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introduction compared to more equitable societies those with wider income gaps between rich and poor have worse population health outcomes 12 including obesity 3 cancer 4 cardiovascular disease 5 and mortality 46 a 2018 longitudinal study found a strong association between statelevel income inequality and life expectancy 7 a commonly used summary measure of population health representing the average number of years a person in an area can expect to live based on current agespecific mortality rates 8 the consensus in public health is the more equitable society is the better the population health 2 however empirical evidence suggests that the association between income inequality and population health is more nuanced for example research has determined that the strength of these associations between le and income inequality in the usa was significantly stronger in areas of higher overall income 4 and in rural areas compared to urban areas 6 results of a canadian study further suggest that rural populations may be more vulnerable to the influence of income inequality on health due to certain population and geographic characteristics such as reduced access to basic health care services and greater socioeconomic and demographic homogeneity compared to urban areas 9 nonetheless the reasons for these observed nuances are not fully understood although ruralurban status is often viewed and conceptualized for analysis as a dichotomy it is more accurately understood as a continuum 10 with important implications for population health 1011 dichotomous measures of ruralurban status may be easier to interpret however important nuances between less urban and rural areas may be missed especially in those areas of intermediate ruralurban status there are a number of ruralurban status measures available on the national scale that attempt to capture a more detailed gradation of what it means for a geographic area to be rural or urban 12 furthermore the magnitude and direction of associations between income inequality and health depend on the geographic unit of analysis 13 the association between higher income inequality and poor health outcomes is well established 14 7 9 however the majority of evidence demonstrating an association between income inequality and worse population health was conducted on large geographic scales such as the national state or regional levels 14 on a finer geographic scale such as the neighborhood or municipal level the processes related to inequality may operate differently 15 it has been posited that income inequality at smaller scales may be less likely to reflect the degree of social stratification and endogenous inequality in the wider society and as a result be related to population health outcomes 14 a 2015 study conducted in switzerland found that mortality was actually lower in neighborhoods with highincome inequality than those with lower income inequality this finding has been deemed the swiss paradox 16 studies examining income inequalities and health on a fine geographic scale are lacking in the usa however despite this there is growing evidence that neighborhood and communitylevel factors play a unique and critical role in population health outcomes according to an analysis by woolf and colleagues a web of conditions on the neighborhood or community level that may be difficult to disentangle contributes to individual behaviors and therefore population health and health inequalities 17 these include but are not limited to raceethnicity education socioeconomic status the built environment access to critical resources of everyday living and social support and cohesion recent evidence supports the importance of examining population health inequalities on a fine geographic scale a 2020 analysis found several key associations between population health outcomes and measures of healthcare access and social determinants of health that would have been masked had the analysis been conducted on a higher level of geospatial aggregation such as the county or state level 18 another study identified smallscale associations between neighborhoodlevel socioeconomic status and premature mortality 19 and hiv status 20 associations which may have been masked had a higher level of spatial aggregation been used therefore there is a support for and a need to investigate more nuanced relationships between socioeconomic status inequality community type and health outcomes on a fine geographic scale to facilitate such investigations improvements to the quality of methods and availability of national data on le on a fine geographic scale such as the census tract allow researchers and policymakers to better understand the subtle but important differences of the impact of potential smallscale geographic and placebased characteristics on population health however to date few studies have directly examined the potential for other socioeconomic and demographic factors to moderate or attenuate the established association between income inequality and le therefore the objective of this empirical study was to determine how income and ruralurban status potentially moderate the associations between le and income inequality on a fine geographic scale methods measures le at birth for each us census tract was the main outcome variable and was obtained from the cdc wonder database 21 census tracts are small subdivisions of a county or statistically equivalent entity such as a city 22 and can be considered as a geographic cluster of neighborhoods or small communities each census tract generally contains between 1200 and 8000 people with an optimum size of 4000 22 le was then linked by census tract to socioeconomic and demographic data from the 2010 us census 23 and the 2010 american community survey 24 the main explanatory variable was gini index which measures the extent to which the income distribution among units within an area deviates from a perfectly equal distribution and ranges from 0 for perfectly equitable distributions to 1 where all income is concentrated in one individual 25 key moderator variables from the 2010 acs included median household income and population density in each census tract population density is a continuous measure and one of the most commonly used proxy measures for ruralurban status in the population health literature all three variablesgini index median household income and population densitywere converted into quintiles to capture the continuous nature of each element and to aid in interpretation 16 26 27 28 covariates used in the analysis were percent of the population that identified as black or african american percent identifying as hispanic or latinoax percent with a bachelors degree or higher and median age of the population in each census tract descriptive statistics were obtained for all study variables checks of normality on all study variables were conducted using kolmogorovsmirnov statistics and visually using qq plots bivariate associations were estimated for all pairs of study variables using spearmans rank correlation tests for nonnormally distributed measures partial correlations were used to estimate the adjusted bivariate associations between le and gini index adjusting for covariates these partial correlations were conducted for all census tracts combined and stratified by quintile of income and ruralurban status to assess differences and linear trends in the magnitude of the associations between le and gini index by these factors average le was also calculated for groups of census tracts crossclassified by quintile of income ruralurban status and gini index lastly multivariable models were used within each quintile of income inequality to examine the adjusted associations between median household income population density and their interaction with censustract le all data were aggregated and no individuallevel data were used for this analysis sas version 94 and ibm spss version 27 were used for analyses results there were 66857 census tracts in the analytic sample the mean tractlevel le was 783 years with a standard deviation of 40 years a minimum le of 563 and a maximum of 975 the mean tractlevel values for median household income were 66792 and 0426 for gini index the mean tractlevel population density was 5231 peoplesquare mile with a standard deviation of 11729 spearman correlation coefficients between le and gini index median household income percent black population and percent with a bachelors degree or higher were 0132 0672 0364 and 0608 respectively all were statistically significant furthermore le was significantly correlated with population density gini index was significantly correlated with median household income black population and population density substantial differences in the associations between le and gini index by quintile of median household income were evident among the tracts in the lowest income quintile le was negatively associated with gini index and le decreased monotonically from 749 years in the tracts with the lowest gini index to 733 years in the tracts with the highest gini index however among the tracts in the highest income quintile the association between le and gini index was reversed and positive higher le was observed in areas with higher gini indices additional variability was observed when stratifying the tracts further by ruralurban status the lowest average le was observed in the tracts with the lowest income highest gini index and with intermediate ruralurban status the highest average le was observed in the tracts with the highest income secondhighest gini index and second most urban the monotonic trends with increasing le with decreasing gini index in the tracts with the lowest income generally held for all levels of ruralurban status but the reverse trends in the highest income tracts varied by ruralurban status the complex associations between gini index and le are further illustrated in fig 2 this figure shows the partial correlation coefficients between le and gini index in each group of census tracts crossclassified by ruralurban status quintile and median household income quintile as well as average le in each class of census tracts for the four lowest quintiles of income in the four most rural quintiles of census tracts the associations between le and gini index were significant and negative in contrast the associations between le and gini index were significant and positive for the census tracts in the highest income quintiles regardless of ruralurban status for the most urban census tracts those in the lowest quintiles of income there were no significant associations between le and gini index lastly multivariable models were used to assess the associations between le and ruralurban status and median household income overall and by quintile of gini index overall each onequintile increase in population density was associated with an average decrease in life expectancy of 013 years the association between population density and le remained significant across all quintiles of gini index yet the magnitude of the association was significantly stronger in areas of low inequality than in high inequality for median household income quintile each onequintile increase in income was associated with an average 1 11years increase in life expectancy and did not vary significantly by gini index the interaction terms for quintiles of ruralurban status and median household income were significant overall and for the areas with the lowest gini index but not significant in the census tracts with higher levels of the gini index with interaction term 017 106 0015 q1 main effects 013 q4 main effects 012 112 107 1 with interaction term 013 111 0005 q5 main effects 007 100 with interaction term 001 107 0023 discussion in this study the association between le and gini index in most us census tracts was negative supporting the vast literature concluding that lower income inequality is associated with better population health 1 2 3 4 5 6 7 however those associations were not present in more urban areas furthermore in the census tracts with the highest income the association was reversed higher le was associated with higher gini indices these findings are partially antithetical to the income inequality thesis which states that increasing wealth is associated with improved population health but only to a certain level of wealth 14 once this threshold of wealth is reached reducing income inequality is the most important driver of improving population health 15 study findings support the tenet of the income inequality thesis proposing that increasing wealth is associated with better population health as measured through le increasing median household income was associated with increased tractlevel le however the findings contradict the part of the income inequality thesis that for sufficiently high levels of wealth reducing income inequality is associated with increased le for the wealthiest census tracts increasing le was associated with increased income inequality consistent with the swiss study described earlier 16 however more research is needed to determine if these unexpected associations are observed for other population health outcomes 2930 the findings for ruralurban status and le were more complex the association between income inequality and le was strongest in areas outside the most rural and most urban census tracts the reasons for this are not well understood one explanation for this finding is that areas with greater poverty could be more vulnerable to the deleterious effects of income inequality on health especially when those areas lie in the intermediate areas of ruralurban status broadly speaking while not specific to urban areas over the past century urban areas are more likely to have adequate housing access to primary health care sanitation and resources 31 which may temper the associations between le and inequality even in lower income areas likewise there are potential health benefits to living in highly rural and remote areas such as the lower cost of living access to green space pace of life improved environmental factors 32 33 34 however like the benefits of urban living these attributes are not unique to the most rural and remote areas therefore the reasons for these highly nuanced differences in the strength and direction of association between le and income inequality jointly by wealth and ruralurban status remain unclear and merit further research the empirical findings of the current study should be interpreted in the context of several limitations first estimating le on a small geographic scale such as census tract is subject to systematic errors 35 second the partial correlations only adjusted for two factors percent black population and percent with a bachelors degree or higher and therefore the observed associations are subject to residual confounding this analysis only considered moderation of the association between income inequality and le by two factors income and ruralurban status factors such as raceethnicity education and built environment likely moderate these associations the analysis also did not consider potential regional differences in the association between income inequality and le 36 only one measure of each main predictor variable was used largely due to limited variables available at the census tract level patterns of association and moderation may vary based on which measure of health was used 37 this study used gini index as the main measure of income inequality 38 as with all measures of income inequality the gini index is only somewhat sensitive to income inequality occurring in the middle of the income distribution 39 future studies could determine if the observed associations are sensitive to the type of income inequality measure used such as the atkinson index which is less sensitive to differences in the middle of the distribution also the analysis considered only one measure of ruralurban statuspopulation density as there is no universally accepted and utilized measure of ruralurban status it is possible that the observed associations would also change if a different measure of ruralurban status such as distance to the nearest metropolitan area or percent urban population were used 40 lastly for analysis and interpretation continuous measuresarealevel income income inequality and population densitywere categorized into quintiles choosing other cutpoints may result in different patterns of associations despite these limitations this study provides empirical evidence that the widely established principle that areas with lower income inequality generally experience better population health may not extend to all areas and in fact may be reversed among highincome populations the rationale for these findings is unclear and requires further research while this analysis found that for most census tracts the established associations held the variation by income suggests that any efforts to improve population health through reducing income inequality must be tailored to the needs of distinct populations to maximize effectiveness future research should focus on identifying and addressing these nuanced associations that lead to critical health inequalities that may be masked when examining such associations on a higher geographic level of aggregation 41 author contributions sac conceived the idea for the study obtained the data conducted the analysis and wrote the majority of the manuscript ccn wrote the introduction and provided critical edits for the remainder of the manuscript enb developed an annotated bibliography that was used in writing the manuscript mlg oversaw the writing process and was a major contributor in writing and critically editing the manuscript all authors read and approved the final manuscript funding the authors did not receive funding to conduct the research presented in this article competing 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background a preponderance of evidence suggests that higher income inequality is associated with poorer population health yet recent research suggests that this association may vary based on other social determinants such as socioeconomic status ses and other geographic factors such as ruralurban status the objective of this empirical study was to assess the potential for ses and ruralurban status to moderate the association between income inequality and life expectancy le at the censustract level methods censustract le values for 20102015 were abstracted from the us smallarea life expectancy estimates project and linked by census tract to gini index a summary measure of income inequality median household income and population density for all us census tracts with nonzero populations n 66857 partial correlation and multivariable linear regression modeling was used to examine the association between gini index and le using stratification by median household income and interaction terms to assess statistical significancein the four lowest quintiles of income in the four most rural quintiles of census tracts the associations between le and gini index were significant and negative p between 0001 and 0021 in contrast the associations between le and gini index were significant and positive for the census tracts in the highest income quintiles regardless of ruralurban statusthe magnitude and direction of the association between income inequality and population health depend upon arealevel income and to a lesser extent on ruralurban status the rationale behind these unexpected findings remains unclear further research is needed to understand the mechanisms driving these patterns

introduction deprivation and other areabased socioeconomic indices are used extensively in public health in a number of countries 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 including canada 19 20 21 22 23 despite their widespread use they have seldom been explicitly validated except in a few mainly british studies 7 24 25 26 27 validating a deprivation index means verifying whether it adequately reflects the reality being measured validation is a complex exercise because the index must respond to a number of criteria and have certain properties that are useful in its field of application the purpose of this study is to subject quebecs material and social deprivation index 23 to these validation criteria and properties the quebec index was developed at the end of the 1990s and has since been used in quebec and canada in various contexts in this paper we first describe the index and then present the validation criteria and properties first with reference to the international literature then to the quebec index finally we discuss the nature of the quebec index and make proposals for additional validations quebec material and social deprivation index the quebec deprivation index was designed to illustrate social inequalities in health and in the use of health services its objectives are primarily exploratory and descriptive in nature it applies to the entire quebec population by place of residence the design and creation of the index is based on peter townsends ideas on deprivation and the international literature on social determinants of health the index has two dimensions material deprivation and social deprivation the index is also geographical it is based on the smallest standardized canadian census unit composed of one or more blocks of neighbouring houses with a population of 400 to 700 persons this unit is the enumeration area for the 1991 and 1996 censuses and the dissemination area for the 2001 and 2006 censuses 28 the quebec deprivation index is made up of six socioeconomic indicators by ea or da the proportion of people 15 years and older with no high school diploma or certificate the employmentpopulation ratio of people aged 15 years and older the average income of people aged 15 years and older the proportion of people aged 15 years and older living alone the proportion of people aged 15 years and older who are either separated divorced or widowed and the proportion of singleparent families all but the last are adjusted according to the age and sex of the quebec population we extracted two components from these indicators using principal component analysis the material component which is associated with employment education and income and the social component which is associated with marital status living alone and singleparent families for each component the pca produces a factor score by ea or da indicating its relative level of deprivation depending on this score quebec eas or das are grouped into quintiles from the most privileged to the least thus it is possible to follow variations in deprivation for each dimension separately and for both dimensions simultaneously the validation of deprivation indices validation of deprivation indices including the quebec material and social deprivation index is based on proposals in the literature 7 24 25 26 27 and more specifically on work focused on the surveillance and measurement of deprivation and social inequalities in health 24 after reviewing the deprivation indices used in the united kingdom carrhill and chalmersdixon 24 suggested using three criteria to evaluate this type of index and also suggested considering other properties useful for health policies while recognizing that the scientific community identify other criteria and properties 29 we used the definition proposed by carrhill and chalmersdixon 24 we used three approaches to measure the validity of the deprivation indices these three approaches are usually referred to as content validity criterion validity and construct validity content validity content validity refers to the agreement between the general concept of deprivation its main dimensions and the indicators selected to illustrate them 24 are the dimensions and indicators appropriate do they represent all the facets of deprivation that the index is attempting to reflect the conceptual foundations of the quebec material and social deprivation index are mainly based on the proposals set forth by peter townsend 30 for whom deprivation is a state of observable and demonstrable disadvantage relative to the local community or the wider society or nation to which an individual family or group belongs the author distinguished between two forms of deprivation material and social the first material deprivation refers to the lack of the normal goods and amenities of modern living in various areas such as food housing the environment and work the second social deprivation which according to townsend is more difficult to define refers to the fragility of social ties this fragility may occur within the family unit or it may extend to close relationships friends confidants neighbours and others who provide emotional and material support it can also reflect the difficulties associated with integration and participation in social relationships and other common activities within the local community such as recreational or educational activities this brief definition of deprivation forms the basis for a number of deprivation indices 79202526 31 32 33 the authors of these indices highlighted the relative character of deprivation its subjective and objective aspects and its material and social dimensions the analysis of deprivation can however involve more than two dimensions or different fields 13 and overlap with other concepts such as poverty disadvantage socioeconomic status or position 1610151626 marginalization 22 or social isolation or fragmentation 3435 in all cases the concepts beneath these areabased deprivation indices and other socioeconomic indicators remain underdeveloped 25 26 27 the areabased scale is however a fundamental element of deprivation indicators that distinguishes them from indicators related to individuals even though they often serve as a substitute or proxy for each other and are sometimes compared 1511162627 an areabased indicator reflects a specific reality 61336 that varies according to the scale considered 3637 criterion validity criterion validity is used to verify whether the variations in a deprivation index correlate highly with those of an external measurement of deprivation 24 criterion validity is not used extensively because it is commonly accepted that there is no gold or reference standard for deprivation nevertheless certain practices are similar for example some authors have compared the areabased variations of different deprivation indices with one another 252737 or with those of measurements involving individuals even though they are different realities 11626 moreover certain authors have compared the areabased variations of a new index to indices already in use such as townsends 671516 because there is no standard or reference measure for deprivation we preferred to discuss the quebec index in terms of convergence validity as will be discussed later construct validity construct validity of a deprivation index in the health sector can take on a number of forms 2429 above all it aims to determine whether the construction is consistent with the concept of deprivation construct validity is also expressed through consistent relationships between the index and other measurements related to the concept of deprivation on the one hand and various health measures and the use of health services on the other these forms of validity will be more specifically addressed through convergence validity and predictive validity respectively to operationalize his vision of deprivation townsend reviewed various indicators used in great britain some from administrative bases and others from health surveys 30 and proposed a material deprivation index combining four indicators 24 other authors added a social dimension by creating a separate social deprivation index 26 or social isolation index 34 combining a number of indicators all from censuses to construct the quebec index we took into consideration these indicators and also conducted a literature review on the social environment and social inequalities in health 34 38 39 40 41 we then selected our indicators on the basis of theoretical and practical criteria affinity with one of the two forms of deprivation known link with health availability at a fine geographical scale in the census 28 and a limited number of indicators in the composition of the index to simplify comprehension we selected six indicators through this process 13 vol 34 no 1 february 2014 chronic diseases and injuries in canada the integration of these indicators in the form of an index was not the subject of any explicit hypothesis the intention was to let the natural areabased variations of the indicators express themselves without a priori grouping for this we used principal component analysis an exploratory synthesis method widely used in the creation of geographically based indices 36713161820223233 while recognizing the relevance of using groups of experts 819 or equally weighted sums 52527 for the integration of indicators related to certain indices the pca revealed the presence of two components in the 2006 census the first component reflected the variations in education employment and personal income 42 the second component reflected the variations in the proportion of individuals who were living alone separated divorced widowed or living in singleparent families these results are similar to townsends proposals concerning the two dimensions of deprivation however they differ in terms of education which according to townsend is associated with social deprivation moreover these two components do not appear to be very explicit with respect to the forms of deprivation work connecting the two dimensions of the quebec index with other indicators from censuses by ea or da makes it possible to clarify these dimensions 4344 for example social deprivation is closely associated with residential mobility and the proportion of renters two indicators used in the construction of social fragmentation and isolation indices 3435 the fact remains that the census is a limited source of data for reporting on the fragility of social networks convergence validity it is therefore necessary to compare the index to external measures that reflect deprivation and its various dimensions we conducted three exercises of this kind we first compared the spatial variations in the deprivation index to those in the proportion of children living with families receiving lastresort financial assistance from the government of quebec such assistance is given to families whose liquid assets are less than a particular amount that corresponds to the size and needs of the family it is the only source of income the family has to meet its basic needs twothirds of the families receiving this assistance are singleparent families 45 therefore we expected material and social deprivation to increase with the proportion of children living with families receiving this assistance which is the case according to the statistics provided by quebecs department of employment and social solidarity 45 the other two exercises made it possible to better define the social dimension of the deprivation index one linked the variations in the quebec index with those observed in an indepth study of three areas in the quebec city region 46 47 48 two of the areas had different health reports the material deprivation index was similar in these areas whereas the social deprivation index differed significantly a telephone survey of 600 respondents in each area collected data on health and perceptions of the local environment the use of a social cohesion index 49 addressing the appeal of the local environment and sense of neighbourhood and community produced coherent results with those obtained from the social deprivation indices where social deprivation was high social cohesion was low and vice versa qualitative interviews with residents revealed that being born in the area and having family members in the area were cohesive factors the last exercise was based on an analysis of a number of cycles of the canadian community health survey 50 and explored the links between certain social support measures at the individual level 51 and the social deprivation index in urban quebec 52 the exercise revealed that an increase in social deprivation went hand in hand with a decrease in three social support measures that is affection positive social interactions and emotional or informational support these associations are independent from the age gender lifestyle education and household income of the survey respondents in summary not only do the indicators used in the construction of the social dimension of the index reflect family structure and marital status the dimension also captures a broader reality at the individual level this reflects the fragility of social support for singleparent families and those who are living alone or who are separated widowed or divorced at the local scale it reflects residential instability which does predictive validity as we have seen the primary objective of a deprivation index is to identify social inequalities in health and therefore the associations between deprivation and health 24 these associations must be plausible corroborate observations made in the literature or be supported by credible explanations or hypotheses predictive validity is by far the most widely used approach to demonstrate the quality of a deprivation index 24 it is seen as proof of its performance for example links have been made with overall mortality 10121427 premature mortality 418 cause of death 318 the incidence of cancer 10 longterm disability 25 26 27 perceived health 137 smoking and nutrition 5 low birthweight immunization status and lead poisoning among children 1114 sexually transmitted infections tuberculosis and violence 54 myocardial infarction 7 hospitalization 1427 and use of medical 8 and psychiatric services 16 moreover the strength of the relationship between deprivation and health varies according to the size of the basic spatial unit of the index the smaller the spatial unit the stronger the relationship 110112654 the quebec deprivation index accounts for various health and social situations it is linked to global health indicators namely life expectancy and health expectancy at birth and different ages 23445556 and mortality including overall mortality mortality by medical cause mortality related to lifestyle premature death death among young people and survival 23 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 for example an increase in the rate of premature deaths was observed both in the early 1990s and the mid2000s as a function of material and social deprivation the same is true for other indicators such as disability 5664 70 71 72 the incidence or prevalence of diabetes and high blood pressure 72 73 74 selfreported health 70 and protective and risk factors for health flu vaccination premature birth or low birth weight smoking and exposure to secondhand smoke obesity food insecurity and physical inactivity 236170 75 76 77 78 social issues such as teenage pregnancy and cases of abuse neglect and behavioural problems among young people are also associated with deprivation 234461 such relationships were also observed in use of health services an increase in visits to general practitioners was noted with increased deprivation but an opposing trend was sometimes found for certain medical specialties 4461 this opposing trend was also true for certain free services available for young people aged under 18 years and under 10 years however the use of local community service centres as well as hospitalization day surgery and stays in longterm care facilities increased with material and social deprivation 44617079 a recent example is the rate of hospitalization following influenza a infection in summary the quebec deprivation index accounts for significant inequalities in health even though their magnitude may vary depending on the theme under consideration the two forms of deprivation usually act independently 2344 56 57 58 59 60 61 63 64 65 66 67 68 69 71 72 73 74 75 76 7879 reliability the reliability of a measurement tool is defined as its ability to produce the same result under the same circumstances 24 for deprivation indices this ability can be expressed through strong correlations between the indicators that form the index these correlations are often tested using cronbachs alpha some authors refer to an indexs internal consistency 6726 this internal consistency however is not relevant when the index has more than one dimension 24 the reliability of a deprivation index can also be expressed through correlation structure stability in time and space the goal is to verify whether the correlation structure remains regardless of the period and environment being considered the reliability of the quebec deprivation index can be seen from the perspective of internal coherence for each dimension of deprivation as seen in table 1 close correlations exist between the indicators that make up each of the two dimensions of the index this fundamental structure of the index can be seen throughout quebec and canada 4268 at various levels regional census metropolitan areas cities of varying sizes and rural environments it is also present for each census year between 1991 and 2006 although the correlations between the indicators may vary slightly according to the location and period considered the twodimensional structure of the quebec index is maintained 42 this fundamental structure seems to be permanent an essential quality for monitoring the social inequalities in health in time and space responsiveness responsiveness reflects the ability of a measurement tool to detect differences or changes according to the location time and individual characteristics 24 variations in the deprivation index are observable at the national regional and local levels through the use of maps for example 2782637 they are also observable in relation to various health characteristics the relationships vary according to the age and gender of the population 341827 with adults usually showing the highest inequalities in health the inequalities change over the years or with the area 341116 and fluctuate according to the health issue under study 101627 the quebec deprivation index was used to create an interactive atlas 4480 that shows wide variations in deprivation at the provincial level and at a smaller level in both urban and rural environments these variations in the quebec index are also associated with inequalities in health that relate to gender and age with adults having the highest mortality ratios between groups at the extreme ends of material and social deprivation moreover as is the case elsewhere 188184 the quebec index has identified an increase in relative health differences in quebec according to the data presented the premature mortality ratio between groups at the extreme ends of deprivation increased from 18 in 19891993 to 24 in 20042008 the quebec index identified health inequalities of varying magnitude according to geographical area and fluctuating over time 626466 thus inequalities are growing throughout quebec except in the montreal area where they are actually bigger than in the rest of the province such health differences have also been demonstrated elsewhere in canada 636768 other properties in the context of the development of public health policies or programs deprivation indices must respond to requirements beyond those that are purely technical or statistical 24 this is the case for the comprehensibility of the index for an audience made up of decision makers and stakeholders in the field the index must be easy to understand appeal to common sense and be conducive to reasonable unambiguous explanations thus the contribution of the indicators to the index must be precise clear and if possible quantified the index must also be objective and be applicable to every part of the area being considered at the national regional and local levels finally the index must respond to practical requirements it must be possible to update it regularly using the same method and be manageable in terms of time and cost it should also be possible to introduce it into health databases as we have seen the quebec deprivation index remains a simple measure made up of two components and six indicators that are well known as being connected to health its structure is clear and the weighting of the indicators in the index reflects their correlation with the components its use demonstrates its comprehensibility for an audience made up of stakeholders and decision makers in the health and social service sectors in quebec local variations in the index corroborated the perception of clsc stakeholders 7985 and at a provincial level material and social deprivation source a surveillance record mede ´cho hospitalization records ministe re de la sante ´et des services sociaux du que ´bec note the relative risk is adjusted by age gender geographical area and other form of deprivation a from q1 the most privileged quintile to q5 the least privileged quintile 17 vol 34 no 1 february 2014 chronic diseases and injuries in canada these variations were used to develop departmental policies 61 and to allocate health resources among regions 86 a recent compilation indicates that most of quebecs regional health and social services agencies use the deprivation index to identify variations in their areas and the connections with various health and social issues 87 although groups of experts were not involved in the design or initial construction of the deprivation index many health experts at all geographical levels have since commented on used and adapted the index to their needs and work contexts contributing to its validation and evolution for example a local version of the index and an interpretation grid of the inequalities in the use of services were developed jointly with local clsc stakeholders 7985 the grid compares the variations in the index and the knowledge of stakeholders regarding their organization directions and practices resources available locally and hardtoreach populations finally the relevance of the quebec index depends on its availability over time and space we have seen that the index exists for 1991 1996 2001 and 2006 and that it covers all of quebec in different versions national regional and local there are supporting products which are all free and available online 8088 tables and figures illustrating the health inequalities in quebec using the deprivation index are regularly produced and posted online 89 conclusion despite the widespread use of deprivation indices there have been few formal validation exercises on the basis of the validation criteria proposed by carrhill and chalmersdixon 24 it can be concluded that the quebec material and social deprivation index responds favourably to various requirements for validity reliability responsiveness and use in public health however there are limitations related to the geographical nature of the index the index characterizes the socioeconomic attributes of all residents of small areas although it is often used as a substitute for measurements related to individuals the index is a measurement linked to an area studies some of which are from quebec and canada 56646790 show that the magnitude of health inequalities is underestimated through geographical measurement especially in small cities and rural environments they also reveal that health inequalities are associated with both types of measurements independently which signifies that they result from both geographical and individual realities 566467 91 92 93 94 95 96 97 a better understanding of these geographical realities is therefore necessary to identify all the content and construct elements associated with a deprivation index to achieve this a research strategy at the local level combining theories concepts methods and indicators is necessary 98 99 100 101 reference frameworks on contextual factors associated with health must be used 5398102103 the social dimension of the index would particularly benefit from being associated with concepts and measurements of social cohesion and capital as well as their components the material dimension would benefit from being associated with various fields such as the physical environment the built environment and public and private infrastructure this roadmap should be followed for future validation exercises of the quebec index finally it should be noted that this index was designed to illustrate the existence of social health inequalities and that its purposes are exploratory and descriptive the index is not an explanatory framework for these inequalities for example it does not consider dimensions related to health such as immigration or aboriginal status even though these dimensions can be accounted for 6366 rather the quebec index constitutes more of a marker of social and health inequalities and as a result is a relevant starting point toward more indepth studies and increased understanding of these inequalities

introduction despite the widespread use of deprivation indices in public health they are rarely explicitly or extensively validated owing to the complex nature of the exercise methods based on the proposals of british researchers we sought to validate quebecs material and social deprivation index using criteria of validity content criterion and construct validity reliability and responsiveness as well as other properties relevant to public health comprehensibility objectivity and practicality we reviewed the international literature on deprivation indices as well as publications and uses of the quebec index to which we added factual databased on the review it appears that the quebec index responds favourably to the proposed validation criteria and properties however additional validations are required to better identify the contextual factors associated with the index

