital divide indicating that the level of urbanization may impact the relationship between internet access and consumption inequality in urbanrural areas 32 therefore we posit hypothesis 2 hypothesis 2 urbanization has a threshold effect on the impact of internet development on urbanrural consumption inequality a significant urbanrural income disparity will inevitably result in a substantial consumption gap between urban and rural residents 34 the application and development of the internet deeply affect the income level and distribution of urban and rural residents 33 as a universal informational medium the internet narrows the urbanrural divide by facilitating the exchange and sharing of information enhancing the mobility of labor resources and improving resource allocation this significantly improves the income level of rural residents the internet as a costeffective and efficient method of information acquisition reduces the costs associated with information searching thus enhancing job matching efficiency promoting employment opportunities and entrepreneurship facilitating industrial upgrading and diversifying income sources for residents the rapid development of the internet not only provides employment opportunities for farmers and improves their income level but also accelerates the accumulation and optimization of their human capital 34 ultimately impacting the income gap between urban and rural areas based on keynes absolute income hypothesis consumption is determined by income the income gap between urban and rural residents has a significant positive effect on the consumption gap therefore we posit hypothesis 3 hypothesis 3 internet development impacts urbanrural consumption inequality through its influence on urbanrural income inequality the industrial structure has a significant impact on urbanrural consumption inequality 3536 with the advent of the internet era it has driven the modernization and development of the service industry manufacturing industry and agriculture with information technology gradually linking all aspects of the national economy the integration of the internet and traditional industries is a doubleedged sword for chinas economy in the case of inadequate innovation the rapid development of the service industry over the manufacturing industry may lead to a premature industrial structure which will have a negative impact on sustained economic growth 37 this is especially evident when workers move from highproductivity manufacturing departments to lowproductivity service industries such as food delivery premature industrial structure in the process of industrial evolution means that although the industrial structure is close to that of developed countries the contradiction between supply and demand or sluggish demand and insufficient effective supply cannot be effectively resolved due to the lack of per capita income and national innovation capacity premature industrial structures constrain the development of the manufacturing industry trigger a retreat in the industrial sector result in sluggish national economic growth and increase the risk of falling into the middleincome trap 38 further affecting the consumption sector and its urbanrural inequality therefore we posit hypothesis 4 hypothesis 4 internet development impacts urbanrural consumption inequality through its influence on the premature industrial structure figure 1 presents the mechanism diagram briefly illustrating the main ideas of hypotheses 1 to 4 a nonlinear relationship and a threshold effect between internet development and urbanrural consumption inequality can be concluded the influencing mechanism is that the internet development affects urbanrural consumption inequality by influencing urbanrural income inequality and premature industrial structure their human capital 34 ultimately impacting the income gap between urban and rural areas based on keynes absolute income hypothesis consumption is determined by income the income gap between urban and rural residents has a significant positive effect on the consumption gap therefore we posit hypothesis 3 hypothesis 3 internet development impacts urbanrural consumption inequality through its influence on urbanrural income inequality the industrial structure has a significant impact on urbanrural consumption inequality 3536 with the advent of the internet era it has driven the modernization and development of the service industry manufacturing industry and agriculture with information technology gradually linking all aspects of the national economy the integration of the internet and traditional industries is a doubleedged sword for chinas economy in the case of inadequate innovation the rapid development of the service industry over the manufacturing industry may lead to a premature industrial structure which will have a negative impact on sustained economic growth 37 this is especially evident when workers move from highproductivity manufacturing departments to lowproductivity service industries such as food delivery premature industrial structure in the process of industrial evolution means that although the industrial structure is close to that of developed countries the contradiction between supply and demand or sluggish demand and insufficient effective supply cannot be effectively resolved due to the lack of per capita income and national innovation capacity premature industrial structures constrain the development of the manufacturing industry trigger a retreat in the industrial sector result in sluggish national economic growth and increase the risk of falling into the middleincome trap 38 further affecting the consumption sector and its urbanrural inequality therefore we posit hypothesis 4 hypothesis 4 internet development impacts urbanrural consumption inequality through its in fluence on the premature industrial structure materials and methods variables selection the variables in this study mainly include explained variables core explanatory variables a threshold variable mechanism variables and control variables the details are as follows explained variable urbanrural consumption inequality can be measured using various methods in academic research 12 the first method is absolute consumption inequality which subtracts rural residents consumption from urban residents consumption however the relative degree of consumption inequality is challenging to determine due to the significant consumption disparities between cities the second approach involves calculating the gini coefficient based on the lorenz curve although this indicates overall consumption inequality the contribution of intragroup and intergroup gaps is difficult to determine the third method is relative consumption inequality which uses the ratio of urban to rural residents consumption however this cannot accurately reflect the impact resulting from changes in the proportion of urban and rural populations the fourth method is the theil index which has the significant advantage of decomposability allowing the urbanrural gap to be separated from the overall gap while maintaining consistency the theil index can also reflect changes in urban and rural consumption polarization while considering demographic factors higher values indicate higher levels of inequality in this paper the theil index is used to measure the total urbanrural consumption inequality combining existing popular practices the formula for the theil index is as follows theil it c uit c it ln c rit c it ln c uit c rit respectively represent the urban and rural consumption expenditure of year t in city i p uit p uit respectively represent the urban and rural permanent population of year t in city i c it p it respectively represent the total consumption expenditure and total population in both urban and rural areas of year t in city i core explanatory variable the core explanatory variable in this study is the level of internet development the tencent research institutes china internet plus index is used as a proxy variable to measure internet development to account for measurement differences the variable is logarithmically transformed threshold variable we employ the level of urbanization as a threshold variable which is measured by the proportion of urban permanent residents in the total population of the region mechanism variables referring to the research of zou et al 6 and tian et al 39 we select the urbanrural income inequality and the industrial structure upgrading as the mechanism variables the urbanrural income inequality is also expressed by the theil index the industrial structure precocity is represented by the ratio of value added by the tertiary industry to that of the secondary industry minus 1 control variables to mitigate the endogeneity problem arising from missing variables this study incorporates significant regional economic characteristic variables that impact urbanrural consumption inequality as control variables based on previous research 1325 and considering the theoretical impact of control variables on dependent variables the following control variables are selected economic development level industrial structure fiscal expenditure educational expenditure level of economic openness and unemployment rate data source and processing data for the core explanatory variables are obtained from the tencent research institutes internet plus index report for china which provides a comprehensive reflection of the internet development status of cities in several dimensions data for urbanrural consumption inequality disposable income inequality industrial structure and control variables are collected from the china statistical yearbook and eps data platform for cities at the prefectural level or above panel data from 2016 to 2019 are selected and processed as the sample for this research samples with missing main variables are removed and some missing values are filled in the data are then combined into balanced panel data resulting in 1323 observations table 1 provides the descriptive statistical results for the main variables during the sample period the minimum maximum and standard deviation of urbanrural consumption inequality for each city are 0001 0319 and 0035 respectively indicating certain differences in the urbanrural consumption gap among cities the level of internet development varies from 0048 to 3604 highlighting significant differences in the level of internet development among cities in china the multicollinearity test results show that the variance inflation factor values of all variables are less than 10 indicating no multicollinearity among the variables in this study the hausman test first significantly rejects the original hypothesis indicating that the fixed effects model should be selected to assess the joint significance of time dummy variables we incorporated them into the individual fixed effects model and conducted an f statistic test the results indicate the necessity of incorporating time fixed effects therefore we employ a panel twoway fixed effect econometric model to examine the impact of internet development on urbanrural consumption inequality to investigate the potential nonlinear relationship we introduce the quadratic term of internet development into the model specifically we construct the following panel model theil it α 0 α 1 net it α 2 net 2 it γz it λ t u i ε it in model i represents cities at or above the prefecture level whereas t denotes the year the variable theil it refers to the urbanrural consumption inequality net it is the internet development index net 2 it represents the squared term of the internet development index z it stands for a series of control variables λ t u i and ε it reflect the year fixed effects the city fixed effects and the random disturbance term respectively threshold regression to further investigate the potential threshold effect in the nonlinear relationship between the internet development and the urbanrural consumption inequality we construct a dynamic panel singlethreshold model based on our theoretical analysis in the previous section we utilize the level of urbanization as a threshold variable in the following model theil it α 0 α 1 net it × i α 2 net it × i γz it λ t u i ε it in model urb represents the threshold variable θ represents the value at which to test the threshold and i is an indicator function for the threshold model that equals 1 if true in parentheses and 0 otherwise results benchmark regression model estimation the regression estimation was performed on the benchmark regression model and the results are presented in table 2 to ensure the robustness of the findings we examined the regression results by transitioning from linear mixed ols regression to nonlinear mixed ols regression twoway fixed effect and twoway fixed effect with control variables added columns display the regression results for each model variation the consistent and significant negative effect of internet development on urbanrural consumption inequality is observed at the 5 significance level but its squared term consistently and significantly indicates a positive effect we give precedence to the findings presented in column in the context of low internet development a linear relationship prevails wherein each unit increase in the level of internet development corresponds to a 05 decrease in the urbanrural consumption inequality index conversely in high internet development scenarios a nonlinear relationship emerges where each unit increase leads to a 02 increase in the urbanrural consumption inequality index this finding confirms the existence of a ushaped relationship between internet development and urbanrural consumption inequality thus supporting hypothesis 1 these findings align with the research of tian et al 39 and jiang et al 40 who previously established a ushaped relationship between internet development and both the urbanrural gap and premature industrial structure the digital divide and digital dividends resulting from internet development vary across different stages of its evolution highlighting the importance of investigating the potential nonlinear relationship between internet development and urbanrural consumption inequality threshold regression model estimation initially we conduct a regression analysis using the threethreshold model and the results indicate that only the pvalue associated with the single threshold is less than 01 suggesting the suitability of the single threshold model for this study in table 3 we analyze the impact of internet development on urbanrural consumption inequality by incorporating the level of urbanization as a threshold variable the results indicate a threshold effect of urbanization on the impact of internet development on urbanrural consumption inequality providing support for hypothesis 2 additionally our regression analysis reveals that internet development has a significant impact on increasing urbanrural consumption inequality when the level of urbanization is below 03474 however this impact becomes insignificant once the level of urbanization exceeds 03474 these findings suggest that a low level of urbanization is not conducive to the internets role in bridging the consumption gap between urban and rural areas to validate the threshold results we perform a likelihood ratio test on the outcomes obtained from the single threshold model as illustrated in figure 2 the results demonstrate that the lr statistical graph of the single threshold intersects with the horizontal line indicating the passing of the significance test and ensuring the authenticity of the threshold result becomes insignificant once the level of urbanization exceeds 03474 these findings suggest that a low level of urbanization is not conducive to the internets role in bridging the consumption gap between urban and rural areas to validate the threshold results we perform a likelihood ratio test on the outcomes obtained from the single threshold model as illustrated in figure 2 the results demonstrate that the lr statistical graph of the single threshold intersects with the horizontal line indicating the passing of the significance test and ensuring the authenticity of the threshold result municipalities directly under the central government possess comparative advantages in political economic transportation and technological resources 38 which results in welldeveloped internet infrastructure this simultaneous change in the internet development index and urbanrural consumption inequality in these municipalities may robustness analysis 431 change of samples municipalities directly under the central government possess comparative advantages in political economic transportation and technological resources 38 which results in welldeveloped internet infrastructure this simultaneous change in the internet development index and urbanrural consumption inequality in these municipalities may introduce a selfselection bias in estimation results in the benchmark regression we control for citylevel fixed effects to mitigate this issue furthermore to enhance the robustness of our analysis we exclude samples of municipalities directly under the central government the regression results presented in column of table 4 are consistent with the benchmark regression results confirming their robustness endogenous test to address endogeneity we carefully select appropriate instrumental variables that can effectively control for potential confounding effects the infrastructure of local post offices affects subsequent stages of internet development as it serves as a continuation of traditional communication technology its influence on economic development gradually diminishes with decreased frequency of use ensuring exclusivity following methods used by zhao et al 41 and nunn and qian 42 we construct an interaction term using the number of internet users in china from the previous year and the number of post offices per billion people in each city in 1984 as instrumental variables for measuring internet development during that year in examining the ushaped relationship using the instrumental variable approach we include a squared term of the instrumental variable the 2sls estimation is manually conducted in this study which may increase the variance of the estimation coefficients in the second stage nevertheless the results remain unbiased estimators 43 the regression results are shown in columns of table 4 the variables post and post 2 represent the instrumental variable and its squared term respectively from the regression results of the second stage we observe that the ushaped effect of internet development on urbanrural consumption inequality remains significant even after considering endogeneity the firststage results demonstrate that the instrumental variables exhibit a high correlation with the core explanatory variable as indicated by their highly significant coefficients the overall f statistic of the model rejects the null hypothesis indicating the absence of a weak instrumental variable problem in general the validity of the instrumental variables is verified the empirical tests of influence mechanism 441 urbanrural income inequality this study calculates the theil index of urbanrural income inequality and regresses it with the level of internet development as the explained variable the control variables are consistent with the benchmark regression the regression results are presented in columns of table 5 the coefficient of the core explanatory variable exhibits a negative but insignificant effect whereas the quadratic term displays a positive and significant impact this indicates that the impact of internet development on urbanrural income inequality is not nonlinear therefore the present study employs a linear regression model column reveals that the impact of internet development on urbanrural income inequality is significantly positive which in turn affects urbanrural consumption inequality through the former 3 hence hypothesis 3 is confirmed premature industrial structure referring to the research of tian et al 39 it is evident that a ushaped relationship exists between internet development and the precocity of the industrial structure therefore this study continues to use nonlinear models to verify the relationship between the two the regression results presented in column of table 5 reveal a ushaped relationship between internet development and premature industrial structure providing support for hypothesis 4 and reinforcing the causal relationship posited in hypothesis 1 the potential explanation for these findings is that in contexts of low internet development the utilization of this technology can enhance labor productivity and manufacturing efficiency within enterprises concurrently the internet has expedited labor market mobility and bolstered employment rates within the service industry 44 45 46 47 48 49 thereby promoting the upgrading of the industrial structure and reducing consumption inequality however a high level of internet development may lead to an excessive transfer of production factors from primary and secondary industries to the tertiary industry when the national capacity for innovation and overall labor productivity within the tertiary industry are insufficient to sustain highquality economic growth over time it can result in a premature industrial structure and aggravate urbanrural consumption inequality heterogeneity analysis the spatial distribution of internet development in china exhibits clear agglomeration characteristics prompting this study to investigate the heterogeneity of its impact on urbanrural consumption inequality across different city clusters urban agglomerations as the most dynamic and competitive core areas in economic development patterns typically exhibit compact spatial organization and close economic links 50 owing to significant regional heterogeneity in industrial structure and development stage the impact of internet development on urbanrural consumption inequality may vary greatly with consideration of the development planning and level of urban agglomerations in china this study primarily examines the heterogeneity in five major agglomerations beijingtianjinhebei yangtze river delta the pearl river delta chengduchongqing and the middle reaches of yangtze river considering the consistency in sample size and geographical location of city clusters this study classifies the three major urban agglomerations into one group while dividing cc and my into another group all cities outside of these aforementioned city clusters are classified into a third group for regression analysis the grouped regression results are shown in columns of table 5 a significant difference is noted in the results between city clusters and other cities specifically in other cities the impact of internet development on urbanrural consumption inequality exhibits a significant ushaped relationship consistent with the regression results of the full sample for the cities of bth yd and prd internet development significantly exacerbates the urbanrural consumption inequality however for the cities of cc and my it significantly alleviates such inequality the reason for this disparity may lie in the fact that bth yd and my as chinas three worldclass agglomerations boast a relatively high level of economic and internet development however they lack sufficient support for innovation and productivity resulting in significant urbanrural income inequality and a premature industrial structure which ultimately exacerbates consumption inequality on the other hand for the agglomerations in the central region namely cc and my they have not yet reached the standard to lead to premature industrial structure instead they promote industrial upgrading and reduce urbanrural consumption inequality discussion chinas internet penetration rate reached nearly 50 in 2014 marking the advent of the internet era and presenting a unique opportunity for development however it is crucial to remain cognizant of the doubleedged sword effect that comes with internet development internet development can directly facilitate consumption upgrading and market renewal simultaneously by improving information exchange and resource allocation it can promote industrial upgrading economic growth employment increase and indirectly provide stable support for expanding domestic demand however the digital divide between urban and rural residents has a significant impact on urbanrural consumption inequality caused by internet development building upon the relevant research conducted by tian and luo we systematically examine the nonlinear relationship and influencing mechanism between internet development and urbanrural consumption inequality the research conclusions are as follows first a ushaped relationship exists between internet development and urbanrural consumption inequality that is with internet development the urbanrural consumption inequality index will first decline and then rise the main reason is that internet development that is not matched with technological breakthrough and product innovation will lead to a premature industrial structure and further affect economic development and urbanrural consumption inequality in the whole country and other cities except for the five major urban agglomerations the ushaped relationship between internet development and urbanrural consumption inequality is statistically consistent and stable indicating that internet development is a doubleedged sword second the level of urbanization exhibits a threshold effect on the relationship between internet development and urbanrural consumption inequality when the level of urbanization is below 03474 internet development will exacerbate urbanrural consumption inequality finally internet development will affect urbanrural consumption inequality by influencing urbanrural income inequality and premature industrial structure practical implications based on the above research conclusions and the previous theoretical analysis this paper proposes the following policy implications first we must fully leverage the positive impact of the internet on urbanrural consumption inequality the internet has penetrated into all links of the intraproduct division of labor and has different degrees of impact on employment in the labor market and the labor productivity of the production link we should fully exploit the role of the internet in resource reallocation deeply explore and continuously unleash the dividends of it digitalization and networking development and maximize the scale effect and network effect of internet development for example we can expand internet services by improving their application content enhance societal digital capabilities reinforce governmental efforts toward digital transformation and promote datadriven governance second a precise analysis of regional disparities must be conducted taking into full account the ushaped impact of internet development on urbanrural consumption inequality for bth yd and other economically developed regions the primary focus should be on bolstering their internet development advantages by augmenting investments in technological innovation and enhancing production efficiency within the service industries for the cities with average or poor development in central and western china they should promptly address the deficiencies in their information infrastructure construction leverage the positive impact of internet development and establish an innovative model for urbanrural interaction development both interregionally and intraregionally this can effectively mitigate resource allocation disparities across different areas and address the issue of unbalanced regional and urbanrural development third as we increase the scale and intensity of our investments in the internet regional disparities in urbanization development must be considered all regions should adhere to the objective law of coordinated economic development conduct policy research on integrating the internet and urbanization based on local conditions and establish and improve relevant guarantee mechanisms only by surpassing the threshold of urbanization can we fully leverage the constraining effect of internet development on urbanrural consumption inequality fourth we should facilitate the effective integration of the internet with industry particularly in manufacturing to compensate for the dearth of technological breakthroughs and product innovation we must harness the innovative potential of the internet to drive evolution toward a kuznets industrial structure within both the manufacturing and service sectors thereby achieving sustained growth in macroeconomic conditions and domestic demand fifth the digital divide among vulnerable groups must be addressed and digital dividends should be created for them enhancing the digital skills of marginalized populations such as farmers and elderly individuals is crucial in bridging this gap we should reinforce effective linkages between poverty alleviation and rural revitalization policies to narrow the digital divide across all regions during the process of internet development fiscal and urbanization policies must be coordinated to promote equitable access to digital dividends and vigorously advocate for equal internet speed in both rural and urban areas in addition the equalization of basic public services should be promoted we should improve educational resource allocation and provide training programs to enhance digital literacy thereby enabling individuals to increase their income levels and fully realize their consumption potential limitations and future research there are several limitations to this study first the sample scope is limited due to the lack of some indicators the selection of cities within china may not be inclusive potentially leading to biased results future research can consider expanding the sample size and incorporating a more diverse range of cities to enhance the generalizability of the findings second the data in this study only begin from 2016 due to the availability and accuracy of internet development index data as such this study fails to explore the relationship between internet development and urbanrural consumption inequality before then future research can consider incorporating earlier data to provide a more comprehensive understanding of the longterm trends and dynamics third although we find that the level of urbanization exhibits a threshold effect on the relationship between internet development and urbanrural consumption inequality we do not examine whether other factors also influence this relationship future research can explore the interaction effects between internet development and various contextual factors to gain a deeper understanding of the complex dynamics at play in future research a multidimensional index system can be established to comprehensively evaluate the development status and trends of the internet in china additionally other factors that impact the relationship between internet development and urbanrural consumption inequality can be further investigated to promote their mutually beneficial growth data availability statement data resources are clear in section 32 of this article no new data were created or analyzed in this study data sharing is not applicable to this article due to privacy author contributions conceptualization jz formal analysis zl and hw writingoriginal draft zl and jz writingreview and editing zl and hw all authors have read and agreed to the published version of the manuscript funding this research was funded by hunan provincial innovation foundation for postgraduate institutional review board statement not applicable informed consent statement not applicable