introduction analysing the relevance of family background characteristics to individuals levels of income is important to understand how individuals income is determined by factors beyond their responsibility and consequently the extent to which a society is able to guarantee equal opportunities for all this article aims to analyse the role family background characteristics play in shaping individuals income and its subsequent effect on inequalities in spanish regions for this purpose we get estimates of inequality for the spanish regions and compute the importance of family background characteristics to the observed levels of income additionally we analyse the differences in inequality levels between the spanish regions trying to disentangle the main drivers of the levels of inequality ensuring equal opportunities in a society would mean that all individuals are able to achieve a certain level of income regardless of the level of income wealth or education attained by their progenitors or any other circumstances beyond their own control the analysis of equal opportunities in economics has been popularised by roemer following the work of several authors whose contributions incorporate the idea of equal opportunities from different perspectives likewise educational inequalities and income inequalities are closely related for instance solga found that education could be a great equalizer for income inequality when accompanied with redistributive policies furthermore checchi and van de werfhorst find that inequality in the quality of education affects income inequality indicating that their results are to some extent consistent with human capital and functionalist theories which argue that education is rewarded because of the skills needed in the labor market so inequality in the quality of education is expected to affect income inequality more palmisano et al show that inequality of opportunity in education is strongly correlated with inequality of opportunity in income the research available in this regard for spain shows a strong relationship between the income and social class of the parent and the school performance of individuals although there are some works that analyse income inequalities and mobility in spain most of them study inequality before the year 2000 in this sense it is important to perform an analysis with a more recent period in order to have a more adequate picture of the current reality which will allow policy makers to carry out public policies that are more in line with current needs likewise the role of parental background in education has previously been analysed in several investigations in equality of opportunity it has been proved that parental education and parental occupation are two of the most relevant circumstances in shaping individual outcome in income moreover focusing on the spanish case found that parental education significantly affects individuals income our objective is to analyse how different educational and family background variables at regional level are related to the observed levels of inequality inequalities and educational achievements can experience great variations between regions in the spanish case this fact could be especially relevant and interesting due to several reasons there are significant income inequalities between regions the distribution of income growth among the population differs between regions and the education systems are different since the competencies in education are shared by the spanish regions and the central government resulting in differences in the educational systems across regions to this end the analyses carried out in this article try to answer two main questions to what extent are family background characteristics important in shaping inequalities and which are the main drivers of inequalities across regions we will consider inequalities in income and for this purpose we will use the disposable income of individuals as an outcome variable to measure both income inequality and inequality of opportunity taking into account that spanish regions are very different from one another one could expect to find different answers to these questions depending on the region in fact suárez álvarez and lópez menéndez showed the importance of the regional dimension for the analysis of inequalities and opportunities therefore we perform our analyses at regional level considering the seventeen spanish nutsii units likewise since the analysis is at the regional level it is important to note that there was no devolution of government responsibilities during the period under analysis the rest of the article is structured as follows section two presents the database and the variables used also providing some descriptive statistics section three shows the estimates of inequality and inequality of opportunity for the spanish regions and the contribution of different circumstances to the level of inequality of opportunity section four provides evidence on the main determinants of the different levels of inequality observed across regions with a focus on educational variables finally section five summarises the conclusions of the article database description the analyses performed in this article rely on the european survey of income and living conditions a survey that contains datasets at individual and household level furthermore data are classified by regionsin particular eu nutsii regions which correspond to the spanish autonomous communities they are first level political and administrative divisions and each one has its own organic laws known as statutes of autonomy which determine the powers they have they are also divided into provinces specifically in this article we use the eusilc surveys conducted in 2011 and 2019 which provide income variables referred to years 2010 and 2018 the use of these two surveys is particularly relevant since they include an adhoc module which incorporates variables regarding individuals family background our analysis is focused on the seventeen spanish autonomous communities and the sample is restricted to individuals aged twenty five to fifty nine years because parental background variables are only provided for individuals within this range of age the variables we use refer to individuals circumstances ie factors that are beyond individuals responsibility for this purpose we use variables regarding individuals family background when they were children the first is parental education which is constructed using the maximum level of education of both progenitors classified into three categories low if both progenitors have at maximum a degree of compulsory education medium if at least one progenitor has completed secondary education and high when at least one progenitor has completed tertiary education similarly we use the variable parental occupation which refers to the occupation of individuals progenitor when they were children this variable is also divided into three categories according to the isco08 jobs classification more specifically these three categories are low skilled when both parents work in elementary occupations medium skilled when at least one parent works in an occupation comprised in groups five to seven of the classification and high skilled if at least one progenitor works in a high skilled occupation 1 we also include the variable childhood financial difficulties which is a perceptionbased measure that considers respondents feeling about the financial situation of the family when the respondent is around fourteen years old it is divided into four categories badvery bad moderately bad moderately good and goodvery good the variables used as circumstances correspond to a period prior to the one for which the income of individuals is analysed these variables correspond to the childhood period of the individuals since the idea is that they provide an approximation of their social and family environment and that they are circumstancesthat is that they do not depend on the responsibility of the individuals and clearly individuals cannot occur to them due to situations that occurred during their childhood finally we include a variable referred to income which will be used to measure inequalitywe use the equivalised disposable income of households which is equivalised by considering the structure of each household specifically this variable is constructed according to the equivalence scale used by eusilc which is the organisation for economic cooperation and development modified scale e 1 05 n 14 1 03n 13 where n 14 is the number of household members who are over fourteen years and n 13 the number of members who are thirteen or younger the equivalised disposable income is considered a good proxy of the available income individuals have in addition this variable has been used in other studies with eusilc data referred to education and inequalitiessuch as brzezinski 2015marrero and rodríguez 2012palomino et al 2016suárez álvarez andlópez menéndez 2018b 2018a table 1 provides a summary of the descriptive statistics at the regional level and for the two years analysed 2011 and 2019 more specifically it shows the share of the population within each category of the abovementioned variables additionally table 1 shows the sample size for each region and year it can be noticed that in some regions the sample size is not very large the survey used provides weights to make the results representative nevertheless caution is advised when interpreting the results estimating inequality of opportunity this section is devoted to estimate income inequality and inequality of opportunity and to compute the contribution of the variables used to circumstances to iop with the aim of showing at what extent family background characteristics and other circumstances are affecting individuals performance in terms of income for this purpose in addition to estimating income inequality we compute inequality of opportunity for the spanish regions and then we analyse the contribution of the variables used as circumstances to this indicator the basis of the study of iop can be found in roemer and yitzhaki and schechtman later on roemer formalise this concept and distinguish between circumstances understood as factors beyond individuals control and efforts that can be attributed to individuals performance and commitment in this context the analysis of iop tries to compute the part of inequality due to the first kind of factors in which parental background characteristics are included to know the effect that parental background characteristics have in inequality and more specifically in inequality of opportunity we estimate the indices of both sorts of inequalities for each of the seventeen spanish regions analysed before computing the contribution of these characteristics firstly to estimate iop in addition to previous variables referring to individuals family background we include two more variables regarding individuals personal circumstances in order to obtain reliable estimates and reduce the omitted variables bias these two variables are gender with two categories female and male and country of birth with two categories foreignborn persons and spanishborn to estimate iop we use the ex ante parametric method although there are many other alternative methodologies we have decided to use the exante parametric method since this is the most widely used procedure in the iop literature and thus allows comparability with other studies furthermore this method has the additional advantage that it does not require including information referred to the level of effort in order to compute iop we divide individuals into types t being each type formed by individuals that share the same categories of each circumstantial variable in our case we have five variables parental education parental occupation childhood financial difficulties gender and country of birth with three three four two and two categories each thus leading to a total of 144 different types of individuals these are the variables considered to be beyond individuals responsibility and therefore treated as circumstances then we estimate individual incomes following the expression lny i c i β u i where c i denotes the different variables used as circumstances and β represents the effect these circumstances have on income once the equation is estimated we get the fitted values μi exp c i β which are a counterfactual distribution of income that depends only on the circumstances the inequality of opportunity indices can then be obtained in absolute and relative terms quite straightforward iop a i μi and io pr i μi i y table 2 shows the results of both income inequality and iop in the equivalised disposable income through two indices the gini and the ge we use the gini index due to its easy interpretation and because it is widely used to measure inequality generalised entropy ge is also computed since this is the only measure with a pathindependent decomposition using the arithmetic mean as reference and can be easily used to compute the contribution of the circumstances to iop according to the obtained results northwestern regions and also two central regions experienced an increase in both income inequality and iop whilst for the remaining regions we observe a decrease in both inequalities with the exception of castile and leon and castillala mancha for which we observe an increase likewise in most regions we can see an increase in relative iop that is to say the share of inequality of opportunity in overall inequality increases and consequently factors that are beyond individuals responsibility become more important in shaping individuals´wellbeing and performance to answer our question to what extent are family background characteristics important in shaping inequalities once we get the estimates of iop we estimate the contribution of the circumstances and pay attention to the amount of iop due to parental education and parental occupation to this end we decompose iop using the shapley value procedure and we compute the marginal effects each variable has in iop in terms of the ge index table 3 shows the average contribution of family background characteristics to iop these circumstances are of great relevance in shaping inequalities the three of them account for about half or more of the total iop the exceptions are four regions of the northeast where the relative importance of family background characteristics is lower as it can be seen in this section both inequalities income inequality and inequality of opportunity both in levels and evolution differ between regions additionally the importance of family background characteristics to determine the levels of inequality of opportunity also varies greatly for this reason it is relevant to analyse the determinants of these regional differences drivers of inequalities the aim of this section is to know which are the main drivers of the observed inequalities across regions we analyse the reasons behind the differences in inequality levels between regions and how these differences can be reduced as a first step we look at the association between inequality levels and several variables we analyse the correlations between inequality variables and potential determinants of inequality we include economic demographic and educational variables table 4 shows the pairwise correlations it can be seen that as expected both sorts of inequality are positively and strongly correlated as figure 1 also illustrates regarding the economic variables included income inequality is positively and significantly correlated with the unemployment rate therefore those regions with higher rates of unemployment also suffer from higher levels of income inequality nevertheless its effect on iop is not significant the other economic variables included are the per capita gross domestic product the average wage the wage of the tenth percentile and the wage of the ninetieth percentile the gdppc the average wage and the wage of the 10 th percentile are negatively correlated with income inequality and positively correlated with iop whilst the wage of the the role of family background and education in shaping inequalities ninetieth percentiles is positively correlated with both sorts of inequalities nonetheless these correlations are weak and nonsignificant with regard to demographic variables we include the share of population over sixty five years and the dependency rate both variables are negatively correlated with the levels of inequality moreover the correlation between the population shares over sixty five years and the inequality variables is quite strong and significant as can be also seen in figure 2 it implies that regions with aged population have less inequalities possibly because retirement benefits an equalising effect on income we also include the net interregional migration rate but its correlation with inequality is weak and not significant educational variables seem to have the highest levels of correlation with inequality variables as educational variables we include five variables at regional level the first of them is the share of individuals with tertiary education which is negatively correlated with both income inequality and iop although this correlation is not significant then the educational dropout rate 2 which is positively and significantly correlated with income inequality and the success rate of highsecondary school which is negatively and significantly correlated with income inequality the two educational variables that show the highest level of correlation with the inequality variables are the average studentteacher ratio and the education expenditure per student 3 the studentsteacher ratio correlation implies that the higher the average number of students per teacher the higher the levels of inequality and iop additionally the correlation between the education expenditure per student and the inequality variables shows that the greater the education expenditure the lower the inequality levels this relationship is also illustrated by figure 3 these results show that there is a significant association between the levels of inequality and educational resource endowments both economic and human capital it is observed that those regions with a greater endowment of educational resource exhibit lower levels of inequality in addition to the pairwise correlations we perform several regressions to see if the previously observed associations also entail causal relationships table 5 shows the results of the regressionsas expected not all positive and significant pairwise correlations are significant in the regression analysis moreover regression results are not robust when comparing fixed effects and pooled ordinary least squares still the regression analysis shows that an increase in unemployment rate would cause an increase in the levels of income inequality additionally the expenditure on education is significant to explain iop showing that an increase in education expenditure would reduce inequality of opportunity summarising the analysis carried out in this section highlights the great relevance of education in reducing inequalities especially the expenditure on education and the number of teachers conclusions throughout this article we show the relevance of family background characteristics in shaping individuals income and the determinants of regional differences in levels of both income inequality and inequality of opportunity we wonder if familiar background characteristics have an impact on individuals disposable income to test that we compute inequality and iop indices for the different regions our analysis reveals that family background has a great impact on individuals income and it is a crucial source of unequal opportunities moreover this analysis reveals that for the spanish regions familiar background characteristicsin particular parental education parental occupation and the financial situation during childhoodare of great importance in shaping individuals performance and opportunities of achieving a certain level of income additionally we analyse the main drivers of the regional differences in income inequality and iop finding that educational variables are highly associated to inequality levels moreover the regression analysis shows that there is a causal relation between educational resource endowments and both income inequality and iopthe analysis shows that regions that invest more in education experienced lower levels of inequality the obtained results suggest that different regional education policies reflected in differences in expenditure per student are an important determinant of regional inequalities especially of inequalities of opportunity which are the sort of inequalities beyond individuals responsibilities and therefore considered unfair consequently some policy implications can be drawn from this empirical evidence the results seem to indicate that an increase in social expenditures could have an equalising effect on income in this sense it is important to mention the work from quiñonez who found that in the case of latin america social spending increases are associated with reduced levels of income inequality he distinguishes four areas of social expending and shows that each of them has different effects on income inequality additionally ellison and fenger show that the implementation of socially equitable and effective state policies or interventions depends on a thorough prior analysis of the relationship between labour market structures inequality social investment and social protection in specific contexts this underlines the importance of specific policies that can directly and effectively address existing inequalities and specifically target the groups that need them it is important when designing public policies to carry out analyses that clearly identify those individuals or groups susceptible to being targeted by the policies the analysis carried out in this article has allowed us to determine which are the most vulnerable groups and which are more likely to receive lower income and be therefore in a position of material disadvantage these are individuals from disadvantaged family backgrounds with parents who have a low level of education and who work in lowskilled occupations therefore it would be advisable to implement public policies targeting this vulnerable group additionally given that this research shows that the greater the educational resource endowments the lower the levels of income inequality it would be advisable to combine specific policies for vulnerable groups with policies aimed to increase educational resources more specifically redistributive policies could be combined with policies aimed at improving the quality of education and guaranteeing access to education regardless of socioeconomic factors and family background to sum up policies aimed at levelling the playing field seem to be necessary in order to improve the situation of those individuals who suffer a lack of opportunities in both educational and economic dimensions and who are more vulnerable to economic shocks data availability statement the data that support the findings of this study are available from the corresponding authors upon reasonable request competing interests to report notes 1 groups 1 to 4 are 1 managers 2 professionals 3 technicians and associate professionals and 4 clerical support workers groups 5 to 7 are 5 services and sales workers 6 skilled agricultural forestry and fishery workers 7 craft and related trades workers groups 8 and 9 are 8 plan and machine operators and assemblers and 9 elementary occupations this classification is made by the international labour organization 2 share of population aged 1824 who have not completed upper secondary education and are not in any form f education or training 3 both are referred to nonuniversity education

family background characteristics and educational resources are crucial in shaping individuals income and therefore a potential source of income inequality and inequality of opportunity this article analyses inequalities in the spanish diverse regions using data from the european survey of income and living conditions eusilc along this article we analyse the relevance of family background characteristics in shaping individuals opportunities as well as the role education plays in income inequality our findings show that family background characteristics are of great importance in shaping individuals performance and opportunities of achieving a certain level of income wellbeing and education also educational variables at regional level such as the education expenditure per student are highly correlated to the levels of inequality in view of the results it would be advisable to implement public policies targeting vulnerable groups to ensure equal opportunities and invest in education given its potential as equalizer of income inequality

background the improvement in breast cancer survival conferred by chemotherapy is the same whether it is delivered before definitive surgery or after 12 there are advantages to neoadjuvant treatment however particularly for certain groups of patients for patients with larger cancers or smaller breast size neoadjuvant chemotherapy increases the likelihood of successful breast conservation and can make inoperable disease resectable 3 furthermore unlike adjuvant chemotherapy neoadjuvant chemotherapy both predicts prognosis and allows assessment of treatment response and therefore has the potential to alter the course of treatment this information about treatment response and prognosis is especially important for patients with higher recurrence risk and guidelines by the national comprehensive cancer network recommend considering neoadjuvant chemotherapy for women with stage 2 cancer or above 3 given these advantages neoadjuvant chemotherapy is now used in some sites for up to a quarter of breast cancer patients receiving chemotherapy 124 however its use varies substantially even between large centers 4 5 6 7 8 research into adoption of other new medical technologies has shown that adoption often varies strongly by nonclinical factors including patient socioeconomic status variation by socioeconomic status would be a particular concern in breast cancer care on average patients with lower socioeconomic status have higherstage breast cancers 9 and therefore have a greater chance of benefitting from neoadjuvant therapy variation in use of neoadjuvant chemotherapy could also stem from differences in patient preferences there appear to be few disadvantages of neoadjuvant chemotherapy but care may appear more complex to the patient and patients may find the delay to surgical excision concerning 10 little is known about patients experiences with neoadjuvant compared with adjuvant chemotherapy the value patients place on the advantages and disadvantages of neoadjuvant timing of chemotherapy or whether these might vary by socioeconomic status to address these gaps we examined a sample of women with breast cancer who participated in a crosssectional multicenter study at eight centers and received chemotherapy examining patterns of chemotherapy timing by socioeconomic status we also describe patients experiences with neoadjuvant compared with adjuvant chemotherapy including their perceptions of the risksbenefits the decisionmaking process and quality of care methods study source and population the study was performed within the greater plains collaborative one of 13 patient centered outcomes research network clinical data research networks the study sample included eight gpc sites from seven midwestern states in brief each center extracted data from their north american association of central registriesformatted tumor registry into its informatics for integrating biology and the bedside system and women aged 18 or older with a first diagnosis of histologicallyconfirmed stage 03 breast cancer made between 112013 512014 were identified a random sample of 250 of these women from each site was then selected for a mailed survey sent in may 2015 with up to 10 replacements for any surveys that were returned with evidence that a subject was ineligible in addition to the survey all subjects were asked for additional consent for investigators to examine their medical records including information from the tumor registry the study was approved and monitored by the institutional review board at the coordinating center with the other centers ceding review patients were asked in the survey to report timing of their chemotherapy specifically whether they had chemotherapy before surgery only after surgery only or both before and after surgery prior studies suggest that patient selfreport of chemotherapy is highly consistent with other measures including administrative data 11 subjects with invasive breast cancer who reported having received either neoadjuvant or adjuvant chemotherapy were eligible for this study because extent of disease is important in cancer treatment decisionmaking only those women who also agreed to use of tumor registry information were included in the final sample variable definitions subject demographics were obtained from survey responses rural residence was identified using the ruralurban continuum categories from 2013 us census data for the subjects zip code extent of disease and tumor markers and human epidermal growth factor receptor 2 were obtained from cancer registry data three likertscaled items were also developed for the survey regarding the importance patients placed on the advantages and disadvantages of neoadjuvant vs adjuvant chemotherapy these items were based on summary statements from physician treatment guidelines 3 and used wording that was similar to previously developed items regarding importance of factors in breast cancer treatment decision making 12 participants responded to when decisions were being made about chemotherapy how important was it that the timing of the chemotherapy … …would allow you to know that your cancer had shrunk …would improve your chances of having a lumpectomy and ……would make sure the cancer was removed by surgery as soon as possible with 5 response levels with labels below the first as not at all important the third somewhat important and the last very important patient experiences with decisions related to chemotherapy were assessed using several measures to assess subjects reports of shared decisionmaking we utilized two instruments with likertscaled items 13 the first of which evaluated patients preferred participation in breast cancer treatment decisions by asking which of the following best describes the way you would prefer to make a decision about your cancer treatment with five responses ranging from i prefer that i make the decisions about treatment with little or no input from my doctors to i prefer that my doctors make the decision about treatment with little or no input from me the second instrument then asked about subjects actual experiences specific to the chemotherapy with responses substituting for example i made for prefer that i make 1314 using an adaptation of the actual experience item subjects were also asked about family participation in the decision patientreported experiences with quality of physician communication and coordination of care were measured through likertscaled items based on the consumer assessment of health care providers and systems these items were previously used in a longer measure of patientperceived quality of cancer care 1516 and are strongly correlated with overall perceptions of quality of care 16 analysis subjects who reported that they had chemotherapy both before and after surgery were not included in the study because of relatively high missingness of information for variables for both her2 status and income missing categories were created for all variables initial examination of the overall sample showed that there was no association of education or income with overall rates of chemotherapy use furthermore few africanamerican or hispanic women were treated for breast cancer at our study sites we thus focused our examination on the potential association of neoadjuvant chemotherapy use with socioeconomic status as measured by education and income in a bivariate examination of the association of income with neoadjuvant receipt there were no differences between the lowest 5 groups we examined so in further analyses they were classified as highest income vs all others in bivariate examination of the association of education with neoadjuvant receipt there were no difference in neoadjuvant receipt in the highest three groups we examined so in further analyses they were classified as lowest group vs all others our primary analyses included either income or education examined in a regression model which included tumor markers stage and demographic variables to examine the robustness of these results we also examined several alternate models of ses a model with both education and income included together and one using a variable which combined income and education into four groups less than 100000 and high school or less less than 100000 and more than high school greater than 100000 and high school or less and greater than 100000 and more than high school finally we examined the inclusion of a measure of health literacy 1718 which in models with education was not statistically significant so was removed from further analyses we also examined subjects beliefspreferences and experiences with care by timing of chemotherapy results for the new variables for importance of neoadjuvant advantagesdisadvantages were examined either in three categories or dichotomized with 13 vs 45 results were similar so the twocategory variable was used following sulayman decisionmaking variables were recategorized as passive shared and active 14 finally we performed exploratory analyses examining whether differences in patients beliefs andor experiences were mechanisms for the association of income and education with chemotherapy timing based on unadjusted findings for the association of perceptions of neoadjuvant chemotherapy advantagesdisadvantages with chemotherapy timing we examined this relationship in adjusted models as well as whether any differences by income in perceptions of advantages might explain differences in receipt of neoadjuvant chemotherapy all analyses were conducted with sas statistical software version 94 and twotailed p values the datasets during andor analyzed during the current study are available from the corresponding author on reasonable request results the overall sample of 1235 subjects and the details of the calculation of survey response rates have been previously described 19 among the 877 survey respondents who provided consent to view their cancer registry information 331 received either neoadjuvant or adjuvant chemotherapy and were included in further analyses about 40 of this sample was age 50 or under 199 had a high school education or less and 292 had a household income that was less than 50000 yearly as shown in table 1 296 of the women received neoadjuvant chemotherapy factors associated with neoadjuvant chemotherapy receipt of neoadjuvant chemotherapy among the chemotherapy sample varied substantially by age tumor markers and extent of disease so that 50 of hrand her2 received neoadjuvant chemotherapy compared with 228 of those with hr and her2 neoadjuvant chemotherapy receipt ranged from a low of 138 for those with stage1 cancer to 400 for those with stage 3 disease although differences in use of neoadjuvant chemotherapy by site of care were not statistically significant there was substantial sitetosite variation from a low of 200 of chemotherapy given as neoadjuvant at one site to a high of 436 use of neoadjuvant chemotherapy among those receiving chemotherapy also varied substantially by income and education so that 419 of patients with household income received neoadjuvant chemotherapy only 182 of those with a high school education or less received neoadjuvant chemotherapy vs 327 of those with at least some college while women residing in rural zip codes were less likely than those in urban zip codes to receive neoadjuvant chemotherapy this difference was not statistically significant in models adjusted for demographics stage and biomarker status patients with lower household income were only slightly more than half as likely as those with income 100000 to receive neoadjuvant chemotherapy the differences in neoadjuvant use by education that were seen in unadjusted analyses were no longer significant in adjusted analyses of education alone or analyses that included both income and education when income and education were combined into 4 categories neoadjuvant use by those with low incomelow education differed from other categories but no other differences were found patient experiences with and preferences regarding chemotherapy patient reports of beliefspreferences and experiences regarding chemotherapy are shown by timing of chemotherapy in table 3 subjects who received neoadjuvant chemotherapy differed from those with adjuvant chemotherapy in their response to two of three questions about the importance of specific advantages and disadvantages of neoadjuvant chemotherapy women who received neoadjuvant chemotherapy were more likely than those who received adjuvant to report that know the cancer had shrunk was important and less likely to report that making sure the tumor was removed by surgery as soon as possible was important women who received neoadjuvant chemotherapy were slightly more likely to report that increasing the chances for lumpectomy were important although this difference was not statistically significant also shown in table 3 are patient reports of chemotherapy decisionmaking for the sample overall and by timing of chemotherapy subjects who received neoadjuvant chemotherapy were slightly more likely to report that they desired a more passive role in decisionmaking about their treatments but this difference was not statistically significant the difference was larger though still not statistically significant when subjects were asked about the role in the decision they actually played with 34 of patients who received neoadjuvant chemotherapy having a more passive decisionmaking role as compared with 24 of those who received adjuvant chemotherapy there were no differences by timing of chemotherapy in response to a similar item asking about the actual role of family participation subjects who received neoadjuvant chemotherapy reported similar quality of communication regarding cancer treatment compared with those receiving adjuvant chemotherapy they also reported similar quality of coordination of care overall and in response to each of the individual items that made up the coordination score potential mechanisms for variation in chemotherapy timing by income given the differences in subjects ratings of the importance of neoadjuvant advantages disadvantages by timing of chemotherapy we explored their potential role in the variation of chemotherapy timing by income in all three cases highincome subjects were less likely to consider the advantagedisadvantage as important specifically 548 of highincome subjects reported that treatment that allowed you to know the cancer had shrunk was important or very important compared to 678 of lowerincome 197 of highincome reported that improving your chances of a lumpectomy was important or very important compared with 469 of lowerincome and 603 of highincome reported that making sure the tumor was removed by surgery as soon as possible was important vs 79 for lowerincome only the result for removed by surgery would be consistent with a preference for neoadjuvant chemotherapy among higherincome patients as would be expected given these differences by income in models that adjusted for the responses improving your chances of a lumpectomy and making sure the tumor was removed by surgery as soon as possible the difference in neoadjuvant receipt between higherincome and lower income subjects was actually widened in the model that included the subjects rating of importance of having the cancer removed by surgery as soon as possible the differences in neoadjuvant use by income shown in table 2 were narrowed but not fully explained discussion in this large multicenter sample of women with invasive breast cancer over 29 of patients who received chemotherapy received it before surgery receipt of neoadjuvant chemotherapy varied as expected by stage and cancer biomarker status but women were also more likely to get neoadjuvant chemotherapy if they were older or in the highest ses groups household income 100000 patients who received neoadjuvant chemotherapy rated the importance of its advantages higher and the importance of its disadvantages lower than those who received adjuvant chemotherapy although there were some differences regarding perceptions of the importance of benefits of neoadjuvant chemotherapy by income these did not appear to be major factors in the association of income with chemotherapy timing patients reports of decisionmaking and quality of care were similar by timing of chemotherapy our study findings regarding differences in treatment by income appears to conflict with one earlier report regarding neoadjuvant chemotherapy 1 this study in the national cancer database found a lower likelihood of neoadjuvant chemotherapy with nonmetropolitan residence and older age but residents of higherincome zip codes in that study were actually slightly but not statistically significantly more likely to receive neoadjuvant chemotherapy 1 our study used individuallevel measures of income that were not available in the national cancer database but it is not known whether that might explain the discrepancies in our findings it is also notable also that our study is consistent with other studies showing that lowerses patients appear to be at higher risk of slow adoption of other advances in chemotherapy treatment in some studies either not receiving chemotherapy despite indications for it 20 or being underdosed 2122 we also were able to measure novel and detailed information about patient beliefs and preferences regarding neoadjuvant chemotherapy in our sample many patients valued the advantages of both neoadjuvant and adjuvant chemotherapy but the relative importance of these advantages differed with the chemotherapy received that these preferences also differed by income is concerning though perhaps not that surprising given that information about neoadjuvant chemotherapy is probably new to many patients 2324 nonetheless differences in preference by income did not appear to explain differences in chemotherapy timing by income in fact when perceived importance of the two neoadjuvant advantages were accounted for differences by income increased future research that measures variation in preferences regarding neoadjuvant care prospectively and with careful attention to health literacy and the information provided to patients is needed there were no statistically significant differences by timing of chemotherapy in reports of desired or actual decisionmaking in our sample although an association of more passive decisionmaking role with receipt of neoadjuvant chemotherapy was suggested a more passive decisionmaking experience may be expected for a procedure that many patients are not aware of until it is actually offered to them many patients want an active role in breast cancer decisionmaking 14 so these findings should be examined in other settings and larger samples our results also showed similar patientreported quality of communication and coordination by timing of chemotherapy this is reassuring given that the treatment experiences might be expected to be quite different particularly since patients who had neoadjuvant chemotherapy had higherstage disease that generally requires more complex treatment our study has some limitations our reports of timing of chemotherapy were based on selfreport and it is possible some patients were unsure or mistaken in their reports however there is high validity to patient reports of chemotherapy receipt generally 11 and recall of its timing relative to surgery might be expected to be high one to two years after the experience as well our study was crosssectional it is possible that a prospective observation of counseling sessions would have had different findings about perceived advantages and disadvantages of neoadjuvant therapy our examination of specific measures of ses were somewhat limited by power so that our ability to tease out differences between lowincome and loweducation was limited there is evidence that a growing number of patients do not need cytotoxic chemotherapy 25 26 27 and it is possible that factors associated with timing of chemotherapy will change as the cohort of patients receiving chemotherapy shrinks finally our results may be affected by survival bias or selection bias if patients with shorter survival or who did not participate in the study would have reported a different relation between chemotherapy timing and experiences than women who did participate however early mortality is low in breast cancer 28 even among patients with stage 2 and 3 disease despite these limitations our study provides important information regarding patients preferences and experiences with neoadjuvant chemotherapy compared with adjuvant chemotherapy our studys findings regarding large differences in use of neoadjuvant chemotherapy by income have important implications while these results are consistent with the patterns seen for adoption of other new technologies and therapies it is particularly important in breast cancer given the restriction of many new breast cancer trials to neoadjuvant users variability in neoadjuvant use by income could perpetuate or even worsen disparities in clinical trial enrollment and deserves further research and if confirmed urgent attention because those with missing data for these variables were excluded from the models results for income vary slightly from appendix

backgroundthere are advantages to neoadjuvant chemotherapy in operable breast cancer particularly for those with higherrisk cancers but little is known about factors that are associated with the use of neoadjuvant chemotherapy outside of clinical trials we examined whether use of neoadjuvant chemotherapy instead of adjuvant chemotherapy varies by nonclinical factors such as patient socioeconomic status or rural residence methodswomen diagnosed with breast cancer in 201314 at eight medical institutions were surveyed by mail regarding their experiences with breast cancer treatment and this information was linked to hospitalbased cancer registries we examined the use of neoadjuvant chemotherapy among women with histologicallyconfirmed invasive stage iiii breast cancer and used regression models to examine the association of socioeconomic status with chemotherapy timing we also explored potential mechanisms for those differences resultsover 29 of the sample overall received neoadjuvant chemotherapy neoadjuvant receipt was lower for those with income 100000 aor 056 95 ci 0209 even with adjustment for other demographics stage and biomarker status and findings for education and a variable for both lowest education and income 100000 were similar ruralurban residence was not associated with neoadjuvant receipt differences by income in perceptions of the importance

introduction since the beginning of the pandemic human rights feminist patient and maternity advocacy groups have voiced their concern over fundamental rights violations in maternity care 1 early in the pandemic covid19 was identified as a risk factor for obstetric violence 2 often accompanied by rollbacks in quality of care 35 in their commentary our colleagues from cost action 18211point 5 points to mounting evidence of adverse consequences that covid19 containment measures enforced in facility maternity care worldwide they call for the priority implementation of evidencebased humanrightsinformed care including during times of crisis such as the current pandemic the commentary authors go on to highlight how the reaction to health services and the way they were reorganized reveals something about the underlying ethos of maternity care provision around the world raising serious questions about how it should be reframed when services are rebuilt once the pandemic is finally over 5 patient advocacy organizations in this case national parents groups monitoring and advocating for improvements in maternity services are relevant stakeholders in healthcare 6 because they work at the intersection of parents lived experiences policies and rights using their unique insight to catalogue and report patients lived experiences in general 7 8 9 policy case studies but also in maternity services specifically 11011 as in any crisis caution is advised when reactions include sudden practice changes to maternity services that are not grounded in the best available evidence these can bring unforeseen consequences for women pregnant and birthing people and families respectful maternity care cannot be seen as secondary to pandemic containment measures in maternity facilities it is imperative that all containment measures are proportionate to the threat and that undue burdens are not put on pregnant birthing and postnatal families practice guidelines for maternity care during covid19 in europe during the first three waves of the pandemic in countries where they existed revealed erratic contradictory and inconsistent approaches to scientific evidence 12 moreover there is emerging evidence that containment measures implemented in maternity services as a response to the covid19 pandemic negatively impacted maternal and perinatal outcomes 1314 including maternal mental health 15 16 17 but also healthcare professionals wellbeing 18 although some authors have reported on parents experiences in neonatal care 1119 to our knowledge no other published research has used a humanrightsbased approach to survey national pandemicrelated changes to care for pregnant and birthing women from the perspective of parents organizations organizations representing patients overall or specific patient groups have been conducting research and publishing reports using similar methodology throughout the pandemic 710 the perspective of patient organizations who collect and monitor information from patients receiving care directly but also through monitoring activities is unique and in a crisis is a valuable source of realtime information this article aims to provide an overview of different changes made to maternity services implemented in some or all maternity facilities over the first 17 months of the pandemic roughly corresponding to the first three waves of the pandemic in europe as reported by maternity service organizations who are monitoring the situation in their countries the article reports on 16 core services and containment measures implemented in maternity services which directly impacted women birthing people and families based on the findings we propose a strategy for reimagining postpandemic maternity services across europe including these 16 issues and consider the implementation challenges strategy for postpandemic maternity services we used a descriptive qualitative and participative approach to gather input from parents organizations across europe by preparing the protocol research questionnaire and semistructured interviews in a participative manner according to sandelowski 20 a qualitative description is especially amenable to obtaining straight and largely unadorned answers to questions of special relevance to practitioners and policymakers in november 2020 a poll of cost action 18211 network members was conducted online with six questions that collected information on the most significant changes in maternity services during the pandemic seven cost member organizations completed the survey identifying some of the major covid19 containment measures implemented in their countries which women and families had reported to them as problematic the authors compared and analyzed the survey responses by clustering the data according to the phases of provision of obstetric care which identified 16 core issues from the survey for national maternity organizations as detailed in table 1 based on these results we prepared a questionnaire with the 16 core issues and conducted semistructured interviews with representatives of national maternity service organizations recruited through cost action 18211 and the european network of childbirth associations five of the organizations from the cost action had also participated in identifying the 16 core issues while the others did not the interviewees were invited to comment on the identified issues and to detail the situation in their countries based on reports they had received from parents on the ground and information they had gathered nationally the focus was on generalized tendencies observed in the individual countries leaving space for single facilities or regions differing from this overall trend the information gathered through the interviews is given in table 1 upon completion of an interview the information was shared with the interviewees who were invited to review and revise the recorded responses if needed data collection processing and storage conformed to the general data protection regulation and the declaration of helsinki consent was given at the beginning of each interview with the possibility of exiting the interview at any time no financial or other incentives were offered to the interviewees table 1 summarizes the data collected during the semistructured interviews for each country a discussion on general trends across the countries continues below antenatal care interviewees reported that inperson antenatal care appointments were reduced overall across the countries studied with the change being quite drastic in some countries in ireland antenatal and postnatal visits were capped at 15 minutes regardless of the reason for the appointment and in slovakia inperson appointments were banned during the first pandemic wave routine tests and scans remained available but were affected by shorter appointment times and were difficult to access during the peaks of the first three covid19 waves companions at antenatal appointments were banned in most countries except the netherlands and the czech republic where interviewees stated that some facilities allowed companions one country did not have the practice of companions at antenatal appointments prior to eur j midwifery 2022671 policy case studies table 1 reports on maternity care during the height of the first second and third waves of covid19 in 13 european countries ✓ ✓ ✓ ✓ ✓ ✓ x ✓ ✓ ✓ companion at antenatal appointment x x x x x x x x x x access to routine tests and scans policy case studies the pandemic overall interviewees commented that the quality of care was compromised as a result especially in countries where the quality of care was already low or varied before the pandemic antenatal mental health services where they existed prior to the pandemic were reduced this is particularly problematic considering that the pandemic triggered the compromise of the mental health of all people especially pregnant birthing and postnatal families 2122 parents organizations reported observing higher stress levels among pregnant women in their countries because of these difficult circumstances one organization quoted a pregnant womans experience in germany ✓ 15 min maximum ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ antenatal mental health services available x ✓ reduced intrapartum care companion at vaginal birth x ✓ ✓ ✓ ✓ ✓ ✓ ✓ x x ✓ x ✓ x x ✓ ✓ companion at cs birth x x ✓ x ✓ ✓ x x ✓ my gyn offered me this test for malformations and my partner was not there but i just did not know what to do and how could i decide this without asking his opinion it is his baby too intrapartum care companionship parents organizations reported differences in the possibility of having a birth companion this measure was subject to the broadest variety over time type of facility and country all interviewees reported a reduced possibility of having a birth companion or the institution of outright bans another experience from germany showed the rapidly changing situation the ward that allowed my partner with me was closed the day before i gave birth because they focused staff on covid patients i had to go to a hospital with a very different policy where my partner stayed in the parking lot the whole time in those situations where a birth companion was allowed interviewees reported severe restrictions including limiting when the companion was allowed to be present or the requirement that the birth companion have a negative covid19 test which before the advent of rapid tests usually meant a minimum 24hour wait only one country stood out for being consistent in maintaining the same level of a right to a birth companion at a vaginal birth throughout the pandemic women who give birth by cesarean section are not always afforded the same rights to companionship as those who give birth vaginally prior to the pandemic reports by interviewees showed that the situation regarding companionship at a cesarean varied widely across the countries in three countries interviewees reported having a companion at a cesarean section was not the norm before the pandemic in four countries where companionship at a cesarean was mostly the norm prior to the pandemic bans were introduced as part of covid19 containment measures with differences between public and private facilities in portugal even though companionship at cesarean section is guaranteed by law 23 doulas have appeared as secondbirth companions over the past twenty years across western europe despite the overwhelming evidence that the presence of a doula can improve birth outcomes for mothers and newborns especially for racialized and poor women migrants and refugees 24 25 26 interviewees reported that second companions and therefore doulas were banned as part of containment measures in the majority of the countries included in the survey with only two countries offering the possibility of doula companionship in some facilities visitor bans were reported by most parents organizations in the study whereby women were not able to see their partners or other family members after birth and for the duration of their stay inhospital at least during the peaks of covid19 waves the exception to this were three countries later research linked these types of bans to increased postnatal traumatic stress response 2127 it is important to note that this study did not collect data on the length of the average hospital stay after vaginal or cesarean birth which may vary across the countries and alter the longterm effects of visitor bans mode of birth while most parents organizations surveyed did not report that women who were suspected of having or were covid19 positive had their labors induced without obstetric indication in two countries there were reports of this happening in some facilities in two countries interviewees reported that most facilities required that women with suspected or confirmed covid19 give birth by cesarean section without obstetric indication in poland women who were covid19 were required to birth in special facilities where cesarean section was mandatory for covid19 mothers in five other countries interviewees reported mandatory cesarean for covid19 women for some facilities during certain pandemic waves this echoes results published for the united states which showed increased medicalization of childbirth for women suspected or confirmed of having covid19 28 availability of home birth services during the pandemic more women sought home birth services 29 in this study organizations in six surveyed countries stated that only privatesector home birth services continued to be available as normal during the pandemic in portugal where home births are only offered in the private sector their number nearly doubled in 2020 compared to 2019 29 which can partially be explained by people wanting to avoid the restrictions implemented in facilities and perceived safety in avoiding covid19 infection as the demand increased substantially some women were not able to find midwives who could attend a home birth two organizations stated that home birth services remained available as normal in both public and private sectors interestingly the irish parentorganization reported that the health service increased the availability of home birth services as a result of increased demand in four of the countries organizations reported that home birth services were not available before eur j midwifery 2022671 policy case studies the pandemic and were therefore not available during the pandemic either despite not being officially available the number of home births in croatia increased by 30 between 2019 and 2020 although the number remained low 30 separation from newborn and visiting bans early in the pandemic the who issued recommendations clearly stating that if the mother is covid19 the mother and newborn should be kept together provided the mother feeling well enough to care for the newborn 31 a recommendation mirrored by the guidelines by the royal colleges of midwifery and obstetriciangynecologists 32 despite this one of the major problems with covid19 response policies was the separation of mothers who were suspected or confirmed covid19 and their newborns especially in the first three to nine months of the pandemic this was reported by most interviewees notable exceptions to these were reports from organizations from ireland and the netherlands which stated that mothernewborn dyads were kept together as normal regardless of the mothers covid status in some countries the health authorities were slow to issue evidencebased recommendations in portugal the first recommendation by the college of obstetrics and gynecology in march 2020 stated that women who are covid19 must be separated from their infants and prevented from breastfeeding 33 as more evidence and international guidelines were published resulting in increased pressure from advocacy groups the general directorate of health updated the guidelines albeit one full year later despite the new guidance the previous policies continued across facilities 34 in croatia women who gave birth before the results of their routine pcr test were available were separated from their newborns as a precautionary measure until a negative result was returned this practice was prevalent in some facilities throughout the pandemic waves but also between waves and was especially a problem in smaller facilities where pcr tests took longer to analyze visiting restrictions for premature or sick newborns were also reported by most national organizations with some interviewees reporting the implemented total visitation bans in most facilities these measures were implemented despite a lack of evidence that they contribute to containing the spread of covid19 and despite being in contradiction with readily available professional and who guidelines that were being updated in realtime 3235 visitor bans were also reported for hospitalized mothers and newborns by all interviewees except those from three countries where parents organizations reported that visitation of mothers was the same as in prepandemic times in the other countries organizations reported that women hospitalized during pregnancy did not have visitation from the time of their hospitalization to postpartum regardless of the duration of that stay a mother from germany stated i stayed at the hospital because of late pregnancy complications but after my cesarean birth i left as soon as they let me i missed my older daughter so much i hadnt seen her in 2 weeks evidence shows that these visiting restrictions can have a negative effect on postnatal mental health 142136 postnatal maternal mental and physical health despite increasing awareness about the importance of perinatal mental health during the pandemic interviewees reported that mental health support services were only rarely available either because they did not exist prepandemic because they were restricted due to containment measures or because demand was so high that services were not accessible interviewees reported that inperson postnatal care usually organized around sixweeks after birth continued to be mostly available as normal much as antenatal care was however they also reported that pandemic measures resulted in increased use of telehealth consultations which depend on women and families having access to reliable affordable internet and devices capable of video calls which is not always possible later evidence about the efficacy of telehealth maternity care during the pandemic showed that this type of care was not always optimal 537 the results we found were similar to those described by others 193839 who defined similar themes less family involvement reduced emotional and physical support for women compromised standards of care increased exposure to medically unjustified cesarean section and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures 40 as well as a decrease in respectful care due to fears surrounding covid19 transmission 23841 at the same time interviewees reported that facilities that were known for providing more motherfriendly and babyfriendly care made great efforts to maintain that level of quality sometimes at considerable staff effort whilst otherwise less friendly facilities more rapidly downgraded their services maternity care guidelines from international and national organizations throughout the pandemic international and national organizations have made efforts to create and regularly update guidelines for covid and maternity care starting even the european parliament was concerned about rollbacks in maternity care in member states 42 despite these efforts our data have shown that facility policies did not change much between the first and third waves of the pandemic even after more evidence was available a specific example is the benefits of labor and birth companions which have been widely studied and recognized 2224 guidance available very early in the pandemic and updated in realtime as new evidence became available 3132 clearly stated that companionship at vaginal birth was important and could safely continue with the implementation of basic pandemic practices despite eur j midwifery 2022671 policy case studies this the political will to maintain proportionally appropriate limitations to companionship among policymakers and professional organizations varied widely throughout the various countries and pandemic waves an example of good midwifery practice was the uk during the second wave where professional organizations reiterated that attendance of partners during labor and birth must be a priority with reliable testing and appropriate ppe available to both ensuring the safety of all those using maternity services and must be proportionate to policies being used in other departments of the facility 3243 a second good practice came from france which did not have a parents organization representative included in this study but is a major european country there the ministry of health issued guidance for hospitals in the first month of the pandemic outlining how to include companions in labor and childbirth while lowering the risk of infection 44 the german society for gynecology and obstetrics issued a similar statement 45 on the inclusion of fathers also in the first month of the pandemic the realtime guidelines by the royal colleges of obstetrics and gynecology and the royal college midwives and world health organization referred to earlier in this article stated that elective induction or cesarean should be avoided for women who have symptoms of or are positive for covid19 without obstetric indication 3132 other european professional societies issued similar statements including the german obstetric society 46 and the italian obstetric society 47 conversely the portuguese college of obstetrics and gynecology recommended a shorter threshold for the decision in the use of epidural analgesia and instrumental birth meaning that women were more likely to have either of these interventions if they were suspected of or confirmed to be covid19 33 maternity evidencebased humanrights care the differing responses to the covid19 crisis have shown that national and local decisionmakers opinions often impact maternity facility policies more than scientific evidence and international guidelines as a result there must be a significant change to the prevailing paradigm and overmedicalization of maternity care in europe especially during crises to one where a proportional evidencebased response prevails a healthier perinatal period sets babies and families on a longterm beneficial health trajectory 48 so while classic impediments to system changes such as financial and human resources must not be underestimated it seems that the biggest challenge to good quality services lies in an ethical decision is the wellbeing physical and mental health of mothers babies and families important to our societies and is an evidencebased humanrights informed salutogenic approach to maternity care politically desired if so policymakers need to take appropriate steps to enforce such an approach as the current political and medical establishments alone seem unable or unwilling to birth the necessary change a womancentered positive birth experience is a valuable longterm investment for any society these birth experiences protect the physical and mental health of mothers 49 and result in higher breastfeeding rates 50 which should be an integral part of public health planning limitations all the countries included in the survey have a mix of public and private facilities and insurance which may have had different policies during the peaks of the pandemic waves these have been noted where appropriate but the mix of public and private facilities varies widely across the countries additionally the results reflect general national trends as they were reported to and collected by parent maternity rights organizations with a national presence in their countries although most of the organizations are large experienced organizations with national networks there is a potential for reporting bias the multinational nature of the data collection and importance of collecting these experiences which may never be reported in official data make them a valuable source of information future quantitative research will shed more light on the nuance in changes in maternity services during the pandemic furthermore the research questions did not take into consideration access to medical abortion or medically assisted fertility services and therefore did not map these aspects of reproductive healthcare finally the research only includes information for the first 17 months of the pandemic roughly corresponding to the first three covid19 waves in europe with data collection happening from may to july 2021 and for this reason does not include information on vaccines rollout to pregnant individuals or data on the fourth wave which began in europe in septemberoctober 2021 conclusion crises such as pandemics are a litmus test for health services and societies requiring a balance between containment measures and quality care the responses to the covid19 pandemic mapped in this article have shown that in some countries pregnant birthing and postnatal women and their families were expected to bear a disproportionate burden of the pandemic response from a parents perspective the solution lies in a paradigm change towards a respectful womancentered and familycentered approach 51 the prevailing biomedical model of maternity services focused on pathology must give way to a neuropsychosocial model of care where maternity care services are shaped according to womans needs based on scientific evidence and focused on the promotion of human health 52 the longterm mental and physical health of mothers newborns and families must be considered when measuring outcomes and reshaping services and mothers and their families must be recognized as stakeholders and be involved in all levels of decisionmaking this is critical as countries are still dealing with and will likely continue to deal with covid19 waves and new variants of the disease which may disproportionately affect pregnant women other conflicts of interest the authors have each completed and submitted an icmje form for disclosure of potential conflicts of interest the authors declare that they have no competing interests financial or otherwise related to the current work dd reports receiving a virtual mobility grant to complete the research on this article and being a member of board of human rights in childbirth and being a paid employee and an unpaid member of board of roda parents in action kh reports receiving grants from mother hood ev cedaw dissemination project and payment for lectures and presentations from university of cologne and first emotional aid conference kh also reports being an unpaid science officer and responsible for international network for mother hood ev cb reports receiving a virtual mobility grant to complete the research on this article and being an unpaid member of board of associação portuguesa pelos direitos da mulher n gravidez e parto rt reports receiving consulting fees for project transitioning motherhood mother2mother support under the registration number 20212hu01ka210adu000050329 to the call entitled strategic partnerships announced in the framework of the eramus as part of the project team from el parto es nuestro in delivering the research services to run the fieldwork activities in spain funding this research was partly financed through a grant from eu cost action 18211 ethical approval and informed consent ethical approval was not required for this study participants gave informed consent data availability the data supporting this research are available from the authors on reasonable request authors contributions dd cb and kh worked together to conceive the articles premise and to collect initial information based on a survey by olga gouni who participated in the initial mapping dd and kh mapped indicators based on survey responses and conducted interviews with parents organizations dd cb kh and rt collaborated on writing the manuscript provenance and peer review not commissioned externally peer reviewed

we surveyed changes to maternity care services in the first 17 months of the covid19 pandemic in 13 different european countries from the perspective of national maternity service parent organizations advocating for a human rights approach to maternity services a qualitative study was conducted in november 2020 an openquestion survey was sent to national maternity service parent organizations and members of cost action 18211 in europe asking about covid19 measures in maternity services antenatally intrapartum postnatally and overall satisfaction from the open answers 16 core issues were extracted between february and august 2021 semistructured interviews with the national representatives of 14 parent member organizations in europe were conducted collecting details on overall national situations and changes due to covid19 measures the reported experiences of parent organizations from 13 european countries show wide variations in epidemiological containment measures during the first 17 months of the covid19 pandemic practices differed between facilities resulting in emotional disquiet and confusion for parentpatients most countries maintained antenatal and postnatal care but restricted psychosocial support antenatal and birth companions visitors organizations from nine countries reported that women had to wear masks during labor and all but two countries saw separations of mothers and babies most parent organizations described a need for more reliable information for new parents during the pandemic nonevidencebased practices were re established in many settings depriving women and families of many factors which evidence has shown to be essential for a positive birthing experience based on the findings we consider the challenges in maternity services and propose a strategy for future crises

introduction in recent years a movement led by humanities undergraduates to decolonise the traditional university curriculum has gathered momentum its aims are to provide a more inclusive education one that looks beyond the traditional eurocentric white male syllabus to include more women and black and minority ethnic authors decolonising the curriculum is an emerging issue for all types of higher educational curricula as seen in the university college london initiative entitled why is my curriculum white 1 priyamvada gopals provocative article in the guardian newspaper yes we must decolonise our teaching has to go beyond elite white men 2 and soas university of london blog decolonising the curriculum whats all the fuss about 3 efforts by the humanities departments for inclusivity finds its parallels in medicines discussions on how a more inclusive curriculum can improve disease diagnosis and treatment patient management professionalism and quality of care stone et al speaking from a planetary health education curriculum perspective also say understanding the differences between equality and equity in theory and practice and concepts of marginalisation vulnerability resilience and who benefits and is harmed in a given scenario is a core objective of planetary health teaching since the effects of environmental change on human health are heterogeneous and mediated by factors such as geographical scale temporal scale socioeconomic factors and political and cultural context students should think critically about whose health is at stake and how it is measured 4 as a result more recently medical educators are beginning to think of how this process of decolonisation can apply to medical education medical schools must address the equality and diversity agenda which requires that the education system produce doctors who can meet the complex needs of a diverse population marginalised groups have poorer healthcare outcomes than patients at the top of the postcolonial hierarchy such as patients who are white male high social class and heterosexual this paper examines this professional and legal impetus to decolonise the medical curriculum and how elements of decolonisation can be applied to the modern medical curriculum the colonial backdrop of dehumanised care decolonising the history of medicine promotes awareness and questions the traditional narratives and power imbalances in order to disrupt the legacy of white male patriarchal colonisation of medicine by reassessing past medical colonial legacies it could be possible to reframe reorient and reform the profession porter a cultural historian says that the 18 th century european enlightenment and subsequent professionalism of medical practice encouraged the school of scientific enquiry which privileged experimentation and discovery at the expense of empathy 5 it encouraged the practitioners to perceive the patient as a subject first and a human second over the course of centuries this emboldened the european male practitioners and moulded a patriarchal medical system allowing a state of medical cultural arrogance to grow the benefits of the 18 th century enlightenment were to favour reason over superstition and further scientific advancement however in the process of establishing medical criteria it entrenched power hierarchies excluded other ideas of healing and other types of practitioners such a midwives folk healers or indigenous healing systems in the colonies medical pluralism was squeezed out of the growing medical power hierarchy proponents of medical decolonisation argue that the story of dr marion sims which is omitted currently should be included in medical curricula simss motivation was to repair fistulae in black women slaves so they could return to the workforce rather than to heal them representing the 18 th century enlightenments aspect of dehumanisation the fistulas in this population were a result of acquiring the skills of forceps delivery by obstetricians whilst disregarding and ignoring indigenous practices of midwifery the black women slaves that were experimented on to improve surgical technique did not give their consent to the procedure and nor were they given any sort of analgesia the names of three of these women anarcha betsy and lucy have now found equal fame from a human rights perspective after protests regarding their treatment sims statue in central park new york usa has been relocated 6 likewise in the history of the tuskegee syphilis experiments in the usa 7 where 600 black men were recruited to eugenics experiments to follow the natural history of untreated syphilis they were intentionally denied treatment though a lack of honesty the us government has since apologised and compensated the families proponents of decolonisation argue that this story should have a place within ethics and law syllabi of medical schools figure 1 useful definitions unconscious bias refers to a bias that we are unaware of and which happens outside of our control it is a bias that happens automatically and is triggered by our brain making quick judgments and assessments of people and situations influenced by our background cultural environment and personal experiences 8 cultural competence education for health professionals aims to ensure all people receive equitable effective healthcare particularly those from culturally and linguistically diverse backgrounds 9 cultural humility was used in a variety of contexts from individuals having ethnic and racial differences to differences in sexual preference social status interprofessional roles to healthcare providerpatient relationships the attributes were openness selfawareness egoless supportive interactions and selfreflection and critique the antecedents were diversity and power imbalance the consequences were mutual empowerment partnerships respect optimal care and lifelong learning cultural humility was described as a lifelong process with a firm understanding of the term individuals and communities will be better equipped to understand and accomplish an inclusive environment with mutual benefit and optimal care 10 the process of dissipating cultural arrogance in favour of cultural humility as part of decolonisation would entail disrupting elements of the hidden medical curriculum where the legacy of colonial norms operates as unconscious bias in professional behaviours by directly tackling the history of medicine through the lens of decolonisation within the ethics and law anthropology or global health frameworks of the syllabus medical educators can critically evaluate the evolution of patient centred care and reflect on who why and how the profession chooses to commemorate knowledge equally educators can then contextualise the legal advancements of human rights in healthcare professional and legal impetus to decolonise the medical curriculum professional impetus the case for decolonising the medical curriculum stems from a social justice perspective on the persistent legacy of colonialism which results in power imbalances and healthcare inequity 11 decolonising the curriculum could equip future doctors with the professional literacy and confidence to deal with the complexity and uncertainty of growing grassroots decoloniality activism by the patients academics and public this debate has started difficult conversations which we will explain further in this article white fragility is the refutation of the existence of structural racism as described in robin diangelos bestselling book white fragility why its so hard for white people to talk about racism 12 defensive responses regarding the concept of decolonisation from doctors who have a sociocultural background which we could call white coat privilege could be regarded as demonstrations of privilege fragility a term that we have coined for this article privilege fragility is at odds with the embodiment of the diversity and equality agenda within professional behaviours such as displaying cultural humility for the purposes of neutralising power imbalances in education and healthcare susan goldsmith chief operating officer and deputy chief executive of the general medical council said we understand and value the diversity within the medical profession and recognise the importance of supporting doctors to serve a diverse population across the uk … we have to be compliant with equality and human rights legislation but being fair goes way beyond just meeting legal requirements it is an integral part of everything that we do 13 these ideas are further reenforced in the gmcs outcomes for graduates 2018 report 14 legal impetus the legal incentives for promoting decolonisation of the medical curriculum are inextricably tied up with the risks of litigation and the relevant laws in statute case law as well as international legal instruments the european convention on human rights 15 has a number of provisions which protect an individuals rights in a healthcare setting in particular articles 2 3 8 12 and 14 enable patients to make choices in line with their own opinions and values even if those choices seem irrational illadvised or rash to others 16 however in addition to the above convention rights the article 9 right to freedom of thought conscience and religion is also pertinent because some modalities of treatment from the perspective of the patient may also have a significant spiritualreligious component examples of these include the many international cases relating to jehovahs witnesses refusing blood transfusions 17 it follows that restricting indigenous modalities of treatments which have religiousspiritual elements may also breach the patients article 9 rights in montgomery v lanarkshire health board 2015 the supreme court said that a patients decision on whether or not to incur a risk regarding their care does not depend exclusively on medical considerations and the patient is entitled to take into account her own values her own assessment of the comparative merits further the relative importance attached by patients to quality as against length of life or to physical appearance or bodily integrity as against the relief of pain will vary from one patient to another this is because many reasons may affect their attitude towards a proposed form of treatment and the reasonable alternatives the doctor cannot form an objective medical view of these matters and is therefore not in a position to take the right decision as a matter of clinical judgment 18 a possible explanation for the doctors not being able to attach a similar level of significance as patients do to issues of relevance to them may be because such a decision does not fit with doctors paradigm of medicine or health 19 if doctors are unable to act in a personcentred manner which in diverse populations would entail being culturally competent by exercising cultural humility it may leave their actions falling short of required standard of duty of care and therefore open to litigation therefore as lord kerr and lord reed in the supreme court put it it is necessary to impose legal obligations so that even those doctors who have less skill or inclination for communication or who are more hurried are obliged to pause and engage in the discussion which the law requires 18 furthermore outcomes for graduates 2018 specifies that graduates must demonstrate knowledge of the principles of the legal framework as well as the importance of the links between pathophysiological psychological spiritual religious social and cultural factors for each individual 14 decolonisation and medical education recent decolonial public engagement events university college london medical school in effort to improve curricula delivery the ucl medical school clinical and professional practice team held two public engagement events the first event practically creating an inclusive curriculum 2017 20 received feedback that there should be an exploration of how to decolonise the medical curriculum this in turn inspired a second public engagement event in 2018 named decolonising the medical curriculum 21 which focused on decolonising the body decolonising the curriculum decolonising learner experience decolonising educational space decolonising professional behaviours and decolonising ideas of healing the event broadly covered the areas of identifying symptoms and signs in varying skin tones in the context of over diagnosisunderdiagnosis feminist pedagogy describing sessions using patient narratives eg session on violence against women mapping the diversity curriculum the attainment gap and students experience of racism the ucl eugenics enquiry anthropology as a vehicle of improving professional behaviours biomedicines colonisation of indigenous healing systems 21 wellcome collection the ayurvedic man encounters with indian medicine accompanied an associated decolonising health symposium at the wellcome collection in 2018 22 the exhibition explored ayurvedic medicine in south asia through its museum antiquities collection the exhibition asked how medicine has been transformed by biomedical and cultural exchanges and what the impact of colonialism has been on medical heritage as the wellcome says we are at a time of growing popularity of pluralistic approaches to health societies around the world are at increasing risk of losing natural resources medicinal plants and traditional knowledge ayurvedic man highlighted the delicate balance between sharing and protecting heritage cultural resources and environmental biodiversity 23 ucl anthropology department flourishing diversity the flourishing diversity series 24 were a series of highprofile events in september 2019 which promoted actively listening to the voices stories and wisdom of the representatives from remote indigenous communities around the world gathered in london these listening encounters promoted key themes about sustainability climate change indigenous land rights indigenous ideas of healing and collective sharing of indigenous knowledge the messages from these public engagement events attracted the attention of major news outlets such as the bbc world service 25 and time magazine 26 soas university of london the learning from active listening to decolonise medical education following the active listening of the above events we have distilled concepts that may have been omitted from conventional topdown organisational equality and diversity policy in the context of medical education these concepts may feel uncomfortable however the emerging grassroots interest in decolonisation is a liminal space for educational transformation in this article we have further explored areas specific to the concept of healing in the individual and in the population figure 2 one man in traditional religious clothing credit wellcome collection 28 medical pluralism the tension between western and traditional healing systems the image used to publicise the wellcome 23 exhibition and associated symposium of two men meeting one in western dress and the other in traditional indian attire with a halo around his head stimulated some thoughts on definitions of the term enlightenment and its different meanings in western and eastern contexts in the east traditional healing ideology about overcoming illness through indigenous medicine can be viewed on a superficial level as symptom reliefcure but their philosophies have a deeper endpoint of paving the road to enlightenment of mind body and spirit through attempting to create ecological balance by working with nature in the west the 18 th century enlightenment refers to the overturning of superstition with science and logic in european colonies this contributed to the subjugation of indigenous medicine in favour of western health practices this meant that eastern practices such as ayurveda traditional chinese medicine and other indigenous healing systems were regarded through the sceptical lens of a western medical perspective and their efficacy rejected the exertion of colonialism led to europeans establishing their own biological structural and cultural superiority and their own epistemology on the narratives of healing as the only legitimate knowledge base of medicine in the countries they colonised 29 however the unique context of decolonisation of healing practices means that the process depends not only on dismantling colonial epistemologies and aspects of patriarchal institutions but also on simultaneously recentring the displaced indigeneity eastern ideas of healing as with many other indigenous healing systems encompass a range of multiple outcomes of mind body and spirit on receiving nuanced individualised treatments such outcomes are awkward to capture with standard epidemiological mathematics and onesizefitsall study design hence it is challenging to develop an evidence base according to western criteria however as conversations relating to decolonisation in healthcare circulate and contribute to ongoing health activism it will be interesting to see what will unfold and what patients want from healthcare systems the decolonising agenda to recentre displaced indigenous healing systems will be challenging for those in biomedicine due to the paucity of epidemiological evidence however equality and diversity training in professionalism within education could have an anthropological component that includes the concept of cultural humility where in this case there could be awareness that western medical practice is just one of many global healing systems this could throw light on biomedical unconscious bias however it should be noted that the outcomes for graduates 2018 says that graduates should respect patient choices about the use of complementary therapies and have a working knowledge of the existence and range of these therapies why patients use them and how this might affect the safety of other types of treatment that patients receive 14 often the unconscious bias is based on the narrative of the assumed superiority of western medicine based on evidencebased research however reviews of the evidence base of medicine guidelines such as wright et al say that practice guidelines by specialist societies are surprisingly deficient and indicate that only a minority of medical guidelines are based on grade a evidence and the majority of medicine practice is not based on evidence or lesser grades of evidence 30 31 analyses of evidence levels in obstetrics and gynaecology and have found patterns of predominantly low grades of evidence for the royal college of obstetricians and gynaecologists guidelines 32 and the society of obstetricians and gynaecologists of canada guidelines 33 subsequently it could be postulated that biomedicine may be more belief based than generally presumed as explored in charles et als paper the evidencebased medicine model of clinical practice scientific teaching or beliefbased preaching 34 given that both western and indigenous healing systems have deficits of highquality scientific evidence there could be a case for looking beyond the western vs traditional antagonism in order to explore opportunities for synergy and codelivery in a medical pluralistic personcentred approaches to healthcare transgenerational trauma and indigenous ideas of healing demographic studies show ethnic differences in diagnosis of psychiatric disease 35 however attention needs to be paid to research into intergenerational trauma originating from the legacy of slavery and subjugation of an indigenous way of life 36 decoloniality academics have proposed that those affected should be approached by being both respectful of the indigenous system of beliefs and healing systems of their ancestors as well as making available standard psychological therapies publications in humanities such as fays in decolonising mental health one prejudice at a time psychological sociological ecological and cultural considerations 37 daviss phd thesis 38 quijanos coloniality and modernityrationality 29 and linklaters decolonizing trauma work indigenous stories and strategies 39 have highlighted the inadequacies of current psychological and psychiatric practices in dealing with this reported phenomena the office of hawaiian affairs is presently backing a bill promoting native hawaiian concepts of wellbeing culturallygrounded health methodologies and traditional healing and health practices 40 this was a governmental response to findings that colonised style of western healthcare did not meet the mental health needs of indigenous people in hawaii the whitepaper to the bill says that the health programs and services that are aligned with native hawaiian cultural identity values and beliefs can significantly increase the number of native hawaiians who utilize mental health services 41 an underlying factor relevant may be the stigma attached to psychiatric disorders which are seen differently from an indigenous treatment perspective for instance psychiatric conditions are commonly seen in indigenous communities as an invasion of an external entity which can be remedied in rituals or looking at psychiatric conditions as a symptom of disharmony in the community as opposed to the individual another perspective might be that psychological conditions are a result of westernisation and labelling of conditions it is probably due to the above reasons that the diagnostic and statistical manual of mental disorders incorporates a greater cultural sensitivity in its latest update see also youngs and nadeaus article on decolonising the body restoring sacred vitality which describes their experience in setting up a program in canada to help native women who have suffered sexual racist and colonial violence makes an interesting contribution in this area 42 molecular medicine has also started to accrue epigenetic evidence 43 that suggest the transgenerational transmission of dna methylation changes from parents to children derived from the experience of trauma it follows that there could be cross linkage between biomedicine and humanities and to act synergistically to explore new conversations on intergenerational trauma and its treatment furthermore we introduce these ideas into this paper within the context of decolonising medical education and propose inclusion of this aspect of cultural psychiatry within the intersect between the mental health and social determinants of health syllabus an ideal educational vehicle for creating professional awareness and cultural sensitivity around indigenous systems of healing would be for all medical students to have a basic knowledge of medical anthropology for instance the ucl medical school curriculum gives students the opportunity to take a special study component which is an anthropological project looking at mental health from an indigenous perspective in a culture ethics and religion in the clinical encounter mini course the course explores some of the complexities of clinical practice with culturally diverse patients for a selection of students medical schools in general could develop medical anthropology as part of the core curriculum as a way of decolonising the medical curriculum and improving cultural competence and a cultural humility in professional behaviours this viewpoint was expressed by a student participant in the decolonising the medical curriculum event in terms of culture in the clinical encounter and her essay and talk can be viewed at the projects website 44 elements of a modern medical curriculum it is invariably difficult to define the areas that should be included in regard to decolonisation within the medical curriculum however in addition to the areas discussed above the following areas have been highlighted as important by the public who attended the prior mentioned decolonising public engagement events due the nature of public engagement events the publics contribution identified through active listing to the publics voice does not at times emerge in a logical and structured way decolonising global health and research at the wellcome decolonising health symposium 22 branwyn poleykett anthropologist and postdoctoral research associate in the centre for research in the arts social sciences and humanities university of cambridge pointed out that decoloniality is rising as a challenge to the average biomedical view of global health and biomedical research funding she referred to richard smith who said in his bmj blog that there was a popular way of talking about developments in global health circles at the moment which said that the global health 30 model is being currently upgraded to the more modern global health 40 model 45 but poleykett reasoned that there are decolonising arguments that say that if we are to use a computer upgrade type terminology for global health development then it should be acknowledged that global health 10 was colonialism and that global health 20 was postcolonial international health the global health 20 model had contained many unresolved aspects of discrimination inequality and power imbalances between former colonising nations and those colonised from her anthropological viewpoint the legacy of models 10 and 20 are still eroding and undermining the ideologies of the global health 30 and the aspirations of version 40 thus global health 40 is still riddled with the legacy of colonisation and not a completely virtuous crusade for health improvement hence this complexity needs to be incorporated from a decoloniality perspective into medical syllabus of global health education poleyketts arguments at this event were relevant as the wellcome trust is a large funder of global health research and the wellcome collection is a large repository of colonial antiquities related to health and medicine also circling back to the arguments of global health and the power imbalances of the able and disabled meekoshas article on decolonising disability thinking and acting globally 46 highlights the lack of global health focus on the challenges that impaired peoples face from a multiplicity of phenomena including war and civil strife nuclear testing the growth of the arms trade the export of pollution to pollution havens and the emergence of sweatshops poleykett also pointed out that research methodology is often accused of being dominated by western perspectives of looking at the individual in isolation from other elements such as mind spirit or nature which in turn distorts the outcome of the research as well as research being dictated by funders objectives which may not have a direct public health benefit 47 scholars attending the soas decolonising event 27 drew attention to global geographic disparities in knowledge production as seen in pan et als global map within their publication world citation and collaboration networks uncovering the role of geography in science where by authors from the global south are grossly underrepresented 48 consequently funders of global health research should have the cultural competence and decolonising knowledge to deal with this complex area which is fraught with power imbalances inherent between research centres of the global north and global south imperial college london is leading the way in examining these biases in their educational development unit as seen by their work described on the website examining geographic bias in our curricula 49 ecology and public health the terminology around ecology and human health is developing and is discussed in buse et als paper on public health guide to field developments linking ecosystems environments and health in the anthropocene the anthropocene is defined as the new geological epoch of humanitys own making based on evidence of damaging human influence on the biosphere this paper describes seven emerging fields which are occupational and environmental health political ecology of health environmental justice ecohealth one health ecological public health and planetary health 50 planetary heath 51 is the most recent development in this area and it is significant that the lancet has a standalone journal dedicated to the topic titled the lancet planetary health this shines the light of importance on the public events such as the ucl flourishing diversity series in which displaced indigenous ideas were recentred and foregrounded to highlight the importance of human health within planetary ecology rebekah jaung in her article on how decolonising health could save the planet says indigenous people have always had ecological perspectives on health which have only recently entered mainstream health discourse the scope now is planetary healthapproaches which benefit all people and the natural environment ideas we have learned from indigenous people include seeing climate breakdown as a symptom of nonreciprocal and exploitative relationships with land and acknowledging that such a relationship exists ways of honouring the land will not only restore it it will lead to good health for the people who live on it this is not just a nice sentiment but the approach on which cutting edge thinking on global climate action is structured 52 presently there is a social tide of interest in climate change and health as popularised by the extinction protests seen in major cities and activists such as greta thunberg these issues are likely to challenge the present and future generations of doctors it is therefore important to incorporate nonbiased critical thinking about these issues on global health and ecological public health and raise awareness of the emerging field of planetary health within the medical education curriculum 53 cultural appropriation cultural appropriation occurs when members of one culture adopts or misappropriates elements of another culture in the context of health some biomedical therapeutic discoveries have an indigenous knowledge bases 54 55 maridass de britto in origins of plant derived medicines 54 say that the discovery of some new medicines are credited to traditional approaches which in some cases were based on trial and error over many years in different cultures and systems of medicine they go on to say that natural products have been the source of many drugs such as quinine morphine paclitaxel camptothecin etoposide mevastatin and artemisinin 54 similar accusations of cultural appropriation are also seen in respect of meditation acupuncture yoga and other indigenous modalities of treatment which are used and rebranded in the west 56 57 the fact that this information is not conveyed in medical education exemplifies an aspect of medical cultural appropriation which involves indigenous cultural knowledge not being acknowledged and respected by a historically dominant group intersectionality intersectionality 58 59 is used to describe the multiple interlocking or simultaneous oppressions of race class gender sexuality and disability it was originally coined by kimberlé crenshaw a feminist in describing the experiences of women of colour social activism has highlighted the health inequalities and higher mortality rates for black women who are disadvantaged by their race and their gender these health disparities are noted in both the uk and the usa in routine national data sets 60 63 indeed a new report from mbrraceuk states that it is striking… we seem to be making little impact research is urgently needed to understand why black women are five times more likely and asian women twice as likely to die compared to white women 63 we recommend that the curriculum should utilise the term intersectionality as part of the social determinants of health in order to teach cultural competency in a way that integrates self social and global awareness as demonstrated at columbia university usa and described by cushman et al 64 they recognised the association between the power and privilege with intersectional identities which often go unrecognised and unacknowledged by the individuals and groups that hold them and ultimately can affect professional behaviours towards patients and the public also using the voices of marginalised individuals or groups who explain their intersectional experiences within teaching sessions would fit in with the concept of social accountability as defined by the world health organisations report that there is an obligation for medical schools to direct their education research and service activities towards addressing the priority health concerns of the community region andor nation they have a mandate to serve 65 in this way marginalised groups experiencing simultaneous oppressions can act as patient educators and become future changemakers finding decolonising solutions for this aspect of inequality 66 67 decolonising symptoms signs and investigations decolonising diagnosis of disease requires an awareness of studies that have shown ethnic differences in routine chemistry fertility endocrine cancer and haematological markers as well as in vitamins and carotenoids in children adolescents and adults this variation in markers is extensively discussed by tahmasebi et al in influence of ethnicity on population reference values for biochemical markers which has a useful table on the available literature evidence for ethnic differences in biomarker levels 68 it follows that if white european biochemical normal values are used by laboratories and clinicians with diverse populations then bame populations are likely to be placed at an increased risk of misdiagnosis this in turn results in bame patients being either treated for conditions they dont have or not receiving the treatment in a timely manner and therefore affect their ability to heal for instance if medical students and doctors are not trained in skin diagnosis in darker skin tones then delays in diagnosis or misdiagnosis in detecting conditions such as skin cancer 69 or cyanosis become more likely indeed the lack of teaching on the appearance of cyanosis in darker skin tones in global north medical schools could feasibly contribute to a bame patient intersectional excess of mortality decolonising reflective practice in the uk the academy of medical royal colleges and copmed define reflective practice as the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible 70 however we suggest that it would be prudent to incorporate the concept of cultural safety which arose originally as a decolonising nursing concept from new zealand to address power imbalances between healthcare practitioners and indigenous new zealanders the process of cultural safety would essentially entail that a nurse doctor or student as part their reflective practice prior to a patient encounter quickly checking on their privilege status and any potential power imbalances between themselves and the patient this quick reflection should give insight and situational awareness aspiring to create a fairer clinical encounter 71 cultural safety could also be incorporated into human factors training to improve patient safety human factors training is defined as enhancing clinical performance through an understanding of the effects of teamwork tasks equipment workspace culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings 72 74 this type of reflective practice could be developed within the medical reflective practice syllabus as a healthcare human rights checklist thus improving professionalism 75 conclusion our article demonstrates that there is guidance from professional regulatory bodies to improve equality diversity and inclusion as well as legal imperatives to improve person centred care which links to our recommendation that it is important for healthcare educators health professionals and researchersfunders to adopt a decolonising attitude and consider the areas that are highlighted in this paper a system of education that encourages doctors to recognise and challenge their own implicit biases and cultivate an attitude of openminded professionalism is vital to address the complex power imbalances of the legacy of colonisation within health care decolonisation includes the tolerance of medical pluralism we can learn from patients as educators and through public engagement with active listening we can acknowledge the emerging field of planetary health which stretches healthcare beyond the individual public health and global health and which indigenous peoples have proposed regarding living harmoniously with the planet precolonisation this is pertinent in light of the growing phenomenon of human migration as consequence of a number of factors including economic opportunities economic crisis conflict and natural disasters stemming from climate change

the legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity in response to the increased interest in social justice medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations this paper aims to explore decolonising ideas of healing within medical education following recent events including the university college london medical schools decolonising the medical curriculum public engagement event the wellcome collections ayurvedic man encounters with indian medicine exhibition and its symposium on decolonising health soas