the impact of the digital dividends from internet development on urban and rural residents is influenced by the existing urbanrural dual structure resulting in heterogeneous and timevarying impacts on urbanrural consumption inequality this study aims to investigate the nonlinear effect and mechanism of the internet development on urbanrural consumption inequality in china using panel data from 263 prefecturelevel cities between 2016 and 2019 we employ a twoway fixed effect model and a threshold model to examine this relationship the findings of our study are as follows a internet development exhibits a ushaped relationship with urbanrural consumption inequality this ushaped relationship is statistically consistent and stable in the whole country and in cities outside the five major urban agglomerations b the level of urbanization acts as a threshold for the relationship between internet development and urbanrural consumption inequality c the influence of internet development on urbanrural consumption inequality operates through its impact on income inequality and premature industrial structure to effectively harness the positive impact of internet development in reducing urbanrural consumption inequality several key aspects deserve attention acknowledging regional disparities and leveraging the internets positive impact on urbanrural consumption inequality considering the joint effects of internet and urbanization developments addressing digital divides among vulnerable groups and promoting effective integration between the internet and industry particularly in manufacturing

introduction since 2016 nineteen companies across multiple industries including google uber and tesla have been involved in developing selfdriving cars aiming at commercializing selfdriving cars for the road by 2021 1 the us government has supported the movement of introducing selfdriving cars by diminishing the related regulations 2 in europe the uk government also announced their strong support for selfdriving cars 3 in asia the south korean government allowed companies such as samsung and hyundai to test selfdriving cars on public roads 4 altogether clear evidence suggests that selfdriving cars are becoming a worldwide trend due to immense potential benefits although commercial autonomous cars are likely to be safe and reliable potential adopters will still experience a high level of uncertainty about the safety reliability and control of these vehicles 56 uncertainty is a major hindrance to technological adoption 7 because if people are uncertain about how the vehicle will behave they will be reluctant to relinquish control to the autonomous system such uncertainty can be reduced through vehicle design approaches that help users trust and thus adopt the technology 89 the present paper builds on the notion that people respond to computational technologies following the social rules that govern normal human interaction 10 specifically we focus on the potential for an autonomous vehicle voice agent to display social characteristics that affect the experience of the autonomous vehicle passenger and thus willingness to adopt autonomous vehicles this paper utilizes the technology acceptance model as a theoretical framework to examine how an avvas style and gender influence the perceived ease of use and usefulness of the autonomous vehicle itself thereby influencing intention of adoption literature review technology acceptance model to adoption of intelligent technology davis 11 adopted the theory of reasoned action to explain how people accept technologies tra suggests causal relationships between beliefs attitudes and intentions based on this notion davis 11 reasoned that perceived beliefs toward technologies influence intentions to adopt technologies since davis 11 proposed the technology acceptance model the model has been tested and supported by a large number of empirical studies the core concepts of the model include peu and pu tam predicts that people are more likely to adopt a technology when it is perceived as easy to use and useful also peu has been found to influence pu 11 scholars have extended the model by adding other contextual variables including social influence and environmental influence 1213 the tam is a useful theoretical framework for investigating the determinants of internal beliefs of use although substantive academic works have focused on adoption of computermediated communication technologies such as email telecom internet and ecommerce 14 scholars have expanded the tam to the context of humancomputer interaction for instance heerink et al used the tam to explain the adoption of a healthcare robot for the elderly 15 the tam framework has also been used to investigate the mechanism of technology acceptance however as we enter the fourth industrial revolution researchers are striving to better understand the psychological processes that influence adoption of intelligent technologies that interact autonomously with humans such as autonomous vehicles choi and ji 16 investigated adoption of autonomous vehicles and as the tam predicted found that peu and pu lead to adoption in particular the results showed that pu was a stronger predictor than other variables the current study intended to replicate these previous findings based on tam as a foundational step for the present research building on a conventional understanding of tam we hypothesize the following hypothesis 1 the peu of an autonomous car will positively influence the pu of the autonomous car hypothesis 2 intention of adopting an autonomous car will be influenced by the peu and the pu of an autonomous car intelligent technology as social actors mobile technologies are becoming increasingly intelligent voice assistant systems such as siri alexa and google home can set schedules read articles and entertain people by telling jokes although these intelligent technologies can only mimic human communications based on preexisting algorithms these mimicked behaviors are enough to elicit social presence defined as the degree of perceiving an object as a social other 17 the question of how people interact with technologies is becoming increasingly significant as people have more chances to encounter intelligent entities that are not human early research on this topic concluded that humans interact with technologies the same ways as they interact with other humans 18 in other words people treat computers as social actors research examining human interaction with technologies have supported the idea of casa and found that people perceive human features such as gender and personality in technologies 19 20 21 people also naturally apply various social rules such as social identification 20 similarityattraction 919 and gender stereotypes 2022 when interacting with technologies according to the casa paradigm social science theories can be extended into the context of humantechnology interaction in order to better design assistant technologies in the current study we consider a dualprocess model to frame the types of information that an avva can communicate in order to influence drivers perceptions dualprocess models generally describe differences between intuitive and reasoningbased cognitive processes 23 that is an avva can be designed to appeal to intuitive cognitive processes by being sociable or to reasoningbased cognitive processes by providing taskrelated information returning to autonomous vehicles and the tam we expect that an avva would lead to different perceptions depending on whether it is informative or social these attributes of an avva should influence perceptions of the autonomous vehicle although the avva is only one piece of the larger assemblage of the autonomous vehicle it potentially serves as the primary information interface between the user and the technology thus we expect that tam factors for an avva are applicable to the entire technology more specifically we expect that the extent to which an avva is informative andor sociable will influence tam factors as related to the autonomous vehicle and thus willingness to adopt autonomous vehicles in general people tend to heuristically ascribe social identities to technologies when the technology displays social cues such as sociability and friendliness 10 further such sociability cues can contribute to peu anxiety toward robots has been found to negatively relate to ease of use 24 just as people can reduce others anxiety by acting friendly and sociably toward those others the anthropomorphic cues of sociability and friendliness may reduce anxiety towards the technology and subsequently increase peu thus we predict the following with respect to an avvas sociability characteristics and peu hypothesis 3 a sociable avva will induce more autonomous vehicle peu than an informative avva on the other hand an avva can appear more intelligent by providing dynamic updates of the driving environment which should contribute to the avps situational awareness and thus sense of control 25 belief in system transparency the degree of prediction of the technologys operation is associated with pu and adoption intention 16 if a technology provides information that people can use to predict surroundings or behavior of technology they perceive it to be more useful hence we expect that an avva that informs the avp with dynamic situational updates will be perceived as more useful hypothesis 4 h4 an informative avva will induce more autonomous vehicle pu than a sociable avva the effects of avva gender is also a topic of interest agent gender plays an important role in peoples responses to such technologies 2627 reactions to an agents communication style are influenced by gender stereotypes developed through interactions with humans multiple studies have identified gender differences in communication style for instance scholars have found that communication from men tends to be more taskoriented while women tend to adopt more sociallyoriented communication styles 30 31 32 given these patterns gender stereotyping occurs in interactions with technologies nass and colleagues found that both male and female participants perceived that evaluation from a malevoiced computer is more valid than evaluation from a femalevoiced computer due to the gender stereotype that men are more dominant and influential 22 studies have found that people tend to apply the same gender stereotypes to synthetic computergenerated voices as they do human voices and this affects how people make decisions while interacting with technology 203334 notably studies have found a stereotypedriven matching effect male voices are perceived as more authoritative in general but female voices are trusted and preferred more in contexts that are stereotypically feminine such as love and relationships 2235 returning to the context of avvas and autonomous vehicles and building on this previous literature the match between an avvas communication style and gender will influence perceptions of the autonomous vehicle connecting this to tam we predict that avva gender moderates the effect of communication styles on peu and usefulness such that a social female avva and informative male avva will be preferred over avvas that reflect a genderstyle mismatch hypothesis 5 h5 an informative male avva and a social female avva will be perceived as easier to use than an informative female avva and a social male avva hypothesis 6 h6 an informative male avva and a social female avva will be perceived as more useful than an informative female avva and a social male avva further given that tam scholars have found that peu and pu play roles of mediators 36 we test for the same relationship in the current context we hypothesize that both variables will mediate the influence of avva style and gender on intention of adoption hypothesis 7 peu and pu will mediate the influence of avva style and avva gender on intention of adopting an autonomous car in addition given that in general peu and pu have a strong association with each other 3637 certain features of a technology increasing peu may increase pu indirectly thus we hypothesize peu will mediate the influence of avva style and avva gender on pu h5 an informative male avva and a social female avva will be perceived as easier to use than an informative female avva and a social male avva h6 an informative male avva and a social female avva will be perceived as more useful than an informative female avva and a social male avva further given that tam scholars have found that peu and pu play roles of mediators 36 we test for the same relationship in the current context we hypothesize that both variables will mediate the influence of avva style and gender on intention of adoption h7 peu and pu will mediate the influence of avva style and avva gender on intention of adopting an autonomous car in addition given that in general peu and pu have a strong association with each other 3637 certain features of a technology increasing peu may increase pu indirectly thus we hypothesize peu will mediate the influence of avva style and avva gender on pu h8ab peu will mediate a the influence of avva style and b the influence of avva gender on pu methods experiment design and procedure an online experiment survey was distributed to undergraduate students at an american university participants were randomly assigned to one of the four conditions 2 by 2 two participants skipped one item each from a measure of pu and peu for these two participants the missing response was replaced with the mean for their other responses so they would not be excluded from the analysis this approach did not change the mean value of the respective metric for each individual participant participants were given a small amount of course extra credit for their participation they watched a driving simulation and listened to one of the assigned avva voices participants were given the following instruction before watching the video of the autonomous car simulation please view the following video in full screen mode with your volume on imagine that you are sitting in the vehicle itself during this experience please watch the full video clip then exit full screen mode and complete the questions about the experience the simulation lasted 5 min and 20 s after the simulation participants were asked to complete a set of survey questions note that item order within the questionnaire was randomized within blocks of questions to reduce potential ordering effects experiment treatments methods experiment design and procedure an online experiment survey was distributed to undergraduate students at an american university participants were randomly assigned to one of the four conditions 2 by 2 two participants skipped one item each from a measure of pu and peu for these two participants the missing response was replaced with the mean for their other responses so they would not be excluded from the analysis this approach did not change the mean value of the respective metric for each individual participant participants were given a small amount of course extra credit for their participation they watched a driving simulation and listened to one of the assigned avva voices participants were given the following instruction before watching the video of the autonomous car simulation please view the following video in full screen mode with your volume on imagine that you are sitting in the vehicle itself during this experience please watch the full video clip then exit full screen mode and complete the questions about the experience the simulation lasted 5 min and 20 s after the simulation participants were asked to complete a set of survey questions note that item order within the questionnaire was randomized within blocks of questions to reduce potential ordering effects experiment treatments the virtual agents voice was generated by amazon polly which is a webbased service that turns text into a voice 38 a female voice named joanna and a male voice named matthew were used the generated voice files were edited on audacity to synchronize the recorded scene and the voice 39 for the social avva messages were constructed to focus on relational aspects of communication by disclosing personal information making jokes and referring to users potential concerns 40 for the informative avva the script was designed to focus on providing information about the autonomous cars actions as well as the surrounding environment such as the weather speed limit and traffic signals 40 the scripts for both agents are available in appendix a city car driving software was used to generate the driving simulation this software is commercially available and allows users to practice basic driving skills in a realistic city environment 41 to generate an autonomous car experience a driving simulation scene was recorded while a researcher drove the car this recording along with verbal prompts provided by an avva were played back during the study multimodal technol interact 2019 3 x for peer review 5 of 12 voice 39 for the social avva messages were constructed to focus on relational aspects of communication by disclosing personal information making jokes and referring to users potential concerns 40 for the informative avva the script was designed to focus on providing information about the autonomous cars actions as well as the surrounding environment such as the weather speed limit and traffic signals 40 the scripts for both agents are available in appendix a city car driving software was used to generate the driving simulation this software is commercially available and allows users to practice basic driving skills in a realistic city environment 41 to generate an autonomous car experience a driving simulation scene was recorded while a researcher drove the car this recording along with verbal prompts provided by an avva were played back during the study measurements manipulation check perception of the avva as informative and sociable were used to check the manipulations as well as in the analyses composites were created from means for the informative measure and social measure perceived ease of use peu was derived from a previous study 11 it would be easy to learn how to operate an autonomous car i would find it easy to get an autonomous car to do what i want it to do interacting with an autonomous car would not require a lot of my mental effort and i would find it easy to use an autonomous car perceived usefulness pu was derived from a previous study 11 using an autonomous car would increase my productivity using an autonomous car would increase my driving performance using an autonomous car would enhance my effectiveness on the driving task and using an autonomous car would be useful for driving measurements manipulation check perception of the avva as informative and sociable were used to check the manipulations as well as in the analyses composites were created from means for the informative measure and social measure perceived ease of use peu was derived from a previous study 11 it would be easy to learn how to operate an autonomous car i would find it easy to get an autonomous car to do what i want it to do interacting with an autonomous car would not require a lot of my mental effort and i would find it easy to use an autonomous car perceived usefulness pu was derived from a previous study 11 using an autonomous car would increase my productivity using an autonomous car would increase my driving performance using an autonomous car would enhance my effectiveness on the driving task and using an autonomous car would be useful for driving intention of adoption intention for future use was measured with a composite measure derived from a previous study 16 i intend to use an autonomous car in the future i expect that i would use an autonomous car in the future and i plan to use an autonomous car in the future a 5point likert scale were used for all measurements results two manipulation checks were conducted avva style was found to significantly influence the perception of the avva as informative f 5598 p 0001 partial etasquared 033 with informative perception being higher in the informative avva condition than the sociable avva condition also perception of the avva as social also differed by style f 6165 p 0001 partial etasquared 028 with social perception being higher in the sociable avva condition than the informative avva condition neither avva gender nor the interaction between avva style and gender significantly influenced these manipulation check measures these results suggest the manipulations were successful the hypotheses were tested through structural equation modeling using amos to test the interaction effects of avvas style and gender we used the contrast coefficient approach we coded matched conditions as 1 and mismatched conditions as 1 we checked the fit of the model for cross sectional research it is suggested to report the root mean square error of approximation tuckerlewis index and comparative fit index 42 regarding the criteria of model fits rmsea of 001 005 and 008 indicates excellent good and mediocre fit respectively 43 for tli and cfi fit values above 095 indicate an excellent model fit 44 the study results showed that the suggested model has an excellent or good fit χ2 10721 df 71 p 0004 rmsea 0057 tli 0967 cfi 0975 supporting h1the peu of an autonomous car will positively influence the pu of the autonomous carpeu significantly influenced pu β 088 se 008 p 0001 participants who perceived autonomous cars as easy to use were more likely to perceive autonomous cars as useful supporting h2a and h2bintention of adopting an autonomous car will be influenced by peu and pu of the vehicles avvapeu significantly influenced intention of adoption β 037 se 017 p 0014 along with pu β 051 se 018 p 0001 participants expressed higher autonomous car adoption intent when they perceived more autonomous car ease of use and usefulness providing no support for h3 the results showed that avva style did not influence perceived autonomous car ease of use β 0003 se 009 p 097 there was no evidence supporting h4 avva style was not found to influence perceived autonomous car usefulness β 0016 se 005 p 078 supporting h5avva gender will moderate the influence of avva style on peuavva gender moderated the influence of avva style on perceived autonomous car ease of use such that an informative male avva and a sociable female avva was perceived as easier to use than an informative female avva and a sociable male avva β 017 se 009 p 005 providing no support for h6avva gender will moderate the influence of avva style on puno moderation effect was found β 003 se 006 p 061 providing no support for h7a and h7bpeu and pu will mediate the influence of avva style and avva gender on the intention of adopting an autonomous carpeu and pu did not mediate the influence of avva style β 0006 ci 015 013 nor the avva gender moderating effect on autonomous car adoption intention β 013 ci 002 027 regarding h8a and h8bpeu will mediate the influence of avva style and avva gender on pupeu was not found to mediate the influence of avva style on pu β 0003 ci 014 016 however peu mediated the influence of the avva gender moderating effect on pu β 015 ci 0003 030 the moderating effect between avvas style and gender indirectly influenced pu through peu in other words the finding that stereotypically matched conditions led to greater pu than mismatched conditions was mediated by peu multimodal technol interact 2019 3 x for peer review 7 of 12 and gender indirectly influenced pu through peu in other words the finding that stereotypically matched conditions led to greater pu than mismatched conditions was mediated by peu discussion this research explored how autonomous vehicle voice agent design influences autonomous vehicle passenger intention to adopt autonomous vehicles results suggest that avva design influences perceptions of the autonomous vehicle as reflected by the core factors of the technology acceptance model perceived ease of use and perceived usefulness both of which strongly predicted autonomous vehicle adoption intention no evidence was found for the predicted main effects of avva style on peu or pu however results indicated that avva gender moderated the relationship between avva informativeness and sociability on peu and pu in ways that were consistent with gender stereotypes these results offer new insights into the role of stereotype consistency in the technology acceptance model as well as the importance of considering agent style and gender in the design of voice agents participants perceived an autonomous vehicle as easier to use and more useful when there was stereotypical consistency between the avva style and gender namely consistent conditions fostered greater peu and pu than inconsistent conditions this is consistent with previous studies which have found that gender stereotypes guide the ways that people respond to virtual agents 203334 such as the perception that malevoiced computers are generally more dominant and influential but femalevoiced computers are trusted and preferred more when discussing stereotypically feminine topics such as love and relationships 2235 the present research makes a contribution beyond these previous studies by illustrating that stereotypical consistency in a voice agent influences not only the perception of the voice itself but also the peu and pu of the technology that the voice agent represents given the strong influence of peu and pu on adoption intention this research suggests that stereotypical consistency is an important consideration when examining technology adoption especially in the context of autonomous technologies represented by voice agents this finding is consistent with the notion that more intuitive interfaces increase peu 45 the casa paradigm suggests that people mindlessly apply various social interaction rules such as gender stereotypes to humancomputer interaction 19 20 21 in other discussion this research explored how autonomous vehicle voice agent design influences autonomous vehicle passenger intention to adopt autonomous vehicles results suggest that avva design influences perceptions of the autonomous vehicle as reflected by the core factors of the technology acceptance model perceived ease of use and perceived usefulness both of which strongly predicted autonomous vehicle adoption intention no evidence was found for the predicted main effects of avva style on peu or pu however results indicated that avva gender moderated the relationship between avva informativeness and sociability on peu and pu in ways that were consistent with gender stereotypes these results offer new insights into the role of stereotype consistency in the technology acceptance model as well as the importance of considering agent style and gender in the design of voice agents participants perceived an autonomous vehicle as easier to use and more useful when there was stereotypical consistency between the avva style and gender namely consistent conditions fostered greater peu and pu than inconsistent conditions this is consistent with previous studies which have found that gender stereotypes guide the ways that people respond to virtual agents 203334 such as the perception that malevoiced computers are generally more dominant and influential but femalevoiced computers are trusted and preferred more when discussing stereotypically feminine topics such as love and relationships 2235 the present research makes a contribution beyond these previous studies by illustrating that stereotypical consistency in a voice agent influences not only the perception of the voice itself but also the peu and pu of the technology that the voice agent represents given the strong influence of peu and pu on adoption intention this research suggests that stereotypical consistency is an important consideration when examining technology adoption especially in the context of autonomous technologies represented by voice agents this finding is consistent with the notion that more intuitive interfaces increase peu 45 the casa paradigm suggests that people mindlessly apply various social interaction rules such as gender stereotypes to humancomputer interaction 19 20 21 in other words interfaces that utilize stereotypes facilitate mindless responses that foster more heuristicbased interactions which ease cognitive efforts that individuals would otherwise spend to understand the interface increasing peu helps people identify the usefulness of the technology and ultimately increase the intention to adopt particularly in the early stages of the adoption process 46 through social interaction people develop schemas that can help them more easily interact with and understand their surroundings the study results imply that designing a voice agent to be more congruent with social role expectations may help people use the technology more easily which leads to a greater perception that the technology is useful ultimately leading to greater adoption intention however we do not mean to suggest that designers should replicate and thus reinforce gender or any other socialrole stereotypes in fact designers have the power to shape the social norms that guide expectations regarding social roles just as perceptions of social norms are influenced by depictions of archetypal individuals and groups in popular media such as television or video games interactions with voice agents have the potential to influence status quo perceptions outside of media use in other words complementing the idea that our understandings of humanhuman interaction guide our interactions with technology 18 our interactions with social technologies also affect our understandings of humanhuman interactions thus designers choices of whether to rely on or move beyond stereotypes in their autonomous agent interfaces have real potential outcomes for social interaction in our society stereotyping or the reliance on limited information to make broad generalizations about individuals and groups is harmful to groups and individuals although humans are cognitive misers who prefer to use heuristics to minimize effort during decision making people are also aversive toward biased thinking and would prefer to act in ways that reflect cognitive complexity 49 thus designers have an incentive to counteract or disconfirm stereotypes in their designs at least to some extent in the present context this could mean offering autonomous agents who are equally informative and sociable regardless of gender furthermore the present research did not compare degrees of informativeness or sociability future research should attempt to identify the extent to which a sociable female voice agent can reflect informative functionality before suffering reductions in peu and pu limitations of this research include the sample the fidelity of the simulation technology utilized and the flexibility of the avva technology utilized first this study was conducted with a college student sample this population is potentially not representative of the autonomous vehicle adopter target market future research should use older samples who have a higher likelihood of using such vehicles second this study was conducted as an online study on the participants own devices because of the constraint the modality may not have felt realistic enough for participants to respond in ways that were externally valid thus future research on this topic should be conducted in more immersive simulators finally the method of providing the avvaa prerecorded driving scenario and set of verbal instructionsonly offered a single driving route and scenario while this scenario was designed to represent a typical driving experience in a lowtraffic city a chance exists that this specific scenario influenced participants in ways that would not generalize to other scenarios thus future research should be conducted in other driving contexts these limitations notwithstanding the present research provides an exploratory examination that yields unique insights about the aspects of avva design that influence autonomous vehicle research future research can build on these findings to develop more targeted externally valid examinations of the relationships explored here i hope you will enjoy this autonomous driving experience currently the weather is 65 degrees fahrenheit and sunny i am excited to drive with you in this perfect weather we have arrived at our destination we have traveled 3 miles with 35 miles per gallon fuel efficiency thank you we have arrived at our destination thank you for using this autonomous vehicle today i hope you enjoyed the ride and that i will see you again soon author contributions conceptualization sl and rr methodology sl tp and rr software sl and tp formal analysis sl and rr resources tp and rr writingoriginal draft preparation sl writingreview and editing sl tp and rr supervision sl appendix a

the present research explores how autonomous vehicle voice agent avva design influences autonomous vehicle passenger avp intentions to adopt autonomous vehicles an online experiment n 158 examined the role of gender stereotypes in response to an avva with respect to the technology acceptance model the findings indicate that characteristics of the avva that are more consistent with the stereotypical expectation of the social role informative male avva and social female avva foster greater perceived ease of use peu and perceived usefulness pu than inconsistent conditions social male avva and informative female avva the study offers theoretical implications regarding the technology acceptance model in the context of autonomous technologies as well as practical implications for the design of autonomous vehicle voice agents

introduction in recent years obesity has become a major health issue in the us and worldwide the world health organization estimated that as of 2007 741 of americans over 15 years old were overweight and the us ranked ninth in the world in terms of obesity 1 the growth of obesity is also remarkable 194 in 1997 245 in 2004 and 266 in 2007 2 mental disorders may be an important issue related to obesity approximately 25 of all adults in the us have been reported to experience some mental health disorder each year 3 psychologists have found that obesity is considered a stigma because it is conpissn 19758375 eissn 22334521 ceptualized as a form of physical deviance 4 according to goffman 5 obese individuals are even viewed as not quite human and subject to discrimination or avoidance richardson et al 6 conducted several experiments to rank preferences for 6 images of individuals they found consistent preferences for no handicap over some handicap remarkably the least preferred image was always that of obese children 78 the stigma attached to obesity may generate considerable stress which can lead to mental health disorders although the precise mechanism that causes depression remains unclear textbook causes known thus far include social isolation abuse certain medications such as cholesterolreducing drugs the death or loss of a significant other genetic factors serious illness and substance abuse 9 therefore social isolation due to the stigma attached to obesity might trigger depression if obesity increases the likelihood of a mental disorder then the true cost of obesity may be higher than has been estimated thus far several studies have examined the relationship between can obesity cause depression obesity and depression 10 11 12 but no study has analyzed their causal relationship the first issue to consider is bias due to omitted variables as faith et al 11 and comings et al 13 report the common gene obd7s1875 may make people obese and depressed simultaneously and omitting this gene may be another source of upward bias for the ordinary least squares estimator unobserved individual characteristics may be another relevant factor if an individual shows a high discount rate then he or she may overeat and engage in other unhealthy behaviors such as smoking or avoiding exercise another source of endogeneity is reverse causality according to which depressed individuals may overeat or undereat 14 which may generate an upward or downward bias this paper attempted to characterize the causal relationship between obesity and depression by using a pseudopanel approach in particular we dealt with endogeneity introduced by omitting unobservable factors such as the obd7s1875 gene and other timeinvariant unobservable individual characteristics methods we used the behavioral risk factor surveillance system which is an annual crosssectional survey of the adult population the brfss is a nationally representative sample based on a phone survey using both landlines and cell phones and was established in 1984 covering 15 states it has one of the largest numbers of observations with state identifiers making it the best dataset available for this paper we used the brfss data from the 19972008 period during which the survey used consistent measures of depression variables depression a measure of mental disorder was calculated as the number of days that the respondent felt not good during the last 30 days due to stress depression or problems with emotions for instance a score of 337 means that a respondent had 3 days that they did not feel good in a month we also defined depression as a binary variable with a respondent considered to be depressed if he or she felt bad on more than half of the days of the month based on descriptive statistics 7 of the brfss population was classified as depressed for the sample period the key independent variable was obesity which was measured by the body mass index we constructed pseudopanel data for the analysis deaton 15 suggested the use of cohorts to estimate a fixedeffects model from repeated crosssections in his approach individuals sharing some common characteristics are grouped into cohorts after which the averages within these cohorts are treated as observations of a pseudopanel 1617 importantly panel data allow researchers to account for unobservable individual heterogeneity such as the obd7s1875 gene or other timeinvariant unobservable characteristics although our data set was not originally a panel data set we were able to at least approximately account for individual heterogeneity that participants were asked to identify for how many days during the past 30 days their mental health was not good may have caused a spurious correlation between bmi and depression by grouping the individuals into homogenous units and constructing pseudopanel data nonetheless pseudopanel data are not genuine panel data importantly if a group consists of very different individuals over different periods then observations in each pseudopanel would not share similar genes and unobservable characteristics and the advantage of constructing the pseudopanel would be limited therefore it is important that the grouping is done so that each person is likely to remain in the same group over time thus we constructed pseudopanel data sets based on individuals physical and socioeconomic backgrounds it is possible that the constructed groups were still heterogeneous over time so we considered multiple levels of pseudopanel data in order to obtain as much information as possible the simplest form is the representative agent for each state and time time is measured by year and month together for example january 1997 is a unit of time for every group and period we averaged the variables and formed a pseudopanel data set we constructed 4 more pseudopanels by adding sex marital status race and education level one by one starting from the simplest state and time pseudopanel that is a group in the second pseudopanel in a period was constructed by averaging values among individuals of the same gender living in the same state in the third pseudopanel each group in the second pseudopanel was further divided into subgroups by marital status the last 2 panel data sets were constructed by adding race and education level successively to the grouping criteria in the previous criteria the econometric model for the estimations is given as follows yitβ0β1bmiitβ2xitαiuit where yit is the measure of mental health outcomes for unit i in the pseudopanel calendar year and month are indicated by t αi refers to the unobserved groupspecific effects uit is the error term and x includes sex marital status race hispanic ethnicity education age annual household income and year and month dummies accounting for longrun trends and common seasonal variability results we present the pseudopanel regression results in table 2 the hausman test suggested that the group fixed effects were correlated with the explanatory variables the first column of table 2 shows the results for the simplest pseudopanel data every 1unit increase in the bmi increased depression by 0159 days per month standard errors are clustered by panel group this method provides consistent standard errors if the errors are independent across groups while arbitrary correlations are allowed within each cluster the second column of table 2 shows results for the pseudogroups of state time and sex in this column male and female are not in the same group any more the sample size doubled but the magnitude of the coefficient decreased slightly as we can obesity cause depression considered marital status additionally the coefficient of interest became 0104 which means that a 1unit increase in bmi led to 01 additional depressed days considering race ethnicity and education level improved the precision substantially although the coefficient was robust for these criteria the specification in column 5 means the following a 1unit increase of bmi would increase depression days by 0093 which is 28 of the sample mean this finding was statistically significant at a 99 confidence level the magnitude of this estimate can be interpreted as follows the average bmi increased by 164 from 258 to 275 kgm 2 during this period which was associated with 015252 more depression days per month since the depression days per month increased by 029 increases in bmi would explain 53 of the total variation in depression days per month based on our estimation this is a remarkably large magnitude but it should be interpreted with caution in particular considering that the pseudopanel approach does not account for reverse causality although it deals with omitted unobservable effects we admit the possibility that this result describes correlation it is nonetheless possible to draw more positive implications if the depressed are more likely to overeat than to undereat this effect would act as an upper bound if both tendencies cancel out the effect would be closer to the true causal effects further research is warranted regarding this issue table 3 presents the results from a robustness check the first concern was specifying the functional form for the obesity measure we tried a quadratic specification and found a ushape a bmi of 208 kgm 2 showed the minimum risk for depression and as shown in the third and fourth columns we found that thin people showed a statistically significant negative relationship with depression however obese people presented a statistically significant increase in depression in the bottom panel of table 3 we show the results using a binary specification of the dependent variable we defined an individual to be depressed if he or she felt depressed for more than 16 days per month and this variable was averaged for the individuals in each pseudopanel group thus the depressed variable was the proportion of those who felt depressed for more than 16 days per month out of the population of the group a 1unit increase of bmi increased the probability of being depressed by 03 percentage points which is 42 of the sample mean this was statistically significant during this sample period the percentage of the depressed population increased from 63 to 74 in our data as shown in figure 1 which is a 11 percentage point increase the bmi increase during the same period would explain 05 percentage points of the increase discussion the prevalence of obesity has been rising for at least 5 decades 18 and mental illness is widespread scott et al 19 conducted a crosssectional survey across 13 countries and found a statistically significant association between obesity and depressive disorders mcelroy et al 12 also found that mood disorders and obesity may be related to each other however neither of the above studies could clarify the direction or nature of the relationship observed due to endogeneity we examined the effects of obesity on mental health using the brfss which is a nationally representative survey we attempted to account for endogeneity introduced by omitting important unobservable factors by using a pseudopanel approach and found that the association was still statistically significant there remains the issue of reverse causality for example a depressed individual may overeat or undereat if the former our estimates overstate the causal effects our pseudopanel data do not resolve the reverse causality issue ideally legitimate and relevant instrumental variables would provide a solution if they can be found we leave this interesting topic for future research our finding has an important policy implication based on the medical expenditure panel survey 362 million people in the us paid for mental health services with expenditures totaling usd 575 billion in 2006 20 currently the economic costs of obesity range from usd 147 billion to nearly usd 210 billion per year 21 these estimated costs however do not include the adverse impacts of mental health conditions if we take this into account the cost of obesity would increase recently countries such as japan and denmark have introduced a fat tax and some schools have removed vending machines evidence from this paper can be used to support these social movements conflict of interest the authors have no conflicts of interest associated with the material presented in this paper

the us ranks ninth in obesity in the world and approximately 7 of us adults experience major depressive disorder social isolation due to the stigma attached to obesity might trigger depression methods this paper examined the impact of obesity on depression to overcome the endogeneity problem we constructed pseudopanel data using the behavioral risk factor surveillance system from 1997 to 2008the results were robust and body mass index bmi was found to have a positive effect on depression days and the percentage of depressed individuals in the populationwe attempted to overcome the endogeneity problem by using a pseudopanel approach and found that increases in the bmi increased depression days or being depressed to a statistically significant extent with a large effect size