introduction transgender is a general term that refers to people with a variety of identities in the broadest sense it refers to people who do not adhere to the cultural definitions of gender 1 this term encompasses transsexual men and women or those that have altered their genitals to match the gender they choose to express but it also includes transgender men and women who express a gender identity other than the one assigned at birth but do not choose to have genital alteration surgery 2 both transgender and transsexual people may use hormones clothing makeup wigs andor hairstyles and other types of surgery in their presentation of gender transgender also may refer to drag kings and queens women and men who dress as the opposite gender for the purposes of performance or people who identify as genderqueerpeople who choose to express both or neither gender in their presentation transgender women experience depression suicidal ideation and suicide attempts at rates much higher than in the general population estimates of the lifetime prevalence of depression in transgender women have been reported as high as 62 3 while the lifetime depression rate for the general united states population is 166 4 the high rate of depression is not surprising given the discrimination transgender women face however it is important to understand the factors influencing depression in this population as well as how depression influences other factors affecting transgender women such an understanding will aid in the development of effective modes of treatment for depression in transgender women this paper reviews the burgeoning literature on depression in transgender women the author searched the databases psycinfo medline and cinahl using the keywords transgender and depression to find articles and also culled citations within the articles found for other relevant papers the majority of research has focused on the factors influencing depression and suicidal ideation second theoretical constructs for the high rates of depression in this population are discussed finally three known studies have included depression as a variable that influences health behaviors in this population findings of these studies are presented the paper concludes with implications for clinicians working with transgender women all articles that included transgender women in the sample pool and discussed relationships between depression and other variables were included a total of fourteen articles were found and are discussed within most of these studies either did not mention how they chose their sample of transgender women 1315 or allowed women to selfidentify as transgender 235910121617 budge and colleagues 11 included only transgender people who identified on what they called a binary gender identity in other words participants who used to identify as one gender and now identified as the other gender this has the potential of excluding many individuals who consider themselves transgender but are along a spectrum of transition in a series of studies nuttbrock and colleagues 7814 used a definition for inclusion that a participant must have been assigned the sex of male at birth but did not consider themselves completely male in all areas of life this allows much more inclusion for people who may be early in transition or for people who are living as a female in only certain social spheres or times study recruitment methods varied but only two studies 1215 were recruited among highrisk groups of sex workers the other studies recruited via venues that are not likely to yield only highrisk participants such as a conference 9 and online 211 the majority of the other studies recruited as widely as possible targeting community groups but also using respondentdriven sampling to reach transgender females who would not be reached otherwise factors predicting depression variables that are proposed to predict depression in transgender women include both interpersonal and intrapersonal constructs the author has discussed variables that do not show a relationship with depression in the sample where the lack of relationship was indicated in the studies social support is a measure that examines the availability of people in ones life who provide emotional and mental resources for coping often this is broken into categories such as family support and peer support family social support is often less available for transgender women as families react to the transition and may reject the transitioning family member 1518 peer support varies as transition might lead to rejection by a womens pretransition peer group but transition often leads to acceptance by other transgender women particularly in urban areas 19 social support does seem to reduce the risk of depression in transgender women several studies have found a direct relationship of family and peer support associated with better mental health 21115 nemoto et al 12 suggest that it is not just the presence of social support in the past month but rather the satisfaction with this support that is protective against depression though it is not conclusive peer support may not be as important as family support in predicting depression 2 however this study measured family and peer support differently family support was assessed via items regarding perceived supportiveness of parents siblings partners and children while peer support was assessed via measures of the proportion of time spent with other transgender people and perceived feelings of isolation in being transgender the inequity of these measures is problematic in terms of comparing these measures another study suggests that the influence of social support at least superficially in terms of accepting versus rejecting the transgender womans gender identity may vary based on life stage more specifically acceptancerejection by parents and siblings matters until middle age when acceptancerejection by a sexual partner matters from young adulthood 14 violence there are three categories of violence often discussed in the literature of transgender women physical violence sexual violence and verbal harassment transgender women are at risk of violence including physical violence and discrimination at rates between 2 and 3 times those of people who are not transgender women 20 violence against transgender women can damage the womans sense of self and being further intensifying the damage 8 studies that examined effects of physical and verbal violence in aggregate indicated that violence against transgender women is associated with increased depression 8 and may be a predictor of depression 7 physical and verbal abuse may have different impacts on victims than sexual abuse testa and colleagues 10 found that physical violence was associated with suicidal ideation and attempts while sexual violence was associated with increased substance use a study examining sexual violence found an association between sexual partner violence and depression 5 indicating that the relationship between the transgender woman and the perpetrator of the violence may be an important factor nemoto et al 12 found that despite high rates of physical and sexual violence only verbal violence predicted depression in a multiple regression model bockting and colleagues 2 found similar results these results contrast with an earlier study that found that physical and sexual violence but not verbal violence predicted attempted suicide 6 perhaps the dynamics behind depression are different than the ones behind suicidal attempts sex work many transgender women engage in sex work often it is the only viable source of income due to workplace discrimination and it is certainly the most lucrative form of income for transgender women who need to finance expensive surgeries andor hormone treatments 2122 sex work is very common in this population as many as 67 of transgender women between 15 and 24 have engaged in sex work at some point in their lives 23 the relationship if any between sex work and depression is unclear several studies show no relationship between sex work and depression 5712 yet several factors leading to depression such as a lack of social support and a lower education status are associated with engagement in sex work as well 23 in addition transgender sex workers have stated during interviews and focus groupbased studies that they engage in drug use to escape the stress of sex work 2124 indicating that mental distress is indeed occurring though interviews with transgender sex workers indicate that high rates of drug use among transgender women are due to an attempt to deal with mental stress and depression 21 no quantitative studies to date have examined whether drug use is associated with depression in transgender women gender identity the very term transgender implies movement a crossing of gender identities this crossing is commonly called transition and takes place over a span of time that may last for several years the process is affected by the social cultural developmental and individual factors and economic and social resources of the person transitioning part of this transition entails resolving issues of conflict regarding gender identity often by altering ones behavior and presentation to better fit a gender identity that did not mesh with ones gender at birth 15 gender identity is a complex multidimensional concept and researchers have conceptualized it in many ways bockting and colleagues 2 examined several aspects of gender identity including gender dysphoria investment in being perceived as their gender of expression and openness and pride about being transgender of these only transgender pride and openness was negatively associated with mental distress in a study of the association between feelings about being transgender and psychological distress sánchez and vilain 9 found that fear about how being transgender would affect life was associated with psychological distress but other thoughts and feelings about being transgender were not predictive of distress budge et al 11 examined the feelings of loss a transgender person has regarding aspects of life that have deteriorated since transitioning including job housing family relations friendship and finances though this variable was not predictive of depression in their final structural equation model they did find that transgender women experienced more loss than did transgender men indicating that transgender women may experience more discrimination than do their male counterparts sociodemographic variables most studies included demographic variables that moderated the main variables of study many of the results assessing these variables are mixed age is a common demographic control several studies indicate that being younger is associated with more depression 267 while still other studies found no association between depression and age 812 a younger transgender woman may not have developed the capacities to cope with the stressors of life as transgender or may be more entrenched in the stressful transition process leading to greater depression among younger women in some studies the majority of studies assessing it found no association between raceethnicity and depressive symptoms 612 but nuttbrock and colleagues 8 found that black transgender women had lower rates of clinical depression than did other racialethnic groups indicating that depressive symptoms and clinical depression may have different correlates less education predicted more depression in two studies 25 but was not correlated in a third study 6 at first glance education is a proxy for income but the relationship between education and income does not only hold for transgender populations due to widespread discrimination indeed income appears to be unrelated to depression 2511 however unemployment was a risk factor for depression in a sample of transgender women in ontario canada 13 perhaps a lack of steady income is a stressor regardless of the amount ones income is in general theoretical constructs explaining transgender womens depression researchers studying depression in transgender women have utilized several sociopsychological theories to account for the choices of variables to study these constructs are presented next roughly in order from the most to the least researched as of this point minority stress this concept is derived from research literature into mental health of lesbians and gay men 2526 which in turn was based on similar theories for other minority groups in our context the definition of minority stress is that the discrimination and stigmatization transgender people face lead to stress which in turn leads to depression and other negative mental health outcomes it seems clear that discrimination both actual in the form of verbal physical andor sexual violence and perceived stigma does lead to depression and suicide attempts 2 5 conversely positive feelings about being transgender are associated with less depression 9 transgender discrimination differs from other forms of discrimination in several ways transgender women may find themselves facing rejection from the family of origin due to their transition 1518 while a person of a given raceethnicity will continue to have acceptance from their family on the basis of homogeneity alone second though exact numbers are unknown for several reasons transgender women face high rates of violent discrimination leading to assault sexual violence and murder 27 coping is the process by which people use various psychological and behavioral mechanisms to manage reactions to stress coping mechanisms are generally divided into two categories avoidant and facilitative coping avoidant coping is considered an unhealthy way of dealing with stress as the person minimizes or avoids thinking about the problem via cognition distraction overeating or substance use which can lead to more stress or additional health problems facilitative coping or addressing the problem via support of others learning new skills or changing behavior is considered healthier as the problem is resolved in a positive manner via social support changing behavior or learning new skills 91128 greater use of facilitative coping would therefore be predicted to be protective against depression while avoidant coping would place one at risk of depression studies of transgender women have indicated that approaches indicative of avoidant coping such as substance use were predictive of depression 6 while facilitative coping mechanisms like utilizing social support led to less depression 111315 avoidant and facilitative coping may interact in terms of their role in predicting depression as budge and others 11 found that avoidant coping mediates the relationship between social support and depression in addition depressed individuals may reject social support further deepening their negative mood state 12 while these studies do lend support to a model of avoidant and facilitative coping affecting mental effect most studies are examining only a small sample of the variations in each type of coping avoidant coping is more than substance use and facilitative coping is more than calling on social support to date no studies have examined the effects of avoidant and facilitative coping in totality identity control theory originated in social psychology and centers on the balance between a persons identity and the labels and expectations of others in the persons life according to this theory a person compares her identity against the perceptions of her from others in her life if there is a discrepancy between the identity and the perceptions then the person changes her behavior to bring these into alignment 29 a transgender woman would be balancing her identity as female with the perceived attitudes of friends and family which would be expressed as rejection or support of her as a transgender woman rejection of her identity would be associated with greater risk of depression only one research team to date has examined identity control theory in the context of depression among transgender women following a preliminary study indicating that both friend and family supports were protective against depression 15 nuttbrock and colleagues 14 examined conflict and affirmation reactions to disclosures of gender identity among parents siblings classmates friends coworkers and sex partners of transgender women and whether these reactions influenced depression they found that conflict was a risk factor for depression and affirmation was protective against depression supporting identity control theory and indicating the importance of a transgender womans social network in her mental health depression as a factor predicting healthrelated variables due to extremely high rates of hiv among transgender women researchers have examined factors contributing to higher risk of hiv or of behaviors that put one at risk for hiv such as unprotected receptive anal intercourse three known studies have included depression as a predicting variable it is unclear whether depression contributes to hiv as garofalo et al 16 found no association between depression and hiv while nuttbrock et al 7 found that depressive symptoms increased the risk of contracting hiv or other sexually transmitted infections similarly results indicating a relationship between urai and depression are also mixed with nuttbrock et al 7 reporting a positive association between urai and depression and operario and nemoto 17 reporting no association conclusions and implications though the literature regarding depression in transgender women is still sparse a few key findings do emerge it is clear that interactions with other people whether positive in terms of social support or negative in terms of rejection or violence are important factors predicting depression in transgender women second the very process of transitioning is stressful and this stress may contribute to depression depression research and treatment in transgender women results regarding gender identity social support across the lifespan and identity control all support this assumption finally the relationship between sex work and depression is not clearly understood given the relationship of sex work to other risk behaviors which lead to higher risk of hiv 19 and given the pervasive workplace discrimination suffered by transgender women which contributes to engagement in sex work it is important to continue research into how sex work affects the mental health of transgender women the variables surrounding a transgender womans physical and emotional health are complex to date nobody has tested a model that attempts to describe the dynamic relationship between sexual risk behaviors transgender identity and support and mental health though the author has proposed a preliminary model 31 still other studies are needed to fully elucidate the many relationships between depression and predictor variables in the population though these studies are ostensibly about depression in transgender women only two of these studies 814 measured clinical depression among study populations the other studies assessed prevalence of depressive symptoms which may not be measuring clinical depression as suggested by the different associations for black transgender women for clinical depression studies indicating associations of variables with depressive symptoms may not mean that clinical depression will be associated with these variables of the fourteen studies described here eleven were cross sectional which limits the conclusions that can be drawn regarding factors that precede depression because of both the lack of time as a factor and the possibility that third variables may be driving the variable relationships seen the studies examining participants longitudinally 7814 are important additions to the body of knowledge as transitioning is a dynamic process that almost necessitates the inclusion of time when studying health within transgender populations future studies should consider a longitudinal study design while addressing the interaction of interand intrapersonal variables influencing depression in transgender women such studies will elucidate the variables affecting health in transgender women providing indications to be used in creating effective interventions to reduce depression drug use and hiv among this population conflict of interests the author declares that there is no conflict of interests regarding the publication of this paper submit your manuscripts at stem cells international hindawi

rates of depression are higher in transgender women than in the general population warranting an understanding of the variables related to depression in this group results of the literature review of depression in transgender women reveal several variables influencing depression including social support violence sex work and gender identity the theoretical constructs of minority stress coping and identity control theory are explored in terms of how they may predict depression in transgender women depression and depressive symptoms have been used to predict highrisk sexual behaviors with mixed results the implications of the findings on treating depression in transgender women include taking into account the stress of transition and the importance of supportive peers and family future studies should explore a model of depression and highrisk behaviors in transgender women

interdisciplinary research conducted in the environmental field is often confronted with the complexity of functional processes the absence of appropriate methods and the dissipation of skills and data in an area of study which is both vast and tackled by many different institutions in addition research that aims to contribute to sustainable development not only involves a systemic and interdisciplinary approach but also requires the empowerment of civil society stakeholders in acquiring knowledge and learning to speak the same language indeed the collective action advocated by this concept is not limited to the scientific realm alone it also involves finding synergies with local management policies and users and implies helping them in their procedure by designing methods and tools and making them available the objective is to promote the enhancement of goods and services of a territory to maintain local populations and ensure their wellbeing the methodology must therefore be part of an interactive process during which stakeholders with diverging interests progressively construct a shared representation of reality give it meaning and set goals for themselves for effective deliberation these stakeholders must be able to access information and produce knowledge public awarenessraising and education are also sought for individuals to become aware of their own role in the ambitious political project that sustainable development represents 12 in the first phase of our study we examined the interactions between socioeconomic and natural dynamics in ushant island 1 by using companion modelling ushant island is part of a regional natural park and was designated part of the mer diroise biosphere reserve in 1988 the international biosphere reserves network has three main objectives biodiversity conservation sustainable development and environmental education training and involvment of the local population 13 this small island located off the western coast of france has been experiencing landuse and landcover changes for several years major land use changes resulted in fallow land encroachment and its consequences on landscape traditional activities and biodiversity 14 within the companion modelling approach a conceptual model of the ushant island system was constructed thereby providing the basis for the development of a prototype using the cormas multiagent platform it was used as the basis of several scenarios to explore trends in the environment and biodiversity according to various socioeconomic options this concrete application together with companion modelling enhanced interdisciplinarity concurrently a roleplaying game run by the platform was initiated to improve the model and raise the stakeholders awareness of the dynamics underway 2 in the second phase the discussion turned to transferring knowledge to the civil society 3 by adapting research outputs to two operational contexts in order to promote their mastering and adoption by two types of publics multiagent simulation and rpg as management support to a territory submitted to constraints rpg to help raise awareness and help young people learn about sustainable development issues 15 this paper refers to the second aspect devoted to transferring a rpg created in a comodelling experiment in a multiagent environment to an audience of schoolchildren objectives 21 sustainable development education involves making links between disciplines and aims at providing students with an understanding of their surroundings and developing their abilities to get involved yet despite definite awareness 4 which occurred some thirty years ago the french highschool system still favours disciplinary mechanisms with no actual contribution to a crossdisciplinary object in this context the goal set by other organisations such as local authorities scientific and technological culture centres programmes including that of the unesco man and the biosphere as well as environmental protection groups is environmental education for youth which involves knowledge transmission methods differing from those traditionally implemented by the ministry of education 22 among these transmission methods a playbased approach would raise young peoples awareness of the environmental processes taking place on several temporal and spatial scales and develop their ability to implement the sustainable development concept in the same way minassian and rufat showed that certain video games had educational relevance in teaching geography since this is related to deliberations between diverse stakeholders the games objective is not just to promote the learning required for a dialogue that would not exclude those who most lack either knowledge or skills but that would also allow new standards and values to be acquired in this context the game for which ushant island was taken as a model should be adapted to a broader geographic framework to raise public awareness of environmental issues and deliberation processes therefore the proposed method must be flexible enough to be transposed to any coastal area since the final objective is to ensure a transfer of tools which can be reutilised in the educational realm without scientists and regardless of the initial application site to raise youths awareness of sustainable development the educational workshop between land and sea coasts familiarisation to the rgp for the educational team 31 the team in charge of this part of the study is the educational department of océanopolis 5 its two relay advisers from the ministry of education and three researchers involved since the beginning of the project the first step for new participants is to become familiarised with the rpg and understand how it works to this end the whole team met several times to analyse the game proposed by the scientists define how it could be incorporated into a broader educational project and provide any modifications required after analysing a 33 the educational workshop is based on three work sessions which take place at océanopolis under the supervision of an instructor the rpg the guided tour of océanopolis temperate pavilion and a summary outline session the study of a local case provides an extension of the school curricula while broadening their outlook the issues could partly be tackled by finding information on the various exhibition displays in the temperate pavilion at océanopolis the summarising exercise can be provided as a sketch or outline in compliance with the official guidelines of the ministry of education and with highschool final examinations in prospect the content of this workshop ties in with fifthform geography courses curricula for civic legal and social subjects in high school fifthform life and earth sciences curriculum adaptation of the rpg for the educational workshop between land and sea coasts 41 the rpg aims to improve schoolchildrens awareness and learning of sustainable development stakes originally developed for adults playing their own role and provided with knowledge about activities and the environment and towards a mediation goal the rpgs adaptation to this new context required various modifications mainly as regards the conceptual model the game board and rules and computer interface 42 the initial game uses the knowledge acquired in the research project and the possibilities presented by the cormas platform the transfer of the prototype described in rouan et al to a rpg involved simplification mainly regarding land leading to abstract representation and rules indeed vegetation dynamics only were taken into consideration as the game aimed at dealing with relationships between different human activities and environmental degradation and correlatively with the latters impact on such activities 43 each session about two hours long included three phases game presentation game play with about ten turns simulating twenty years and game analysis by all protagonists the conceptual model 44 in order to elaborate this new rpg an adapted conceptual model has been built figure 1 conceptual model of the natural and social interaction in the new rpg 45 this model highlights the modifications that were required to adapt the rpg to meet its new target a new class of vegetation has been added the impassable scrub it was included in order to bring in a strong constraint as regards accessibility and visibility and to generate potential collective decisionmaking in the game it is indeed impossible to clear this type of vegetation using the default means available to players 46 eight roles were retained local elected representative natural park representative cattle farmer restaurant owner president of the hunting society turf collector secondhome owner and permanent resident in the previous configuration two secondhome owners were represented but due to the relative passivity of this role only one was maintained 47 it is important to note that most of the roles involve several actions for instance the hunter restaurant owner and the turf collector also keep sheep the role of the visitor is played by the secondhome owner who organises walks on the island 48 a protected bird species that nests in coastal cliffs was also included in the game in order to introduce the concepts of biodiversity and conservation two pairs present at the beginning of the game may breed persist or disappear depending on the evolution of the environment and of the players activities the position of nests is set randomly at the games initialisation the park representative is the only one to be aware of this species status and possibly location its protection may be the subject of a collective decision or may not arouse any specific interest the game board and rules 49 the game board is similar to a draughtboard with 100 cells representing 5000 m 2 each cell represents land including coastal sod heathland grassland scrub and impassable scrub a game board was specially created by an artist taking account of the educational departments comments to make it more attractive for a young public colours of board and squares squares with holes for easier handling and shape and appearance of the playing pieces the content of the game cards has also been adapted figure 2 presentation of the board roles and actions 410 the game rules are structured as follows 411 gathered around a game board representing an area of land eight players are given action cards the players actions cause environmental evolution that may lead for instance to scrub encroachment on ungrazed plots management of mowed plots deterioration of the coastal area etc the computerised prototype is used at the end of each turn to determine the land changes induced by the players actions the scrub encroachment process on open land is voluntarily accelerated in order to create reactions from the first turns which may involve various individual or collective strategies to maintain an open area six to ten rounds can be played per session simulating the evolution of the environment over a timeframe of 12 to 20 years computer application interface 412 a specific graphical user interface was developed in collaboration with an it consultant from oxiane 6 in order to adapt it to the workshop and to make it easier to use for the facilitator in the previous configuration the prototype required three people to operate it one acted as a game master another transmitted the players moves to a third person who was in charge of entering the data in a text file and running the model finally the game board had to be updated with the results of the simulation 413 the challenge was to design the application in order to make it usable by the game master alone therefore the oxiane consultant had to take into account some constraints ie simplifying the operations to be performed checking the rules and making the interface more userfriendly the system had to be robust intuitive and simple to use a peripheral device was opted for to allow the facilitator to remain mobile and always present for the players 414 obviously in order to make the application thoroughly tabletfriendly it was necessary to design it with a unique window eliminating any sort of dropdown or contextual menu regarding the stylus behaviour it was decided to use a drag drop metaphor trying to make it as intuitive as possible 415 the application is based on cormas a powerful framework developed with the visualworks implementation of smalltalk language this framework offers many interesting tools for programming multiagent systems including some components for visualising the space model but it had rarely been designed for a roleplaying game purpose in concrete terms the standard cormas tools used in the application consist of three windows one is the main menu one is opened to configure the simulation and the last is a visualisation of the space model 416 the first difficulty was to gather these three windows into one and to eliminate unnecessary functionalities in order to satisfy the ergonomic constraints of the game 3 12102015 417 smalltalk language is particularly suitable for this kind of activity components are programmed with the concepts of object and class and it is easy to directly reuse modify or refine them the main window was simply derived its menus were removed the initialisation step was automatically activated and finally the spaceinterface and its spaceview 7 were also derived and integrated in the right part of the main window figure 3 the interface 418 the second challenge was to actually make it userfriendly it should be usable after a couple of hours of coaching for this purpose it was decided to use a metaphor of the real play on the board players take their playing pieces and drop them on the squares of their choice they may take their pieces back and change their choices the game master has to report their moves in the system provides playing pieces that can be carried provides an icon and its offset provides an action symbol used to easily test the current mode provides an interact method called in response to a user click 420 the second trick is the use of a very powerful method called followwhileon 421 this method is used to continually display an icon at the stylus position until a stylus click occurs giving visual support for a drag drop feeling it is used in the displaymode method frequently called in the main window 422 in addition a number of operations were created to optimise the handling and supervise the sessions by automatically verifying the game rules for example cow playingpieces must always be paired on 2 successive boxes and cannot be dropped on the same boxes as the previous round or only undergrowth can be cleared etc the same visual features as the game board and colour codes of the players are used in the graphic interface of the application after several uses this interface allows the scientific facilitator to work alone and take on the game masters missions 423 to supplement the game appropriate teaching tools and documents were also developed a film called the coast as a medium for a collective multidisciplinary approach was designed by the scientists working in collaboration with the océanopolis relay advisers 424 it shows students the interdisciplinary work carried out by researchers opens and closes the session an educational document drawn up for students allows them to report on the different activities in the workshop and a file assists teachers in preparing their day at océanopolis evaluation 51 in order to evaluate the running of the game by educators the involvement of students and teachers and whether the workshop has met its aim of raising awareness of shoreline issues 33 test sessions were set up these sessions involving 590 high school students from 16 classes and diverse backgrounds were monitored from january to june 2010 method 52 in order to analyse the progress of sessions and their ability to meet the initial goals the whole team developed a monitoring process each session takes place in the presence of an observer provided with an evaluation grid taking into account various criteria 53 in addition a satisfaction survey was conducted among teachers on the workshops organisation and content results 54 after 33 sessions the team was gathered together through a workshop to analyse the observations made three observations made respectively by the teachers océanopolis educators and scientists were listed 55 half of the teachers completed the survey by océanopolis out of the 7 surveys completed 5 reported the informant to be very satisfied with the workshop its organisation and its content two of the teachers were satisfied criticising two points the length of the game and its aims which were considered to be too vague 56 the unanimous view of the 4 océanopolis educators involved in the 33 sessions was as follows while familiarisation with the game and the handling of the board are not considered problematic the educators experienced difficulties in introducing and concluding the session the games success with students varies according to classes certain sessions are very lively with the students getting very involved in the game while others are more passive teachers participation is just as variable some are keen to join in others are absent 57 during these test sessions the scientists observed both the students and educators the goal was to identify how playershigh school students integrate knowledge specific to environmental management natural and socioeconomic dynamics as well as conservation issues this also entails the analysis of the skills involved as regards the wording of a problem codes for taking part in the discussion the capacity to listen to others and comprehend differences the development of sensible arguments the students quickly understand the rules and by the end of the session have a critical approach to the game some complain of the inactivity of certain roles the lack of money and the limited means to control scrub encroachment in response to the question what is the purpose of this game asked during the debriefing two types of answers emerge it raises awareness of land management and it demonstrates the difficulties involved in cooperation the complexity the challenges and the dynamics of the shoreline are rarely mentioned 58 in terms of the workshop organisation the students consider the film to be slightly too long and complicated in particular the section describing the conceptual model on the other hand the introduction to the game is considered useful as is its conclusion which also links in with the debriefing the scientists observed that the debriefing is often shortened or even omitted because the rounds of the game take too long furthermore when it takes place the educator has difficulty in running it improvement of the rgp 59 the analysis of this monitoring effort enabled the team to improve the running of the game mainly so as to facilitate the leadership of the session by the educator the improvements include the drawing up of specifications the simplification of the introductory film and the preparation of a powerpoint presentation for the debriefing no alterations were made to the game itself or its rules 510 specifications were drawn up for the educator by the team they guide the educator through the different stages of the session specify the aims and expected outcomes of the game enabling them to face unforeseen situations and answer various technical questions 511 the film considered to be too long and complicated was shortened to focus specifically on the geographical context and the introduction to the game 512 finally a powerpoint presentation provides a framework for the debriefing and helps to conclude the session a multiagent model devoted to interactions between social and natural dynamics on ushant island was used as the medium for a rpg adapted to the school curriculum of fifthform classes on the theme of sustainable development and coastal areas adapting it required close collaboration between the scientists behind the project the educational department at océanopolis and teachers 62 transferring the game required transforming both its substance and form running it with an easytohandle ergonomic platform as well as support from scientists in presenting the approach to teachers and a film to introduce the game 63 in terms of methodological aims the rpg allows students to play an active part in their learning process through handson experience and to concretely set out the issues involved yet what is the real aptitude of this type of tool to raise awareness and facilitate the learning experience of young people with respect to the environment forecasting issues and integrated and participatory management this question is difficult to answer as it begs the question of how to assess the efficiency of these participatory tools nevertheless the likelihood is that without the involvement of the teachers resulting in subsequent work in class on the notions conveyed by the game its aptitude to raise awareness will only last as long as the session … it is simply yet another experimental element

the study refers to the interactions between socioeconomic and natural dynamics in an island biosphere reserve by using companion modelling this approach provides scientific results and involves interdisciplinarity in the second phase of the study we transferred knowledge by adapting the main research output a roleplaying game to young people our goal was to introduce interactions between social and ecological systems coastal dynamics and integrated management adapting the game required close collaboration between the scientists and educators in order to transform both its substance and form and to run it with an easytohandle ergonomic platform

introduction cervical cancer is the second most common cancer among women worldwide at a yearly death rate of 274000 88 of these cases were reported in developing countries according to the world health organization cervical cancer is highly curable therefore the main culprits for high mortality rates were lack of effective prevention early detection and treatment programs and access to available preventive programs epidemiological studies found that cervical cancer was highly correlated to human papillomavirus after controlling for other risk factors several risk factors were studied worldwide to find that smoking sexual relationships with multiple partners multiple marriages and dietary habits were leading in cervical cancer diagnoses early marriage and childbirth and multiple pregnancies were also found to be high risk for cervical cancer muradi et al stated that vaginal inflammation was a high risk factor for developing cervical cancer as chronic infection could develop into cervical research article knowledge attitudes and practices of women in the southern region of saudi arabia regarding cervical cancer and the pap smear test enas a dhaher dysplasia and cervical cancer in addition to poor hygiene and low socioeconomic status since the time of introducing the conventional pap smear test and early detection programs mortality rates have shown dramatic decreases in developing countries by 70 reports from developing countries showed that the main barriers to receiving pap smear tests were lack of overall knowledge about the disease its signs and symptoms the importance of prevention and the preventive measures womens attitudes towards the preventive measures for cervical cancer and general myths and beliefs the american college of obstetricians and gynecologists urged women who had been or were still sexually active and those at least 21years of age to have an annual pap smear test and pelvic examination for those 30 years and above who have had three successive normal pelvic examinations and pap smear tests the acog advised for monitoring on longer intervals according to saudi arabias cancer statistics of the 152 cervical cancer cases detected yearly 55 die with a 13 incident rate according to alsbeih in saudi arabia cervical cancer placed at the eighth common cancer among women in the age group 14 to 44 there were some studies conducted for hpv detection 100 women were tested in jeddah at king fahad university hospital resulted in a 94 negative rate for hpv another study of volunteer cervical cytology screening was conducted in the western region of the kingdom with 485 women at king abdulaziz university hospital only 56 were found to be highrisk hpv and 188 women from the 4049 age group were found more likely to accept hpv testing while a study in riyadh revealed that 316 of 120 women had hpv 1618 and 10 had cervical abnormality out of which six were positive hpv 1618 al sheikhs study found that the hpv prevalence in the saudi native population was still unknown one recent study conducted in riydh by jaradi and bwazir assessing womens knowledge attitudes and practices towards cervical cancer through focus group discussion with 77 women revealed that women were lacking knowledge regarding cervical cancer and pap smear test neither immunization and screening was not necessary since they do not complain of any diseases the main objective of this study is to measure womens knowledge attitudes and practices of cervical cancer and its preventive measures in the southern region of saudi arabia materials and methods study design a crosssectional survey of 255 saudi women of at least 15 years of age was conducted at the obstetrics and gynecology outpatient clinic of the armed forces hospitals southern region in saudi arabia regardless of the visit reason the study was conducted between march and april 2017 the clinic was selected as it provided reproductive health care services to the entire southern region of saudi arabia which included antenatal care highrisk pregnancy gynecology infertility treatment postnatal care and family planning furthermore the clinic was connected to the obstetrics and gynecology of the hospital where on average about 370 patients receive care daily study instrument based on literature review selfadministered questionnaire was developed it consists of two main parts demography and knowledge attitudes and practices of cervical cancer and the hpv vaccine all questions were formulated in a simple direct language and the answers were given in a list of options where women supposed to choose one option only an option was provided for the knowledge question which is i dont know the questionnaire was pilot tested with 25 women whom were not included in the study the questionnaire was reliable with persons correlation of 080 the alpha value for the overall questionnaire was 090 sample and data collection sample size the sample was designed assuming the total population visiting the clinic in one month was 8000 women based on clinic statistics and appointments a sample of 250 women with a confidence level of 95 will provide 50 of women answering the questions of the entire relevant population with a 50 ± 61 confidence interval and 80 power to check for differences given the excellent response rate the questionnaire was distributed to 275 women and 255 questionnaires were returned with a response rate of 93 data was collected daily for one month questionnaires with additional health education materials or educational materials without questionnaires were distributed in sealed envelopes to ensure randomization to all the women women with at least 15 years of age and all present in the clinic regardless of their reason for attendance were the target subject of the study the researcher was available to assist illiterate women and those with questions regarding the purposes of the study ethical consideration this study was approved by the research ethical committee at the armed forces hospital in the southern region prior to the research being conducted and furthermore consent forms were signed by all participants in the research where it included the purpose of the study and ensure anonymity and privacy statistical analysis the predictive analytics software 18 was used to enter and analyze the data frequency distributions were used to present womens demographic characteristics knowledge attitudes and practices related to cervical cancer and the pap smear test cross tabulations were used to assess the demographic factor relations regarding the same results sample demographic and obstetric characteristics the mean age of women was 32 years with the majority above 25 years approximately 11 of the women were illiterate and 32 were university graduates the educational levels of the husbands were halfattained secondary schooling and 19 were diploma and university degree holders among the womens professional careers 27 were in health professions and 19 were teachers and educators overall only 15 of the women participating in the study were currently employed womens obstetric and marital characteristics revealed half were married for more than 10 years and the majority had four pregnancies the median and mean number of deliveries was 295 and 280 respectively when excluding women with no children the mean number of children factor but almost none knew the direct cause of cervical cancer regarding attitudes of prevention approximately 57 responded that cervical cancer could be prevented only two women had ever conducted papsmear test based on doctors referral but close to all women had never heard of the hpv vaccine and consequently only one woman had received the vaccination in the united states a new variable was created with the total number of risk factor recognized by women in four categories to find out that the highest percentage was with those recognize no risk factors number of risk factors was highly significant with womens level of education as those with higher education recognize more risk factors whereas none of the demographic factors was correlated with number of risks recognized neither the availability of cervical cancer immunization regarding the pap smear test 43 of women had ever heard of the test through various media channels 32 had received health and wellness information from female medical professionals approximately 64 were increased to 357 nine percent of women reported having more than six living children and nearly half of the women had never used family planning methods interestingly only 23 of women had ever conducted a comprehensive reproductive health assessment womens knowledge attitudes and practices of cervical cancer and pap smear test while close to three quarters of the women had ever heard of cervical cancer the primary source of information was from social media mainly facebook and twitter responding to further questions related to the risk factors of cervical cancer around two thirds of women responded with either do not know or not a risk factor more than half of the women recognized vaginal inflammation as a risk unaware that the test could discover asymptomatic lesions and 56 recognized that early detection could lead to better outcomes regarding attitudes towards the test only 38 of women said they would participate in a screening if they were properly informed the reasons mentioned for those not willing to participate ranged most from no complaints to least husband disagreement 455 and 26 respectively two third of those willing to participate in the screening preferred served by a female gynecologist at an obgyn hospital the relationship between womens characteristics and their kap towards cervical cancer and pap smear test based on cross tabulation a significant relationship was found between womens level of education and knowledge about cervical cancer in addition women of higher education levels showed significant acceptance of participation in screening tests when properly informed significant relationship was found between the belief that cervical cancer can be prevented with educational level those with medical professions or those with any other professional careers were more knowledgeable about the disease than other areas number of deliveries showed a significant relationship between womens knowledge of both cervical cancer and the pap smear test none of the other demographic characteristics showed a significant relationship between womens knowledge attitudes and practices discussion in the southern region of saudi arabia there were no this study demonstrated that while close to two third of women recognize cervical cancer few knew of its risk factors and almost none knew of the direct cause which represents the studied women having less knowledge than participants in the jeddah study and kuwait previous studies found that lack of knowledge regarding risk factors of cervical cancer might be the most important factor for women not obtaining screening tests the lack of national screening programs and public education campaigns could explain why women were not aware of the diseases risk factors regarding the pap smear test less than half the women were aware of it and about two thirds had no knowledge of the purpose of the test which again represents a stark contrast to the jeddah study additionally half of the women thought early detection could lead to better outcomes our study showed the majority of womens source of information regarding both cervical cancer and the pap smear test was from social media which is considered the most popular form of communication including the communication of health information eight out of 10 internet users seek health information online and two thirds seek social media to access health information in the united states social media could help improve and promote healthy communities when used properly increase access to educational health resources and even track personal health progress however use of social media as the main source of health information could be dangerous in terms of content reliability and accuracy currency affiliation and authority eventually in this study we found that women recognized cervical cancer and the pap smear but were not familiar with risk factors or preventive measures despite the dangers of social media it could be used as an effective educational tool in the southern region of saudi arabia wellorganized media campaigns featuring famous regional figures or movie stars could be beneficial hyacinth et al suggested a similar recommendation with the dissemination of information regarding knowledge and awareness of cervical cancer and the pap smear test level of education and type profession were found to be highly correlated to womens knowledge about cervical cancer and the pap smear test as well as their attitudes toward preventing cervical cancer level of education was found to be a positive factor in other studies in saudi arabia and kuwait regarding attitudes toward preventive pap smear tests more than half of the women agreed that early detection could prevent cervical cancer and 38 agreed to participate in a screening program similar to the akanb et al and almobarak et al studies the main barrier for not getting the pap smear test was having no complaints which could be explained by lack of knowledge regarding the disease and prevention as discussed above moreover if women had no symptoms and did not feel sick it was assumed that diagnostic procedures like the pap smear test were unnecessary the study in riyadh supports the same result similar beliefs were found in studies in indonesia qatar and iran fear of pain and embarrassment which could be considered a misconception of the test were barriers found in studies in malaysia and ghana another barrier mentioned by the women no information about where to go considered a very important and devastating barrier as found in the ghana study other barrier as waiting for the physician to recommend the pap smear test was found in the kuwait and jeddah studies the aforementioned barriers could be explained as lack of awareness about cervical cancer and its prevention techniques and lack of knowledge about the pap smear test and its implications and procedure several other studies posited the same our study showed that women with a higher level of education and those with medical backgrounds or other professional careers were more likely willing to have pap smear tests compared to those with less education no education or other educational backgrounds this would support the thinking that awareness and knowledge played a significant role in womens attitudes medical backgrounds and high levels education were previously found to be significant with womens attitude of having the pap smear test in a kap study in the sudan study conversely among those who were willing to have the test in this study 94 preferred a female health care provider which was also found in a kuwait kap study and among older american women the study also found that a high number of deliveries were significantly associated with more awareness regarding cervical cancer and the pap smear test which could be related to frequent contact with a medical and health staff during the reproductive life span and more chance for health education or health related information to be given alsbeih concluded that neither national screening programs nor national vaccination programs against the hpv virus would be costeffective in reducing cervical cancer in saudi arabia as the reported incidence was already low while the same study discussed the real prevalence of hpv was not recorded among native women in saudi arabia our study showed that women were lacking knowledge regarding the pap smear test and cervical cancer risk factors implications and methods of prevention despite the recommendation from alsbeih women should have the right to choose screening tests in which case information on preventive measures need to be available to all women freedom of choice could be accomplished when women are wellinformed of the disease and its available preventive measures therefore its recommended in this study to organize a mass media campaign educating women about cervical cancer the pap smear test and prevention measures targeted to women of the southern region of saudi arabia funding statement no funding source study strength and limitations high response rate is considered one of the study strength variation in between the sample is also a strength but since the study is taking place at the obstetric clinic social desirability bias might be significant here statement conflict of interest no conflict of interest declared