introduction a social network is a graphbased model where vertices model individuals and edges model the existence of relationships between individuals the type of relationship modelled by a given social network varies and is a function of the application in question however three commonly modelled relationships are friendship social influence and informationresource flow social network modelling has successfully been applied in many application domains for example de la haye et al and ranciati et al performed social network modelling of obesityrelated behaviours and terrorist activities respectively a social network intervention is a process of intentionally altering a social network to help achieve some objective here altering a social network includes actions such as adding or deleting an edge in the social network the objective in question may relate to accelerating behaviour change or improving organisational performance many studies have demonstrated the usefulness of social network interventions wang et al finally we are unfortunately too well aware of the interventions of reducing facetoface interactions performed by many governments to reduce covid19 transmission valente defined a set of models of social network interventions which involve making alterations to the social network by considering vertices edges and individual communities a community is defined as a subset of individuals who share a particular characteristic for example in the area of security one may be interested in modelling communities corresponding to individuals belonging to terrorist groups and national security agencies in this work we propose a novel model of social network interventions which considers topological properties of relationships existing between communities we refer to such relationships as topological relationships relationships existing between communities can exhibit many different properties broadly speaking topological properties of such relationships include properties described by natural language descriptions such as contains partial overlap or disjoint the proposed model represents a generalisation of the original models proposed by valente specifically the proposed model provides a higherlevel abstraction which in many cases is more useful or suitable for solving problems involving social network interventions to illustrate this point consider a social network which contains one community corresponding to terrorists and a second community corresponding to individuals with access to and skills in the use of weapons furthermore let us say these communities are modelled by the social network displayed in fig 1 where individuals belonging to the former community lie in the blue coloured region while individuals belonging to the latter community lie in the red coloured region in this social network the existence of an edge between two vertices indicates the flow of information between the individuals in question due to the fact that individual c belongs to both communities the relationship between the communities may be described as partial overlap such a relationship may be considered a security threat because the community with access to and skills in the use of weapons may share this with the terrorist community modelling the topological relationship between these communities allows the detection of this threat furthermore the ability to apply an intervention which considers the topological relationship allows the elimination of this threat for example if one could apply an intervention to the social network in fig 1 to remove the individual c the social network would change to that in fig 1 that is the relationship between the communities would change from partial overlap to disjoint and in turn the security threat would be eliminated the operation of removing individual c could be performed by detaining the individual in question by defining interventions in terms of topological relationships we abstract away details relating to individual vertices edges and communities which are unnecessary for solving many problems for example when modelling the relationships of partial overlap or disjoint we can abstract away which vertices belong to which communities or how these vertices are connected by edges instead we can model both relationships as a corresponding binary variable indicating the presence or absence of the relationship in question the use of this higherlevel abstraction can therefore in many cases make the process of reasoning about intervention less complex note that an intervention defined in terms of topological relationships will ultimately be implemented in terms of interventions defined in terms of vertices edges and individual communities for example performing the intervention in the above example which transforms the relationship from partial overlap to disjoint is ultimately implemented by removing the individual or vertex c the model proposed in this work can take an intervention defined in terms of topological relationships and determine a corresponding implementation the remainder of this paper is structured as follows in sect 2 we review related works on social network communities social network interventions and modelling topological relationships in sect 3 we present the proposed model of social network interventions which considers topological relationships between communities in sect 4 we demonstrate that the proposed model provides a useful abstraction for solving many realworld problems involving social network interventions this is achieved by simulating interventions on a number of hypothetical and real social networks finally in sect 5 we draw conclusions from this work and discuss possible directions for future research related works social networks communities are a wellstudied research topic however to date most research on this topic has focused on the problem of automatically detecting communities existing in a given social network one of the most commonly used models for performing this task is the stochastic block model which can detect flat hierarchical and overlapping communities in this work we assume the communities in question are known and do not require detection we instead focus on the problem of modelling relationships existing between these communities as such the work presented in this paper is distinct from most existing research on this topic modelling relationships existing between geographical regions is a wellstudied problem in the field of geographical information science the most cited model for performing this task is the intersection model proposed by clementini et al which models topological properties of relationships as discussed later this model provides inspiration for the model proposed in this work modelling the topological properties of graphs or networks is a wellstudied problem in the fields of complex systems and network science models for performing this task commonly consider statistical features such as the vertex degree distribution or algebraic features relating to connected components and holes or cycles the authors are unaware of any previous works that have considered the problem of modelling topological relationships existing between social network communities valente defined four models of social network interventions an individual intervention is a type of social network intervention where a set of individuals are identified and their characteristics are altered this type of intervention is commonly implemented by selecting a set of individuals to act as influencers of other individuals in the social network for example starkey et al used this approach when implementing an intervention to reduce the practice of smoking a segment or community intervention is a type of social network intervention where a set of individuals sharing a given characteristic are identified and their behaviours are altered for example buller et al used this type of intervention to increase fruit and vegetable intake among lower socioeconomic multicultural labour and trades employees an induction or relationship intervention is a type of social network intervention where a set of relationships existing between individuals are identified and the features of these relationships are altered for example hoffman et al used this type of intervention to perform peer education of hiv prevention finally an alteration intervention is a type of social network intervention where individuals and relationships are added and deleted from the social network for example litt et al used this type of intervention to help treat alcoholics by reducing their network support for drinking a social network intervention which is defined with respect to an event such as a terrorist attack or an election is known as an eventbased intervention such interventions can take place before during or after the event in question innes et al examined how eventbased interventions can influence public understandings and definitions of terrorist attacks after they happen the authors identified three corresponding models of social network interventions associated with the communication of misinformation and disinformation they entitled these models spoofing truthing and social proofing spoofing involves the use of trickery deception or misdirection to misrepresent the identity of sources andor the validity and reliability of information truthing involves the use of truth claims including conspiratorial hidden truths or presenting factual information to try and persuade finally social proofing involves the use of feedback mechanisms to construct an aura of social support to influence the behaviour of others dobreva et al examined how eventbased interventions which considered the dissemination of soft facts were used to influence the public before and after the uk brexit referendum the authors define soft facts as facts where the corresponding information provenance is uncertain and include rumours conspiracy theories and propaganda based on the above review of related works we believe that the proposed model of social network interventions represents a novel combination of research ideas from the domains of social network analysis topology and geographical information science social network intervention model in this section we present the proposed model of social network interventions which considers topological relationships between communities the proposed model provides a framework for both defining and determining an implementation of a social network intervention in this context defining an intervention means to state the desired state of the social network one wishes to achieve on the other hand determining the implementation of an intervention means to determine a sequence of steps which achieves this state in the following three subsections we present in turn a model of social networks a model of topological relationships and a model for both defining and determining the implementation of a social network intervention social network let g denote the space of graphs l denote a set of commu nity types and c denote the space of mappings from l to g we model a social network as a graph g ∈ g plus a mapping c ∈ c v is a set of elements called vertices which model individuals and e is a set of pairs of vertices called edges which model relationships existing between pairs of individuals note that the type of relationship modelled by a given social network is a function of the application in question but commonly modelled relationships are friendship social influence and informationresource flow a vertex may belong to zero one or more than one community the map c is a mapping from community type to the corresponding vertexinduced subgraph of the community in question note that we assume crisp as opposed to fuzzy community membership this choice is motivated by the fact that most social network data have this property to illustrate this model consider again the example social network illustrated in fig 1 which contains two communities represented by blue and red regions let the community types in question be blue and red respectively given this the social network in question is modelled as v a b c d e e l blue red c c the mappings c and c corresponding to this model are illustrated in fig 2 and respectively the above model of social networks is general in nature and can be used to model many different types of realworld social networks later we demonstrate this by considering three realworld social networks and associated problems in the domains of health and security topological relationships modelling topological relationships is a challenging problem given a social network simply modelling topological properties of the corresponding graph cannot distinguish between different topological relationships for example consider the topological relationships of disjoint and containment illustrated in fig 3 and respectively despite having different topological relationships the graphs in question are identical and therefore have identical topological properties to overcome this challenge we define a set of subgraphs which are a function of the relationship in question specifically these subgraphs are defined using a set of mappings i u and s which have the form g × g → g we refer to these mappings as binary relations for example the binary relation i corresponds to the intersection of the communities in question the use of binary relations is motivated by the intersection model proposed by clementini et al for modelling topological relationships between geographical regions in this model relationships are modelled by defining a set of regions which are a function of the relationship in question given the above set of binary relations we model the topological relationship in question by modelling topological properties of these relations specifically we define a mapping t ∶ g → z which is applied to each binary relation where z denotes the set of multisets of positive integers in this context an element of z models the number and size of connected components contained in the binary relation in question the use of multisets to model topological properties is motivated by persistent homology which is a model of topological properties from the field of applied topology in the remainder of this section we describe in detail the above model of topological relationships and demonstrate that it can make useful distinctions between topological relationships the specific binary relations one considers are determined by the application in question and in turn what topological properties one is attempting to model in this work we consider the three binary relations i u and s which we found to be sufficient for making useful distinctions between topological relationships the binary relation i is defined in eq 2 where g ∩ g � denotes the graph containing the inter section of the vertex and edge sets corresponding to g and g ′ for example the binary relation i c between the communities illustrated in fig 1 and is the graphs and respectively the binary relation u is defined in eq 3 where g ∪ g � denotes the graph containing the union of the vertex and edge sets corresponding to g and g ′ for example the binary relation u c between the com munities illustrated in fig 1 and is the graphs a n d respectively the binary relation s is defined in eq 3 where gg � denotes the graph containing vertex and edge sets corresponding to g less the vertex and edge sets respectively corresponding to g ′ note that subtracting a vertex causes all adjacent edges to also be subtracted for example the binary relation s c between the com munities illustrated in fig 1 given the three binary relations i u and s we model the topological relationship in question by modelling the topological properties of these relations specifically the topological properties we model are the number of vertices in each connected component this is achieved using the map t defined in eq 5 where z denotes the set of multisets of positive integers and g c denotes the set of connected com ponents contained in the graph g i ∶ g × g → g g × g � ↦ g ∩ g � u ∶ g × g → g g × g � ↦ g ∪ g � s ∶ g × g → g g × g � ↦ g g � to illustrate the map t consider the social network displayed in fig 4 containing blue and red communities which exhibit the topological relationship of containment the binary relation i of these communities is a graph containing three connected components of sizes two one and one therefore the map t of this binary relation is the multiset 2 1 1 this inference is formally stated as follows composing the set of binary relations with the map t we define the set of maps t•i t•u and t•s as follows the maps t•i and t•u are symmetric while the map therefore given two communities a and b we model the topological relationship in question using the set of maps to illustrate this model consider again the social network displayed in fig 4 in this example the topological relationship existing between the blue and red communities is modelled by the map t models both the number and size of connected components modelling the size of connected components is necessary for solving many problems involving social network interventions to illustrate this point consider a social network which contains one community corresponding to a terrorist group and a second community corresponding to undercover agents working for a government intelligence agency furthermore let us say these communities are modelled by the social network illustrated in fig 5 where individuals belonging to the former community lie in the blue coloured region while individuals belonging to the latter community lie in the red coloured region the objective of the undercover agents is to secretly infiltrate the terrorist community in a manner which minimises the probability that the discovery of one agent by the terrorist community causes the discovery of the other achieving this goal may be posed as transforming the topological relationship in question as follows first the connection between the agents is removed so the agents become disjoint as illustrated in fig 5 that is the size of each connected component in the agents community is one next the agents become members of or contained within the terrorist community as illustrated in fig 5 this example illustrates that interventions with multiple objectives can be modelled using the proposed approach by either performing a series of individual interventions or defining a single desired topological relationship which models all objectives t•s is not that is t•i t•i while t•s ≠ t•s t•i t•u t•s and t ∶ g → z g ↦ v � ∶ ∈ g c i c t 2 1 1 t•i ∶ g × g → z g × g � ↦ t t•u ∶ g × g → z g × g � ↦ t t•s ∶ g × g → z g × g � ↦ t t•s finally one does not need to consider the full set of binary relations defined above to model many topological relationships for example consider the topological relationship corresponding to disjoint this topological relationship can be modelled using only the binary relation i which corresponds to the intersection of the communities in question specifically the topological relationship is disjoint if and only if t•i equals the empty set that is this is a necessary and sufficient condition t•i c 2 1 1 t•u c 3 1 1 t•s c t•s c 1 defining and implementing interventions in this section we describe how the proposed model of topological relationships can be used to define and determine the implementation of a social network intervention recall that defining an intervention means to state the desired topological relationship one wishes the social network communities in question to have on the other hand determining the implementation of an intervention means to determine a sequence of operations which if applied achieves this topological relationship for example consider again the social network displayed in fig 1 where the desired topological relationship is disjoint communities a sequence of operations which achieves this relationship is the removal of vertex a and the result of applying this operation is displayed in fig 1 the remainder of this section is structured as follows in sect 331 we define a set of operations which can be applied to a social network in sect 332 we describe how an intervention can be formally defined in terms of a corresponding set of necessary and sufficient conditions if these conditions are satisfied this implies the intervention in question has been successfully implemented finally in sect 333 we describe how the implementation of the intervention can be determined where this implementation is defined in terms of the above operations the above conditions and implementation for a given intervention are both determined automatically hence this allows the process of reasoning about interventions to be performed completely at the abstraction of topological relationships social network operations recall that g denotes the space of graphs l denotes a set of community types and c denotes the space of mappings from l to g furthermore recall that we model a social network as an element of g plus an element of c let 2 l denote the power set of l given a social network g ∈ g and c ∶ l → g ∈ c we define the following set of operations the operation v removes a specified vertex from the graph g note that removing a vertex results in all edges adjacent to the vertex also being removed for example applying the operation v to the social network dis played in fig 1 a how each of the operations defined above is performed in reality and not in the abstract graph model will depend on the realworld application domain in question for example consider the operation of removing a vertex which corresponds to removing an individual from the social network in some application domains this may be performed by detaining the individual while in other application domains it may be performed by confiscating the individuals mobile communication device furthermore the usefulness of each operation will also depend on the application domain in question for example removing a vertex which corresponds to removing an individual from the social network possibly through detainment may be very difficult or impossible to perform in a particular application domain to model these characteristics of the problem we define a set of feasible operations which are a subset of the operations defined above these operations correspond to those which can be successfully performed and are specific to the application domain in question note that the set of operations defined above are very similar to the set of intervention models originally proposed by valente for example an individual intervention which alters the characteristics of individuals is similar to the operation c δ likewise an alteration intervention which alters the structure of the social network is similar to the operations v e and e v ∶ v → g e ∶ v × v → g e ∶ e → g c δ ∶ v × 2 l → c defining interventions a social network intervention can be formally defined in terms of a corresponding set of necessary and sufficient conditions for example consider again the social network in fig 1 where we wish to perform an intervention which transforms the topological relationship to disjoint communities a necessary and sufficient condition for the topological relationship of disjoint is defined as follows which states that the intersection of the communities in question is empty there exist many different topological relationships which may exist between social network communities table 1 lists some possible topological relationships plus corresponding necessary and sufficient conditions the last row in this table provides the necessary and sufficient conditions corresponding to the topological relationship of touching we describe a topological relationship as touching if no vertex is a member of both communities in question but there exists one or more edges connecting the vertices of these communities for example the communities displayed in fig 3 have this topological relationship because the vertices c and d which belong to the blue and red communities respectively are connected for most topological relationships in the above table it is selfevident why the corresponding conditions are necessary and sufficient therefore here we only present a proof of the necessary and sufficient conditions for the topological t•i c relationship of touching this proof is provided in theorem 1 where denotes the multiset cardinality function theorem 1 necessary and sufficient conditions for the topological relationship of touch between communities a and b are t•i and t•u t t proof to prove the conditions are necessary and sufficient we prove that the topological relationship exists if and only if the conditions are satisfied we first prove that if the topological relationship exists the conditions are satisfied if the topological relationship is touch then by definition communities are disjoint and the condition t•i is satisfied furthermore if the communities are connected by edges the number of connected components in the union will be less than the sum of the number of connected components in each community next we prove that if the conditions are satisfied the topological relationship exists if the conditions are satisfied then the communities are disjoint furthermore if the number of connected components in the union is less than the sum of the number of connected components in each community then the communities are connected by edges ◻ implementing interventions in this section we consider the process of determining the implementation of a social network intervention recall that an implementation corresponds to a sequence of feasible operations which if applied achieves the necessary and sufficient conditions of the intervention in question the algorithm used to determine an implementation will vary depending on the intervention in question and the set of feasible operations in the remainder of this section we demonstrate the process of determining the implementation of a specific intervention to demonstrate the process for determining the implementation of an intervention consider again the social network in fig 1 where we wish to perform an intervention which transforms the topological relationship to disjoint communities by examining table 1 we see that the necessary and sufficient conditions corresponding to the topological relationship of disjoint are t•i if we assume all operations in eq 11 are feasible we can determine multiple different implementations for this intervention one implementation can be determined using algorithm 1 this algorithm first determines the graph corresponding to the intersection of both communities it next applies the operation v to all vertices in this graph •i a contained in b t•s b contained in a t•s a and b equal t•s t•s a and b partial overlap t•i ≠ t•s ≠ t•s ≠ a and b touch t•i t•u t t algorithm 1 disjoint communities input a social network g ∈ g l blue red and c ∈ c 1 begin 2 i c 3 for v ∈ v i do 4 v 5 end 6 end applying algorithm 1 to the social network in fig 1 returns an implementation which contains the single operation v which removes the vertex c from the social net work the result of applying this implementation is displayed in fig 1 in theorem 2 we prove that this method for determining an implementation of the intervention in question generalises to all social networks theorem 2 consider a social network where g ∈ g l blue red and c ∈ c plus a set of feasible opera tions containing v algorithm 1 determines an implemen tation of the intervention which transforms the topological relationship between the communities in question to disjoint proof the necessary and sufficient conditions for the intervention in question are t•i c algorithm 1 returns an implementation of the intervention which applies the operation v to all vertices in the graph i c applying this implementation will result in i c being an empty graph and in turn t•i c red hence the necessary and sufficient conditions are satisfied ◻ an alternative implementation of the above intervention can be determined by applying the operation c δ to all vertices in the graph t•i c in the context of this example this results in an implementation containing the single operation c δ which removes the vertex c from the red community given multiple implementations of an intervention in many cases one may wish to select a single implementation to apply the actual implementation selected will in many cases depend on the realworld application domain in question one implementation may be less difficult or expensive to implement in the application domain in that case it makes sense to select that implementation for example removing an edge which corresponds to removing a communication link in the application domain may be less difficult to implement than removing a vertex which corresponds to removing an individual in the application domain furthermore one implementation may have a higher probability of being successful in a given application domain again in that case it makes sense to select that implementation badham et al performed an analysis of social network interventions involving the diffusion of behaviour change the authors found that the success of such interventions is strongly affected by the connectivity structure of the network note that the methods described above for defining and implementing interventions assume that while they are being performed the social network in question does not undergo any changes other than those specified by the implementation if this were to occur the definition and implementation in question may need to be redetermined furthermore if the social network underwent changes after the intervention was successfully performed again the definition and implementation in question may need to be redetermined simulation of social network interventions in this section we demonstrate that the proposed model of social network interventions which models topological relationships between communities provides a useful abstraction for solving many realworld problems in the following subsections we consider three specific social networks and associated problems in the domains of health and security two of these correspond to hypothetical social networks while the third corresponds to a realworld social network the interventions in question are performed in simulation which is a standard practice in the field of social network research using the above problems we demonstrate that the proposed model makes the process of reasoning about intervention less complex than previous models which directly model vertices edges and individual communities for a given problem the intervention in question is first defined in terms of a desired topological relationship as described in sect 3 this definition maps to a set of necessary and sufficient conditions which in turn maps to an implementation corresponding to a sequence of feasible operations since both of these mappings are determined automatically this allows the process of reasoning about interventions to be performed completely at the abstraction of topological relationships infiltrate a terrorist group in this section we describe a social network intervention in the security domain with respect to a hypothetical social network consider again the social network displayed in fig 5 where the blue community corresponds to a terrorist group and the red community corresponds to undercover agents working for a government recall that the undercover agents wish to secretly infiltrate the terrorist community in a manner which minimises the probability that the discovery of one agent by the terrorist community causes the discovery of the other in the context of this domain we assume the following three feasible operations firstly we assume the operation e which removes a given edge can be applied to an edge if and only if the adjacent vertices correspond to agents this is a reasonable assumption given the intervention in question is being carried out by the agents secondly we assume the operation c δ which changes the community membership of a given vertex can be applied to a vertex if and only if the vertex corresponds to an agent this is a reasonable assumption given the agents are trained in the art of infiltrating terrorist groups for example performing the operation c δ would involve the agent d successfully hiding their membership of the agent community from members of the terrorist community finally we assume the operation e which adds an edge between pairs of vertices can be applied if and only if one of the vertices in question corresponds to an agent again this is a reasonable assumption given the agents are trained in the art of infiltrating terrorist groups successfully infiltrating the terrorist community can be achieved by applying two interventions which we now describe in the first intervention the desired topological relationship between the communities is disjoint agents who are not members of the terrorist group let 1 … 1 denote a multiset containing only elements equal to 1 necessary and sufficient conditions for this relationship are the first condition states that each agent is not connected to any other agent while the second condition states that the two communities are disjoint if we assume the two communities initially have the topological relationship disjoint an implementation of t 1 … 1 t•i c this intervention can be determined using algorithm 2 the first step in this implementation determines the red community corresponding to agents subsequently each edge between vertices in this community is removed using the operation e algorithm 2 infiltrate a terrorist group input a social network g ∈ g l blue red and c ∈ c 1 begin 2 c 3 for e ∈ e r do 4 e 5 end 6 end applying the above algorithm to the social network displayed in fig 5 results in an implementation containing the single operation e which removes the edge from the social network figure 5 displays the result of applying this implementation in theorem 3 we prove that this method for determining an implementation of the intervention in question generalises to all social networks theorem 3 consider a social network where g ∈ g l blue red and c ∈ c plus a set of feasible opera tions containing e if we assume that initially the communi ties have the topological relationship disjoint algorithm 2 determines an intervention implementation which satisfies the necessary and sufficient conditions in eq 13 proof initially the communities have the topological relationship disjoint therefore the first condition in eq 13 is immediately satisfied applying the operation e to all edges in the graph c results in this graph having a set of connected components each of size one hence the second condition in eq 13 is satisfied ◻ in the second intervention the desired topological relationship between the communities is disjoint agents who are members of the terrorist group necessary and sufficient conditions for this relationship are the following the first condition states that each agent is not connected to any other agent the second condition states that the agent community is contained in the terrorist community the final condition states that t•u c is a single con nected component and in turn that each agent is connected either directly or indirectly to each member of the terrorist community t 1 … 1 t•s c t•u c 1 an implementation of this intervention can be determined using algorithm 3 the first step in this implementation is to determine the red and blue communities corresponding to agents and terrorists respectively next the community membership of each vertex in the red community is changed to blue red using the operation c δ finally an edge is added between each pair of vertices in the red and blue communities algorithm 3 infiltrate a terrorist group input a social network g ∈ g l blue red and c ∈ c 1 begin 2 c 3 c 4 for v ∈ v r do 5 c ∆ 6 end 7 for v ∈ v r do 8 for v ∈ v b do 9 e 10 end 11 end 12 end applying this algorithm to the social network displayed in fig 5 results in an implementation containing the sequence of operations c δ a and e figure 5 displays the result of applying this implementation in theorem 4 we prove that this method for determining an implementation of the intervention in question generalises to all social networks c δ e e e e theorem 4 consider a social network where g ∈ g l blue red and c ∈ c plus a set of feasible opera tions containing c δ and e if we assume that initially the conditions in eq 13 are satisfied algorithm 3 determines an intervention implementation which satisfies the necessary and sufficient conditions in eq 14 proof initially the conditions in eq 13 are satisfied therefore the first condition in eq 14 is immediately satisfied applying the operation c δ to all vertices in the red community will result in s reducing the spread of hiv in this section we describe a social network intervention in the health domain with respect to a hypothetical social network a common social network intervention concerns attempting to influence members of or spread information within a social network this type of intervention can be modelled in terms of topological relationships to illustrate this consider the two communities displayed in fig 7 where the blue community corresponds to a particular set of individuals who have a high risk of hiv infection while the red community corresponds to a set of individuals educated in hiv preventing techniques in this graph a directed edge represents the presence of assimilative social influence whereby the source individual influences the target individual towards reducing differences the topological relationship between the communities in question is disjoint and this may be considered a contributing factor to the existence of the highrisk community modelling the topological relationship between the communities allows the automated detection of such contributing factors furthermore applying an intervention which alters the topological relationship so that the red community is contained in the blue community would eliminate this factor a necessary and sufficient condition for this topological relationship is if we assume a set of feasible operations containing the operation c δ an implementation of this intervention can be determined using algorithm 4 the first step in this implementation defines a new community which we call the green community containing highly influential members of the red community next the community membership of each vertex in this community is changed to red blue using the operation c δ this operation in turn has the effect of through influence changing the community membership of other vertices in the red community to red blue algorithm 4 reducing the spread of hiv input a social network g ∈ g l blue red and c ∈ c 1 begin 2 c 3 for v ∈ v g do 4 c ∆ 5 end 6 end applying this algorithm to the social network displayed in fig 7 results in an implementation containing the single operation c δ figure 7 displays the result of applying this implementation this operation in turn has the effect of changing the community membership of all other vertices in the red community to red blue this is displayed in fig 7 in theorem 5 we prove that this method for determining an implementation of the intervention in question generalises to all social networks theorem 5 consider a social network where g ∈ g l blue red and c ∈ c plus a set of feasible operations containing c δ if we assume a highly influential green community which is a subset of the red community and directly connect to all other vertices in this community algorithm 4 determines an intervention implementation which satisfies the necessary and sufficient condition in eq 15 proof applying the operation c δ to each vertex in the green community will change the community membership in question to red blue since the green community is directly connected to all other vertices in the red community this will have the effect of changing the community membership of all other vertices in this community to red blue ◻ reducing network support for drinking in this section we describe a social network intervention in the health domain with respect to a realworld social network michell and amos collected a social network where vertices correspond to students in a school in scotland and edges correspond to the existence of a friendship each student was asked to indicate if they consume alcohol more than once a week once a week once a month once or twice a year or never this social network was collected at three different time points for the purposes of this work we consider the social network collected at the second time point and a excerpt containing fifty students which can be downloaded from the internet1 we consider two communities in this social network corresponding to frequent and infrequent drinkers specifically the first community corresponds to those students who drink once a week or more than once a week while the second community corresponds to all remaining students this social network is illustrated in fig 8 where students belonging to the frequent and infrequent drinker communities are represented by red and black vertices respectively the network support for drinking refers to the degree to which an individuals social connections encourage drinking network support for drinking has been found to be predictive of drinking behaviour in fact studies have found that social network interventions which alter the network support for drinking can improve drinking behaviour we now demonstrate how the model proposed in this work provides a useful abstraction for performing such interventions let g ∈ g denote the social network graph in question also let l frequent infrequent denote the set of community types in question corresponding to frequent and infrequent drinkers let n be the following map from a vertex to its corresponding ego community informally the ego community of a vertex v is the graph containing v plus all vertices adjacent to v consider the social network displayed in fig 9 where a single vertex v is indicated the corresponding ego community n contains four vertices and is displayed in fig 9 let us assume that the network support for drinking can be reduced by performing an intervention such that each vertex either belongs to the infrequent community or is directly connected to a vertex belonging to this community a necessary and sufficient condition for this topological relationship is n ∶ v → g v ↦ ∈ e for example the value t•i c cor responding to the vertex v in fig 9 is 2 if we assume a set of feasible operations containing the operation e an implementation of this intervention can be determined using algorithm 5 the first step in this implementation determines the frequent and infrequent communities next for each vertex v in the frequent community where the above condition does not hold a vertex v ′ belonging to the infrequent community is selected uniformly at random and the operation e is applied algorithm 5 reducing network support for drinking input a social network g ∈ g l frequent infrequent and c ∈ c 1 begin 2 c 3 c 4 for v ∈ v f do 5 if t • i 0 then 6 v random 7 e 8 end 9 end 10 end t•i c ≥ 1 ∀ v ∈ v this result of applying this intervention to the social network displayed in fig 8 is displayed in fig 10 the intervention in question added six additional edges and we can see that each vertex now either belongs to the infrequent community or is directly connected to a vertex belonging to this community in theorem 6 we prove that this method for determining an implementation of the intervention in question generalises to all social networks theorem 6 consider a social network where g ∈ g l frequent infrequent and c ∈ c plus a set of feasi ble operation containing e if we assume that initially the infrequent community contains one or more vertices algorithm 5 determines an intervention implementation which satisfies the necessary and sufficient conditions in eq 14 proof for each vertex in the infrequent community the condition in eq 14 is immediately satisfied for each vertex in the frequent community for which this condition is not satisfied an edge is added connecting the vertex in question to a random vertex in the infrequent community this results in the condition in eq 14 being satisfied for each vertex in the infrequent community ◻ conclusions in this work we proposed a novel model of social network interventions which considers topological relationships existing between communities we subsequently demonstrated that this model provides an abstraction which in many cases is useful for solving problems involving social network interventions to the authors knowledge this is the first such model to consider topological relationships as such there exist many worthwhile directions for future research and development of the model some possible directions include the following the proposed model assumes a set of feasible operations which can be applied to a given social network to implement an intervention this is an abstract view and does not consider how each operation is performed in reality for example removing a vertex from a social network may be performed in reality by detaining the individual in question or by confiscating their mobile communication device the former approach may be feasible in the security domain if the individual is a known criminal and those performing the intervention are national police however in most domains detaining an individual is illegal therefore it is important that the set of feasible operations is defined with respect to the application domain in question where how each operation is implemented in reality is clearly specified furthermore the proposed model does not model the fact that different intervention implementations may have different probabilities of being successful modelling such probabilities would be useful in many situations for example where one has many possible implementations of a given intervention and wishes to select the one with the highest probability of success the task of defining the intervention with highest probability of success could potentially be posed as an optimization problem the proposed model makes a distinction between defining and implementing an intervention where these tasks are performed independently that is one first defines an intervention and then determines how best to implement it this may be a suboptimal approach whereby in many cases it may be beneficial to perform both tasks jointly for example by doing so one could define an intervention which both achieves a desired objective and is inexpensive to implement the task of jointly defining and implementing an intervention which meets a specified objective could also potentially be posed as an optimization problem in this article we have considered a handful of specific applications in the domains of health and security however the proposed model is very general in nature with many potential applications beyond these considered here an interesting direction for future research would be to consider applications of the model to eventbased interventions discussed in the related works section of this article finally in this article we have highlighted many potential benefits of using social network interventions however existing models generally only consider the direct consequences of interventions and fail to consider the potential for indirect or secondary consequences these indirect consequences can potentially be very significant for example consider the interventions of reducing facetoface interactions performed by many governments to reduce covid19 transmission the indirect longterm impact of these interventions on the education of children due to school closures is not yet fully understood therefore more research and improved modelling is needed in this space data availability the datasets generated during andor analysed dur ing the current study are available from the corresponding author on reasonable request open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0