the main barrier for women to receive papanicolaou pap smear tests and immunization is lack of knowledge about the diseases signs and symptoms womens attitudes toward prevention programs and cultural myths and beliefs therefore the main objective of this study is to measure womens knowledge attitudes and practices about cervical cancer and the pap smear test in the southern region of saudi arabia and to assess the findings in relation with womens demographics methods a cross sectional survey was conducted at the armed forces hospital southern region obstetrics and gynecology clinic using a selfadministered questionnaire with a sample size of 255 women between the ages of 15 and 65 years results fortythree percent of the women in this region are aware of cervical cancer but do not recognize its risk factors implications timing or main cause which is human papillomavirus hpv in fact the primary source of information was obtained through social media only two women conducted pap smear test and that was based on doctors referral where womens main reason from not conducting the test was feeling good and no need conclusions there is a need therefore to create awareness programs for cervical cancer its causes and risk factors as well as its preventive measures for women in the southern region of saudi arabia

introduction child marriage referring to a marriage of a young person less than 18 years is still widely practiced in many parts of the world and predominantly affects girls it is estimated that if nothing changes a 100 million young girls aged 15 years or less will be married within the present decade 1 regional estimates of its occurrence for girls include 48 in southern asia 42 in africa and 29 in latin america and the caribbean 23 with wide differentials across the countries in the west african subregion the proportions of girls affected vary from 28 43 to 6080 in nigeria the practice of child marriage is deeply entrenched in tradition culture and religion and the country has one of the highest rates of child marriage in the world with estimated 42 of girls married before 18 years and while this is found among many ethnic groups across the country its predominance is clearly in the northern part of the country 4 while nationwide 20 of girls are married by age 15 and 40 are married by age 18 child marriage is extremely prevalent in some regions such as among the predominantly muslim hausafulani of the northwest and northeast where 48 of girls are married by age 15 and 78 are married by age 18 54 while average age at first marriage is 17 years nationwide average age of marriage for girls is just over 11 years in kebbi state and about 15 years in most other parts of northern nigeria among the yorubas made up of a mixture of christians and muslims in the southwest childmarriages are no longer arranged and for the igbo in the southeast that are predominantly christians the practice has declined considerably and restricted to few communities 6 and situations where pregnant teenagers are forcefully married off to prevent family shame or restore honour 6 the reasons for child marriage are based on a mix of cultural social economic and religious factors poverty is observed to be at the core of decisions and practices related to early marriage more in lowincome societies than in their highincome counterparts as they lack resources to support healthy alternatives for girls such as prolonged schooling and skill acquisition to secure their future the girls in turn have higher chances of being poor and remaining poor and of facing serious social and health consequences inimical to their personal growth and development a study 8 makes it clear that the widespread practice of child marriage makes it increasingly difficult for families to escape poverty in the developing world thereby undermining critical international efforts to fight poverty hivaids and other development challenges and making huge investments in development assistance less effective it is therefore very costly in terms of the consequences for these societies girls who marry early are more likely to experience abuse and violence than others with inevitable psychological as well as physical consequences studies indicate that women who marry at young ages are more likely to believe the justification for wife battering as a corrective measure and therefore acceptable for a husband to do so and are therefore more likely to experience and accept domestic violence themselves 91011 child marriage for girls often means a confinement to a helpless lifetime of domestic and sexual subservience the psychosocial requirements of marriage are often beyond child brides who are largely unprepared for their roles in complex family settings young brides are more often than not subjected to forms of abuse such as psychological trauma domestic violence forced sexual acts marital rape by the husband and inlaws and subjected to domestic slavery given her position as the young wife evidences of the links of early marriage with divorce abandonment separation widowhood and denial of property rights abound in contemporary literature 12 child marriage is widely and globally regarded as a surviving form of social discrimination and is challenged by the nigerian constitution and several human rights laws in the last century particularly intense global opposition to child marriage has deepened and the concerns are expressed in various conventions and charters under the nigerian law the concept of the child is based exclusively on calendar age the legal age at marriage is 21 years and anyone under this age is considered a minor and would require a parental consent before legally entering into a marriage in the country 13 the rights of the girlchild in nigeria are protected by a legal framework including national laws and international and regional conventions which the country has ratified the persistence of the practice of child marriage has been linked to lack of sufficient political will to engage the problem in many countries and despite the ratification of the international treaties and agreements existing laws against child marriage are not enforced or upheld and sanctions are either not clearly spelt out or enforced at all 14 however it is evident that the key national and international instruments that challenge child marriage focus on age consent equality within marriage personal and property rights of women the study therefore examines the implications of child marriage on maternal health and freedom data and methods the study was conducted in gombi lga in adamawa state of nigeria which is one of the twenty one lgas in the state the trf is 67 while the mean number of children ever born to women of aged 4049 is 71 women in the reproductive age group 1549 years are 32527 the gombi lga has a population of 146429 the lga is made up of gombi and other surrounding villages such as fota fadchi walawal garkida guyaku balwhona wushipra gaanda lala bokki tsakuwa gudawi gombi ladiel fadchi kwallamba misamba and ferwumarah the unique characteristics of these villages include common language religious beliefs and cultural practices which make the lga homogeneous in nature the study was carried out in rural areas qualitative and quantitative methods were used for data gathering for quantitative data the structured questionnaire was used while focus group discussion and indepth interview methods were used for the collection of qualitative data two hundred copies of questionnaire were administered stratified sampling technique was employed to select the sample for the study the study area was stratified with the listing of the villages and eleven of the enlisted villages were randomly selected the selection constitutes 50 of the total villages in the study area it will also make the study representative of the study population from the selected villages houses were randomly selected using the national population commission house numbering from the selected houses young women aged 1524 years who married before age 16 years and have had at least one child were interviewed using the specially designed questionnaire the questionnaire was pretested for validity and reliability of the instrument the reliability test was conducted before the administration of the questionnaire in all 200 questionnaires were correctly filled and analyzed for the study seven were discarded the information collected covered the sociodemographic characteristics reproductive health issues child bearing sexual behaviour factors influencing child marriage in the study area and the risks of early marriage and childbearing six focus group discussions were held to elicit information on traditional expectations regarding sexuality impact of early marriage on wellbeing and consequences of early marriage the participants were those in reproductive age 1549 years who had at least a child as at the time of the survey sturctured interview guide was used for the fgds one focus group discussion each was carried out in six of the villages selected for the quantitative study the fgds were conducted by two trained research assistants from the state who are conversant with the culture and language of the people but not from the local government information provided was strictly maintained and the real names of the respondents were not used for the study issues about traditional expectations regarding sexuality womens right regarding marriage reactions to infected partners and the extent to which men have control over sexuality indepth interviews were also conducted among 12 stakeholders in the study area the exercise covered areas like issues of child marriage factors influencing child marriage girl child education sexual rights and choices in the community and common maternal health risks for each of the session of the fgds and idi two trained research assistants were used the discussions from the fgds and idis were transcribed and translated verbatim analysis involved developing a system of indexing the data into sets of categories or codes that provided structure to the data based on the research objectives and the topic included in the questions guide a qualitative software zyindex software package for ethnographic data was used for textual data analysis this does not allow the use of percentages and statistical analysis some striking expressions were for verbatim reporting data from qualitative survey have been extensively used inthis paper to validate quantitative analysis where and when necessary the quantitative data collected from this survey were subjected to three levels of analysis the first level involves an examination of the distribution of the respondents according to selected characteristics this is because the behaviour of individuals in society is to a large extent determined by their personal characteristics as well as those of the environment in which they live for this reason it is expected that child marriage will be greatly determined by background characteristics such as education age marital status type of marital union and reproductive health decision making to this end simple percentages were employed to describe these variables the second level involves the examination of the pattern of relationship between the dependent variables ie child marriage and other independent variables such as perceived risks of hiv maternal health risks reproductive decision making and antenatal care the third level of the analysis involves the use of logistic regression techniques to show the effect of the relationship between the dependent variable and other independent variables were in the 2024yrs age cohort and had little exposure to formal education as 60 had attended a primary school while 30 had opportunities to attend and complete secondary school education all the respondents were young mothers who married early at various ages before 16 years of age and had been married less than 5years 59 years and few for more than 10 years some of the respondents were engaged in farming trading salaried workers in the local administrative offices while about one in every three was a fulltime housewife they were more muslims than christians estimated incomes of respondents reveal that more than half earned less than n15 00000 per month about a third earned between n20 00000n40 00000 per month while 20 of the respondents earned more than this per month table 1 percentage distribution of respondents sociodemographic characteristics the respondents weretherefore young mothers characterized by little education largely informal sector engagement low income early marriage and rural residences family and marriage early marriage for girls was still generally favoured to protect the girlchild and chart a good future for her information from fgds revealed that culture plays very important roles in the lives of the people religious prescriptions were cited by male participants in the fgds but there was a general agreement by female participants that poverty plays a major role in decisions to marry off girls early particularly when they are withdrawn from schools for marriage sometimes with the hope that they may continue after marriage and sponsored by the husband this was corroborated by the quantitative data on the factors influencing the timing of marriage in the area 47 of the respondents agreed that poverty was the major factor influencing child marriage in the area while 215 and 125 respectively mentioned culture and religion gombi and surrounding communities are largely rural and there were expressions of anxiety over the spread of certain values from the nearby urban areas which may lead to the breakdown of longheld family and community values the need to prevent prostitution unwanted teenage pregnancies childlessness and other unwholesome western values that allow what is considered unnecessary freedom for young girls majority of the respondents expressed the wish to experience schooling beyond the level they presently were and their admiration for welleducated women in terms of appearance confidence and material possession this was supported by the fgds conducted religious leader in lala a girl must be in her husbands house before or at puberty this is why parents give their young girls hands in marriage at their younger ages education is good for girls but they must be properly marriedif a good marriage arrangement that favours the girl and the family comes up it is good for the girl to leave school and marry first then continue later if the husband permits community elder wushipra the main reason why parents allow their daughters to marry very early is to avoid shame they try to avoid promiscuity which may lead to unwanted pregnancy they prefer early marriage to our young girls becoming prostitutes our culture does not permit misbehavior by girls even boys must marry early to be responsible it is the duty of a girlss father to marry her of appropriately decisionmaking decision making on the choice and timing of marriage is the exclusive preserve of fathers in the study area as revealed by 79 of the respondents and more often than not husbands arranged for young girls are older men within the society who can afford the bride price and other items demanded by the brides parents on the womens economic status 78 of the respondents depend on their husbands for all their daily needs and that of their children even when involved in some employment trade or farming african the status of women in the study area is revealed in the generally low educational attainment low income and the pattern of family and fertility decisionmaking that is highly patriarchal majority responded that husbands were the sole decision makers on issues of fertility and family size and use of contraception this is evident in the overwhelming 825 of the respondents that reported that husbands determined the decision to register for and timing of antenatal care as well as particular health facility to use which may be heavily dependent on affordability since husbands were the main providers in the households wives were generally very submissive as culturally expected this was corroborated by the fgds in which participants revealed that fertility decisions taken by husbands were sometimes injurious to the health and wellbeing of the wives and cited decisions to have another child to ensure a male child or more male children a 24 year old gombi since we depend on our husbands for the daily needs and they are the ones that can determine the number of children if i have the resources and i make a lot of money from it i can say i want this number of children or this is the hospital i want to use they are the ones that own the land and the crops we are just assisting them to support our family a trader fadchi it is our religion that allows husbands or the heads of the family to be the one to decide on the number of children even if the wife desires more children and the husband says no there is nothing she can do likewise if the husbands desire more children the wife cant say no to him male children are favoured in our culture a housewife guyaku it is not the fault of women not to go to the hospital their husbands must approve of it because you cant take the decision on your own only 25 of the respondents ever discussed the need for family planning and use of contraceptives with their husbands spousal communication on the use of contraceptives as previously revealed is therefore still very low the data also revealed that spousal communication on fertility issues is very low as a result of the wide age differences between the young mothers and their husbands the fgds revealed a general lack of confidence by respondents in articulating the issues around reproductive health issues and associated with childbearing maternal health risks the data revealed that respondents commenced childbearing between 14 and 18 years of age and 71 had experienced at least one serious pregnancy or birthrelated health problem which include excessive bleeding during labour obstructed andor prolonged labour frequent miscarriages and pro longed sickness after childbirth as shown in table 3 african health sciences vol 16 issue 4 december 2016 991 in addition to these of those that had experienced various health complications 37 had been exposed to the risk of vesicovagina and rectovigina fistula and were at various stages of treatment this and discussions in the fgds revealed that maternal morbidity is very high among the young mothers the uptake of opportunities for antenatal and postnatal care was reportedly low among women due to distance from the facilities cost husbands attitude and ignorance birthspacing is not deliberately practiced and contraceptive use is almost nonexistentwhile there were no locally collated figures health personnel also confirmed a high and increasing frequency of maternal deaths involving young mothers in and outside health facilities in the study area 121417 a nurse gombi most of the cases we witness in the health facilities are prolonged labour vvf and excessive bleeding some of these women are too young for childbearing but because of our culture and religion there is nothing we can do we are educating them still we still have new cases every day sexually transmitted infections are very common around here but many are treated at the local chemists and herbal clinics rather than in the hospitals because of shame we know that the most important issue is the immaturity of their bodiesthat is the risk a civil servant gombi it is prolonged and obstructed labour that is more common in this area with excessive bleeding it has led to loss of many girls in our community some of these women are not well informed about the pregnancy complications some of them will not attend antinatal clinic they are too young and not yet ripe for childbearing but are married and expected to have children they are also children a full housewife misamba miscarriage and excessive bleeding are very common pregnancy complications in our community also prolonged labour mainly because pregnant women do not register early for ante natal care because the young ones dont have money they dont know when its appropriate to do so a nursemidwife balwhona we are used to complications in this health facilities this was common among young girls who married before age 18 years some of them will not come to the health facilities for antinatal until it has resulted to complications sometimes it might result to death we have witnessed several deaths of young girls that are wives and too young to safely deliver their children a medical doctor gombi majority of the complications we have handled were as a result of early marriage and their negligence of not attending antinatal for proper medical advice vvf cases are also common in this area but we are trying our best to educate them the sample of young earlymarried mothers was analysed for differentials in experiences of pregnancyrelated complications across categories as shown in table 5 religious affiliation had minimal impact on the occurrence of pregnancy complications as slightly more muslims than christians had experienced complications however the fgds and indepth interviews with religious and community leaders revealed that early marriage of before 18 years is the norm in the study area but child marriages are conducted mostly among muslims because the religion permits it with caution the experience of serious pregnancyrelated complications decrease with increasing exposure to educational opportunities with more respondents with primary level education reporting complications compared to those with secondary and post secondary levels of education similarly respondents husbands level of education was found to be associated of the respondents that had experienced complications more husbands had no formal education or primary level education compared with those that had secondary and post secondary levels the data also show that pregnancyrelated complications were reported more among respondents aged 1519 years low income full housewives and farmers than among those aged 2024 years high income traders and civil servants in salaried employment significantly experiences of pregnancyrelated complications increase with increasing number of children of the respondents from one to at least four children in the study area the data therefore reveal that level of education of respondents and their husbands income of respondents maternal healthseeking behaviour place of delivery is one of the factors that influence maternal deaths and 28 of the respondents delivered their last baby at home while 23 delivered at the homes of traditional birth attendant from the survey 33 of the respondents indicated that the health facilities were far more than 5kms from their homes and this may be one of the reasons for none use of the health facility participants from the fgds expressed confidence in nurses midwives and traditional birth attendants compared to doctors this was collaborated by the responses in table 4 delay in seeking medical treatment is one of the factors mentioned among the fgds participants as a cause of maternal death and complications in the study area this may be as a result of the revelation that decisionmaking regarding medical treatment is the responsibility of husbands and only 175 of the respondents reported their ability to decide on their medical treatment only 435 of the respondents used antenatal care regularly while 11 indicated that they had never attended anyantenatal prior to their delivery a medical personnel gombi we dont have enough hands in this hospital but most of these women particularly the young ones will not report at the health facilities on time until their cases are getting out of hands with no history of the pregnancies delays are caused in diagnosis prior to treatmentalso many women are referred to this facility from surrounding villages and sometimes they are very young for childbearing and have not been to any facility for antenatal care so it could be too late to save them and the babies african discussion this study has established that girls in gombi locality are facing significant cultural and social barriers to living wholesome and healthy lives that are often strengthened by religious prescriptions on marriage these include the facts that their marriages were arranged without their consent the opportunities for schooling were either disrupted or not utilized at all they were made to commence sexual relations and subsequent childbearing early they were exposed fully to various reproductive health risks as shown in this study another cultural factor revealed in the study is the issue of patriarchy husbands have the final say on almost all the household decisions including the respondents health issues this may be one of the reasons for the delay in seeking medical care as reported among the medical health officials who participated in the indepth interview haberland nicole eric chong and bracken have revealed that girls married at a very younger age experience social personal and psychological challenges when compared with those who marry latter there is also greater control by their husbands with restriction on movement ability to seek health care and family planning services limited capacity to earn independent income and paid labour force financially theydepend on their husbands and unable to ask their partners to go for test use contraceptives or abstain from sex even when they know their partners are infected the notion of good reproductive health encompasses all aspects of the reproductive process including the right to engage in sexual relations and to decide when to have children and these are the rights not accessible to the young women in the study area earlier findings 184 revealed that child brides are likely to commence childbearing early and there is a strong correlation between the age of mother and maternal morbidity more than two thirds of the respondents indicated that they have experienced at least one the complications during their life births some of the complications me tioned in this study include prolonged and obstructed labour which may lead to hemorrhage excessive bleeding and prolonged sickness after birth this reaffirms the impact of child marriage on the health of the mothers previous studies linked child marriage with some health consequences such as cervical cancer vvf genital ulcer etc 1920 these girls are expected to prove their fertility immediately they are married off which often results into pregnancies a stage they are not prepared for eventually leading to maternal and newborn morbidity girls aged 14 years and younger run a risk of complication in pregnancy and child birth when compared with those of older ages 21 poverty has also been shown to be at the core of the way young girls are regarded as economic burden and quickly married off to alleviate household expenses as reported among the fgds participants in the study area in these communities educational and economic opportunities available to girls are few and girls are often quickly married off to protect them as well as improve the economic wellbeing of the family considerations for family honour also put pressure on families to marry off young daughters to avoid embarrassment and shame that may come with loss of virginity and unwanted pregnancies as they grow up early marriage invariably confines young girls to a life of poverty in a cycle that is often difficult to break and significantly deprive them of freedom and entitlements to life a study reveals that girls are viewed as economic burden and marrying them off is a way to alleviate household expenses 22 the practice of child marriage dooms girls and women to a life of poverty another strong factor identified in the study is the issue of promiscuity among the girls as a strong reasons for their early marriage parents believed that instead of bring shame to the family it is better to allow suitor to come for them studies have shown that girls who married early are more likely to be infected with sexually transmitted infections especially hiv and human papilloma virus evidences from subsaharan african countries revealed that half of the married girls are more likely to be infected with hiv than the unmarried 323 the study also affirmed the significant relationship between education and pregnancy complication those who have higher education are less likely to have complications participants from the fgds and idis explained that those with higher education have knowledge about signs of pregnancy complications and they can quickly access health facilities more than twothirds of the respondents in the study area delivered outside government hospitals and clinics this is also a point that can influence the high maternal mortality and morbidity in the area in her study of utilization of delivery services in ilesa nigeria observed that high stillbirth and early neonatal mortality rate have been long associated with unattended deliveries compared with hospitalbased deliveries 24 those with postsecondary education also delay their marriage and have the ability to make choices and this was confirmed by the fgd participants it was stated that schooling helps girls achieve ambitions and gives them skills to discuss who and when they will marry 25262728 behind the practice of child marriage is a failure to guarantee child and young peoples rights manifested by denial of education low status deep poverty and restricted mobility while the nigerian child is supposed to be protected by a well articulated legal framework earlier outlined in this paper it is evident that in practice this is not so and there is a need to engage social and cultural norms surrounding the practice of child marriage the issues of legal sanctions are desirable but complicated as the laws of the country exist alongside customary and religious laws on marriage country laws are also not applicable to customary marriages 29 within the context of poor registration of marriage and failure to apply recommended sanctions to law breakers child brides are generally left unprotected it is for these that in nigeria inconsistencies exist between the legal minimum age at marriage which is 21 years and actual practice as marriages of children as young as 7 to 10 years were reported in the fgds conducted in few communities in the study area conclusion initial concerns about child marriage centred on its contributions to rapid population growth as early childbearing in the absence of contraception results in large family sizes however in the latter part of the 20 th century advocates of safe motherhood and adolescent health turned attention to child marriage emphasizing the vulnerability of young girls to hivaids stis and other serious health issues beyond this however and more recently attention has further shifted to the need for widespread education for girls and its benefits a situation that necessitated greater focus on child marriage and the exclusion of girls from schools within a rightsbased approach in the context of widespread hivaids very high maternal mortality and growing sexual violence against girls within permissive traditional practices the demographic and health implications of early marriage as practised in gombi are grave for nigeria this study has identified the negative impact of early marriage on young women in gombi expressed in form of high maternal morbidity through various pregnancy complications in the study area with this it is clear that the practice of child marriage in the study area and in other parts of nigeria is directly impeding the ability of the country to achieve six of the millenium development goals which are those of eradicating extreme poverty and hunger achieving universal primary education promoting gender equality and empowering women reducing child mortality improving maternal mortality and combating hivaids cervical cancer sexually transmitted diseases vvf malaria and other communicable diseases by 2015 progress in health and gender matters towards the achievement of mdgs has been scored low in nigeria strategic interventions planned for gender issues infant and maternal health hivaids malaria tuberculosis and primary health and implemented since 2000 have failed to yield any appreciable results and the government at all levels are being pressured to increase allocation of resources to the sectors to ensure an overall progress in the wellbeing of the population while increase in commitment and funding are important there is an urgent need to refocus the development lens in nigeria to a critical and crosscutting issue as child marriage the reduction of which can speed up the achievement of the mdgs if not by 2015 in as short a time as possible there is an urgent need to focus on the cultural traps to which the practice of child marriage has confined girls in gombi and other parts of the country through renewed commitment to compulsory education beyond primary school level for girls enforcement of legislation and commitments to uphold the fundamental rights of the child in particular men in their capacity as fathers community and religious leaders must be targeted for change given their roles as custodians of tradition and decisionmakers on marriage and family matters the several elements of marriage and maternal health must be understood afresh as entitlements and the freedom associated with them must be granted to every citizen coflict of interest

background efforts toward liberation of the girlchild from the shackles of early marriage have continued to be resisted through tradition culture and religion in some parts of nigeria objective this study therefore examines the maternal health implications of early marriage on young mothers in the study area methods multistage sampling technique was employed to obtained data from 200 young mothers aged 1524 years who married before aged 16 years findings the study reveals that more than 60 had only primary education while more than 70 had experienced complications before or after childbirth age at first marriage current age level of education and household decisionmaking significantly influence p 0005 maternal health risks in the study area the study establishes that respondents in age group 1519 years are 1234 times more likely to experience complications when compared with the reference category 2024 years entitlements and freedom that are highly relevant to reduction of maternal mortality provided by international treaties are inaccessible to young women in the study area conclusion strategies to end child marriage in the study area should include mass and compulsory education of girls provision of other options to early marriage and childbearing and involvement of fathers in preventing and ending the practice