a social network intervention is a process of intentionally altering a social network to achieve an objective the objective in question may concern accelerating behaviour change or improving organisational performance in this work we propose a novel model of social network interventions which considers topological properties of relationships existing between communities broadly speaking topological properties of such relationships include properties described by natural language descriptions such as contains partial overlap and disjoint the proposed model provides an abstraction which in many cases is useful for solving problems involving social network interventions we demonstrate this by simulating interventions on a number of hypothetical and real social networks in the domains of health and security

oral disease indeed several studies over the last decade have shown that parity is related to tooth loss but the reason for this relationship is unclear few studies have examined whether parity is related to dental caries a prerequisite to tooth loss the purpose of this study was to determine whether parity is related to dental caries and to examine whether this relationship can be explained by the effect of parity on sociobehavioral variables related to dental caries methods study population and sample selection we used data from the third national health and nutrition examination survey of 7073 black and white nonhispanic women aged 1864 yrs we included women who had received a dental examination retained at least one tooth reported at least one pregnancy and were not missing parity or socioeconomic status data of the 6501 white and black women who received a dental examination 952 retained at least one tooth of these 189 reported no pregnancies and 96 were missing data on ses or parity since the aim of this analysis was to identify pathways by which parity affects dental caries we excluded those with multiple missing explanatory variables and our analysis therefore included 600 of the eligible women the institutional review boards of new york and yale universities approved this study theoretical model our theoretical model of the paritycaries relationship was adapted from that of adler et al who suggested that socioeconomic status may affect health through three pathways health care psychosocial factors and health behaviors we hypothesized that parity would influence dental caries through dental health care psychosocial factors and dentalhealthdamaging behaviors parity untreated dental caries in us women measurements tooth surfaces were scored as sound decayed missing or filled according to the dmfs index dental caries was expressed as the proportion of surfacestotal examined surfaces and included cumulative caries experience the proportion of filled surfaces and the proportion of decayed surfaces all women were asked what is the total number of live births you have had ses included the poverty income ratio education and occupation duncan socioeconomic index a measure of occupational prestige dental care included dental insurance and frequency of dental visits we included two measures of psychosocial status financial stress and social support women reporting one or more days during the previous month with no foodmoney for food were considered to have financial stress social support was measured with six questions exploring frequency of social contacts attendance at churchmeetings and club memberships dentalhealthdamaging behaviors included smoking which included selfreported smoking number of cigarettes smokedday and serum cotinine level and cariogenic diet which combined a monthly consumption of four groups of cariogenic foods cakescookies chocolate candy sugared beverages and sugared sodas age marital status time since last live birth and race were included in all models statistical analysis we created summated standardized scales for ses smoking and agetime since last live birth to maximize use of the available data and avoid collinearity for modeling to create scales we examined correlations between items standardized the items and examined cronbachα reliabilities we then stratified by parity and by ses and conducted univariate and bivariate analyses using anova or the kruskalwallis test since we found that many respondents had missing values on multiple explanatory variables in the model we used multiple imputation with prelis 2 we began with candidate regression models to predict nonmissing endogenous variables with assorted other explanatory auxiliary variables and used monte carlo analysis with multiple chains to simulate five datasets with which to impute missing values along with the covariance structure among them for all other analyses we used statase we used dunnsidak corrections for multiple comparison adjustment we used path analysis to explore complex relationships among variables because of skewed and nonnormal distributions of multiple variables and influential outliers and notable heteroskedasticity in the data we performed robust path analyses using two algorithms the first symptotically attenuated heteroskedasticity with a white sandwich variance estimator and the second downweighted the influence of the outliers path analysis for each robust regression algorithm included performing generaltospecific regressions for variables loading significantly on the outcome variable trimming the full models of nonsignificant paths and creating path diagrams based on the final models to compute total effects we calculated zeroorder relationships between the exogenous variables that loaded on each endogenous variable in the path diagram we performed intermediate regressions for each of these variables identified all indirect paths and calculated the sums of each of these indirect effects as the products of direct paths finally we computed the unexplained effects for each independent variable as the difference of zero order and total effects and calculated an error term for each endogenous variable since our participants represented only a small subpopulation compared with that anticipated by the sample design we chose not to perform a weighted analysis when comparing our sample with the us population of women giving birth over the years 19881992 in the national vital health statistics birth records for the same years as the nhanes iii we indeed found the demographics of our sample to be dissimilar to that of the general us population of childbearing age consequently because our analysis was unweighted our results cannot be generalized to the us population results scale construction education pir and sei were correlated at levels of 042 036 and 049 smoking number of cigarettes and serum cotinine were correlated at levels of 067 070 and 064 age and time since last live birth were correlated at 084 cronbachα reliabilities for the summary variables ses smoking and agetime were 069 087 and 089 respectively women with missing data were older had higher parity were less educated had lower incomes and were more likely to be black than those in our selected subsample descriptive analyses parity was inversely related to ses women with the highest parity levels exhibited similar total amounts of filled decayed surfaces but had more untreated decay than women with lower parity robust regression modeling race ses dental insurance dental care frequency and age time since last live birth were significant predictors of the proportion of filled surfaces and the proportion of decayed surfaces parity was an important predictor of decayed but not filled surfaces and marital status was an important predictor of filled but not decayed surfaces robust path analysis robust path models show variables that significantly relate to the filled surfaces and the of decayed surfaces standardized robust regression coefficients are on the paths and error terms are in grey with the exception of ses and social support higher measurements of all variables indicate less favorable characteristics direct paths leading to both filled surfaces and decayed surfaces include those from ses to dental insurance and dental frequency the directionality of these relationships was reversed between the two path models higher ses having dental insurance and visiting the dentist at least once a year were all related to more filled and fewer decayed surfaces the relationship between dental visit frequency and decayed surfaces was especially strong common paths for both models included those from ses to dental insurance and to dental frequency and the path between these two variables women of higher ses were more likely to report going to the dentist at least once a year and were more likely to have dental insurance the relationship between ses and dental visit frequency however was almost twice as strong as the relationship between ses and dental insurance additional consistent paths included those between ses and parity ses and marital status and marital status and parity higherses women were more likely to be married and married women had higher parity the sesparity relationship was twice as strong as the sesmarital status relationship cariogenic diet was unrelated to caries a small indirect effect of ses through smoking and dental frequency was found for both filled and decayed surfaces major differences between the two path diagrams included a path between marital status and filled surfaces indicating that married women were more likely to have more filled surfaces and a path between parity and decayed surfaces demonstrating that higherparity women were more likely to have more decayed surfaces discussion this is the first evidence in a large heterogeneous sample of us women that parity is related to untreated dental caries regardless of ses race and age despite the public perception that childbearing causes oral health deterioration only two studies have specifically examined the relationship between parity and caries while neither of these previous investigations identified a relationship between parity and caries it is possible that because these existing studies were performed in africa the results are not completely relevant to women with access to dental care the old wives tale a tooth for every child is generally attributed to the idea that pregnancy depletes maternal teeth of calcium making them more cariessusceptible in truth the developing fetus actually draws needed calcium from the skeleton but other biologic mechanisms for an increase in susceptibility to caries during pregnancy have been proposed many of these physiologic mechanismsincluding variations in saliva oral flora alterations and the immunosuppressed state of pregnancy are those that possibly contribute to a documented mild but persistent sexgender disparity in caries rates in the us our finding that increased parity is associated with untreated decay along with other evidence that relates parity to tooth loss suggests that greater caries susceptibility associated with higher parity may not be solely biological but also sociobehavioral it is possible that higherparity women are more likely to have carious teeth extracted while lowerparity women are likely to have teeth restored pregnancy and maternity alter patterns of dental treatment and traditionally dentists have been advised that routine dental care for pregnant women should occur only during a limited window the second trimester also because of a lack of knowledge regarding the safety of treatment during pregnancy fear of malpractice or fear that a woman may go into labor dentists may refuse outright to treat pregnant women may revise treatment plans when they discover a womans pregnancy or may postpone care until after the woman has given birth additionally some pregnant women feel that going to the dentist is unsafe during pregnancy and may postpone treatment until after the birth but at that point access to dental care may be restricted due to childcare and time or financial constraints pregnant women in the us have high levels of dental disease and treatment needs but the proportion of pregnant women who report having a dental visit is low in fact even pregnant women with a dental problem are unlikely to see a dentist our finding that being married was related to filled surfaces supports the findings from a previous study that most pregnant women who reported a dental visit were nonminority married and educated beyond high school unfortunately since rates of dental access and utilization among pregnant women vary significantly by ses those pregnant women most at risk for dental disease are least likely to receive dental care when pregnant there are several limitations to this study because we did not use the sampling weights supplied by nhanes iii our results are not generalizable to the us population second because of the complexity of our analysis we chose to limit the study to only black and white women mexicanamerican women are likely different from nonhispanic women regarding issues related to parity including culture and psychological factors related to parity such as social support in the future studies should examine the parityoral health relationship among different ethniccultural groups third we were limited to those variables measured as a part of nhanes iii finally these data are crosssectional and although the directionality of the associations in the path models were created based on judgment of how relationships would work in reality we should emphasize that one cannot assume directionality in the case of this study receiving dental care during pregnancy is safe and guidelines have been published that advocate for dental care for pregnant women interventions aimed at pregnant women and women with small children could have a bearing on the dental health status of this significant proportion of the us population not only because most women do have children but also since maternal oral health is related to a childs oral health efforts to correct disparities in parityrelated dental caries may serve to correct this imbalance by addressing specific needs of women with children regarding issues including care of dental disease during pregnancy access to dental care and dental programs aimed at families

while parity number of children reportedly is related to tooth loss the relationship between parity and dental caries has not been extensively investigated we used path analysis to test a theoretical model that specified that parity influences dental caries levels through dental care psychosocial factors and dental health damaging behaviors in 2635 women selected from the nhanes iii dataset we found that while increased parity was not associated with a greater level of total caries dfs parity was related to untreated dental caries ds the mechanisms by which parity is related to caries however remain undefined further investigation is warranted to determine if disparities in dental caries among women are due to differences in parity and the likely changes that parallel these reproductive choices

introduction ugandan academic mahmood mamdani has been dividing his academic activity between columbia university in the united states of america and makerere university in uganda for a long time mamdani has been the herbert lehman professor of government at the school of international and public affairs columbia university as well as professor of anthropology political science and african studies at the same institution 1 concomitantly mamdani has been director of the makerere institute of social research a social sciences institute whose space he has used to focus his academic energies to train a new generation of social science and humanities academics in other words mamdani holds at least two formal academic appointments in two countries on two continents in 2018 years following a clash over his proposed core course on africa at the university of cape town in south africa in 1997 dubbed the mamdani affair which led to his resignation the langa african diaspora and its multiple academic affiliations distinguished scholar was reappointed as an honorary professor at the centre for african studies 3 in addition mamdani is a respected political commentator on africa and a widely published author he can therefore be acknowledged as an african diaspora scholar with multiple translocal scholarship engagements while mamdani might epitomise the prominent public intellectual and ads the literature shows a growing tendency of scholars some less publicly visible holding multiple academic appointments in the era of the socalled global academic marketplace possibilities for multiple international academic appointments have increased significantly as exemplified by mamdani in the case of uganda most african countries have their own class of translocal academics these scholars can either be africanbased diaspora scholars taking up appointments in a country other than their country of origin or ads based outside the continent but collaborating through temporary appointments with universities in africa the elements uniting these scholars are international leadership in their respective disciplines high productivity in terms of scientific publications and impact measured through citations and their status as global public intellectuals these particular academics possess high levels of scientific and symbolic capital academics with multiple appointments and affiliations are no longer an uncommon phenomenon in the global higher education context while on a global level academics display high local and international mobility the data on academic mobility particularly in africa remain inaccurate and insufficient and consequently a persisting challenge despite the growing tendency to collect data on student mobility a paucity of data on academic staff mobility in general and mmas in particular remains the norm on the continent according to altbach et al the academic profession will become more internationally oriented and mobile but will still be structured in accordance with national circumstances hence although academic profiles similar to mamdanis are becoming more common and more visibleespecially in the context of the globalised academic marketplace not all institutions and academics have the ability to attract and engage in such appointments in general globalisation tends to concentrate wealth knowledge and power with those already possessing these elements by and large in developed countries institutions and corporations own most knowledge knowledge products and information technology infrastructure though southtosouth collaborations and networks are increasing especially in asia latin america and africa different circumstances might determine whether the mobility of scholars is classified as brain drain particularly when there is departure to the diaspora or brain gain when an academic returns to his or her country of origin after a position abroad in general academics go from developing countries to north america western europe and asiapacific there are also significant flows from subsaharan africa to south africa from south asia to the middle east and africa from egypt to the wealthier arab countries and from the united kingdom to canada and the usa a key motivator for the direction of this flow is the level of salaries but among other factors improved working conditions research support infrastructure opportunities for advancement and academic freedom may also play a role those in the diaspora can exert a strong influence by keeping in contact with the academic communities in their home countries and by sharing research and experience however the global flow of academic talent works to the disadvantage of emerging countries although there are indicators that this status quo is changing more chinese scholars are choosing to return home after sojourns elsewhere for example universities in singapore hong kong china and elsewhere are attracting western academics with high salaries and favourable working conditions in fact the volume of southsouth cooperation in higher education and research has significantly increased in the past decade one common argument for southsouth cooperation by southern countries is their similar phase of development and hence their mutual capability to develop practices relevant to each others contexts compared with northsouth partnerships southsouth cooperation is often also cheaper to implement in terms of mobility and is based on fewer prerequisites thus facilitating the start as well as ongoing administrative procedures however developing countries in subsaharan africa are rarely involved in intraafrican cooperation accurate growth data on southsouth including intraafrican cooperation are often unavailable because they are not systematically collected at the national or international level initiatives and programmes largely financed by the north are focused on the south additionally international academic mobility favours wellestablished education systems and institutions thereby compounding existing inequalities the international mobility of african academics particularly to developed countries has been regarded as a negative consequence of global market forces since the early 1990s there has been an almost uncontested narrative that developing countries have been losing higherlevel skilled professionals each year to the developed world this alarming description of a dangerous human capital exodus from africa to the developed world has dominated the political and academic discourse the economic commission for africa claims that between 1960 and 1989 some 127000 highly qualified african professionals left the continent according to the international organization for migration africa has lost 20000 professionals each year since 1990 the idea that africa suffers from brain drain thus became the conventional wisdom in media and academic circles there are no indications to date that scholarly opinion has shifted significantly however in the era of relatively easy air travel and everincreasing digitalisation many internationally mobile academics retain close links with their home countries or continent a more optimistic approach regards the current status quo as brain gain or brain circulation and can offer many opportunities for developing countries the article argues that is that the concepts of maas and brainsharing particularly in the age of digitalisation broaden both the scope and the possibility of a winwin situation by sharing the academic and intellectual capacity of highly productive academics through capitalising on maas and collaboration between universities and their diaspora scholars while the article provides insight into the extent and structure of maas further research into the contractual and organisational nature of maas in africa is needed to inform policy and decisionmaking on the issue the article concludes by suggesting that if properly managed maas together with the effective use of information and communication technology and elearning platforms can offer an opportunity to curtail the undesired consequences of brain drain literature review brain drain a bleak picture of african diaspora at the transition into the twentyfirst century the body of literature on the african academic diaspora has grown significantly in the last two to three decades however there continues to be a paucity of literature and research on the kinds of appointments diaspora academics occupy in their collaboration with african institutions even literature which presents the notion of brain circulation as an antidote to the undesired effects of brain drain does not elaborate on the actual forms of engagement diaspora academics undertake with their partner institutions often examples provided from those countries which are considered to have adopted strategies to curb brain drain such as china and india do not provide the particularities of the contractual agreements these academics make with both the home and host institutions likewise studies on the contractual nature of maas are still rare in general the literature tends to focus on brain drain in the context of human capital losses or gains this trend is related to a perspective from the discipline of economics which diaspora studies have frequently embraced hence while human capital gains enhance economic growth losses generate important problems in the growth process of any country notwithstanding this recognition research attention on the international movement of economic resources has focused more on the physical movement of people across borders and continents as opposed to the virtual exchange of human capital via ict and elearning platforms in a world increasingly characterised by virtual connectivity and the rise of the network society the recurring definition of the international movement of human capital as loss brain drain is generally accepted as it is perceived as the drainage of talented people from one country region or continent to another in search of better professional and personal opportunities usually the concern with brain drain becomes relevant in the context of competition amongst nations which may lead to scarcity of skills and talents in this sense brain drain constitutes a great loss for the country from which migration takes place because it is the exodus of the most educated stratum of a particular society the concept of brain drain is therefore used to describe the loss of advanced professional and technical skills such as scientists academics doctors engineers and other professionals with university training in that sense it alludes to the most trained fraction of a particular society the literature on the african diaspora denounces the academic mobility of highlevel skilled personnel from emerging countries for example in africa to western countries this view assumes that the diaspora negatively affects the socioeconomic and sociocultural prospects of developing nations since they lose human capital to the developed world literature produced in the late 1990s and early 2000s proposed remedial measures to deal with brain drain which was regarded as a national threat to developing nations this dreary picture was often based on imprecise figures and presented a worrisome situation figures on african brain drain in the case of africa the idea that the best and brightest are fleeing the continent has been documented and supported with figures provided by various sources including organisations such as the international organisation of migration the united nations educational scientific and cultural organisation the world bank and researchers according to the iom africa had already lost onethird of its human capital and continues to lose its expert personnel at an increasing rate with an estimated 20000 doctors university lecturers engineers and other professionals leaving the continent annually according to the iom over 300000 african professionals live outside of the continent and approximately 20000 african professionals migrate to western countries every year the iom estimates over 300000 highly qualified africans were in the diaspora 30000 of whom were phd holders at the same time africa was spending us 4 billion per year to employ some 100000 expatriates performing functions generically described as technical assistance while skilled africans leave the continent nonafricans work in skilled jobs on the african continent in figure 1 below capuano and marfouk use a dataset developed by docquier marfouk özden and parsons to compare the highly skilled emigration rates when emigration to nonoecd countries is also considered the figure shows that the brain drain is mostly underrated in subsaharan african countries such as burkina faso chad lesotho namibia swaziland niger and mali for instance for lesotho the high skilled emigration rate to the oecd and nonoecd countries is approximately six times higher than the highskilled emigration rate to the oecd countries capuano and marfouk also in figure 1 show that the magnitude of the brain drain is also underrated for nonafrican countries in fact dmop only considers 76 receiving countries due to the low quality of the data the information on sending countries is partial but enough to give an overall idea of the immigration trends of high skilled people furthermore in the year 1999 africa as a whole counted only 20000 scientists and its share in the worlds scientific output had fallen from 05 per cent to 03 per cent as it continued to suffer a brain drain of scientists engineers and technologists reports based on figures from iom and unesco show that the problem of brain drain has reached quite disturbing proportions in certain african countries with ethiopia ranked first on the continent in terms of rate of loss of human capital followed by nigeria and ghana over the past 10 to 15 years about 50 per cent of ethiopians who went abroad for academic training did not return after completing their studies according to the iom ethiopia lost about 746 per cent of its human capital from various institutions between 1980 and 1991 the report states that while ethiopia had only one single fulltime economics professor there were more than one hundred ethiopian economists in the usa this bleak braindrain scenario resulted in the united nations recognising that the emigration of african professionals to the west was an obstacle to africas development studies in the first 15 years of the new millennium show that research collaborations between african scholars and international academics recorded a slight improvement in african research output a major area of african governments higher education policies have tended to respond to the migration of african professionals including academics to the north in one of three ways first they admonish the brain drain and engage in mutual accusations with the diaspora governments of originating countries may view their migrants as unpatriotic for leaving their countries when they are needed the most attitudes can also shift from positive to negative if migrants gather resources become more organised and hence become politically influential implying a potential threat to the status quo second some governments have pursued the brain gain argument to encourage the diaspora to return permanently for instance ghanas main concern has been the health sector and it acts to prevent the departure of its health professionals at the same time it encourages ghanaians abroad to provide temporary service in the national health system furthermore policies can be developed as ways to promote the extension of rights of citizens residing outside national boundaries relevant policies include the political incorporation of migrants either by allowing dual citizenship and providing expatriates with passive and active voting rights or by granting migrants access to civil and social services in this respect the government of ghana passed a dual citizenship law in the year 2000 and more recently provided ghanaian migrants with the right to vote in elections in ghana another example is the government of india which has created a systematic method to attract the skills and human capital of its diaspora for the development of various sectors of the indian economy the third governmental response is the diaspora option which recognises migrants as new diasporas efforts are made to build effective strategies of brain mobility or brain circulation between them and their countries of origin as well as the continent as a whole the latter requires developing innovative strategies for knowledge and skill circulation such as the creation of national regional and continental knowledge networks facilitating brain mobility through academic exchanges consultancy assignments and temporary return migration movements changes in the academic profession in the knowledge society globally substantial research has been produced on the changes taking place in the academic profession in the era of the knowledge society however with the exception of south africa africa has generally been neglected in such studies in the new era the framework of higher education has experienced major changes similarly the backgrounds specialisations expectations and work roles of academic staff have undergone transformation the academy is expected to become more professional in teaching more productive in research and more entrepreneurial concomitantly knowledge has come to be identified as the most vital resource of contemporary societies to respond to the multiple demands and challenges of the knowledge society academic work has been adapting itself by developing new content and reshaping its forms translocal and transnational institutional affiliations and engagements with multiple stakeholders both facetoface and online have become part of the portfolio of many academics as an integral part of their academic work thus academic affiliation is becoming an elusive home however in some cases the academic profession still maintains certain features that are not always compatible with the new demands on the translocal context of higher education this is the case particularly in the african context where academics still tend to be employed on manual workertype contracts which require physical presence in the workplace this situation is amplified whenever academics are remunerated on the basis of the number of hours they are supposed to dedicate to teaching activities and research and where outreach is not specified as part of their work in an era marked by increasing globalisation and internationalisation of the academic profession and langa african diaspora and its multiple academic affiliations scholarly work with academics engaging in multiple international institutional affiliations certain traditions and practices in academic management such as single institutional contracts are being challenged research approach and data sources being an exploratory study the information and data used in this article derive from multiple sources including a literature review conversations with africanbased and african diaspora scholars 4 and reports of bibliometric databases on academic collaborations the conversations with africanbased scholars and ads took place in the context of their participation in the establishment of two postgraduate programmes and an academic staff exchange and mobility programme the council for the development of social sciences research in africa through its programme african diaspora support to african universities sponsored seven academic exchanges between abs and ads from 2016 to 2018 through these a number of joint activities took place including i curriculum design of two new phd programmes in higher education studies at the university of the western cape and eduardo mondlane university ii cosupervision of postgraduate students iii delivery of public lectures iv seminars with doctoral and postdoctoral fellows at the institute of post school studies of uwc and uem v joint grant applications and vi reciprocal institutional visits between abs and ads the collaboration between abs and ads has since continued by means of another funding source the carnegie corporation of new york for the period 20162019 the ccny also sponsored seven doctoral students and three postdoctoral research fellows in higher education studies at uwcs ipss enabled by codesria and ccny sponsorship combined more than ten abs and ads visited the ipss between 2016 and 2018 the article interweaves a theoretical research exploration together with the perspectives of those abs and ads who participated in the doctoral programme in higher education studies at the ipss the main research objective is to explore the types of engagement and the nature of contractual arrangements diaspora academics engage in all academics and visiting fellows in the dphes display different contractual arrangements and maas with various african institutions as well as with their current or permanent universities in europe or america a variety of topics are discussed in what follows reflecting concerns and views regarding opportunities and challenges of engagement with the academic diaspora the research focus was on multiple international appointmentsaffiliations which are emerging as a global trend in the academic profession with implications for african academia brainsharing exploring multiple academic affiliations studies by paul zeleza on engagements between ads in the usa and canada and african institutions of higher education shed muchneeded light on possible roles that the african academic diaspora can play in supporting african universities although zelezas studies mostly turn a blind eye to intraafrica or internal african academic diaspora they are nevertheless an invaluable contribution to scholarship on the role of academic diasporas a dimension that is largely absent in zelezas research on diaspora as in most literature on the african academic diaspora is the specific forms of affiliation scholars engage in including contractual arrangements indeed as far as the african research community is concerned little is known about the modalities of engagements and contractual arrangements to promote collaboration between african academic diasporas and their academic peers on the continent in fact zeleza acknowledges that many african diaspora academics have established vibrant albeit largely informal engagements with individuals andor institutions across africa these engagements range from research collaboration to curriculum development and graduate student supervision he also recognises that diaspora engagements frequently face institutional and attitudinal barriers zelezas work identifies some of the major obstacles that hinder engagement with the diaspora i differences in resources and facilities ii a mismatch in expectations between africanbased and african diaspora academics iii different academic status teaching loads and institutional priorities and iv scheduling around incompatible academic calendars between the sending and receiving institutions this study reinforces zelezas observations in that traditional structures paired with a lack of knowledge about new trends in the academic profession impede new creative and f lexible modes of promoting langa african diaspora and its multiple academic affiliations collaboration between ads and abs the next section explores the challenges and opportunities of miaas in the african context for a comprehensive overview see table 1 below the sports contract mentality an internationally competing football player cannot perform in and be contracted by two national teams therefore strict rules from football governing boards such as the international federation of association football subscribed to by national football confederations sanction and prevent players from double contracts with clubs obviously the circumstances of professional athletes in highperformance sports which imply physical engagements and presence are decisive in contractual obligations unlike in professional sports the academic profession and the nature of academic work is more flexible as it allows for virtual nonfacetoface interactions in the age of web 40 even laboratories can be shared virtually the rise of eclassrooms is no longer an imagined reality there has been a profound structural and morphological transformation of the conditions under which learning and teaching as well as research take place downes argues that new technologies allow for the deinstitutionalisation of learning the rise of virtual classrooms is well documented as are various elearning tools and technological resources for example moodle blogs facebook wikis which have revolutionised the meaning of a classroom the rapid spread of ict has changed traditional ways of communication and informationsharing new technologies have brought innovations to different aspects of society and of relevance here to teaching and learning processes in higher education these innovations have improved the types of communication interaction and knowledgesharing engaged in between individuals and groups a new generation of students known as digital natives the net generation or generation y has not known the world without the internet nowadays it is possible to share the knowledge of ads or any other international experts without them having to physically move to africa likewise it is possible for abs to teach in universities in the north technology has become both a facilitating element and a tool to create bridges between african universities and institutions in other parts of the world nevertheless most african universities treat their academics as manual workers who have to be physically present at their workplace this trend is related to the following factors i most african universities have seen an increase in student intake on campuses therefore requiring the physical presence of lecturers in classes and lecture halls ii academic work is mostly conceived of in the traditional way of teaching usually very large classes thus requiring physical presence iii some institutions have introduced attendance registration books to keep a record of the physical presence of lecturers in classes in some cases fingerprintenabled digital control of lecturers physical presence in class is taking place particularly in private institutions that pay staff per hour taught the traditional idea of academic work being defined as teaching in class reinforces the predisposition of most african universities to oppose international collaboration and mobility the professional athlete mentality therefore obstructs the mobility and ability of ads to engage in multiple affiliations and international academic collaborations academic staff managers and human resource departments in most african universities have set rules and regulations to control the local mobility of academics although claiming to promote academic mobility langa african diaspora and its multiple academic affiliations university managers regularly apply restrictive regulations and measures which infringe on this principle the digital fingerprint tool mentioned above for instance is utilised as a control mechanism to monitor academic staffs class attendance thereby reinforcing the prevalent physical presencebased facetoface teaching culture the turbo lecture the downside of multiple local institutional affiliation africanbased academics commonly teach in more than two institutions or in different time shifts in the same institution as a way to supplement their relatively meagre salaries usually these lecturers carry a heavy workload leaving little or no time for research the absence of national and institutional databases facilitating staff administration contributes towards the poor management of academic affiliations in order to curb the socalled turbo lecture that is an individual with multiple teaching appointments it would be necessary to establish onesizefitsall regulations which prevent academics from engaging in collaborations with other national and international institutions while it may seem reasonable for universities to want to counteract the turbo lecture as denounced by mamdani as an unpleasant side effect of the commercialisation of higher education they also need to promote the international mobility of their academic staff while turbo lectures may represent the decay of african academia internationally mobile and engaged academics are outliers and represent the positive side of multiple international engagements global networks and multiple international engagements contribute to giving african institutions a positive reputation outlier academics have profiles that are similar to those of their peers in research universities in the north yet unlike their counterparts they do not usually receive the same recognition furthermore they are usually confronted with the demands of a heavy teaching load and overcrowded classrooms in their home institutions with their physical presence being required at all times despite the advantages that miaas can bring to african universities most do not seem ready to explore their benefits in the context of changing incentives and reward systems it is increasingly important for academics to cooperate and copublish internationally for instance internationalists increasingly compete with locals in university hierarchies for prestige and for access to projectbased research funding across europe in africa despite the paucity of data research shows that more productive academics are likely to engage in multiple networks of collaboration with international partners a study conducted by kyvik and reymerton shows that membership in a research group and active participation in international networks are likely to enhance publication productivity and the quality of research collaboration is hence central to the viability of engagement with the diaspora collaboration in research can take different forms from giving informal advice to colleagues to working closely together via institutional agreements teamwork can be undertaken between colleagues in a university department between peers in different departments with other universities or research institutes with industry and with research establishments in other countries collaboration can take place between two individual researchers or between many scientists as members of large teams paradoxically in order for african academics to be more productive they need the autonomy to engage in miaas and networks of collaboration with translocal research groups this requirement often clashes with the inflexibility of their academic job descriptions and the contractual obligations at their home institutions joint and double degrees an opportunity for reciprocity in maas a recent development in african higher education is the establishment of joint and dual or double degree programmes particularly at postgraduate level in collaboration with international universities in europe america and asia a joint degree programme usually at masters or phd level is offered jointly by two or more international universities and results in a joint diploma which is formally accepted by all degreeawarding partner universities a double degree programme also known as dual degree combined degree conjoint degree joint degree simultaneous degree or double graduation programmeinvolves students registering and studying for two different university degrees in parallel either at the same institution or at different institutions including in different countries at times and completing those degrees in less time than it would have taken to earn them separately the two degrees might be in the same subject area applicable in particular when the course is split between countries or in two different subjects langa african diaspora and its multiple academic affiliations in latin america and southeast asia the number of northsouth doublejoint degree programmes has grown for example between a latin american country and france spain the usa or germany and between japan south korea and vietnam cambodia or mongolia in africa joint degree programmes are also taking off in europe the process of establishing joint degree programmes was started by the bologna declaration in 1999 it formulated a set of goals including the development of a european higher education area to promote citizens mobility and employability to achieve greater compatibility and comparability of the systems of higher education and to increase the international competitiveness of the european system of higher education as well as its worldwide attraction for students and scholars some northsouth double degree programmes have received international funding for example from the european union or via the german academic exchange service programmes from germany aimed at promoting the development of these types of degrees african universities have also benefited from such programmes particularly through the eufunded intraafrica mobility programme the number of northsouth dual and joint degree programmes appears to be growing currently dual degree programmes still dominate as they have to adhere to fewer regulations and are thus easier to establish in addition not all countries legally allow the creation of joint degree programmes joint degree programmes are one example of promoting equal collaboration between abs and ads where all sides have similar opportunities for academic exchange and maas however as it stands european partners including the african diaspora regularly benefit more than their abs partners from these programmes in most cases the engagement of african diaspora and northern partners is viewed by the latter as a generosity resulting in intellectual and academic remittances to african universities african diaspora as an intellectual generosity the idea that engagement with ads results in intellectual and academic remittances to abs raises some questions this understanding leads to abs being placed in a disadvantaged position when compared to their counterparts academic collaboration involves a free sharing of ideas and the possibility of coproduction of new knowledge for mutual benefit however ads frequently position their collaboration as an expression of intellectual generosity through nurturing the development of less experienced colleagues ads thus position themselves as mentors providing a platform for the better visibility of abs through joint publications the exploitation of junior researchers by those in positions of power and seniority a constellation also referred to as collaborationasparasitism is also sometimes observed in ads and abs collaborations whilst collaboration has always been at the heart of academic work its paradoxes illustrate how individual and collective goals can conflict through measuring academic performance on the one hand and the way in which such audits reduce the meaning of collaboration to absurdity on the other new dynamics in african diaspora engagement with africa in 2017 a consortium comprised of harvard university the university of johannesburg the united states international universityafrica the ford foundation codesria the ccny and the institute of international education organised a conference entitled role of the diaspora in the revitalization of african higher education the conference gathered some of the most prominent ads including the authors of the postconference report the report is a comprehensive document featuring current debates and ideas about diaspora academics role in advancing africas higher education to curtail the continents brain drain and introduce a cycle of brain gain and brain circulation some of the key conclusions extracted from the report suggest that ads represent a huge asset for the continent in meeting the challenges of african higher education and exploiting all opportunities south africa for example is amongst those african countries that have benefited the most from the presence of intraafrican immigrants despite many of them being met with hostility according to the report ads are an indispensable player in africas rapidly growing and increasingly diversified education sector their intellectual remittances are fundamental to the realization of integrated inclusive and innovative sustainable development envisioned in numerous national and regional development agendas the authors also indicate that there is huge demand by african institutions for diaspora academics and there is need to expand beyond fellowships to other modalities of engagement to appeal to different stakeholders while the report highlights the role diaspora academics can assume as remitters of intellectual capital it does not outline a role that internal africanbased diaspora should or could take up there is an implicit notion that the african diasporic condition is restricted to those academics outside the continent based in europe america and australasia the report thus fails to acknowledge the intracontinental diaspora in fact it refers to the following afrodiaspora categories as claiming the entire african diaspora africaamericans afrobrazilians afroeuropeans afroasians and others the report also does not extensively consider the forms of affiliation engaged in by african academic diaspora the fact that some diaspora academics especially those working in the usa get three months unpaid leave mostly during their holidays is habitually presented as a window of opportunity to engage in academic mobility and exchange on other continents including africa for instance there are records of usagerman academic exchange dubbed elective diasporas occurring since the end of world war ii the notion of elective diaspora stresses the elective nature of diasporic identities and belonging by emphasising that individuals can choose whether they wish to support diasporic networks of one or more communities and cultures they feel connected to it also suggests that this civic rather than ethno territorial understanding of diasporic networks has wider relevance for theorisations of diaspora for studies of transnational mobility and knowledge transfer and for university and public policies seeking to attract talent from abroad the occasional affiliation especially during holidays may be complemented by new forms of joint dual or multiple appointments academics who are based on the continent as well as in the diaspora can explore new forms of engagement which are mutually beneficial new forms of research collaboration which include joint curriculum development shared graduate student supervision joint research projects and joint grant applications require a much longerterm type of engagement beyond the duration of a summer holiday therefore there is a need for new institutional arrangements and the removal of barriers as well as research on the changes in the academic profession in africa including the new forms of academic work taking place conclusion the main discourse around the african academic diaspora follows a typical pattern of focusing on the wideranging costs of losing some of the continents best and brightest intellectuals through brain drain this focus on the disadvantages however obstructs the expansive and often innovative interactions that ads and abs have forged on both sides involving their home and host institutions emerging patterns of multiple institutional and international academic affiliations between both ads and abs are reinforcing scholarly and personal engagements while there are still many challenges to overcome particularly in african institutions the collaborations between ads and abs are gradually gaining financial support from international funding agencies with the aim to build capacity in african universities funding schemes such as the eus erasmus programme and the intraafrica academic mobility scheme codesria and the carnegie corporation of new york african diaspora fellowship program are crucial in promoting more equitable and fair ads and abs engagements but also need to be aligned with revised contractual conditions for academic staff allowing more flexibility and multiple affiliation the professional athlete contract mentality exhibited by some academic staff managers at african universities is not compatible with the global trend of internationalisation of the academic profession there is evidence that a significant and growing proportion of scholars with multiple affiliations also display high levels of academic integrity and productivity this evidence validates the need for african scholars to attribute the necessary importance to studying multiple affiliations in the context of scientific research and institutional capacity development this article discussed multiple affiliations and their conditions as a possibility to curb the effects of brain drain while promoting brainsharing it argued that multiple affiliations not only reflect the dynamics and competitive advantage of the higher education sector in specific countries but also that they can make a valuable contribution in minimising knowledge production inequities globally the use of ict and associated elearning platforms represents an advantage for all actors involved by promoting a more integrated culture of blendedlearning environments in conclusion maas have not been studied extensively despite their enormous potential to redress knowledge and academic inequities globally but specifically in emerging countries by curbing the effects of brain drain and promoting brain gain brain circulation and brainsharing it is recommended that maas be explored in more detail in future research and policy