introduction migration incidences and crises at the european unions external land and seaborders have been covered by traditional media and debated from various perspectives within social media frances calais italys lampedusa greeces aegean islands and more recently the greekturkey evros landborder and the polishbelarusian borderamong others are albeit to different extents sites for the deployment of migration crises spectacles which lend themselves to the demarcation of the boundaries between us and the other around them a mediated debate is evolving rooted in a perceived fear that the events of the summer and autumn of 2015 marking the peak of the socalled european refugee crisis during which thousands of people requested asylum in europe could be revived this is coconstituted with the idea which seems to be transcending the mainstream political spectrum that new arrivals should not be too much for europe to handle progressively the idea that migrants are pushed over by europes enemies or ungodly friends as we will argue here to harm it is consolidated justifying more border securitization regardless of the cost to human lives borders and identities are underpinned by practices and discourses which circulate in various media online and offline in social media the farright is mostly outspokenly antimigrant while the populist rightwing often uses coded antimigrant discourses which have contributed to mainstreaming european exclusionary politics through the politics of fear eus migration agenda falls little outside the restrictive frames proposed by the farright and the populist authoritarian rightwing as the characterizations fortress europe and apartheid europe suggest naturally the eu is not openly suggesting that deaths at the borders are acceptable sideeffects of its border securitization but the farright on social media may in fact be uttering the unsayable when they are asking for explicit violence towards migrants as indicated by the use of hashtags such as rapefugees or refugeesnotwelcome the knot that ties together ideologies that advocate fierce antimigrant politics and mainstream european migration politics is perhaps the elephant in the room that critical scholarship should not hesitate to pinpoint importantly the connections between extreme antimigrant and mainstream eu migration discourses and politics need to be drawn out at times when fears related to migration give rise to the dehumanization of people on the move effected by the othering of other key migration actors the legitimization of border atrocities and the turning of the death of migrant others into a banal occurrence in view of the above we offer an indepth analysis of othering in twitter around the hashtag istandwithgreece associated with a border crisis at europes periphery in early 2020 concerning neighbouring countries greece and turkey with a turbulent history of antagonisms in so doing we reflect on the extent to which the othering processes we track in these tweets by farright elite and nonelite voices offer a more overtly racist expression of official eu discourses about migration to the extent that they may be mutually constituted hashtag istandwithgreece created in the midst of the events studied began trending on twitter and around it a network of intolerance was organized to strategically promote ideologies ranging from white supremacism to greek nationalism glued together by antimigrant positions focus on these events and on twitter allowed for an indepth analysis of transnational boundary making its relationship to greek nationalism and european border politics and discourses boundary construction othering and the mediated european migration debate othering is a process of differentiation and demarcation between us and thembetween the more and the less powerful and through which social distance is established and maintained as lister indicates the differentiation of us from them is done in a way that favours the ingroup and undermines the outgroup such that the outgroups subjugation and exclusion from the ingroup follows naturally postcolonial approaches to othering understood it as a process of portraying the other the indigenous communities as different stressing their inferiority to the self the colonizers capitalizing on the constructed inferiority of different others discrimination and exclusion was justified by the dominant group enabling it to maintain unequal power relationships thus othering aids the preservation of hierarchies and the propagation of ingroupdominationprotection policies in the case of migration the othering of migrants is linked to specific policies such as border management and securitization representations of the other are instrumental in that they justify political decision making this connection is achieved through a process of political imagination that is creating imageries future scenarios of how life would be if the other penetrated it this process consists of building representations of others which are then used to limit or enhance those others abilities to achieve their political aims labelling people on the move as migrants versus refugees for example is deeply political leading to the endorsement of certain representations of these people which give rise to opposing political demands the support of open or closed borders similarly crisis imaginaries legitimize the actions of those in power in view of utopian futures that as in the case of migration capitalize on the threatening nature of the other mediated othering of migrants largely reflects and reproduces the above processes and has been the focus of ample research studies have shed light on how traditional media in europe have represented the migration debate within and across member states during the socalled 2015 refugee crisis and explored also the role of more transnational sites such as social media preexisting antithetical migration frames reemerged during the european refugee crisis the humanitarian one representing refugees as victims and as passive actors in need of help and the fear and securitization one construing refugees as intruders who are agentic opting to perform illicit actions and practices such as crossing borders without permission and therefore threatening all in all the strategic use of the word crisis by the media to describe migration in europe set the ground for boundary construction between us and them regardless of the valence of the discourse another aspect of othering as noted by dervin is defining or redefining the self in relation to the other within the migration debate the socalled influx of noneuropeans into europe has triggered discussions around european identity or europeanness in an attempt to redefine the self in juxtaposition to the other himmel and baptista explored migration discourses in german and portuguese media between 2011 and 2017 and found for example that when migrants or refugees were assigned as the other being european was equaled to not being muslim interestingly research illustrated the multiple and often conflicting media representations of europe and the eu in particular in national media thus shedding light on its inherent fragmentation and intraantagonisms for and against close migration policies and on what being european means othering can take particularly interesting forms in social media for a host of reasons social media host transnational discussions while also allowing for national affiliations which means that the self is not constant and can alternate between the national self or a more overarching self such as being european there is for example research showing how transnational farright audiences bond in social media to spread antimigrant ideas as well as how nationalism emerges in discussing refugee issues on twitter among users affiliated with specific national contexts research is however rather undeveloped when it comes to how transnational and national debates online intertwine in spreading antimigrant stances in addition the presence of antimigrant and nationalistic discourse capitalizing on othering processes appears stronger online migrant othering in twitter was found to be more blatant compared to traditional media in 2015 as indicated by the frequent use of openly negative hashtags such as rapefugees with the farright being almost exclusively responsible for endorsing the representation of refugees as terrorists or rapists yet indepth examination of how the othering of both refugees as well as other actors is motivated in social media is rare as the field is dominated by big data approaches simultaneously and partially perhaps due to this dominance research is rather undeveloped when it comes to the intersections of how transnational othering in social media intertwines with ethnonationalism and vice versa this is a gap our study seeks to address through a qualitative analysis of antimigrant tweets during a crisis at europes borders eu border politics and the evros events quo vadis europe our study focuses on the evros events of late february and midmarch 2020 broadly attributed to turkeys decision to suspend a controversial agreement with the eu regarding the handling of refugees fleeing turkey to enter europe briefly the euturkey migration deal of march 2016 meant that migrants crossing into greek islands would be relocated to turkey and in return turkey would receive monetary compensation from the eu and turkish citizens received a visa waiver for eu travel the deals suspension resulted in refugees previously locked in turkey moving towards the turkish greek and bulgarian landborder demarcated by the river evros to enter the two eu member states thousands also attempted to cross to the greek islands greece closed its borders and deployed security forces reportedly members of the farright from greece and other eu member states travelled to the border in early march 2020 furthermore greece suspended all asylum procedures until midmay 2020 citing the covid19 pandemic and progressively adopted more restrictive containment measures for refugee populations in its camps the evros events concerned primarily neighbouring countries greece and turkey with a turbulent history of geopolitical antagonisms in the area evros has been a place of symbolic struggles where greek and turkish nationalisms tend to compete as a greekmuslim minority inhabits villages around the border the events were also of european interest as evros composes eus external border which rendered them relevant to the euturkey migration deal the european commissions president visited the area and alongside some ambiguous remarks about turkeys role she spoke of greece as our european ασπίδα and shared the conviction that we will hold the line thus giving the eus decisive support to border closure and securitization the year after greece proceeded to an extension and surveillance upgrade of a fence in the evros area which coincided with the talibans resurgence and dominance in afghanistan of august 2021 greek officials argued that this border upgrade would enable it to deter afghanis from entering declaring that we will not allow a reliving of the scenes of 2015 at the time the czech prime minister also said that there was no room for afghani refugees in europe importantly the eu corroborated these concerns an eu ministerial statement appearing to focus on the prevention of a new humanitarian crisis underlined the eus goal to prevent the recurrence of uncontrolled largescale illegal migration movements faced in the past fears about massive numbers of afghanis arriving in europe are only part of a series of relevant analogies made by eu and national leaders in the post2015 era earlier the controversial belarusian president aleksandr g lukashenko was accused of using migrants at belarus borders with lithuania an eu member state to conduct a hybrid war against the eu 1 the situation escalated and by the end of 2021 the polishbelarusian border had turned into a battleground resembling the evros 2020 events around which a blamegame between key actors evolved while hundreds of people remained trapped in deteriorating conditions and some died helpless the european commissioner for home affairs tweeted among others at the peak of the events that europes urgent priority is to turn off the supply coming into minsk airport 2 with supply meaning people on the move notwithstanding the cruel instrumentalization of migrants by several international actors and authoritarian leaders the eus preoccupation with the threat of just another influx and its routinely dehumanizing metaphor of migrants as weapons has implications for attitudes and policies about migration from the global south specifically namely in the backdrop of this debate border securitization across the eu increases with severe consequences for the lives of people en route to europe balkan states continue the harassment and intimidation of people on the move poland and lithuania are constructing their own fences and eu member states of the mediterranean sea increased pushbacks in the last 5 years violating international regulations such as nonrefoulement in the name of national and european security 3 ultimately eu border politics do cause deaths and eus controversial border and coast guard agency is routinely accused of playing an active role in pushbacks 4 migrant lives matter and it is an imperative to outline how these othering processes that border discourses engender are linked with and thus feed into the existing eu border regime research rationale methodology and method social media and particularly twitter have become a powerful communication tool during many kinds of crises political or otherwise twitter affordances allow communities outside a specific country to debate on topics of wider appeal an example is migration which has drawn the attention of a transnational audience from the farright which often bond around negative evaluative hashtags in english such as refugeesnotwelcome used during the socalled refugee crisis or islamexit used after the brexit referendum occasionally elite and nonelite farright voices may coordinate to spread antimigrant positions in social media using more covert hashtags too simultaneously on twitter nationalism is reproduced from below when twitterers of a particular country debate refugee issues our focus is on an evaluative yet ambiguous hashtag istandwithgreece used in the midst of the evros events and which became the most popular hashtag on twitter around which a social network was organized promoting antimigrant views the tweets shared by istandwithgreeces top influencers form our research focus namely we sought to interrogate the othering discourse in social media post2015 by looking for wider reasons for othering going beyond the welldocumented representation of the threatening migrant in so doing we performed a qualitative thematic analysis to identify meanings promoted approaching each tweet in our dataset as an integrated discourse comprised of text multimedia and other twitter affordances below we describe the data gathering method that resulted in the collection of 1850954 tweets the sampling strategy and the qualitative analysis of a smaller sample of 818 tweets to clarify our qualitative sampling was purposeful driven by the research question and not by a concern for representativeness data collection and sampling rationale when turkey declared the suspension of the 2016 deal with the eu at the end of february 2020 we started collecting tweets using relevant keywords refugeesgr turkey asylum through dmitcat which provides a realtime stream of tweets including retweets and replies the 31st march 2020 is the last day of our sampling period because we observed a local minimum in the 5day rolling window variance in the frequency distribution in our data istandwithgreece was the most frequently used hashtag used in about 32 of the tweets collected using social network analysis we identified the networks top 10 influencers and the subnetwork communities in which they belonged as explained ethnonationalists white supremacists and other antimigrant voices almost exclusively dominated the debate under istandwithgreece for example farright british social media persona katie hopkins and members of the french identarian movement were among the top 10 influencers all eventually banned from twitter our understanding of the meanings that istandwithgreece influencers promoted was informed solely from cohashtag analysis which provided us with descriptive insights to identify a more manageable number of tweets for an indepth analysis in line with our current research question we isolated the retweets of the top 10 influencers tweeting in english and in the greek language in which we are fluent two of the top 10 the british tabloid mail online and french president emmanuel macron had not tweeted using istandwithgreece so we added the next two top influencers number 11 did not retweet in either english or greek but top number 12 retweeted 29 tweets in english this provided us with a total of 818 tweets of which 607 had a photo or a video and which we deemed sufficient for the indepth analysis we aimed for overall they concerned retweets of five of the most representative communities of the network anglophones 1 and 2 which discussed the events adopting a global conspiratorial perspective the greek community comprising mostly greek nationalists the germanic community headed by the german and austrian farright and the french community this led to the greek community being overrepresented in our qualitative sample although this can be considered a limitation it enabled us to have rich data to study a specific nationalist discourse that developing among users tweeting in greek with more transnational antimigrant discourses in english furthermore as clarified we were not preoccupied with representativeness in this analysis thematic analysis our thematic analysis a method for identifying analysing and reporting patterns within data was driven by our primary and secondary question who is othered and why in identifying and reporting themes as active researchers we primarily focused on nomination and predication that is the representations of actors and their characteristics and the representation of positive self and negative other this guided our coding too codes are tags or labels for assigning units of meaning to the descriptive or inferential information compiled during a study in this case the entire tweet was coded which is a rather pragmatic choice given the rather small length of a tweet and a choice that allowed us to avoid decontextualization of codes each code represented an actor of the events and additionally we had other codes drawn from our data coding was exhaustive as all the tweets were assigned at least one code to identify the themes we engaged in a close reading of coded tweets reflecting what braun and clark referred to as a recursive process of moving back and forth as needed throughout the phases looking for unanticipated insights one of the great advantages of qualitative research although focusing on meanings we do shed light on discursive instances that promote usother binaries when relevant or to highlight common antimigrant discourses or rhetoric strategies adhering to the tradition of critical discourse analysis this is in line with reisigl and wodaks assertion that through discourse discriminatory exclusionary practices are prepared promulgated and legitimized as we studied twitter discourse we also follow jackson and welles paying attention to meanings provided by the combination of language with images and other affordances finally in reflecting on the affinity of this antimigrant discourse with the eus we do not aim for a strictly comparative analysis but to rather offer a critique of how we see this empirically grounded othering and the political aims connected with it relating to broader mainstream eus border politics with the expectation that this will motivate further work to foreground relevant arguments more systematically findings turkey and migrants as imminent and a real threat erdogans hordes of illegal immigrants istandwithgreeces influencers represented turkey and migrants as a joint mutually reinforcing threat to greece greek people and europe or the west turkey was represented as the mastermind behind the border events and migrants were construed as threatening due to their sheer size gender composition and propensity to radicalization an indicative tweet exemplifying the representation of turkey and migrants as a coordinated threat against greece while assuming that all migrants were en route to germany read the scale of erdogans operation against greece is huge tens of thousands of migrants have been bussed to the border constantly attack greek border guards in their attempts to storm the border march through the balkans reach germany greeceunderattack istandwithgreece this tweet interpreted the events as an orchestrated attack implemented by migrants and coordinated by turkey who it was claimed was literary bussing them to greece the word operation is telling as it conveys the message that the events were preplanned the tweet is accompanied by a video showing people in some form of congregation with smoke visible at the background evidently this choice of warlike images facilitates the representation of the border as a battlefield and serves to underscore the severity and the urgency of the situation in similar tweets the migrant other was intentionally gendered whereas women and children were almost absent perhaps because reference to them would challenge the ubiquitous image of a threatening other where reference to women and children was made what was discussed was their absence an indicative tweet noted count the women and children among the migrants at the greek border they cant make up more than 5 thus influencers corroborated the representation of an unquestionably threatening migrant other merely on the basis of gender and age and assumed religion the multiple images that the network shared of young violent men collide with the notion of the deserving other connoting that these migrants are not worthy of being let in as the following suggests sorry but when people who seek asylum use tear gas grenades to achieve their goal they are not refugees they are invadors and they are not accepted borders closed forever greeceunderattack istandwithgreece the above twitterer appears to be apologetic claiming that had people at the border been genuine refugees then they would be accepted but given these people carry tear grenades instead this strips them from any right to claim refugee status importantly not being real refugees is eventually used to justify permanent border closure probably the ultimate restrictive migration policy that a nation state can implement and a measure that ensures that these nonrefugees stay away permanently as the capitalized forever denotes another dominating male presence in these tweets was turkeys leader tayyip erdogan represented as the vicious mastermind tricking migrants to believe that they would be able to cross from greece towards other european countries reference in one tweet to erdogans hordes of illegal immigrants alludes to how these events are in part a oneman show controlling the migrant crowds moreover a twitterer compared erdogan to hitler but funnily also prompted greek soldiers to kill border crossers using twitter affordances as the hitlererdogan analogy is a hashtag the tweet becomes an amalgam of paradoxes the twitterer considered calling someone hitler as an insult but then demanded the killing of anyone crossing borders and used hitler an ultimate figure of intolerance to support it this ad hominem attack against erdogan by association with hitler was coupled with insults that repeatedly described erdogan as a madman a criminal and a tyrant ad hominem attacks and insults are used to pathologize erdogan representing him as a culpable supervillain capable of calculated acts but also unable to moderate the uncanniness of his acts due to psychological instability erdogans supervillain nature can only be topped by that of the jihadists another common representation of people at the border and together they form very potent antiheroes historical other greece guarding the thermopylae of the western world the history of intergroup relations in the region as merely one of ethnoreligious conflicts leading to territorial disputes between two main homogenized groups christians and muslims was deployed by istandwithgreece influencers to justify othering these representations were expectably infused with greek nationalism promoted by greeceaffiliated influencers and diffused widely by nongreek influencers the tweet below is a good example of a hellenocentric historical representation according to which turkey is a serial perpetrator attacking greeks and the evros events form recent evidence of the omnipresent turkish aggression turkey committed genocide on the greeks turkey invaded cyprus in 1974 occupied for 46 years and violate human rights and international laws turkey also violates greek airspace daily turkey is weaponising immigrants but apparently greece is the aggressor istandwithgreece this tweet refers to certain events in an ostensibly historical sequence to illustrate the continuity of turkish aggression against greece and cyprus an eu member state which according to greek nationalists is greek despite the longstanding presence of a turkishcypriot community on the island the reference to a greek genocide probably alludes to the 1922 conclusion of the grecoturkish war in asia minor that led to among other things the formation of the turkish republic and a large compulsory population exchange between the two countries this is linked to the 1974 turkish invasion of cyprus and turkeys alleged violations of greek airspace occurring simultaneously with the evros events the connecting thread justifying lumping together arab migrants and turkey is islam which is deterministically associated to fundamentalism and terrorism therefore migrants by virtue of being muslims fit the historical enemy narrative the tweet below illustrates vividly the representation of these events as an omnipresent conflict between the crescent represented by turkey and muslim migrants and the cross defended by greek soldiers kthopkins erdogan says he will flood europe with muslims until the crescent triumphs over the cross this is the border with greece mosque in the distance soldiers of the cross holding the line this is biblical istandwithgreece in another example a myth is invoked to sketch turkey and migrants as a joined enemy not only of greece but of europe more broadly it is accompanied by a photo illustrating a number of weaponized men resembling jihadists getting out of a wooden horse the tweet reads turkey trying to pull a trojan horse on europe but having to get through hellas that originally invented it proves impossible istandwithgreece the analogy attempted here is interesting not least because the trojan horse myth which the image portrays is of a time when neither the greek nor the turkish nations existed it refers to a trick that causes the target to invite a foe into its own home according to mythology odysseus a rather canny figure conceived the idea of using it to deceive the trojans and enter their city during the trojan war the madeinturkey trojan horse as the red flag with the white crescent and the star indicates corroborates the narrative that turkey is the mastermind behind the border events using stratagems of this nature to implement a secret agenda to damage europe by sending over dangerous radical islamists despite the triumphant image of jihadists greece is the ultimate winner because it is historically superior for having invented the trojan horse a primordial understanding of nations is evident as reference to hellas instead of greece is the characteristic way the greek nationalist dictatorship of the 1960s referred to greece another tweet clearly represented the events as a conflict of civilizations the oriental versus the occidental drawing from antiquity it noted greece guarding the thermopylae of the western world once again this time you can help pressure your gvmts to provide us with military assistance to sanctionturkey now our a photo of a barbed wire in front of policemen standing underneath a sign with the inscription greece welcome and the greek flag completes the tweet thermopylae refers to a place in greece literally meaning hot gates where a battle between persians and greeks took place the persians outnumbered the greeks but the latter demonstrated enormous bravery according to the same narrative in this context the hot gates under siege are those of the entire western world the portrayal of the barbed wire and security forces in front of the welcoming sign is telling of the paradoxes of borders as nonentry points articulations of europeanness europe they are at the gates this theme focuses on the ways the networks tweets represented europe and europeanness identifying a tension between ideas about europe at the symbolic level and the eu and its leadership as a failed promoter of european values istandwithgreece influencers were sending a wakeup call to the leadership warning them of the imminent threat against the whole of europe one characteristic tweet noted that europe they are at the gates and another read europe as you sleep well tonight remember it is the greek people who are keeping erdogans hordes of illegal immigrants out of your countries we will continue to do this but do you stand with greece istandwithgreece europe here is most likely used to refer to western european countries typically the desired countries of destination for refugees and the eus powerful decision makers europe is represented as not wanting these illegal migrants but conveniently expecting greece to do the job for them the tweet is essentially inquiring whether europe will ever show solidarity with its ailing members therefore casting doubts about its role and intentions these accusations are not really meant to be othering in the sense that the attempt to present europe as morally inferior or lacking in bravery is not done in order to distance it from the self they are rather a form of provocation and a cry for help and union nevertheless the opening sentence implies a level of hypocrisy from europe because while greeks are in a brutal fight with an enemy keeping all europeans safe europe is passive influencers recurrently reinforced the longstanding divide between affluent western europe and the more exposed and victimized south and east for allegedly suffering more from migration due to its geographical proximity to areas of conflict in the following tweet top influencers are cheering central eastern europe for pulling its weight and defending europe at large while western europe would not help thus picturing europe as a fragmented union last night the migrants bussed to the greek border by turkish authorities continued to attack greek border guards with the use of rocks fireworks tear gas cannisters western europe wont help greece centraleasterneurope must do it greeceunderattack istandwithgreece those severely targeted by the network were certain highlevel eu politicians in the following the ec president is characterized as a disgrace and erdogan as a tyrant the eucopresident is a disgrace expressing condolences to erdogen why is the eu appeasing this tyrant his rogue blackmailing genocidal terror state they should support greece against this erdogan organised invasion greeceunderattack istandwithgreece cyprus idlib simultaneously greekaffiliated influencers used twitter to convince europeans to take action to protect greece and by extent the entire ingroupself this is illustrative of a desire to articulate the self as genuinely european fellow europeans you must take a stand do you want us to be the bridge to your home we must find a solution to this together please apply pressure to your politicians this is serious istandwithgreece greecedefendseurope greeceunderattack the tweet makes a clear distinction between ordinary fellow europeans and political leaders ordinary europeans are represented as the real carriers of europes ideals for union and internal solidarity in juxtaposition to the political elites who undermine authentic europeanness a video showing mostly young male migrants one of them shouting in english we want to go to europe and adding that your country is a bridge to us completes the tweet by supporting the networks main argument that greece was protecting europe from unwanted others who aimed at reaching destinations outside greece interestingly the speaker does not really consider greece as europe since he notes that they want to go to europe which is a striking contrast to the networks symbolic representation of greece as the ultimate heroic european or as one twitterer noted the foundation of europe adding that if greece fails the rest of europe will fail too christian europe was another assertion of the network grounded around the idea that evros was not only the border of greece and europe but also of christianity indicative hashtags foregrounded this assertion such as letsreturntochristianity and christianityunderattack while one tweet noted greece is europe islam is not istandwithgreece finally a tweet read interestingly christian identity is treated by influencers as a unifying element between greece and europe silencing greeces orthodoxy which for greek nationalists was in the past viewed as a dividing element distancing greece from other eu member states discussion and conclusion the pawns discourse and why it matters this study sought to answer who was othered and why in a twitter debate around istandwithgreece triggered by border incidents between greece and turkey in early 2020 the tweets studied belonged to the top influencers of what we have already identified as a network of intolerance promoting ideologies from within the farright cutting across national contexts of the global north focusing on the networks english and greek tweets we inevitably located othering processes at the intersections of transnational farright perspectives which share rhetoric and ideologies and of greek nationalism therefore bringing new insights on migrant othering in social media subsequently we reflect on the extent to which the othering promoted by these antimigrant influencers may serve mainstream eu migration politics our findings yielded the othering of three actors of the events turkey migrants and europe mirroring earlier media and social media research othering of migrants was centred around the cultural and security threat and the national threat while the predominant representation of migrants during the 2015 crisis was mostly that of a faceless voiceless flood of numbers in this networks tweets we located their representation as pawns according to this migrants are likened to a chess piece with no value in their own right as they are literally pushed towards europe by another actor erdogans turkey who elevated them into a sizable threat by turning them into invaders this representation is evident in recurrent references across the three themes that migrants have been bussed to the border that they are erdogans hordes that turkey was weaponizing them or hopkins tweet that erdogan was threatening to flood europe with muslims moreover the trojan horse analogy is illustrative of this migrant pawn representation because had it not been for the madein turkey wooden horse jihadists would not have made it to europe this dehumanizing nonagentic representation of migrants exacerbates an understanding of them expendable but it does not contradict their representation as invaders in contrast the two are strategically consolidated because migrants agency to pose a threat depended exclusively on turkey they can invade only because erdogan moves them across the chessboard towards europe therefore their fate is turkeys responsibility which has willingly if not purposefully sacrificed them as pawns europe is also wiped of any quilt or responsibility for these people because they are merely seen as serving the other actors aims the consolidation of these representations has implications for the future it provides another argument to justify europes border securitization foregrounding its representation as a paradoxical other the fallen self for not rising to the opportunity to decisively protect its sovereignty and identity through more securitization istandwithgreece influencers homogenized people at the border as muslim fundamentalists which is common in antimuslim online debates that ignore the complex identities of asylum seekers the representation of middleeastern masculinity as threatening a common strategy of twitterers using refugeesnotwelcome in 2015 was used in this network too this allowed twitterers to exacerbate the bond between the people at the borders and turkey and the corresponding representation of the events as a religious and cultural conflict as the crescent versus the cross metaphor illustrates similarly the network endorsed hellenoand eurocentric representations of modern and ancient history in which turkey was portrayed as an eternally malevolent actor in the geopolitical chessboard various motivated historical analogies were mobilized to convince readers that turkeys enabling of wouldbe terrorists into european soil stems naturally from its historical desire to conquer or destroy europe notably turkey has long been represented as one of europes key historical external others alongside russia simultaneously christiangreece is seen as protecting the west from barbarian others from the east due to its position at the crossroads between west and east as the thermopylae battle analogy claimed greece is a separate nation but its europeanness is takenforgranted both by greekaffiliated and nongreekaffiliated influencers despite this narrative being disrupted by migrant people explaining that they want to go to europe implying that greece to them is not europe the eugreece relationship is even more complex greek twitterers called for solidarity but they were rather disappointed or expected little from european leadership as evident in the rhetorical question but do you stand with greece the othering mainly of western europe was motivated by representing the eu and its leadership as passive hypocrites accused of not protecting their own people and washing their hands instead that europe is passive and hypocritical when it comes to migration crises matches earlier media criticism but from a promigrant perspective effectively the eu was failing to protect the networks racialized notion of europeanness as the christian occidental self and keep out those migrants who not only posed a tangible threat by violating its sovereignty but who on top of that were unworthy of coming to europe and by extent of becoming europeans due to their muslim culture this is evidence of a strategic deployment of both euroscepticism and eurocentrism to exclude others in farright transnational discourse again the self is personified in the image of greece and its soldiers who are flagging the cross and guarding europes borders to safeguard its space but also its identity and values from vicious antiheroes europe and european leaders are being requested to follow the lead of greek defenders the istandwithgreece network demanded border securitization in its most extreme form for the global north and not just greeces border with turkey for example metaphors and historical analogies such as erdogan being likened to hitler were used to not only other turkey but to also authorize killings of migrants therefore the networks pseudonegation of nazism that we located is rather evidence of its partial identification with it and of the ingroup it is constructing an intolerant self migrant othering was in this instance too begetting border securitization and militarization which ironically is not too far from europes concurrent border politics yet these twitterers assumed that europe was too tolerant promoting rather flexible migration policies thus they construe the event as a border management problem to which the only solution is the implementation of stricter border and migration policies simultaneously it is also grounding a demand to protect europeanness illustrating how exclusionary border politics and identity politics are mutually constituted the clear demand of a twitterer to europeans to protect our way of life resembles the initial naming of a controversial newly introduced portfolio of the eu commission protecting our european way of life which was altered to promoting our european way of life after backlash the reference of another twitterer to greek soldiers as holding the line is almost identical to von der leyens call for europe to hold the line mentioned earlier effectively the network and the eu agree that keeping unwanted others out is about maintaining our racialized europeanness we argue therefore that these seemingly marginal voices from within the farright that bonded around istandwithgreece were serving not a marginal political agenda but rather the concurrent eu migration agenda at a supranational and national level pushing it to reach new extremes such as killing muslim border crossers in cold blood we conclude that this network of intolerance istandwithgreece functioned rather as europes alterego mouthpiece saying the unsayable using social media and their affordances social media thus provided the symbolic means for the normalization of a ruthless reality at europes land and sea borders to conclude europe is shown in yet another mediated debate about migration as being threatened by another alleged influx of migrants this time migrants were represented as pawns of a more vicious other turkey the othering we located may be common because fierce opposition to migration and particularly to muslim migrants from the east as circulated in various media and particularly by the farright is longstanding in their simplicity and very obvious essentialization of identities as fixed in time these representations can be adjusted to almost every border event they are the archetype of a eurocentric exclusionary antimigrant discourse infused with nationalism influencers regardless of their national affiliations put similar emphasis on the need for border securitization regarding the othering of turkey we observed emphasis on both its historical turbulent past with greece relevant to greek nationalism and on its peculiar relationship with europe and the west relevant to eurocentric approaches across the global north and simplistic dichotomizations of the civilized christian self and the inferior muslim other the two were reinforcing each other for the common goal discussed border securitization future research could shed more light into how social media offers space for this transnational dialogue of antimigrant voices to evolve and reinforce each other during other border events the subsequent mediated discourse about the mid2021 afghan events and those at the polandbelarus border later the same year perhaps exemplifies this as it appears to promote seemingly nontranscended distinctions between us and the other with the undeserving other being weaponized by longstanding enemies and during which europes memberstates in proximity flag their national interests therefore the pawns representation returns to justify atrocities and ultimately to legitimize the continuation of an exclusionary repressive and oppressive european migration regime which is racialized future research can better warrant the affinity of these extremist discourses with the mainstream and the politics they underpin as identifying othering processes in social media is the first step towards uncovering and therefore resisting the restrictive political agenda that they feed into supplemental material supplemental material for this article is available online notes 1 2 3 4

this article explores how europes border crises in the post refugee crisis years were discussed in the microblog twitter through an indepth analysis of boundary making our focus is on the tweets of the top influencers of the hashtag istandwithgreece who strategically promoted ideologies ranging from white supremacism to greek nationalism glued together by an antimigrant stance during a border crisis at europes periphery this network of intolerance promoted a representation of migrants as pawns seen like a chess piece with no value in their own right literally pushed towards europe by turkey who elevated them into a sizable threat within this europe was represented as a paradoxical other the fallen self for not rising up to the opportunity to protect its sovereignty and identity through more securitization despite being diffused by extreme antimigrant twitterers we argue that these tweets offer a more overtly racist expression of otherwise mainstream european union discourses and politics on migration effectively istandwithgreeces influencers functioned as europes alterego mouthpiece saying the unsayable using social media and their affordances contributing to the normalization of an oppressive and restrictive european border management

3 in a comprehensive metaanalytic review of research on the relationship between intergroup threat and prejudice riek mania and gaertner suggest that in order to better understand the aetiology of prejudice it is important to identify variables that increase the likelihood of interpreting intergroup situations as threatening we propose that collective narcissism ingroup identification tied to an emotional investment in an unrealistic belief in exaggerated greatness of an ingroup is related to high susceptibility to signs of intergroup threat and enduring prejudice against outgroups stereotypically perceived as threatening previous studies indicate that collective narcissism predicts intergroup hostility in response to perceived threat to ingroups image collective narcissism predicts retaliatory intergroup hostility over and above such robust predictors of intergroup violence as social dominance orientation authoritarianism high ingroup identification or destructive forms of idealization of a national ingroup such as blind patriotism nationalism or ingroup glorification importantly collective narcissism has been shown to reliably predict enduring negative attitudes towards certain but not all outgroups for example polish collective narcissism predicts antisemitism but it is not related to negative attitudes towards the french or british people american national narcissism predicts negative attitudes towards arabs but not towards asians europeans or latinos arabs are perceived as more threatening than the other outgroups the above results suggest that collective narcissism may be related to prejudice because it increases sensitivity to intergroup threat in addition it is likely to predict negative attitudes only towards social groups stereotypically construed as threatening running head collective narcissism and in this paper we present results of two studies that indicate that the relationship between collective narcissism and prejudice is driven by chronic beliefs that the ingroup is exposed and vulnerable in intergroup relations and that the particular outgroup targeted by prejudice is a source of threat our studies focus on the relationship between polish collective narcissism and antisemitism one of the most prevalent forms of prejudice in poland and across europe particularity curious because in most countries it is a case of antisemitism without jews ie prejudice against an almost nonexistent minority however stereotypically perceived as threatening to the national selfimage collective narcissism and exaggerated regard for self and ingroup the concept of collective narcissism extends into the intergroup domain the concept of individual narcissism a grandiose view of self that requires continual external validation 1 and is related to unstable and defensive personal selfesteem individual narcissists are emotionally attached to the belief in their own greatness and they are preoccupied with protecting it collective narcissists believe in unique prominence of the social group with which they identify collective and individual narcissism although positively correlated are functionally separate variables their relationship across studies ranges from weak to moderate importantly collective narcissism predicts intergroup attitudes and behaviors that individual narcissism does not account for and individual narcissism predicts interpersonal anger and aggressiveness that is not related to collective narcissism the concept of collective narcissism corresponds directly to the research that differentiates between belligerent vs constructive forms of positive regard for ones nation this research has been successful in describing several forms of ingroup love that is systematically accompanied by outgroup hate such as nationalism blind patriotism ingroup glorification and essentialist national identification however the concept of collective narcissism is in several important ways distinct from the above conceptualizations of extensive ingroup favouritism and unlike them it offers an insight into the psychological mechanism underlying the relationship between the preferential positivity for an ingroup and outgroup hositlity 2 firstly previous studies indicate that people can be narcissistic about various social groups not only about their nation to our knowledge this is the only belligerent form of ingroup attachment that has been empirically demonstrated to extend beyond international context nevertheless national collective narcissism blind patriotism and national ingroup glorification do overlap in the uncritical approach towards the national ingroup and concern with protection of the ingroup positive image however unlike blind patriotism and ingroup glorification that avoid criticism collective narcissism is preoccupied with it 3 collective narcissism just like the narcissistic idealization of self is contingent on external validation therefore collective narcissists are constantly vigilant to threat to the ingroups image in addition only the narcissistic exaggerated image of the ingroup is shadowed by internal doubts regarding ingroups assumed greatness national collective narcissism and nationalism share the belief in the nations inherent superiority unlike nationalist however narcissistic intergroup aggressiveness is defensive running head collective narcissism and antisemitism 6 and retaliatory it does not serve the purpose of achieving a dominant ingroup position born out of competitiveness crucial for nationalism studies confirm that collective narcissism predicts intergroup hostility over and above other destructive national attachments and it partially mediates the effects of blind patriotism ingroup glorification and nationalism on intergroup negativity moreover when the common variance between collective narcissism and constructive patriotism is controlled only collective narcissism emerges as a suppressor of the negative relationship between genuine patriotism and prejudice we argue that it is the very nature of the beliefs about the ingroup which make up collective narcissism that inspires the sensitivity to intergroup threat and links it to outgroup hostility people with contingent selfworth exaggerate failures and underestimate successes in the domains of contingency therefore collective narcissists rarely see the acknowledgement of the ingroup by others as satisfactory they quickly develop tolerance to known sources of external validation and are constantly on the lookout for new signs of anything that may undermine the ingroup they retaliate against what they perceive as a threat to the ingroups positive image collective narcissism and polish siege beliefs we propose that collective narcissism with its extraordinary sensitivity to anything that can undermine the ingroups image is likely to inspire the siege beliefs system about the ingroup the siege mentality prompts generally distrustful and negative attitudes towards other groups as it is a belief held by group members stating that the rest of the world has running head collective narcissism and antisemitism 7 highly negative behavioural intentions toward them siege beliefs explain and justify hardships suffered in the name of the ingroup in intractable conflicts and legitimize the hostility and violence perpetrated by the ingroup importantly people differ with respect to how much conflict they perceive and how much they find the siege beliefs convincing the siege beliefs offer an explanation and justification for the constant monitoring of the signs of the mistreatment associated with collective narcissism they are also likely to satisfy narcissistic need for the sense of ingroups uniqueness special status and moral superiority because they maintain that the misunderstood and righteous ingroup stands alone against the hostile and dissolute world most importantly the siege beliefs may appeal to collective narcissists because they confirm what the narcissists seem continuously to suspect that other groups do not properly acknowledge their greatness we propose that because of its association with the siege beliefs about the nation polish national narcissism will be related to antisemitism polish studies indicate that jews are perceived as an outgroup more than any other minority this outgroup is salient to poles and inspires ambivalent emotions guilt anger and fear importantly the jewish people are seen as a threat to the positive national image to polands national interest or to national security thus collective narcissists are likely to be prejudiced against jews because this is a particularly salient outgroup in polish national context in addition this outgroup is seen as running head collective narcissism and antisemitism 8 particularly threatening as such it is well equipped to be seen as a model example of the hostile intentions of the external world towards the ingroup collective narcissism and the conspiracy stereotype of jews the relationship between collective narcissism and antisemitism is likely to be independently driven by stereotypical beliefs about the jewish outgroup intergroup threat can be embedded in a negative stereotype of an outgroup conveying the prediction of its hostile intentions towards the ingroup although antisemitic beliefs and attitudes in europe are understudied several studies indicate that the jewish minority is quite universally perceived as threat to national identity especially the regions where the jewish minority was large before wwii no matter how well assimilated jews tend to be perceived as a group that stands outside the national order of the world remaining essentially alien to the surrounding societies in addition the ingroups ambivalent position during the holocaust is experienced as threat to the national selfimage poland is a good example of the ambivalent position towards the holocaust there are reported cases of pogroms of polish jews perpetrated by poles during the wwii and shortly afterwards at the same time many polish soldiers fought in the warsaw ghetto uprising and poles represent the biggest number of people who rescued jews during the holocaust and were awarded the righteous among the nations medal by israel in addition to being perceived as alien to the national ingroup in poland and other european countries jews are stereotypically perceived as a dangerous outgroup they are seen as motivated by a common intention to dominate the world the alleged dominant and controlling intentions are executed by means of indirect and deceptive methods hidden and nonobvious ways whose negative consequences can only be observed this makes the jewish outgroup particularly dangerous and threatening according to the conspiracy stereotype past present and even future harm and hardship experienced by the ingroup can be explained by the veiled actions of the jewish outgroup the conspiracy stereotype of jews predicts antisemitism in poland and support for this stereotype increases in times of elections and intense political campaign we expect that collective narcissists sensitive to signs of potential threat to the ingroup will be likely to find the conspiracy stereotype of jews convincing and threatening a tendency to uphold the conspiracy stereotype of jews will mediate the relationship between collective narcissism and antisemitic prejudice the mediation through the beliefs about the outgroup will be parallel to and independent of the mediation through the polish siege beliefs that emphasize the vulnerable position of the ingroup in other words we expect that collective narcissism will be associated with antisemitism either because it is related to perceived vulnerability of an ingroup or because it is related to the perception of the outgroup as threatening this assumption is different than the expectation that collective narcissism is associated with perceived vulnerability of an ingroup which leads to a tendency to construe the jewish outgroup as threatening thus we assume that the multiple mediations via the siege beliefs and via the conspiracy stereotype of jews are parallel ie simultaneous and independent rather than chain ie consecutive and depended even though the siege beliefs about the ingroup and the conspiracy beliefs about the outgroup may share common components we assume that each of these variables should have a unique ability to mediate between polish national narcissism and antisemitism above and beyond the other variable siege beliefs and the conspiracy beliefs about jews are stereotypical beliefs that may exist in sociocultural repertoire separately and they are two discrete reasons why collective narcissism is likely to be linked to running head collective narcissism and antisemitism 10 prejudice one reason pertains to the beliefs about the characteristics of the ingroup whereas the other pertains to attributes of the outgroup overview of the studies in study 1 we test the prediction that polish collective narcissism is associated with the polish siege beliefs the set of convictions indicating that the national ingroup is constantly threatened by the hostile intentions of other groups we expect that polish siege beliefs will mediate the relationship between collective narcissism and antisemitism the jewish outgroup with whom they share a long and complicated history of competitive relations is particularly salient to polish participants in study 2 we seek to replicate the results of study 1 we also test the hypothesis that the relationship between collective narcissism and antisemitism is independently mediated by the conspiracy stereotype of jews the conspiracy stereotype conveys the image of jews as a powerful and skilful outgroup whose competitive intentions threaten the interests image if not the mere existence of the ingroup the stereotype of the jewish outgroup poses the intergroup threat we test the parallel against the chain multiple mediation hypothesis in addition in study 2 we seek to demonstrate that collective narcissism rather than the mere strength of national group identification predicts the perception of intergroup threat and outgroup negativity study 1 method participants and procedure participants of study 1 were 148 undergraduate students of a large polish university the study was conducted online participants obtained a research participation credit and the possibility to take part in a prize draw in return for participation the age of the participants ranged from 18 to 45 there were 135 women and 13 men among the participants measures collective narcissism the 9item collective narcissism scale was used in order to measure this construct the items for this scale were generated based on the definition of the construct and existing inventories of individual narcissism mostly the narcissistic personality inventory only the items that corresponded to the core aspects of the concept of individual narcissism but at the same time could be meaningfully translated onto the group level were used for selected items beliefs about the self were replaced with beliefs about ones ingroup the 9 items that make up the collective narcissism scale were selected on the basis of their face validity as evaluated by experts the results of confirmatory and exploratory factor analyses and the strength of their contribution to the overall reliability of the scale assessed in three studies the scale contains items reflecting the belief in the ingroups greatness and lack of its proper recognition if my group had a major say in the world the world would be a much better place i wish other groups would more quickly recognize the authority of my group my group deserves special treatment not many people seem to fully understand the importance of my group i will never be satisfied until my group gets all it deserves i do not get upset when people do not notice the achievements of my group i insist upon my group getting the respect that is due to it it really makes me angry when others criticize my group or the true worth of my group is often misunderstood participants were instructed to think about their national group while responding to the items of the scale participants were running head collective narcissism and antisemitism asked to indicate how much they agree with statements using a 6point scale siege beliefs the 12item general siege mentality scale proposed by bartal antebi was used to measure this construct the scale was translated from english to polish by a bilingual translator it was then back translated by a bilingual expert in social psychology in order to ensure the equivalence of meaning of items on both scales the scale contains items reflecting the belief that the ingroup is constantly threatened and has to protect itself in this time of need participants were asked to indicate how much they agree with each statement using a 7point scale from 1 definitely disagree to 7 definitely agree antisemitism in study 1 we defined antisemitic prejudice in terms of social distance ie unwillingness to engage in contacts with the jewish outgroup we used a 4item scale measuring preferred social distance from jews would you like a jew to be your neighbor would you like a jew to be your friend would you mind your child playing with a jewish child would you mind your child marrying a person of jewish origin participants were asked to respond to these items using a scale from 1 definitely no to 7 definitely yes results in the first step of data analysis we compute zeroorder correlations among variables collective narcissism was significantly positively related to the polish siege beliefs 48 p 001 and antisemitism 20 p 02 siege beliefs were significantly correlated with antisemitism 37 p 001 running head collective narcissism and antisemitism 13 in order to test the main hypothesis that siege beliefs mediate the relationship between collective narcissism and antisemitism we used the bootstrapping method recommended by preacher and hayes to obtain bias corrected 95 bootstrap confidence intervals for the indirect effect of the mediator bootstrapping does not require assumptions about the shape of the sampling distribution of the indirect effect and is considered as a suitable method for assessing indirect effects in smaller samples the mediation model is presented in figure 1 the total effect of collective narcissism on the tendency to keep ones distance from jews was positive and significant b 29 se 12 t 237 p 02 the relationship between collective narcissism and antisemitism was reduced and became nonsignificant after the mediator was added to the model the direct effect amounted to b 04 se 13 t 31 p 76 collective narcissism was positively associated with siege mentality b 54 se 08 t 652 p 001 siege mentality was positively associated with antisemitism b 47 se 12 t 391 p 001 the difference between the total and direct effects of collective narcissism on antisemitism is the total indirect effect via the siege beliefs we computed its confidence interval with 10000 bootstrap samples the indirect effect had a 95 bootstrap bias corrected confidence interval of 12 to 40 which indicates that the indirect effect of the mediator was significant the whole mediation model was also significant r 2 14 f 566 p 001 although considered the most appropriate method of assessment of indirect effects bootstrapping is also a relatively new approach thus we performed the mediation analysis also using a more familiar sobel test to provide an alternative test of the significance of the indirect effect of collective narcissism on antisemitism via siege beliefs the sobel test indicated that collective narcissism had a significant indirect effect on antisemitism via the siege beliefs discussion of study 1 the results of study 1 confirm the positive relationship between collective narcissism and antisemitism most importantly as hypothesized the present results reveal that this relationship is mediated by the siege beliefs portraying the national ingroup as constantly threatened by hostile intentions of other groups thus collective narcissism is associated with the perception of the ingroup as exposed and vulnerable in the context of intergroup relationships such a perception is likely to increase susceptibility to intergroup threat this perception drives the relationship between collective narcissism and prejudice against jews the outgroup stereotypically perceived as threatening in study 2 we test the assumption that the stereotypical belief that the jewish outgroup is particularly threatening and hostile mediates the relationship between collective narcissism and antisemitism over and above the mediation through the siege beliefs we expect that a belief that the ingroup is particularly threatened and a belief that the outgroup is especially threatening will mediate the relationship between collective narcissism and prejudice independently in study 2 we use more direct indicators of antisemitism in order to conceptually replicate the results of study 1 namely negative emotions and hostile behavioural intentions towards jews in study 2 we also compare the role of collective narcissism and the strength of ingroup identification as predictors of perceived intergroup threat and antisemitism study 2 method participants and procedure study 2 was conducted among 89 undergraduate students of a large polish university participants were asked to take part in an online survey in return for research participation credit the age of the participants ranged from 17 to 24 there were 63 women and 26 men among the participants measures collective narcissism the collective narcissism scale was used in order to measure this variable as in study 1 group identification the overlap ingroup identification measure proposed by tropp wright was used participants were asked to indicate the degree of their identification with the national ingroup as represented by two overlapping circles one representing the self and the other representing national ingroup the circles formed an 8point scale from a set of two separate circles through degrees of overlap to full overlap siege beliefs the same polish translation of the general siege mentality scale as in study 1 was used conspiracy jewish stereotype this variable was measured with a 6item jewish conspiracy stereotype scale proposed by kofta and sędek the scale measures the belief that secret and deceptive actions of the jewish outgroup are aimed at taking control over the world the jewish outgroup is seen as an entity driven by one common motivation to dominate others the conspiracy stereotype is considered a central characteristic of antisemitism in poland the items of the scale reflected the belief that jews strive for power and that their actions are secretive and well coordinated participants were asked to indicate how much they agree with each statement using a 9point scale from 1 definitely disagree to 9 definitely agree negative evaluation of jews this variable was measured following the procedure proposed by wright aron mclaughlinvolpe ropp participants were asked to indicate their feelings towards jews using six semantic differentials cold warm unfriendly friendly trustfuldistrustful positive negative respect contempt admiration disgust scores could range from 1 to 8 higher scores indicated greater outgroup negativity hostility towards jews aggressive behavioral intentions against jews were measured by four items adopted from struch and schwartz hypothetical aggressive acts towards jews were listed eg refusing to hire jews because of their origins convincing friends not to rent flats to jews listening to noisy music in order to irritate a jewish neighbor participants were asked to indicate how much they agree with each action and would perform it themselves using a scale from 1 definitely reject it to 7 agree with the action and would perform it myself in certain conditions the negative evaluation of jews and support for aggressive actions against them were positively correlated we created a composite score of antisemitism that encompassed the two direct indicators of antisemitism because the two components of the composite score were measured on different scales responses were first transformed into z scores before the composite indicator of antisemitism was computed results running head collective narcissism and antisemitism 17 correlational analyses presented in table 1 indicate that collective narcissism is positively related to siege mentality the conspiracy stereotype of jews and antisemitism national ingroup identification is related to siege beliefs but not to the conspiracy stereotype or to prejudice against jews in order to control for the common variance between collective narcissism and ingroup identification we regressed collective narcissism and group identification on siege mentality collective narcissism was positively and significantly associated with siege mentality b 73 se 11 t 683 p 001 whereas the relationship between ingroup identification and perceived threat from hostile intentions of others was reduced and became nonsignificant b 04 se 05 t 078 p 44 r 2 40 f 1404 p 001 once the common variance of the strength of ingroup identification and collective narcissism is controlled collective narcissism emerges as the unique predictor of the siege beliefs insert table 1 about herein order to test the hypothesis that siege beliefs and the jewish conspiracy stereotype independently mediate the relationship between collective narcissism and antisemitism we used the bootstrapping method suggested by preacher and hayes this approach allows us to assess the extent to which each of these variables mediates the effect of collective narcissism on antisemitism conditional on the presence of the other variable in the model since siege beliefs and conspiracy stereotype were positively correlated analyzing them simultaneously in a multiple mediator model teased apart their individual mediating abilities that could be attributed to their content overlap to assess the independent indirect effects of collective narcissism on antisemitism via the siege beliefs and the conspiracy stereotype of jews we used bootstrapping to obtain the bias corrected 95 confidence intervals for the total indirect effect and the specific indirect effects of each mediator analyzed together the analyses controlled for age and gender 3 the coefficients of the model are presented in figure 2 and the bootstrapping confidence intervals are presented in table 2 insert figure 2 and table 2 about here the total effect of collective narcissism on antisemitism amounts to b 23 se 11 t 199 p 05 while its direct effect is b 21 se 14 t 153 p 13 the difference between the total and direct effects is the total indirect effect via the two mediators it had a 95 bootstrap confidence interval of 25 to 69 ie the total indirect effect of both mediators is significant the path from collective narcissism to siege mentality had a coefficient of b 69 se 10 t 728 p 001 and the path from collective narcissism to conspiracy stereotype had a coefficient of b 118 se 23 t 511 p 001 the direct effects of mediators on antisemitism were also significant b 27 se 12 t 234 p 02 for siege mentality and b 21 se 05 t 433 p 001 for conspiracy stereotype the predictors included in the full model accounted for a significant portion of variance in antisemitism r 2 30 f 704 p 001 an examination of the specific indirect effects indicated that both siege beliefs and the conspiracy stereotype of jews were statistically significant and independent mediators of the effect of collective narcissism on antisemitism the specific indirect effect via the siege beliefs had a confidence interval of 05 to 40 and the specific indirect effect via the conspiracy stereotype had a confidence interval of 13 to 41 in order to establish whether the effects of mediators differ significantly in magnitude we conducted a pairwise contrast of the two indirect effects since the siege mentality minus conspiracy stereotype contrast had a confidence interval of 18 to 26 we cannot infer that the two effects differed in magnitude finally we used the sobel test to confirm the significance of the indirect effects of collective narcissism on antisemitism via siege beliefs and via the conspiracy stereotype collective narcissism had significant indirect effects on negativity towards jews both via siege mentality and via the conspiracy stereotype of jews since siege mentality and the conspiracy stereotype of jews were positively correlated it is also plausible that they influenced each other in driving antisemitic sentiments for example one could argue that collective narcissism is related to siege mentality which in turn leads to conspiracy stereotyping and thus to hostility towards jews to verify this possibility we tested the multiplestep multiple mediator model proposed by hayes preacher myersa we used the modthree macro that allows for a simultaneous test of specific indirect effects of each mediator alone and a specific indirect effect through both mediators in the first analysis we tested the collective narcissism the siege beliefs conspiracy stereotyping antisemitism multistep mediation while the independent specific indirect effects of siege mentality and the conspiracy stereotype remained significant the indirect effect of both mediators became insignificant similar results were obtained when we tested a model with collective narcissism conspiracy stereotyping siege beliefs antisemitism multistep mediation both indirect effects of single mediators were significant and the indirect effect of the two mediators was not significant these analyses provide further support for our hypothesis that the siege mentality and conspiracy stereotype are two independent links between narcissistic attachment to the polish national group and antisemitism discussion of study 2 the results of study 2 replicate the findings of study 1 in addition they confirm the hypothesis that siege beliefs and the belief that jews secretly conspire to achieve economic and political power and dominate the world independently mediate the relationship between running head collective narcissism and antisemitism 20 polish collective narcissism and antisemitism collective narcissism is associated with a tendency to perceive the ingroup as threatened and the outgroup as particularly threatening both tendencies independently predict outgroup negativity the strength of ingroup identification is not related to prejudice against jews it is related to the polish siege beliefs but this relationship is driven by the overlap between the strength of ingroup identification and collective narcissism once the narcissistic aspect of positive ingroup identification is teased out the relationship between the strength of ingroup identification and siege beliefs disappears these results support our claim that it is not the strength of ingroup identification in general but rather the individual level of specific narcissistic identification that is related to the perception of intergroup threat consequently it is not the strength of ingroup identification but collective narcissism that is related to outgroup negativity general discussion according to social identity theory a tendency to derogate outgroups intensifies under perceived threat to the social identity and increased salience of group membership an intergroup threat may be realistic and concern group interests or symbolic and concern difference in worldviews values and beliefs it can come from outgroup aggression embarrassing rejection unjustified discrimination or uncertainty and awkwardness in the presence of outgroup members importantly intergroup threat can be also embedded in a negative stereotype of an outgroup that attributes threatening features and intentions to the group and its members running head collective narcissism and antisemitism 21 it has been suggested that the strength of ingroup identification is one of the important antecedents of perceived intergroup threat the more people identify with their group the more they are chronically aware of their group membership and the more sensitive they are to anything that can harm the ingroup in addition high identifiers are more likely to see the threats to the ingroup as personally threatening however the metaanalytic review indicates that the relationship between the strength of positive ingroup identification and perceived intergroup threat although statistically significant is inconsistent and on average rather weak moreover the relationship between positive group identification and prejudice is not consistent and across numerous studies averages close to zero we propose that it may be not the strength of ingroup identification that reliably predicts the perception of intergroup threat and prejudice but rather its specific narcissistic form the results of two studies presented here confirm that people who narcissistically identify with their national ingroup perceive more intergroup threat stereotype a stigmatized outgroup as particularly threatening and report more prejudice results of study 1 show that polish collective narcissism is related to the polish siege beliefs pertaining that the national group is threatened by aggressive intentions of other groups and stands along against the hostile world this relationship mediates the link between collective narcissism and antisemitism results of study 2 replicate these findings in addition they indicate that the relationship between collective narcissism and antisemitism is independently mediated by increased narcissistic sensitivity to the intergroup threat embedded in the negative stereotype of jews as a particularly threatening outgroup that conspires to dominate and rule the world the perceptions of the ingroup as vulnerable to intergroup threat and the outgroup as running head collective narcissism and antisemitism 22 threatening independently drive the relationship between collective narcissism and antisemitic prejudice the present results complement earlier findings indicating that collective narcissism predicts retaliatory hostility in response to the threat from outgroup aggressiveness outgroup distancing and rejection of the ingroup or outgroup criticism of the ingroup the present results go beyond the earlier findings revealing an intriguing novel aspect of the relationship between collective narcissism and outgroup negativity they indicate that collective narcissism predicts not only retaliatory hostility in response to momentary intergroup threat but is also associated with enduring prejudice towards an outgroup stereotyped as threatening the present results confirm suggestions that antisemitism is related to threat and narcissistic national pride they indicate that antisemitism is grounded in beliefs in national superiority that are insecure and narcissistic and fuel the sense of the ingroups vulnerability in an intergroup context and fear of the hostile intentions of the jewish outgroup we suggest that a similar mechanism is likely to drive the relationship between collective narcissism and prejudice against other outgroups with whom the ingroup shares competitive or conflictual relations in such relations the opportunities to injure the collective pride are plenty collective narcissists neither forget nor forgive wrongs done to the ingroup by outgroups thus they are likely to see the outgroups that in the past transgressed against the ingroup as potential threats even if the transgression was mostly in the eye of the beholder thus the more frequent and less unequivocally positive the intergroup relations with a given group the greater the chance is that this group will be targeted by prejudice the examination of the generalizability of the present mediation model beyond antisemitic prejudice would be an important direction for further research it is however noteworthy that the previous and present results indicate that collective narcissism is not universally associated with prejudice instead collective narcissism seems to describe a combination of groupbased feelings that can fuel hostility in certain intergroup situations and in response to certain outgroups we propose that the relationship between collective narcissism and the sensitivity to intergroup threat can be explained by the nature of narcissistic ingroup evaluation collective narcissism is related to high regard for the ingroup combined with a belief that the ingroup is not sufficiently recognized by others and the lack of the positive evaluation of the ingroup on the implicit level thus collective narcissists are easily convinced that the image of their ingroup is being undermined intergroup hostility in response to the perceived threat serve as means of protecting the ingroups image and maintaining the ingroups positive esteem in addition our results reveal that collective narcissism is a better predictor of the perception of intergroup threat embedded in stereotype and prejudice than the mere strength of identification with the ingroup the positive relationship between the strength of ingroup identification and perceived intergroup threat was reduced and became nonsignificant after collective narcissism was taken into account limitations the present studies provide strong support for the hypotheses derived from the concept of collective narcissism however they have several shortcomings that should be considered firstly in both samples there is a disproportionate number of women among the participants however in all analyses we included gender as a control variable and found no significant effect of gender in addition we do not have any theoretical reasons to assume that men and women differ with respect to their individual levels of collective narcissism secondly the present findings are based on university student samples which may not be representative of the population as a whole future studies should extend the investigation of collective narcissism and its correlates and effects to different populations however it is worth noting that we found remarkably consistent patterns of relationships across both presented studies in addition although the present studies provide support for the mediational hypotheses derived from the concept of collective narcissism they are based on correlational data and do not allow for unequivocal conclusions about causality and order of the variables in the present paper we provide sound theoretical reasons to justify our assumption that collective narcissism is related to siege beliefs and the conspiracy stereotype of jews and through these beliefs to antisemitism in addition most research in the social sciences confirm the direction of causality assumed in the proposed model suggesting that broader ideological orientations and basic ingroup identification constrain specific attitudes and beliefs such as the siege belief or the conspiracy stereotype of jews and outgroup hostility however further experimental studies are needed in order to examine the role of collective narcissism in eliciting increased sensitivity to intergroup threat and prejudice such studies will deepen our understanding of individual difference variables and situational conditions increasing the likelihood of outgroup negativity and intergroup aggression footnotes 1 collective and individual narcissism are positively associated although this relationship is rather weak importantly collective narcissism is related to intergroup hostility whereas individual narcissism is associated with interpersonal aggressiveness especially in the context of ego threat 2 collective narcissism is also distinct from social dominance orientation or authoritarianism and independently predicts outgroup negativity we discuss these differences in more detail in a separate paper summing up collective narcissism and social dominance orientation overlap in the preoccupation with the ingroups greatness however for collective narcissists any excuse not only power social status or economic dominance is sufficient to support the belief in the uniqueness and greatness of the ingroup collective narcissism is not related to opposition to equality an important aspect of the social dominance orientation collective narcissism and authoritarianism are related because of the concern with the coherence and homogeneity of the ingroup for authoritarians cohesiveness secures a predictable social environment and reduced cognitive uncertainty for collective narcissists it confirms the assumed unanimously accepted greatness of the ingroup authoritarians aggress against others to protect the group as a predictable social environment collective narcissists to protect the ingroups positive image 3 for example our data indicate that only collective narcissism but not blind patriotism or high national ingroup identification is predicted by the interaction of high private and low public collective selfesteem measured with reference to ones national group 4 analysis controlling for group identification was also conducted the pattern of results remained the same note bcbias corrected 10000 bootstrap samples figure captions