scholars with multiple affiliations have become more visible by assuming their particular role in redressing global knowledge production inequities this article explores multiple academic affiliations maas as one way to curb the effects of brain drain particularly in african universities it argues that maas is an effective way to reverse the effects of brain drain and promote brain circulation and sharing the article proposes the concept of translocal academic engagement tlae as a form of international academic exchange and brainsharing which is not limited to physical mobility circulation from one geographical location to the other but which includes virtual exchange and knowledgesharing through blended learning delivery methods epedagogies and the use of digital communication technology platforms such as communities of practice the article concludes by suggesting that maas if properly managed can be a success factor in tlae activities particularly in the age of web 40 in mitigating or shifting currently dominating knowledge production flows tlae offers possibilities for a winwin situation of academic exchange between higher education institutions in emerging systems

introduction parental oral health knowledge and behaviors are critical for prevention of early childhood caries in young children 1 among latino families in the us children are more likely to experience ecc than nonhispanic white and nonhispanic black children 2 also latino children have the lowest average number of dental visits of all racial and ethnic groups and the highest rate of untreated tooth decay 23 according to a recent report based on the national health and nutrition examination survey 20112012 dental caries prevalence was higher for hispanic children than for nonhispanic white children aged 28 4 among colorados latino population oral health screenings conducted by the colorado department of public health and environment in 20112012 revealed 55 of latino children aged 56 years have had dental caries experience while 32 of white children in the same age group had experienced dental caries 5 reasons for disparities in ecc prevalence in latino children are not well studied initial research has shown that the latino population experiences oral health disparities related to access to care 6 it has been suggested that latino mothers might lack knowledge related to risk factors associated with dental caries 7 and cultural beliefs and norms may negatively influence oral health behaviors 8 few studies have focused on the oral health knowledge attitudes and practices of latino mothersparents existing studies show that latina mothers are aware of sugar consumption and inappropriate bottle use being the risk factors for dental caries although the depth of knowledge was limited 7910 in a qualitative study latina mothers strongly agreed that oral hygiene routines contribute to good habits in children but they were often inconsistent in adherence and had limited depth of knowledge about the benefits of fluoride 7 latino primary caregivers had limited knowledge about the etiology of dental caries and preventive concepts 9 another study found that latino parents beliefs about sugarsweetened beverages were limited and many parents did not understand nutritional labeling related to store bought beverages they viewed some beverages as healthy for their children despite high sugar content 11 this purpose of this study was to conduct a needs assessment with latino families to better understand the challenges in maintaining oral health for their children the study followed communitybased participatory research methodology to develop and conduct the study cbpr is an approach that intends to involve community members stakeholders and community organizations representative with academic investigators in all aspects of the research processes and enhancing integration of the produced knowledge into the community 12 following the guidelines of cbpr methodology goals for the academiccommunity partnership were developed and followed throughout the research conduction we started the partnership development process before the grant application was submitted and had set the responsibility and expectations for both the academic and community team the mission of the partnership and partner roles were decided before the grant application the goals of this partnership were to develop a deeper understanding of the oral health knowledge oral health behavior and attitudes of latino parents towards their children the academic researcher relied on the community partners expertise in connecting with the community and recruiting community members mainly primary caregivers of preschool children for the focus groups the community partners relied on the academic researcher to conduct the research and dissemination of the results methods the study was approved by the colorado multiple institution review board thirty latino primary caregivers who had at least one child under the age of six were recruited the study enrolled the primary caregivers for the child which will include grandparents and other relatives apart from the mother and father of the child information about the study will be provided in english and spanish with a consent form detailing the approach of the study all participants were recruited by servicios da la razas staff which is a latinoserving community organization working in the denver metro area the community organization approached head starts and kindergartens to recruit participants for the focus groups six focus groups were conducted the focus group was conducted using a semistructured focus group guide consisting of ten openended questions that were developed by the investigators before the start of the study the questions were developed based on previous qualitative studies conducted with latino communities 7911 and based on the experience of the investigator and the community partners working with the latino population a translator was provided for all the focus groups each session lasted 4550 minutes and the time taken by the translator was additional all focus groups were digitally recorded translated from spanish and transcribed into english grounded theory approach was used to develop the code structure a systematic approach that allows for open discovery of emergent concepts with a focus on generating a theory was used to analyze the data with this approach the coding was done using a purely inductive technique which helped to minimize the potential for forcing a preconceived result and thus provide for a more valid reflection of the ground or the true experiences of participants quotations provided in the results section reflect some sentiments and comments expressed by mothers during the focus groups both the research and a community partner independently coded the data and then conducted several meetings to discuss the codes and once they felt saturation was reached they finalized the codebook the focus groups were analyzed using qda miner the coding frequency was calculated for all codes under each of the three themes using the frequency tool within the qda miner software the code frequencies represent the percentage of the codes being repeated under each theme in the entire data results focus group findings focus group participants were primary caregivers of children under the age of six years there were about 20 mothers seven grandmothers one father and two aunts who participated in the focus groups the focus group themes and codes are reported in box 1 oral hygiene 20 dietsugars 27 frequency 10 protective foods 12 use of bottle 1 microorganism 1 fluoride 25 primary teeth 4 figure 1 percentage of codes that were repeated under etiology of dental caries etiology of dental caries many factors were reported as being responsible for causing dental caries in children including diet poor oral hygiene the frequency of consumption of sugary foods and drinks and the role of microorganisms in development and progress of dental caries primary caregivers reported that diet was a major factor in dental caries development and gave examples of high sugar foods such as candies soda cookies and juice about 28 percent of the participants reported some sugary food being responsible for the development of dental caries in their children participants mentioned the frequency of consumption of these sugary foods and drink as a cause of dental caries in their children the frequency code appeared about 10 percent in the transcripts within the theme for etiology of dental caries participants said that their children had soda or juice 23 times a day but the frequency of consumption increased over the weekends or while visiting the family where the participant had less control of the food choices of their children participant comment there is a lot of sugar in everything things that you do not even know about if they go to sleep at night without brushing their teeth it just stays on their teeth all night participant comment i think the frequency is going to be the biggest factor how may time they drink soda is important to manage fruits and milk were mentioned as protective foods for teeth as it has calcium which is good for teeth milk was specified as protective food repeatedly by most parents and they emphasized that it was good for teeth only two participants mentioned that milk should not be given to the child during bedtime and that adding sugar to milk increases the risk for caries development in children participant comment i know that milk is good it has calcium but if you put your child to sleep with a bottle then thats going to decay their teeth so you have to be careful only a handful of participants knew that microorganism caused caries in their children the code appears less than 2 percent within the theme for etiology of dental caries even after several probes participants did not mention microorganism as one of the causes for the development of dental caries most of the participants said that sugary foods were the main reason for caries development and had not heard that bugs were responsible for cavities most of the focus groups participants related poor oral hygiene practices to dental caries development they understood the importance of good oral hygiene and 30 percent of the focus group thought teeth should be brushed at least two times daily they also spoke about the importance of supervising their children while brushing or helping them brush their teeth however more than half of the participants said that they did not supervise their children over the age of 45 years during brushing they said it was hard to find time to do that and thought they told their children to brush in the morning and at bedtime another important discussion was based on fluoride and its role in dental caries prevention only two participants in the entire group knew the sources of fluoride including tap water toothpaste and fluoride varnish mechanism of action of fluoride in the prevention of caries was not known most participants had not heard about fluoride and when probed they reported that neither the pediatrician nor the dentist had mentioned fluoride they had no knowledge that tap water was the source of fluoride additionally when probed about fluoride varnish some of the participants remember their children receiving fluoride varnish during dentist appointments they did not know that it had fluoride and recollected that it was mentioned as vitamins for teeth experience of parents at dental visits all the participants said that they have a dental home for their children or grandchildren when discussing their experience during dental visits most participants said that the environment at the dental clinic made a difference in changing their oral health behaviors the code environment at the dentist appeared 53 percent within the theme two types of environments were described few participants received a supportive environment where the dental team gave preventive recommendations to the children they had toys information pamphlet and videos in the waiting area that captured the parent and childs attention participant comment at the clinic where i go in the waiting room they show some videos a video got my attention my children also paid attention to it because it shows you a soda and asks you how many tablespoons of sugar does a soda have 12 tablespoons sugar they say in your right mind would you give 12 tablespoons of sugar to your child however the majority of the participants were not satisfied with their dentist interactions were more with the hygienist and dental assistants and dentist spent the least time interacting and educating the parents participant comment i feel like dentists have not been very personable i think it is always very fast pace you spend most time maybe with a technician rather than with the dentist and they dont provide enough information to really understand how to prevent cavities few parents reported that some intricacies related to treatment decision were not discussed in detail and other stated that reasons for applying fluoride varnish at the end of the visit were not explained nevertheless for some parents the environment at the dentist was a cause of frustration because they felt judged these parents had children who had higher dental caries experience and went more often to the dental clinic participant comment i have these frustrating conversations with the dentist and they almost think that you are lying i am like no i am not lying and they do not drink sugary drinks he was off the bottle very early i have tried to make it different from my older son and it still happened the same way apart from the dental office the participants also received some oral health knowledge from the pediatrician or at women infant and child clinics the participants wanted the dentist to demonstrate the oral hygiene practices or provide the reason for a recommended oral health behavior participants mentioned that some dental offices had a show and tell method that was very useful in engaging and educating the children participants felt motivated when the dentist or other medical personnel were polite and showed concern for their childrens oral health rather than just giving them instructions oral health beliefs of parents child temperament had the highest frequency with this theme participants faced challenges when brushing their childrens teeth mainly those related to the childs behavior and most mothers believed this affected their childrens oral health they were not able to engage their children in brushing when they started to cry or refused to brush in addition they said it was difficult to make it into an interesting exercise for the child child temperament was also mentioned in restricting them from consuming sugary foods and drinks if the child had a liking for soda or candies the parents struggled in controlling the frequency of consumption participant comment we prohibit all sweets but that is what she likes most sweets soda apple soda apples what can i do lack of time on their part was another challenge participants mentioned jobs and other chores that prevented them from finding time to supervise their children while brushing or encouraging their children to brush selfefficacy of the participants was an important factor controlling their oral health behaviors towards their children parents thought they had no control over their childs food habits and they felt helpless participant comment if they are hungry and they just grab something it is hard to say no participants discussed cultural variations in their community related to oral health knowledge and access to care some participants mentioned they struggled to overcome peer and familial pressure when they took their children to the dentist for preventive visits they mentioned their family and friends suggested visiting the dentist if the child has pain and that preventive dentists visits were unnecessary another topic they discussed was about multiple caregivers especially grandmothers and aunts who provided care when the mother was at work participants had little or no control over the feeding practices of additional caregivers they mentioned their children have easy access to highrisk foods such as soda and candies in the us as compared to children in their countries which they deemed as a negative effect on the oral health of their children participant comment my motherinlaw lives in mexico when she comes she stays for two months and when she is watching him it is a harder to control his diet because she eats breakfast with cocacola so then trying to get her not to give the baby these juices and stuff gets a little harder the role of schools and head starts in educating the children about oral health was emphasized by many participants children spend most of the time at schools that would be a suitable place for the child to learn about oral health discussion the results of this study highlight that although latino parents have some understanding of factors associated with dental caries their knowledge did not translate into positive oral health behaviors however the focus group findings have provided some indepth information on the challenges these parents may face in implementing their knowledge into actions few culturally tailored studies conducted with latino parents to improve oral health knowledge and behaviors have been well accepted by the community and have shown sustained improvements in oral health knowledge and behavior change in latino parents 613 child temperament and selfefficacy of the parents were two concepts that surfaced several times during the discussions parents discussed their childs resistance towards tooth brushing and lack of time in supervising the children during brushing as some other reasons for poor oral hygiene for the children evidence suggests child temperament has been strongly associated with ecc positive temperament appears protective and negative temperament may increase the risk of ecc 1415 it also has been shown that negative child temperaments can exacerbate parental stress and worsen parental feeding and oral health practices 15 additionally some of the participants reported the lack of selfconfidence in engaging the child in oral hygiene activities mostly because they did not know how to teach the oral hygiene techniques to their child the dentist physician and the schools were held responsible for teaching oral hygiene to children and only a few parents felt that they were accountable for their child oral health skill building exercises with parents have shown improvements in tooth brushing behaviors in parents for their children 1316 a peer based skill building study concluded that after a 3month intervention of teaching tooth brushing skills to parents there was a significant increase in parents confidence to ensure brushing twice a day as well as in perceptions of the importance of tooth brushing and in selfefficacy for tooth brushing skills 16 in addition to providing oral health knowledge approaches such as motivational interviewing which provides supportive guidance for choosing behavioral goals and strategies may be more appropriate and culturally sensitive in a latino population 17 few studies that have used mi have reported that this approach can positively impact behaviors addressing infant feeding practices and diet oral hygiene behaviors and dental attendance 18 limitations of this study include the relatively small sample size and a convenience sample these results may not be generalizable further research is warranted with a larger sample to validate these results disclosure contents are the authors sole responsibility and do not necessarily represent official nih views conflicts of interest the authors declare that there are no conflicts of interest regarding the publication of this paper