two studies examined the relationship between collective narcissism an emotional investment in an unrealistic belief about unparalleled greatness of an ingroup golec de zavala et al 2009 and antisemitism in poland the results indicate that this relationship is simultaneously mediated by a a belief that the ingroup is constantly threatened by hostile intentions of other groups polish siege beliefs bartal antebi 1992 and b a belief that the jewish outgroup is particularly threatening because its members secretly aim to dominate the world the conspiracy stereotype of jews bergmann 2008kofta sędek 2005 the results confirm earlier findings that collective narcissism is linked to increased sensitivity to intergroup threat which drives its association with intergroup hostility the sensitivity to intergroup threat is composed of beliefs about vulnerability of the ingroup and hostility of the outgroup

introduction s ocioeconomic inequalities exist in paediatric metabolic syndrome 1 2 3 and parental health literacy may partially explain these inequalities mets is a cluster of cardiometabolic risk factors 4 which can result in increased cardiometabolic risk later in life 56 due to the longterm impact of mets prevention early in life would likely provide favourable consequences over the life course in order to prevent paediatric mets we need a better understanding of the mechanisms linking socioeconomic status to mets such as the role of parental health literacy parental health literacy may be an important modifiable mechanism linking ses to paediatric mets but this pathway remains understudied in children health literacy can be defined as the degree to which individuals have the capacity to obtain process and understand basic health information and services needed to make appropriate health decisions 7 in adults there is evidence that health literacy mediates the relationship between own ses and health and that the strength of these relationships vary depending on which proxy of ses is used 8 education has the strongest relationship with health literacy additionally there is a wellknown relationship between parental health literacy and various aspects of childrens health 9 parents with low health literacy are more likely to experience difficulties managing their childs chronic diseases and are more likely to incorrectly use medications 9 additionally parents with low health literacy are more likely to have less optimal health behaviours eg smoking alcohol nutrition and physical activity 9 these factors contribute to the association between low parental health literacy and childrens obesity which is a major contributor to mets 10 in children 9 given these relationships it seems that parental health literacy may mediate the relationship between ses and paediatric mets evidence on the mediating role of parental health literacy is relevant because it is a modifiable target for preventive interventions to reduce socioeconomic health inequalities in paediatric mets therefore we aimed to assess the extent to which parental health literacy mediates the relationships between different measures of ses and mets methods setting and population data were used from the lifelines cohort study a multidisciplinary prospective populationbased cohort study examining in a unique threegeneration design the health and healthrelated behaviours of 167 729 persons living in the north of the netherlands 1112 it employs a broad range of investigative procedures in assessing the biomedical sociodemographic behavioural physical and psychological factors which contribute to the health and disease of the general population with a special focus on multimorbidity and complex genetics a detailed description of the recruitment strategy and data collection can be found elsewhere 11 briefly dutchspeaking individuals aged 2549 years were asked to participate by their physicians those who accepted were subsequently asked to invite their family members individuals could also selfregister through the lifelines website the first measurement wave took place between 2007 and 2014 and 2010 and 2014 in adults and children respectively during the first and fourth measurement wave participants were asked to fill out questionnaires and if aged 8 years or older they also underwent physical exams for the purpose of this paper lifelines provided the data of 15 016 children aged 017 years at baseline whose data could be linked to at least one parent for this study we included all 6683 children aged 817 years during t4 and they had a mean followup duration of 362 months children under the age of 8 years at t4 were excluded because the components of mets were not assessed in those children and children who turned 18 years old during the followup were excluded as this study focuses on paediatric mets in addition to the 6683 children included in our analysis 3086 eligible children were lost to followup an additional 1748 children were lost to followup but would have likely been excluded due to being too old or too young during t4 because they were aged 04 or 1617 years during t1 written informed consent was obtained for each participant prior to participating in the cohort the lifelines cohort study is conducted according to the conventions set forth in the declaration of helsinki and it has received approval from the medical ethics committee of the university medical center groningen procedures participants completed questionnaires physical exams and venous blood draws during both the first and fourth assessment during the third assessment participants only completed questionnaires questionnaire data were selfreported and covered various topics including demographics physical exams and venous blood draws were conducted by trained research nurses using a standardized protocol 11 measures mets was measured by a continuous mets score which was defined using measures of waist circumference mean arterial pressure fasting glucose triglycerides and highdensity lipoproteins from t4 following an approach similar to eisenmann et al 4 each component of mets was regressed on age and sex and their residuals were standardized then a cmets score was built by summing the standardized residuals of all components the standardized highdensity lipoprotein residuals were reversed due to their inverse relationship with health the cmets score indicates how an individuals cardiometabolic health compares to the rest of our sample 4 parental health literacy was measured at t3 using selfreported answers to the three validated questions from chew et al 13 how often do you have trouble understanding your medical situation because you have difficulty with the written information how sure are you of yourself when you fill out medical forms how often does someone help you with reading information materials from the hospital or another healthcare provider the parents of our participants indicate how often or to what extent these items apply to them on a scale ranging from nevernot at all to alwaysvery we reversed the scores of the first and third questions and then added up the scores of all questions resulting in a health literacy scale ranging from 3 to 15 this score was then categorized into low and adequate health literacy as was done in previous studies using data from lifelines 1415 and leads to percentages of low and adequate health literacy comparable to those from largescale health literacy surveys in the netherlands 16 because dutch mothers usually spend more time parenting 17 we constructed the parental health literacy variable using the mothers health literacy if this was missing the fathers score was used additionally we created an average measure of parental health literacy if data from both parents were available we took the mean of their health literacy scores and then dichotomized this into low and adequate health literacy if data were only available for one parent that parents health literacy was used ses was measured using three separate indicators parental education occupation and income these data were obtained from both parents during t1 education was assessed by asking parents about the highest educational level they attained with eight potential responses ranging from no education to university in an approach similar to de graaf et al 18 these categories were recoded into years of education using the number of years it would take to complete each category by the fastest route possible eg no education primary school secondary school and university were coded as 5 6 12 and 16 years respectively occupation was coded using the international standard classification of occupations 2008 19 this was recoded into treimans standard international occupational prestige scale which is a continuous measure of occupational prestige 2021 for both education and occupation the highest level from either parent was used if only one parent was registered in lifelines then only data from that parent were used to construct the measure of equivalized household income net household income was divided by the square root of the number of people living on this income 22 similar to how health literacy was constructed the mothers response was used but the fathers response was used if this was missing parental age was defined as the mean parental age from t1 if we only had records for one parent then that parents age was used this approach was used because both parental ses and health literacy come from a mixture of maternal and paternal data statistical analysis first we described the characteristics of our sample we compared the characteristics of the eligible children who participated in t4 and the eligible children that were lost to followup for this comparison we only included children from the lost to followup group who most likely would have been eligible to participate in our study before conducting any further analyses we first imputed missing values for our variables as all missing variables were continuous we used the predictive mean matching method from mice 23 we used as predictors of the missing values lowdensity lipoprotein total cholesterol glycated haemoglobin weight height hip circumference body mass index systolic blood pressure diastolic blood pressure age sex and parental age to assess the extent to which parental health literacy mediates the relationships between different measures of ses and mets we conducted a causal mediation analysis which uses the potential outcomes framework 24 this approach defines the causal effect of an exposure as the contrast of outcomes that would be observed under different exposure and mediator values 24 to achieve this contrast of potential outcomes we expanded our dataset using an imputation procedure from the medflex package for r which results in the same individuals being evaluated at different levels of our exposure 25 after expanding the dataset we fit natural effects models using the medflex package 25 both the imputation procedure used to expand the dataset and the natural effect models were adjusted for baseline parental age we also conducted sensitivity analyses in which we used average parental health literacy instead of the mostly figure 1 model demonstrating the direct and indirect pathways connecting parental ses to paediatric mets maternal measure of parental health literacy all data preparation and analyses were conducted using r version 402 26 results sample characteristics onefifth of the children included in the sample came from households with low parental health literacy when parental health literacy was defined as the average of both parents health literacy scores the proportion of children from households with low health literacy rose slightly to 212 the prevalence of low parental health literacy was similar in the children lost to followup as in those retained however the children lost to followup were older than the children included in the analysis 104 and 98 years respectively the children lost to followup also had worse biomarker levels and came from households with slightly lower parental ses than the children included in our analysis ses and cmets relationships and mediation by parental health literacy higher levels of parental ses were related to lower cmets scores and this was partially mediated by parental health literacy if parental education were 4 years longer eg university instead of secondary school cmets scores were on average 0499 95 confidence interval 03640635 units lower which is a small effect similarly if parental income and occupational level would be 1 sd higher cmets scores were on average 0136 and 0196 units lower respectively the effects of parental income and occupation on cmets were small parental health literacy mediated the relationship between the individual measures of ses and mets by 67 118 and 83 respectively the total effects remained the same in the sensitivity analyses however the percentages mediated by parental health literacy which was based on the average of both parents health literacy increased to 105 175 and 125 discussion we assessed to what extent parental health literacy mediates the relationships between different measures of parental ses and paediatric mets we found that higher parental ses resulted in slightly lower cmets scores and this was partially mediated by parental health literacy the proportion mediated by parental health literacy varied across indicator of ses it was the largest for income additionally the percentage mediated was higher when parental health literacy was defined using the average of both parents health literacy but the pattern of our findings remained the same the extent to which health literacy mediated the relationship between ses and mets was limited the proportion mediated was largest for income to the best of our knowledge this is the first study to assess this mediating pathway importantly we have done so in a robust manner by using a causal mediation analysis our findings are supported by a recent review which found that health literacy mediates socioeconomic inequalities in adults 8 given that education has the largest impact on health literacy 8 it is not surprising that the indirect effect was largest for education however we also expected the proportion mediated by health literacy to be largest for education instead of for income despite the strong relationship between education and parental health literacy other factors appear to mediate this relationship health literacy may be an important attribute especially amongst individuals with low income as it could result in making better lifestyle choices given ones resources finally it should be noted that the pattern of our findings was consistent in the sensitivity analysis which used average parental health literacy instead of primarily using maternal health literacy the proportion mediated increased across all indicators of ses when using average parental health literacy and this may be explained by the fact that if only one parent has low health literacy the other may be able to a pvalues from testing the difference between the two groups using fishers exact test for categorical variables or kruskalwallis test for numerical variables b equivalized household income calculated as the net household income in euros divided by the square root of the number of individuals who live off of the income c occupation measured using the standard international occupational prestige scale which is a continuous measure of occupation it focuses on the prestige an occupation gives its holder not on the incomes associated with occupations ses and pediatric mets mediation by health literacy 181 compensate in short parental health literacy explains a small portion of socioeconomic differences in paediatric mets we found that the effect of ses on mets was rather limited confirming findings of other studies that also used cmets scores 227 in the first study it is difficult to gauge the size of the effect as the authors do not provide a standard deviation for their cmets score 2 however they found that cmets scores at baseline were on average 028 units higher for children whose parents had low educational levels than for children whose parents had high educational levels the other study on a subsample of the children included in the present study only found a small effect of parental education on cmets 27 the larger sample used in the present study may have provided additional power to detect the relationship between both parental income and occupation and mets compared with that study strengths and limitations this studys strengths lie in the quality of its data and the robustness of our findings due to the communitybased nature standardized protocols and longitudinal design of lifelines we were able to obtain highquality data for a large sample of children that are generally representative of this region of the netherlands 1112 using multiple indicators of ses to account for their unique relationships with health and the use of a causal mediation analysis added to the robustness of our findings furthermore our sensitivity analysis which had the same pattern of results as our primary analysis demonstrated the robustness of our results this study also has some limitations first the children lost to followup had slightly worse biomarkers and came from households with slightly lower ses at baseline than the children included in our study this loss to followup may have introduced some bias but it is unlikely to have had a major impact given the differences between the two groups were rather small additionally we may have underestimated the full effect of health literacy as our measure of health literacy focused primarily on functional health literacy which is a specific component of health literacy more comprehensive measures of health literacy that include other components of health literacy eg critical health literacy and communicative health literacy may have led to a stronger mediating effect nonetheless we used a validated questionnaire for health literacy 13 that has been used in other studies 1415 implications this study indicates that interventions which aim to improve parental health literacy may partially reduce inequalities in paediatric mets health literacy can be targeted at various levels for example a recent study found that using a health literacy intervention to target both the childrens parents and their health care providers resulted in less weight gain during the first 18 months of life 28 additionally the children themselves can be taught about health literacy during their schooling and this has the potential for many benefits throughout the life course 29 however further research is needed into the potential impact of improving health literacy in children additionally our results demonstrate that the effect of health literacy differs when defined using mostly maternal data vs the average of both parents future studies should take this into consideration and we also suggest studies should investigate the role of paternal health literacy finally previous research has shown that health literacy impacts various aspects of childrens health 9 so it is likely that interventions targeting parental health literacy will influence various socioeconomic health inequalities conclusion socioeconomic inequalities in paediatric mets are relatively small being largest by parental education targeting parental health literacy may not have a major impact on socioeconomic inequalities in paediatric mets additional research is needed into the mediating role of parental health literacy on other socioeconomic health inequalities in children a education measured using the minimum number of years of education required to attain their highest level of education the reference level is 12 years of education and the treatment level is 16 years of education b due to rounding the proportion mediated may differ from the value calculated using the indirect and total effect presented in the table c equivalized household income calculated as the net household income in euros divided by the square root of the number of individuals who live off the income the reference level is the mean income level and the treatment level is 1 sd above the mean d occupation measured using the standard international occupational prestige scale which is a continuous measure of occupation it focuses on the prestige an occupation gives its holder not on the incomes associated with occupations the reference level is the mean occupation level and the treatment level is 1 sd above the mean e parental health literacy was primarily measured using maternal data in the primary analysis and it was measured using an average of both parents data in the sensitivity analysis data availability researchers can apply to use the lifelines data used in this study more information about how to request lifelines data and the conditions of use can be found on their website welfare and sport the dutch ministry of economic affairs the university medical center groningen university of groningen and the northern provinces of the netherlands the authors are also grateful to josue ´almansa phd who assisted with any statistical questions conflicts of interest none declared

background parental health literacy may explain the relationship between parental socioeconomic status ses and paediatric metabolic syndrome mets for this reason we assessed to what extent parental health literacy mediates the relationships between parental ses and paediatric mets methods we used data from the prospective multigenerational dutch lifelines cohort study our sample consisted of 6683 children with an average followup of 362 months sd 93 and a mean baseline age of 128 years sd 26 we used natural effects models to assess the natural direct natural indirect and total effects of parental ses on mets results on average an additional 4 years of parental education eg university instead of secondary school would lead to continuous mets cmets scores that were 0499 95 confidence interval ci 03640635 units lower which is a small effect d 018 if parental income and occupational level were 1 sd higher on average cmets scores were 0136 95 ci 00520219 and 0196 95 ci 01080284 units lower respectively these are both small effects d 005 and 007 respectively parental health literacy partially mediated these pathways it accounted for 67 education 118 income and 83 occupation of the total effect of parental ses on paediatric mets conclusions socioeconomic differences in paediatric mets are relatively small the largest being by parental education improving parental health literacy may reduce these inequalities further research is needed into the mediating role of parental health literacy on other socioeconomic health inequalities in children