the aim of this study is to describe oral health knowledge behaviors and beliefs of latino parents with children under the ages of 6 years and to conduct a needs assessment with latino families to better understand the challenges in maintaining oral health for their children the investigator collaborated with a community serving the organization to recruit latino primary caregivers for focus groups interviews and 30 primary caregivers were recruited the focus groups data was transcribed and analyzed using a grounded theory approach using qda miner software findings from the focus groups demonstrate that the primary caregivers described barriers in maintaining oral health for their children including cultural barriers childs temperament lack of time and easy access to highrisk foods all participants said that they wanted to receive information on the oral health of their children they wanted the dentist or the hygienist to demonstrate oral hygiene practices and explain to them the reasons for oral health behaviors although the primary caregivers recognized some factors related to caries development their knowledge was limited in depth culturally appropriate oral health education is required for this population which could lead to more adherent oral health behavior and a higher sense of selfefficacy in latino parents

historically undernutrition primarily affected children under five years of age but today its influence on the health condition of older adults is more widely known undernutrition is the pathological state resulting from inadequate consumption of one or more essential nutrients it involves weight loss associated with caloric and protein deficits and low levels of other specific nutrients that are necessary for the adequate homeostasis of the organism in the case of children those who are affected have limitations in their physical mental and psychomotor development they can suffer biochemical and physiological disorders such as growth delays cognitive impairments and lower physical and intellectual capacity in older adults undernutrition increases the risk of mortality hospitalization hip fractures and institutionalization due to the reduction of functional autonomy the colombian health situation analysis surveillance system shows that the country had a decreasing trend in undernutritionrelated mortality rates in children under five from 1487 per 100000 children under five in 2005 to 682 deaths in 2014 in the case of older adults a study by cardona et al found that in 2008 in colombia the mortality rate from nutritional deficiency in those over 65 years was 345 deaths per 100000 the same study also highlighted the great variability within the country in mortality risk with the highest rate in the department of vaupés and the lowest in tolima other departments that exceeded the national rate were guaviare guainía bolívar and atlántico regarding the determinants of undernutritionrelated mortality one of the most important factors is families poverty level as their financial restrictions mean limited access to healthy food while among older adults it is associated with living alone deficient social support networks and limited functional ability several studies have emphasized the relationship between undernutrition and the place of residence showing that children and older adults living in poor areas have a higher risk of undernutrition as do those living in areas with low availability of healthy food additionally there are other factors associated with undernutrition especially in children such as unfavorable socioeconomic conditions related to inadequate sanitation food and health care practices in colombia poverty and development levels in municipalities are very heterogeneous and therefore we can assume that these differing conditions contribute to an unequal distribution of undernutritionrelated mortality in such context our study focused on establishing if the differences between municipalities also reflected on their undernutritionrelated mortality rates in children under five years of age and adults over 60 between 2003 and 2016 additionally we aimed to determine the relationship of those mortality rates with the socioeconomic conditions of the municipalities materials and methods we conducted a longitudinal ecological study to analyze aggregated data of colombian residents under five and over 60 years of age between 2003 and 2016 the geographic units of analysis were six regions 18 subregions and 1096 municipalities to improve municipal estimates we created a geographic map at this level where the nonmunicipalized areas were added to their respective cities likewise the four municipalities created after 2005 were regrouped into their original municipalities additionally the municipalities of the archipiélago de san andrés providencia and santa catalina were excluded because they did not have contiguous or neighboring geographic areas allowing reliable municipal estimates of their mortality risks consequently we analyzed data from 1096 municipalities information sources we obtained the data on deaths from the vital statistics available on the national administrative department of statistics website and aggregated them according to the geographic units of analysis the data regarding municipal socioeconomic characteristics were obtained from the sistema nacional de vigilancia en salud pública the united nations development programme and the departamento nacional de planeación variables dependent variables we analyzed two aggregated variables 1 the municipal undernutrition mortality rate in children under five per 100000 children under five and 2 the municipal undernutrition mortality rate in people over 60 per 100000 inhabitants over 60 years of age undernutrition deaths were defined as those with primary cause codes according to the 10th revision of the international classification of diseases corresponding to undernutrition other nutritional deficiencies or nutritional anemia independent variables these included the following municipal socioeconomic conditions • the percentage of the population with unsatisfied basic needs was measured in 2005 to characterize poverty in municipalities by quantifying the proportion of people experiencing at least one of the following conditions overcrowding inadequate housing inadequate water supply lack of sewers and poor school attendance municipalities were categorized into quintiles the lowest one comprising the wealthiest municipalities and the highest one the poorest • the human development index measured in 2005 represents the degree of development achieved by a municipality in terms of quality of life education and per capita gross domestic product municipalities were categorized into quintiles the lowest one including those with low human development and the highest one those with very high human development • the multidimensional poverty index identifies multiple deficiencies in the areas of health education and living standards in the period 20052014 municipalities were categorized into quintiles the lowest one including the richest group of municipalities and the highest one the poorest municipalities • the institutional capacity of the municipal government an index that sorted and compared municipalities between 2006 and 2015 based on the following aspects effectiveness in meeting the goals of their development plans efficiency in the provision of basic services compliance with budget execution requirements defined by law and administrative and fiscal management the municipalities were classified into four performance groups outstanding or satisfactory medium low and critical • the dynamics of the index of water quality for human consumption 20072010 which measures the water qualityrelated risk and classifies municipalities into five waterquality risk groups none low medium high and unviable sanitary risk given the variability of the index during the available period its dynamics pattern was summarized into one variable for the present analysis the resulting variable classifies the municipalities into five groups improving constant positive constant negative and worsening data processing for the descriptive analysis we estimated national and regional mortality agespecific crude rates for two periods 20032009 and 20102016 using the total number of undernutrition deaths as the numerator the denominator was either the total population of children under five or people over 60 multiplied by 100000 as for the municipal rate estimates we used the bayesian hierarchical model proposed by besag et al to obtain smoothed rates for the whole period 20032016 which improved the precision of the estimated rates especially for those municipalities with a low number of deaths due to undernutrition andor a small population in brief this model combined the aggregated number of deaths in each municipality with the average of the neighboring municipalities thus decreasing the variability of the estimates the bym model was specified as follows where n i is the denominator in each municipality and the rate in each municipality i is represented by p i the model has two random effects that represent nonspatial and spatial variability v i v i and u i u i these effects allow for the estimation of the smoothed rate for each municipality with the equation exp the a priori distributions of spatial effects was assigned through an intrinsic conditional autoregressive distribution with variance σ u 2 while for the nonspatial effects we used a normal distribution with zero as mean and variance σ v 2 a halfnormal distribution with a mean of 0 and a precision of 00001 was assigned to the standard deviations σ v and σ u for parameter we assigned a normal vague prior distribution the model estimated the smoothed mortality rate with the corresponding 95 confidence interval for each municipality as well as the a posteriori probability which indicates whether each municipality had a smoothed rate significantly higher than the rate of colombia this was calculated as prp i probability the model was estimated by using the integrated nested laplace approximation method available in the statistical package r2153 inla library statistical analysis tables and maps were used for the descriptive analysis of regional and municipal estimates by period and agegroup we extended the ecological bayesian hierarchical model at level two to to include socioeconomic variables and analyze their relationship with municipal smoothed rates nbi hdim and mpi were categorized into quintiles and included in separate models as four dummy variables with the less poor or less developed areas serving as the reference group for the other two socioeconomic variables outstanding performance and riskfree water quality were used as reference where each municipality is represented as i and β j is the effect of the category of the socioeconomic variable on the smoothed rates by using exp β 1 the results of the models are presented as the relative risk of mortality in each socioeconomic group along with the corresponding 95 confidence intervals the research protocol was approved by universidad de antioquia ethics committee for the health area results between 2003 and 2016 a total of 2754943 deaths were reported in colombia and 24388 of them were due to undernutrition ie a rate for the period of 385 per 100000 inhabitants according to the age group 238 of the total mortality due to undernutrition corresponded to children under five and 614 to people over 60 the estimated rate during the period was 86 deaths per 100000 children under five and 245 deaths per 100000 adults over 60 when we compared the two periods we found a general decrease in mortality rates from 100 to 72 deaths per 100000 children under five and from 260 to 232 deaths per 100000 people over 60 as for the mortality by region the atlantic and the orinoquiaamazonia regions registered the higher mortality risk for children under five in the two periods in the case of those over 60 the atlantic oriental pacific and orinoquiaamazonia regions showed the highest risks in both periods and the smallest decreases over time figure 3 displays the smoothed mortality rates by municipality for the whole period the areas with the highest risk for children under five were located in the north of the country within the guajira cesar and magdalena subregions followed by barranquilla and the atlantic and pacific coasts in contrast the lowest mortality risks were observed in the municipalities of medellín and bogotá subregions in the case of mortality for people over 60 municipalities with the highest risk were located within the atlantic oriental pacific and orinoquiaamazonia subregions table 1 describes the distribution of deaths from undernutrition according to the socioeconomic indicators for children under five the risk of mortality was higher in municipalities with a higher proportion of population with unsatisfied basic needs less development and poorer and worse overall performance evidencing a negative social gradient of undernutrition for this age group in contrast for those over 60 the social gradient of undernutrition was positive with higher risks of mortality in municipalities with better economic advantages and development the results of the ecological regression were consistent with these findings according to the results for children under five the risk of dying from undernutrition is higher in the poorest municipalities ie in areas with more unsatisfied basic needs less development critical comprehensive performance and drinking water quality representing low or medium risk in these municipalities the risk was approximately 50 higher than in reference municipalities the risk of mortality from undernutrition in children under five was not statistically associated with water quality in contrast adults over 60 had a higher risk of mortality from undernutrition in more developed affluent municipalities with no water quality risk exceeding significantly that of reference municipalities this risk was not statistically associated with water quality or the municipalitys comprehensive performance discussion in general we found that the mortality due to undernutrition in colombia decreased during the 20032016 period moreover risk maps revealed substantial geographic variations in the size of the risk with reductions over time most importantly we found an association between mortality caused by undernutrition and the socioeconomic indicators of the municipalities our results highlighted a more significant decrease in the risk of undernutritionrelated mortality for children under five than for people over 60 this finding may be explained by the fact that colombian nutritional policies have focused mainly on the population under five to meet the millennium development goals and the sustainable development goals that include the eradication of hunger the decrease of child mortality and undernutrition and the development of food and nutrition surveillance systems however despite this decreasing trend there are regions that still show a high risk of child mortality for example the high mortality rates for children under five in the municipalities of the atlantic region could be explained partly by the presence of the large mining and energy companies that have caused a decrease in food production resulting from the lack of water sources used elsewhere in the orinoquia and amazonia region the highest rates of mortality due to undernutrition in children under five could may respond to the fact that this region has the highest rates of chronic and global undernutrition in this age group compared to the rest of the country the red color indicates a probability of 90100 that the smr is higher than the colombian rate and the green color indicates the same probability that it is lower mortality in under ve years old mortality in adults over 60 years old rate by 100000 rate by 100000 34 respectively besides this region has the highest percentage of indigenous communities whose food production and eating patterns have changed to the detriment of their identity and culture resulting in the loss of their food sovereignty and the substitution of native foods for products that must be purchased thus limiting food availability due to their low income levels on the other hand although all regions have decreased their undernutritionrelated mortality rates in children under five the poorest municipalities continue to have the highest rates consistent with the literature review some of the social conditions associated with these higher mortality rates are the lack of potable water the scarce institutional infrastructure to carry out social and health programs the low social security coverage and the difficulties in food distribution and the supply chain in terms of public policies this situation highlights the need to develop specific strategies to close social gaps the situation regarding mortality in adults over 60 is different as mortality rates have decreased very little and are higher in more developed and affluent municipalities which evidences that due to different factors such as limited income this population group does not have adequate access to food which impacts their health status and those factors that make them more vulnerable in this stage of life the lower mortality rates in the poorest municipalities would respond to their location in rural areas where there is a greater availability of food from family farming the breeding of small animals selfsufficiency and family support for obtaining food the risk of mortality due to undernutrition in the urban population over 60 years of age is a global challenge because many of the worlds largest cities are in the least developed countries where the aging process is not occurring slowly and families or states do not have the resources to respond in contrast with the situation in industrialized countries in these urban centers inequalities regarding the health conditions of older adults are evident in colombia for example according to the 2015 national survey on health welfare and aging eight out of 10 older adults live in urban areas and of the total population surveyed 30 do not receive assistance from the state or the family in conclusion the mortality from undernutrition in children under five is an unmet objective and remains a social issue because the rates continue to be high especially in the poorest municipalities simultaneously the mortality from undernutrition in adults over 60 especially in city residents constitutes a huge challenge due to the accelerated growth of urban populations in the developing world and their aging process regarding the data quality a special consideration must be made studies on death cause registration in colombia have shown that this process has improved considerably in the last 30 years and continues to improve cendales et al state that it is possible that the classification of colombia rises to the category country with high quality in the certification of mortality since our percentage of deaths certified as signs symptoms and illdefined conditions is less than 10 likewise the last who coverage report of death shows that colombias coverage rose from 799 in the period 19901994 to 881 in 19951999 931 in the period 20002004 and 985 in 2009 thus we assumed the data used in our study had enough quality an initial review of the data showed that 40 of municipalities consistently reported zero cases of undernutrition in children under five whereas 9 of the municipalities reported zero cases of mortality in adults over 60 the present analysis assumed that all zero counts represented a true absence of cases in the year analyzed to improve the accuracy of the municipal estimates the mortality and population counts were aggregated in a single period in this way undernutrition rates were estimated for each of the 644 municipalities that reported at least one case of mortality in children under five and for the 992 municipalities reporting at least one case of mortality in adults over 60 besides we used the bayesian model which averages the data of neighboring municipalities conservatively decreasing the possible qualityunderregistration problems of some municipalities on the contrary as this is an ecological study our findings can only contribute to the evidence of a possible association between inequality in malnutrition and urban territory conditions but we cannot affirm that this is necessarily a causal relationship additionally although this design allowed us to detect and evaluate socioeconomic inequalities in malnutrition it was not possible to identify whether inequalities in the risk of malnutrition among municipalities were due largely to the characteristics of the municipalities or to the differences between the individuals residing in them this design does not allow for evaluating the role of individual conditions such as confounders mediators or modifiers of the effect of the municipality in this sense the ecological relationships we found could be further explored with multilevel analyses taking into account the exploration of both individual and contextual factors finally we stress the importance of extrapolating our results exclusively at the area level given the aggregated nature of the data it would be erroneous to assume that the statistical association between the socioeconomic variables at the municipal level would be equal to the association between the corresponding variables at the individual level a multilevel analysis would be the next step in this research to properly explore both individual and municipallevel relationships conflicts of interest the authors declare that there are no conflicts of interest

children under five years of age living in poor areas and with low availability of healthy food have a higher risk of undernutritionrelated mortality however this relationship has not been well established among older adults objective to analyse socioeconomic inequality trends related to undernutrition mortality in children under five years of age and adults over 60 in colombian municipalities during 20032009 and 20102016we conducted an ecological study of trends between 2003 and 2016 the study population consisted of children under five years of age and adults over 60 residing in the colombian municipalities during the study period we estimated smoothed and standardized mortality rates by fitting a hierarchical bayesian model and explored their relationship with five socioeconomic arealevel variables results in most of the municipalities undernutritionrelated mortality was three times higher in older adults compared to children moreover the difference in the risk of undernutritionrelated mortality between municipalities showed a marked reduction finally the poor and less developed municipalities had higher rates of undernutritionrelated mortality in children conversely wealthier territories had higher rates in older adults conclusions although in most of the municipalities the mortality rates due to undernutrition in children under five and older adults have decreased their socioeconomic conditions influence in different ways the risk of mortality for these two populations so there is the need to develop agespecific strategies to close social gaps considering the structural conditions of the areas