introduction names are often one of the first things we learn about people with whom we interact a vast body of literature highlights the impact of first impressions in part because they shape the way we process further information names may thus influence perceptions and decisions especially when other information is limited one important example comes from the hiring process bertrand and mullainathan find that resumes with distinctively black names such as lakisha receive 50 fewer callbacks from employers compared to resumes with distinctly white names like emily the authors postulate that this disparity may be due to employers use of quick heuristics in screening applications this explanation is supported by bartoš et al s finding that employers spend less time reviewing resumes of minority job candidates 1in this study we elicit peoples beliefs regarding demographic characteristics noncognitive skills and productivity levels associated with different worker names beliefs are measured probabilistically which provides precise variation in race associations both within and across respondents for given names this novel data allows us to estimate the role of race perceptions on hiring decisions more accurately without relying on distinctly black names or making assumptions about how people perceive names we can also estimate how much of hiring discrimination is accounted for by other beliefs than race including unobserved beliefs about names that are shared across employers by randomizing the hiring decision time we further gain insights into racebased heuristics employers may use the research design features two stages similar to those of barron et al and bohren et al in the first stage we recruit black and white workers and collect data on their first names and productivity measured as the share of financial receipts that they correctly transcribe in the second stage we recruit a nationally representative sample of 1500 individuals from the us over half of whom have reallife experience making hiring decisions to serve as employers in our experiment we first elicit their beliefs about demographic characteristics noncognitive skills and productivity levels for a set of names from our worker sample 2 for the second task employers make hiring decisions for ten worker pairs with names drawn from our worker sample they receive a bonus each time they select the more productive worker we present four main results following a registered preanalysis plan firstly the data show substantial variation in beliefs about characteristics across worker names and that these associations are strongly correlated with perceptions of race names commonly associated with being black are associated with lower levels of education and noncognitive skills the magnitude of the racial disparity is very large for instance perceiving a name to be 100 black compared to 100 white is associated with a 16 pp decrease in the likelihood of holding a masters degree and a 29 pp and 26 pp decrease in the likelihood of being perceived as responsible and trustworthy respectively traits that play an increasingly important role in labor markets but are hard to observe from a resume our findings reveal that these biased perceptions lead to disparities in worker assessments resulting in a 25 gap in productivity beliefs based on perceiving someone as black vs white however this race penalty is not primarily driven by differences between distinctly black names and distinctly white names controlling for name fixed effects which accounts for commonly shared associations of names only reduces the productivity race penalty by 10 pp or 40 it remains large at 15 highlighting the importance of variance in race perceptions between employers for the same name this withinname variation in beliefs is important as it may help explain heterogeneity in discrimination observed in recent studies the second key finding is that participants racialized perceptions are highly predictive of their hiring choices on average employers are 296 pp less likely to hire a worker they perceive as black compared to white controlling for productivity and noncognitive skill beliefs reduces this gap to 213 pp and 203 pp respectively accounting for age education productivity and noncognitive skill beliefs simultaneously reduces the race gap to 131 pp these results are robust to excluding distinctly black names from our sample results are also unchanged when we exclude respondents who suspect that the research is about discrimination which assuages social desirability concerns we find that discrimination varies substantially based on certain employer characteristics the overall 296 pp race gap narrows for female younger black and liberal employers as well as those who support racebased affirmative action despite these reductions the race gap remains substantial and statistically significant across each of these groups by contrast no significant differences in the race gap are observed based on employers educational attainment the level of racial diversity in their zip code or whether they had previous experience with hiring third we investigate mechanisms underlying discrimination in hiring decisions across various tests we find evidence suggesting that employers use race as a heuristic in their decisionmaking process differences in race perceptions between candidates increase employers confidence in their hiring decision and reduce the decision time even after controlling for differences in perceived productivity 3 however in cases where a candidate is perceived as both more productive and more likely to be black the decisionmaking time increases indicating that decision heuristics based on race and productivity beliefs are in conflict 4 to further investigate the role of heuristicbased decisionmaking we randomize onethird of employers to make hiring decisions within a twosecond time frame reflecting the fact that recruiters often spend very little time reviewing resumes at early screening stages we find that time pressure exacerbates hiring discrimination by around 25 with the most adverse effects observed for black candidates perceived to be highly productive importantly there is substantial heterogeneity in who is affected by rushed decisions discrimination increases by almost 70 among white employers who support racebased affirmative action but has no effect on the hiring decisions of black employers or white employers who oppose aa fourth to parse and quantify the role of heuristic biases and analytical beliefbased evaluations we use data on hiring decisions response times as well as race and productivity beliefs to estimate the parameters of a structural driftdiffusion model the ddm which is widely used in neuropsychology posits that decisionmakers sequentially sample information about choice options from memory and make a decision once an evidence threshold has been reached 5 this process causes decision values to drift gradually in the direction of preferred candidates motivated by reduced form evidence we model this drift to be affected by employers race and productivity beliefs our structural estimates reveal that both productivity and race beliefs affect the decision drift and that their relative importance in the decision process varies over time in quick decisions there is a significant drift favouring workers with white names suggesting the use of heuristics in hiring decisions especially when people are under time pressure interestingly despite observing similar levels of discrimination in long hiring decisions between black employers and white employers who support aa the underlying mechanisms behind this outcome are very different black employers exhibit a relatively weak heuristic response to black names whereas white employers who support aa initially display a strong negative heuristic response which is subsequently overridden in longer decisions white employers who oppose aa also exhibit a strong heuristic response but this judgement aligns more closely with that of their slower analytical cognitive process counterfactual analyses based on our structural estimates indicate that on average a black worker would need to be 203 pp more productive to have an even chance of being hired over a white worker in slow decisions this figure increases to 39 pp for very quick decisions 6 and siegelman 1993 we also find that the race gap does not differ along employers level of risk aversion 4 this aligns with the concept of implicit association tests which measure the unconscious associations of for example race and evaluations by comparing the speed of sorting decisions when concepts and evaluations are aligned versus misaligned 5 the ddm relates to a recent set of models eg in bordalo et al memories about past consumption experiences and prices both serve as anchors for evaluating choices other models explore the role of memory in forming beliefs bordalo et al enke et al 6 these results align with previous research that highlight the need for members of discriminated groups our study relates to an extensive body of literature that uses audit studies to detect discrimination in dimensions such as race gender or nationality bertrand and duflo neumark in these studies the characteristic of interest is typically signaled through individuals first names however a wellknown challenge in interpreting audit study results is that employers may associate candidates with distinctly black names also with other characteristics important for the hiring decision such as lower educational attainment while other studies have collected name associations crabtree et al gaddis our study is to our knowledge the first to incentivize truthful belief elicitation for demographic characteristics and to validate that reported noncognitive skill associations are predictive of incentivized decisions another key innovation is the collection of data on peoples distribution of beliefs about names 7 simulations based on our data show that if we had followed existing studies and collected binary race associations we would have missed about half of the race penalty in hiring and beliefs this suggests that a significant share of discrimination occurs between candidates for whom employers agree on the most likely race category but differ in their level of certainty for example our data indicate that colin is perceived as 77 likely to be white whereas robert is seen as 60 likely to be white yet for both these names around 90 of employers believe that the single most likely race category is white binary race perception data would treat these two names as equally white and thus fail to attribute employer preferences for colin to race beliefs leading to an underestimation of discrimination a second key benefit of using probabilistic data is the ability to more precisely estimate the variance in race beliefs induced by studies that randomize names this in turn allows calculating local average treatment estimates from intenttotreat estimates reported in audit studies such as differences in callback rates the late is important as it provides a more accurate measure of the impact of perceiving a candidate as black our study also contributes to the growing body of literature examining the role of employers beliefs about workers traditional models distinguish between tastebased discrimination and statistical discrimination recent research has added more nuance to this categorization by demonstrating that beliefs can often be inaccurate due to biases stereotypes or lack of information bohren et al bordalo et al coffman et al chakraborty and serra bohren et al develop a model of inaccurate statistical discrimination and show that the accuracy of beliefs has crucial implications for identifying underlying mechanisms and for designing policies to reduce discrimination comparing employers productivity beliefs to actual productivity data of 2400 workers to outperform others in order to overcome discrimination 7 reporting the variance of the binary race belief measure does not capture the withinperson distribution of beliefs abel and burger describe in more detail how researchers can access and use our data performing the same task shows that employers perceived race gap of 25 greatly exceeds the actual productivity difference of 9 our paper quantifies the effect of such biased beliefs on hiring decisions and employs a structural model to investigate how these beliefs are incorporated into the decisionmaking process we are to our knowledge the first to apply the ddm to study hiring decisions methodologically we are also the first to extend the ddm to allow decisions to be determined by elicited beliefs rather than relying on stated preferences and to allow the drift to be affected by perceptions of both race and productivity in addition randomizing the decision time helps identify the extent to which discrimination operates through heuristic and analytical cognitive processes these findings relate to a growing literature showing how beliefs affect how much attention people pay to information which may inhibit learning last our paper helps explore the reasons behind the large heterogeneity in discrimination documented across jobs and industries in recent studies for example kline and walters conclude that while most jobs barely discriminate a few discriminate heavily these findings are inconsistent with traditional models of statistical discrimination but could be explained by heterogeneity in tastebased discrimination our findings suggest that variation in beliefs across hiring managers is one reason for this type of heterogeneity this may help explain why variance in discrimination is more common for firms without centralized hr systems in which individual hiring managers have more decision power our results are also in line with studies identifying variation in the decisionmaking process including the time dedicated to screening of applicants as an important source of heterogeneity in discrimination our findings also highlight limitations of interventions to reduce discrimination eg by increasing attention the paper proceeds as follows section 2 describes the research design and section 3 introduces the empirical strategy section 4 discusses results on name associations and section 5 investigates the role of these associations on hiring decisions section 6 explores underlying mechanisms and reports results from our structural estimation section 7 concludes study design worker recruitment and name selection a key feature of our study design is that it leverages reallife worker productivity data obtained from a previous field experiment specifically we collect data on how people performed in transcribing financial receipts for a detailed description of the study for the current study we obtain permission from 150 of the initial sample of workers to use their first name in our research we also collect data on incentivized choices in a trust game as described in more detail below we oversample black workers to obtain a racially balanced sample and categorize worker names as predominately black predominately white or of ambiguous race based on pilot surveys that elicit race perceptions of names8 from each of these three categories we sample five female and five male names these 30 names are used as our worker sample in the hiring experiment employer recruitment and sample characteristics the research design for our hiring experiment conducted in the second stage is summarized in figure 1 we recruit a new sample of 1500 people based in the us to act as employers in our experiment these participants are recruited through prolific which allows us to recruit a sample that is nationally representative in terms of key demographic characteristics such as age race and gender this represents a significant advantage over other studies that recruit subjects online which tend to be disproportionately young and white the characteristics of our sample can be found in column 3 of table a1 the median income of participants is approximately usd 45000 which is close to the national median of usd 41500 despite being representative on key demographic characteristics our sample is more educated than the national average with 47 holding a college degree 56 of our sample has previously been involved in hiring which is important since it allows us to test whether hiring behavior in our experiment differs for those with actual hiring experience our data is also notable for its broad geographical representation with participants from all 50 states and 1373 zip codelevel locations by linking the zip code level data to census data we are able to learn characteristics of the participants geographic locations including levels of racial diversity belief elicitation we inform employers that the study aims to learn about the associations people have with names we first present employers with six names the names consist of one female and one male from each of the three categories distinctly black distinctly white and ambiguous race associations for each name we collect belief associations from approximately 300 respondents we elicit beliefs about raceethnicity age and education levels by asking participants the following question for each name out of 10 people named how many people are followed by the categories of raceethnicity age and education described in more detail below 9 this method has several key advantages over previous research that asked about a single race category most importantly it provides more nuanced data of the distribution of race beliefs and captures peoples level of certainty over name associations 10 another advantage is that we incentivize participants to provide accurate answers by informing them that their responses will be compared to official national statistics and that they will receive a bonus of usd 200 if they correctly order the characteristics of five name comparisons 11 in addition to eliciting beliefs about race age and education we also collect data on noncognitive skill associations specifically we ask participants to select from a list of seven traits that they believe are characteristic of someone with a particular name 12 we chose noncognitive skills that are widely regarded as important in the workplace while there is no objective data on how noncognitive skills vary by name we can still compare peoples responses to incentivized choices described in more detail below last to elicit beliefs about the productivity of workers we present participants with six names in random order and ask them to estimate the productivity of workers with each 9 we mix concepts of race and ethnicity as preliminary data collections showed that participants are confused by questions that elicit data separately 10 conceptually a larger variance of beliefs may either mean that a person knows that the distribution is more disbursed or that the respondent is more uncertain about the name distribution both can be sources of uncertainty in pilot data collection we confirmed that reported certainty about associations are negatively correlated with a persons variance in race beliefs 11 to further explain this scheme we present people with a concrete example of worker names and beliefs about age that determine the bonus payout we do not specify which characteristics we use to determine the payout in practice we have administrative data on race and age 12 we ask what characteristics do you think does a person with the name name have the seven traits are presented in random order name we provide context by explaining that we have collected performance data in a financial receipt transcribing task we further follow bohren et al and inform participants that a typical worker correctly transcribed 65 of receipts and incentivize accurate responses by offering a bonus of usd 050 for each correct productivity guess they make hiring decision and randomization after eliciting beliefs we conduct the hiring experiment in which employers make sequential binary hiring choice for ten pairs of worker names the ten pairs presented in random order are selected from the six names for which beliefs were elicited and include combinations of workers with both the same and different race categories similar to barron et al each time they select the more productive worker the employer receives a bonus of 10 cents we also record the time taken to make each hiring decision the average decision time is 21 seconds this means that making correct choices could result in an additional payout of up to usd 100 over less than half a minute employers do not learn about how many correct choices they made until the end of the experiment the hiring experiment features a crossrandomization design that introduces exogenous variation in decision time and worker bonus for the time variation onethird of employers is informed that they must make a hiring decision within two seconds in order to be eligible for a bonus in a given hiring round for the worker bonus variation onethird of employers are informed before making their choices that the workers have the opportunity to earn an additional payout each time they are selected 13 this worker bonus treatment mimics the benefit workers receive from being selected in realworld hiring decisions importantly the worker bonus does not affect the monetary incentives that employers face and thus only affect hiring choices if people differentially care about the payout of white vs black workers which could be one reason for why employers hire white workers after completing the hiring task we offer participants the opportunity to earn an additional bonus through a trust game14 specifically we explain that we collected data on how much money each worker in our sample returned in the role of the recipient in the trust game participants can then choose a partner from a list of six names and are paid a bonus according to how much the selected worker decision finally we administer a short survey that collects data on employers sociodemographic characteristics including age education income location and race as well as their political leaning experience in hiring level of risk aversion and performance in a cognitive reflection test empirical strategy beliefs of worker characteristics and productivity suppose an employer believes the productivity of a worker y is determined as y α rθ xδ u where x is a vector of observable worker attributes δ is a vector containing the perceived productivity effects of these attributes r is binary vector containing a single 1 corresponding to the workers race θ reflects perceived race productivity effects and u is a scalar summarizing the perceived effect of unobservable worker attributes on productivity in our experiment employers are provided with a name n and are then asked to state their beliefs regarding the race observable attributes and productivity of the worker we denote these as rn ≡ e xn ≡ e and ŷn ≡ e since race beliefs are elicited as probabilities this directly measures rn where each element represents the employers reported probability that a worker with name n is of race white black hispanic asian or other respectively if the employer believes consciously or subconsciously that worker attributes are correlated to race then this would induce a correlation between race associations for a worker with name n rn and beliefs about worker attribute k for a worker with name n xkn xkn η k rn π k e this relationship can be estimated by regressing employer beliefs regarding worker attributes on employer beliefs regarding race across all names as we do in section 4 below if employers form productivity beliefs according to bayes rule productivity predictions for a worker with name n are ŷn α rn θ xn δ e the relationship between the employers race beliefs and productivity predictions can be assessed by regressing predicted productivity on race beliefs ŷni α β b rbni β h rhni β a rani β o roni xni δ λ n u ni where subscript i refers to the beliefs held by employer i we choose the perceived probability of being white rwn as the reference category in our empirical analysis so the race coefficients for race q now represent β q θ q θ w ie the perceived productivity effect of belonging to race q compared to white we cluster standard errors at the employer level to account for correlation in outcomes between choices for the same employer when not controlling for employer beliefs regarding worker attributes the estimated race coefficients reflect both the direct perceived race effect on productivity as well as the indirect affect that operate through perceived correlations between race and other worker attributes that are believed to determine productivity we can move closer to estimating this perceived race productivity effect by controlling for beliefs regarding commonly observable human capital measures and noncognitive skills xni our experimental design also allows us to control for name fixed effects λ n which can capture any variation between names and unobservable productivity determinants like socioeconomic status that is shared between employers in contrast to other studies in this literature we directly measure employer beliefs regarding worker attributes that are difficult to observe from resumes this means we can more comprehensively control for confounding effects that may inflate the race association coefficients hiring decisions when making a hiring decision between two workers with names n 1 and n 2 the employer may compare their predicted productivities and select worker n 2 if e e and candidate n 1 otherwise following equation 31 the expected difference in productivities can be expressed as e e e θ eδ e e assuming that e e is normally distributed allows the estimation of βσ and δσ with a probit estimator a linear approximation of this process can be expressed in terms of observable sample data h ji β b ∆r bji β h ∆r hji β a ∆r aji β o ∆r oji ∆x ji δ v ij where j denotes a specific name pair ∆r qji ≡ rqn 2 i rqn 1 i is the difference in the perceived probabilities that worker n 1 and n 2 are of race q and ∆x ji ≡ xn 2 i xn 1 i is the perceived difference in worker attributes the estimated coefficient β q θ q θ w measures the effect of being perceived to belong to race q rather than being white as before we cluster standard errors at the employer level race figure 2 shows the distribution of race associations for the 30 worker names in our sample the names are ordered based on the perceived likelihood of being black although many names in the sample are clearly categorized as either predominantly black or white some names such as jackson and darryl are perceived to be black and white in roughly equal frequency in addition to differences in the aggregate perceptions of names there is also considerable variation in beliefs for a given name across employers for example while charisma and alijah share similar aggregate race associations figure a3 shows that there is a higher variance in beliefs for charisma eliciting data on the distribution of race associations has several key implications conceptually it provides a more nuanced understanding of individuals levels of uncertainty about their beliefs appendix figure a4 shows that had we asked for a single race categorization we would miss much of the nuance in peoples beliefs and discriminatory behavior 15 from a methodological perspective the distribution of beliefs about race is crucial for interpreting the results of studies that use names to signal race for example differences in callback rates from sending fictitious resumes present intent to treat estimates to back out the arguably more meaningful treatmentonthetreated estimate it is necessary to know the variation in race perception that is induced by names education figure a1 shows the distribution of beliefs about the highest level of educational attainment across names while there are some outliers there is a clear correlation between beliefs about race and education table 1 shows results from specification 1 names perceived as black are associated with having 073 years fewer years of education next we compare beliefs about specific categories of educational attainments strikingly perceiving a name as black lowers the chance that the person is believed to have a masters degree by 16 pp by contrast we do not see a difference for having completed a four year degree and an increase of 9 pp for having completed a two year degree people also associate black names with a 10 pp lower likelihood of holding a high school diploma and 38 pp higher chance of having less than a high school degree panel b shows the corresponding results controlling for name fixed effects only exploiting within name variation in race beliefs reduces the race gap in the number of years of education by 012 coefficients for specific education categories also converge towards zero but remain highly significant age we elicit age associations by asking participants how many people with a given name fall in each of the following age bins 1829 3044 4559 60 using the midpoint for each bin we compute the average age for each name perceiving a name as black is associated with being 65 years younger one explanation is that distinctly black names were more commonly used in the 1970s and 1980s controlling for name fixed effects the age difference drops by almost 80 to 14 years suggesting that much of the age race gap is associated with namespecific associations 16 15 to assist researchers who want to choose names for studies on race and gender discrimination we are compiling a companion paper with associations for a comprehensive set of names and guidance on how to systematically select names 16 to assess how accurate peoples beliefs are we use census data to estimate the actual average age in the us population specifically we look at the frequency of birth at the midpoint of the age bins used in our belief elicitation method which we use to compute a weighted average as a proxy for the actual age figure a2 plots the perceived vs actual age data for our names with points on the 45 degree line presenting noncognitive skills figure 3 shows the belief distribution for four noncognitive skills across names ordered by the perceived share of being black visual inspection shows that perceiving a name as black is negatively correlated with being trustworthy and responsible positively correlated with being assertive and uncorrelated with being motivated table 2 reports the corresponding coefficients from specification 1 for each noncognitive skill perceiving a name as black reduces associations with responsibility by 294 pp trustworthiness by 265 pp cooperativeness by 248 pp and perfectionism by 196 pp by contrast it increases associations with assertiveness by 341 pp and decisiveness by 126 pp while motivation perceptions are not correlated with race associations including name fixed effects reduces most coefficients by around 3050 but they remain large and significant noncognitive skill perception data also show clear differences at the intersection of gender and race for example gendered associations regarding women being less assertive more trustworthy and more cooperative only extend to female names perceived to be white while not the focus of this paper this points to additional distinct challenges faced by black women accurate perceptions it shows that people tend to overestimate the age of people with names of younger people and underestimate the age of names of older people however there is a strong positive relationship between perceived and actual age with a correlation coefficient of 081 as previously explained to test whether these associations affect behavior respondents can choose who they want to partner with in a trust game and receive the amount that person returns as a bonus figure a5 plots the relative frequency with which names are perceived as trustworthy and how often workers with these names are picked as a partner in the trust game while there is some divergence associations and incentivized choices are highly correlated stating that a name is trustworthy increases the probability that this person will choose a worker with that name in the trust game by almost 80 overall these results suggest that the noncognitive skill associations we collect are predictors of incentivized choices perceived productivity we first show the relationship between productivity beliefs and race beliefs graphically figure 4 plots the average perception of being black and productivity for each worker name averaged across 300 employers while there are some positive and negative outliers we find a strong negative and relatively linear relationship table 3 shows results from specification 3 using individual perceptions of productivity measured in log of correctly transcribed receipts as the dependent variable without control variables a black name is associated with about 25 lower productivity compared to a white name while our preanalysis plan does not include tests of discrimination towards other race groups given the limited variation in perception for names included in our sample it is noteworthy that the race gap is half the magnitude for hispanic names and that there is no gap for asian names when we control for the number of years of education the blackwhite race gap slightly decreases to about 23 reflecting that education is a positive determinant of productivity that is negatively correlated with perceptions of being black every year of education is associated with a 31 increase in productivity meaning that the raw penalty of a black name is equivalent to about 8 years of education controlling for age beliefs only has a very small effect reducing the race productivity gap to 241 as age is only weakly correlated with productivity controlling for noncognitive skill perceptions reduces the race gap by almost a fifth to 21 this reflects that most of the traits positively associated with productivity such as trustworthiness and responsibility are also more likely to be associated with white names by contrast while black names are more likely to be perceived as assertive this trait is not correlated with productivity perceptions for our most flexible specification we estimate regressions with name fixed effects which effectively only uses betweensubject variation in beliefs for the same name to estimate the race gap this specification reduces the race gap from 25 to 15 or to 12 when we control for other beliefs the importance of variation in perceptions for the same name points to an important potential source of heterogeneity in discriminatory behavior observed in audit studies to assess the accuracy of employer beliefs we use data on the actual productivity of 2400 workers in this task table a4 compares the productivity race gap as perceived by employers versus the actual data while the perceived race gap is between 22 and 25 the actual gap is below 9 implying that employers overes figure 5 shows how productivity beliefs vary across employer characteristics while every subgroup overestimates the race gap there is substantial heterogeneity along certain characteristics in how much groups do so most strikingly those supporting racebased affirmative action think the productivity race gap is 16 while those opposed to aa believe it is more than 40 participants involved in realworld hiring also overestimate the racegap more by contrast it does not vary along other characteristics including employers race and level of education the next section will first test the extent to which these employer beliefs affect hiring decisions section 6 will then explore mechanisms of how beliefs factor into the decisionmaking process hiring decisions hiring race gap figure 6 shows the relationship between race perceptions and hiring probability for each of the worker pairs included in our experiment17 the xaxis shows the difference in the likelihood of being black between the two candidates averaged across roughly 300 employers we include worker pairs of similar race distinctly different race and intermediate race differences resulting in three clusters of pairs along the xaxis the yaxis presents the average hiring probability for the person listed first in the pair notably almost all pairs are above the 50 hiring probability line indicating the strong negative relationship between perceiving a name as black and hiring that candidate while we are fitting a quadratic function the relationship is almost exactly linear suggesting that there is not a threshold at which the hiring penalty of being perceived as black is changing pairs above the fitted line present cases where the first worker is hired more than predicted by race perceptions overperforming names include sara josh and isaiah while underperforming names include brandon krystal and charisma these patterns point to other beliefs eg regarding education that may systematically vary across names to gain precision and account for other employer beliefs table 4 presents results from specification 5 using the full set of more than 14000 hiring decisions without controlling for other beliefs we find that a worker perceived to be black is 296 pp less likely to be hired than someone with a name perceived to be white col 2 controls for employers productivity perceptions of the two candidates a one percentage point advantage in perceived productivity increases the likelihood of being hired by 073 pp controlling for productivity perceptions reduces the race gap in hiring by roughly 30 to 213 pp as productivity perceptions may not affect hiring decisions linearly we next include a binary variable indicating whether a worker is perceived to be more productive this increases the likelihood of being selected by 27 pp but only narrows the race gap to 237 pp next we control for perceived differences in years of education and age a one year increase in education is associated with a 63 pp increase in the likelihood of being hired this implies that being perceived as black has a similar impact on ones chances of being hired as having almost five fewer years of education accounting for differences in education perceptions narrows the hiring race gap by 5 pp age has a smaller but still positive effect on hiring and reduces the racial gap in hiring by 21 pp perceptions of most noncognitive skills are highly correlated with hiring decisions and explain as much of the variation in hiring as productivity perceptions for example perceived a worker as more responsible than their competitor is associated with a 128 pp increases in the chances of being hired by contrast the trait most commonly linked to black names assertiveness is not associated with hiring decisions overall accounting for differences in noncognitive skills reduces the race gap by approximately 32 to 203 pp highlighting the importance of employer beliefs about these traits notably perceptions of noncognitive skills remain significant predictors of hiring even after accounting for education age and productivity beliefs this is important since many of these latter characteristics are observable to employers on a candidates resume this most flexible specification reduces the race gap by about 45 to 133 pp 18lastly we can estimate the previous specifications with worker pair fixed effects akin to our name fixed effects analysis this specification estimate coefficients only from variation in race beliefs between people for the same candidate pair table a5 shows that while this reduces the race coefficient by about 45 the race gap remains large at 158 pp results further show that the size of the race gap is robust to including employer fixed effects subgroups figure 7 presents the findings of various subgroup analyses as specified in our preanalysis plan we find that women exhibit less discriminatory behavior as the race gap is 26 pp compared to 34 pp for men in contrast the race gap is not affected by whether a person has a college degree or not the hiring race gap among black employers is 19 pp compared to 33 pp for white employers and 27 pp for other race groups the fact that we observe a substantial race gap among black employers provides evidence against racial animus as the main driver of our results we also find a negative relationship between participants age and their level of discrimination the race gap is 50 higher for people over 55 compared to 18 to 35 with regard to peoples political leaning we find that the the race gap is 70 larger for conservative compared to liberal employers likewise we observe a strong negative relationship between support for racebased aa and hiring discrimination among those opposed to it the gap is 42 pp compared to 19 pp for those in favor next we look at the role of participants location figure a6 shows how the race gap varies across states we do not observe a clear geographical pattern of race discrimination we can also compute the racial diversity of participants zipcode level area using census data dividing this measure into terciles we find no variation in discriminatory behavior along this dimension although results show that white respondents display a slightly higher race gap if they live in the most diverse areas last hiring discrimination does not differ based on whether participants have experience in hiring this partly assuages some concerns about the external validity of our results figure a7 replicates the same subgroup analyses but controls for differences in productivity education age and noncognitive skill perceptions between workers while the race gap closes by around 50 the overall pattern across subgroups persists notably the race gap remains statistically significant for all subgroups at the 01 level it is important to note however that these coefficients only provide a correlation between groups such as measuring the behavior of people with or without a college degree rather than a causal relationship between obtaining education and exhibiting discriminatory behavior robustness in research related to discrimination participants may be hesitant to reveal their true attitudes and behaviors which would compromise the internal validity of results to address this concern we do not reveal the exact research question at the outset of the study elicit a range of associations beyond just race and also included hiring choices for worker pairs without racially distinct names despite these efforts about 33 of respondents suspected at the end of the experiment that the research was related to race 19 this share increases to 49 when we include other forms of biases and discrimination table b5 replicates our main results separately for those who suspected the research was related to race and those who did not while we acknowledge endogeneity and misreporting concerns it is reassuring that our results remain robust both for the overall race gap and the effect of controlling for beliefs specifically the race gap is only about 19 pp smaller for those suspecting the research is related to race using our broad measure this difference decreases to less than 1 pp a related concern is that people do not suspect the research question in the beginning but may alter their behavior once they become aware of the studys focus on race to investigate this possibility we analyze how discrimination changed over time by examining the order of the hiring pairs our results as shown in figure b2 indicate that the race gap does not vary systematically across the ten hiring decisions one possible explanation for these findings is that incentivizing choices may have addressed surveyor demand effects however it remains possible that people hide discriminatory behavior our results should thus be regarded as a lower bound of the prevalence of discrimination one potential sets of concerns about the external validity of our results is related to the choice of names would we obtain different results if we had chosen a different set of names and specifically if we had excluded distinctly black names we address these important questions in two steps first we run simulations using 5000 different subsets of the data each time estimating the race gap for a random sample of 50 of worker pairs the results are shown in figure b3 with dashed lines indicating the bottom and top 5 of estimates we find that the 5th percentile of estimated coefficients is around 24 and only 1 percent are below a race gap 216 20second we reestimate our hiring results and exclude any worker pairs with at least one distinctly black name these are defined as having an average perception of being black above 70 and include shanice tyrone deshwanta deshawn and terell table b3 shows that estimates of the race gap remain almost identical this reflects the fact that the relationship between perceived race differences and hiring probabilities is linear implying that results are robust to excluding pairs with large race differences mechanisms motivation what explains decisions that contradict beliefs the results from section 5 demonstrate that although productivity beliefs play an important role in hiring decisions other beliefs about worker attributes such as race education and noncognitive skills also strongly impact employer choices in fact in roughly 30 of hiring decisions employers select the worker that they previously predicted to be less productive this may seem surprising given that the hiring task explicitly instructed and incentivized employers to choose the most productive candidate however it is in line with a large literature showing that humans are prone to making errors when faced with simple binary decisions particularly when placed under time pressure one potential explanation for this phenomenon is linked to the process of forming beliefs by retrieving memories about people with the same name employers may initially retrieve salient attributes such as race which are perceived to be correlated with productivity 21 as this process continues less salient but more relevant information will be retrieved and beliefs may drift away from this initial raceanchored impression and towards their true productivity belief this process relates to dualprocess models of cognition which posit that one set of processes is fast reflexive and unavailable for conscious introspection while the other is slow analytical and able to process information sequentially applied to our study racial discrimination can either be instinctive and subconscious or deliberate and selfaware this cognitive process is both noisy and effortful and employers may terminate it when the cost of searching for additional evidence exceeds the potential benefits of improving belief accuracy due to the inherent noise in this process employers may make different predictions about people with the same name at different times leading to inconsistencies between their productivity beliefs and hiring choices particularly when placed under time pressure to explore this prediction we investigate how the probability of being hired varies based on employers race and productivity beliefs as well as the randomly assigned decision time while we formalize these ideas in section 62 figure 8 presents a visual representation of our findings based on previously elicited employer beliefs we divide candidate pairs into three race difference groups and four productivity difference groups as expected when two workers are predicted to be roughly equally productive and equally likely to be black the probability of being hired is close to 50 this is true for both long and short decision times 22examining long decisions with workers of a similar race we observe that the hiring probability gradually increases as a candidates productivity advantage grows up to 75 for an advantage exceeding 30 pp workers who are perceived as more white receive an additional advantage in the hiring process which increases from 10 pp to 15 pp as the perceived the productivity advantage grows conversely workers with more blacksounding names face a hiring penalty of 5 to 10 pp for decisions under time pressure the benefits of productivity advantages remain largely unchanged for more whitesounding names by contrast figure 8 hiring probabilities by productivity race perceptions and decision time notes more black includes workers perceived to be more than 20pp more likely to be black more white includes all worker who are perceived to be more than 20pp less likely to be black and similar race includes workers whose difference in perceived likelihood of being black is 20pp or less in absolute value there is a notable decrease in the productivityslope for workers with more blacksounding names leading to an almost 50 increase in the hiring race gap for black workers with large productivity advantages in other words black workers who are perceived to be highly productive are the most adversely affected by rushed hiring decisions these findings are in line with the framework presented below which posits that employers may initially anchor their productivity beliefs to easily retrievable race associations when they are forced to terminate their search for worker attributes prematurely due to time pressure productivity beliefs have less influence on hiring decisions leading to a larger race gap for highly productive workers in such scenarios the error rate defined as the inconsistency between hiring choices and stated productivity beliefs increases from 10 pp for white workers to 43 pp for black workers framework employers make a simple twochoice hiring decision in our experiment while economists have focused mainly on observed choice outcomes cognitive and mathematical psychologists have made significant progress in understanding the joint distribution of choices and response times by modelling the neurological mechanisms that underpin such decisions neurophysiological data have provided support for a class of models that posit that individuals make these decisions by sequentially sampling noisy information allowing them to accumulate evidence favoring one choice over the other the most successful of these models is arguably the driftdiffusion model which offers a highly parsimonious representation of the cognitive process underlying binary decisionmaking according to the ddm decisionmakers accumulate evidences regarding the relative merit of choosing option a over b through sequential sampling of relevant information stored in memory such as past consumption decisions and associated pleasure levels to predict the hedonic impact of each option denoted as v and v these cognitive computations are subject to noise caused by the stochastic nature of neuron firing rates the relative decision value at time t can then be expressed as z t z t1 θ v e t 6 where θ is a constant drift rate and e t represents the noise in the mental computations which is assumed to be identically and independently distributed according to a standard gaussian distribution23 when the decision value z t surpasses a positive threshold b option a is selected while crossing a negative threshold b leads to the choice of option b this process entails a sequential likelihood ratio test which has been demonstrated to be the optimal statistical solution to the decision problem the model also distinguishes between nondecision time which is required for stimulus encoding and motor response generation and the decision time which involves the accumulation of evidence the drift rate θ determines the speed at which evidence is accumulated and can be interpreted as the quality of the information available for evaluating the choices when θ has higher values decisions are reached more rapidly and consistently the decision thresholds b and b represent the required level of confidence for making a decision due to the inherent noise in the evidence accumulation process different realizations of the same process with identical drift rates may not terminate at the same time or at the same threshold however the decisionmaker can influence the quality and speed of the decision by adjusting the value of b lower values of b correspond to quicker decisions that are more prone to errors whereas higher values of b lead to slower but more accurate decisions this illustrates the speedaccuracy tradeoff inherent in this model experimental manipulations have consistently confirmed these model predictions but it has not been tested in the context of hiring decisions24 figure 9 illustrates the application of the ddm to our experiment employers are presented with candidate names from which they infer that candidate a is white while candidate b is black according to the ddm employers initiate a cognitive process where they sequentially sample information from their memory emotions beliefs and expectations related to these names this information is utilized to compute decision values for each candidate which are then combined to generate a relative decision value z t following equation 6 we elicit these types of beliefs from the employers prior to the hiring task in a incentivecompatible way and without imposing any time constraints 25based on the descriptive results indicating that both race and productivity beliefs affect the decision and decision time we specify the drift process as follows θ v θ 1 θ 2 θ 1 and θ 2 measure the relative importance of race and productivity during the process of gathering evidence for the hiring decision krajbich proposes an extension to this model that incorporates heuristic and subconscious racial biases by allowing race to influence the starting value of the evidence gathering process 26 we specify this as α α 1 this leads to the following estimable equation for the hiring decision z t α 1 θ 2 t e t where e t t τ 1 e t the next section will present reduced form analyses that test the models predictions regarding the impact of race and productivity beliefs on the hiring choice and decision time we then estimate a structural model to jointly estimate key parameters of this model including decision thresholds initial bias as well as productivity and race drift reduced form analysis to examine the predictions of the ddm we begin by analyzing how employers beliefs impact their decisionmaking time according to our model response times will be shorter when one worker is perceived to be more productive or more likely to be white and especially when both of these perceptions align conversely if the more productive worker is perceived to have a lower probability of being white the race and productivity drift will have opposing influences on the decision value resulting in slower decisionmaking table 5 provides evidence in support of these predictions a greater difference in race beliefs is associated with faster decisions choosing between one candidate perceived as black and one perceived as white shortens decisionmaking time by 019 seconds equivalent to 018 sd compared to choosing between workers of the same race while controlling for the difference in perceived productivity between candidates reduces this estimate to 015 seconds it remains statistically significant at the one percent level additionally larger differences in perceived productivity also shorten decisions times these correlations are driven by decisions with unlimited time which are less affected by noise overall these findings confirm our model assumption that both race and productivity beliefs are important determinants of the drift 26 biased starting values capture an immediate bias in favor of white workers that will be particularly influential in short decisions but that dissipate over longer decisions this may allow us to distinguish between racial biases that emanate from heuristics and more analytical cognitive evaluations however since the estimated starting values are extrapolations of the linear drift function to decision times of zero which is unobserved in the data the validity of this interpretation hinges crucially on the assumption of constant drift rates if system 1 and system 2 processes are more accurately depicted as a gradual shift in what employers attend to then this process may induce nonconstant drift rates which deviate from the ddm assumptions and which would invalidate the interpretation of starting value estimates as the effect of heuristic biases on employment decisions one way to test the validity of this assumption is to estimate the ddm separately for hiring decisions made under the randomized short and long decision treatments and to test whether the drift rates are equal these tests are performed in section 64 below notes the dependent variable in the time people take to make a hiring decision prod measures to the difference in productivity between worker 1 and 2 scaled to be between 0 and 1 black measures the difference in the share associated as black between worker 1 and 2 scaled to be between 0 and 1 specifications in columns 14 use the absolute values of these differences the interaction term uses the perceived productivity and race of worker 1 minus worker 2 all estimations are ols robust standard errors clustered at individual level are in parentheses p 010 p 005 p 001 next we investigate the interaction of beliefs while perceptions of productivity and being black are negatively correlated there are many instances where a candidate is perceived as more productive and more likely to be black to explore these scenarios we estimate specifications with an interaction term of differences in perception of being black and productivity between candidates without converting belief differences into absolute values a positive interaction term thus indicates that a candidate is perceived as more productive and more likely to be black as predicted by the ddm the coefficient on this interaction term is positive when decisionmakers have unlimited time the ddm also offers predictions regarding the outcomes of hiring decisions and the effect of time pressure in particular it suggests that rushed decisions can exacerbate the race gap in hiring as employers may place greater emphasis on race during the initial stages of the decisionmaking process confirming this prediction column 1 of table 6 shows that in the overall sample the race gap widens by 67 pp or 242 when employers are required to make fast decisions kahneman and frederick conceptualize system 2 as a analytical slowthinking process that acts as a supervisor that can endorse correct or override the quick heuristic judgments of system 1 in the context of our experiment we hypothesize that system 2 will only override these system 1 judgments under two conditions first if system 1 exhibits bias against black workers and second if these biases are not aligned with the analytical notes the dependent variable in a binary variable for choosing worker 1 independent variables are coded to show the difference in perception of worker 1 minus that of worker 2 short is an indicator variable for the randomly assigned fast decision time col 56 and 78 divide the sample according to whether respondent are in support of racebased affirmative action measured by whether they rate their support above 50 on a 0100 scale all estimations are ols robust standard errors clustered at individual level are in parentheses p 010 p 005 p 001 evaluation of system 2 to test this hypothesis we compare the impact of time pressure 27 on the race gap across three distinct groups black employers white employers in support of racebased affirmative action and white employers more opposed to aa 28 we focus on support for aa for two reasons firstly it is the single most important predictor of the race gap in hiring and was specified in our pap secondly while opposition to racebased aa can stem from various factors studies indicate that racial resentment is one 27 to test whether time pressure increases reliance on system 1 we divide our sample based on participants performance in the cognitive reflection test threequestion survey which measures peoples inclination towards analytical versus heuristic decisionmaking in line with predictions from dual process models we find that the increase in discrimination in short decisions is driven by employers scoring above the median crt who tend to rely more on analytical decisionmaking in the absence of time pressure table b7 col 5 shows a similar pattern for productivity beliefs while perceiving a candidate to be 10 pp more productive increases the chances of hiring that person by 78 pp when employers have unlimited time this effect drops to 6 pp when employers are under time pressure this decrease is also driven by employers who score high on the crt these findings are in line with other studies showing that those with higher levels of cognitive reflection are less prone to heuristic biases 28 we split the sample by whether they rate their support for racebased affirmative action above 50 on a 0100 scale figure a8 shows the effect of time for each decile of the key predictors of such opposition support for aa can thus act as a proxy for whether people deem it desirable to override the biases of system 129 our findings indicate that rushed decisionmaking does not impact the race gap in hiring among black employers this suggests that this group does not exhibit a strong negative heuristic response towards candidates with black names conversely for white employers who support aa rushed decisions increase the race gap by 70 from 20 pp to 33 pp controlling for productivity beliefs further increases this difference in sum white employers who support aa make decisions that align more closely with those of black employers when given sufficient time however when put under time pressure their decisions align more with those of white employers who do not support aa these findings suggest that both system 1 and system 2 processes play distinct roles in influencing the race gap in hiring and that their relative importance varies across employers to further explore this heterogeneity we present the hiring results across different subgroups of employers and decision time in table 7 panel a shows that among white employers opposed to aa both race and productivity beliefs have similar effects on decisions in short and long time frames the race penalty of around 40 decreases by 7 pp when controlling for productivity beliefs and an additional 8 to 12 pp when we control for other beliefs white employers supporting aa exhibit a similar pattern for short decisions the large race gap of 325 closes by similar magnitudes when controlling for productivity and other beliefs and the race penalty decreases by nearly 50 when controlling for productivity beliefs and becomes indistinguishable from zero when controlling for other beliefs notably the magnitude of productivity coefficients is approximately 80 larger for this group compared to employers opposing aa suggesting that productivity beliefs play a more important role when sufficient time is available in panel c we find that the hiring pattern for black employers closely resembles that of white employers supporting aa when making decisions without time pressure however changes in coefficients are smaller when black employers face time constraints structural estimation of driftdiffusion model given the reducedform analysis support for the prediction of the the ddm we proceed to estimate the parameters of the structural model using our experimental data we start by estimating a single ddm model on the observed response times and hiring decisions pooling data across both short and long decision frames this model assumes that only the decision thresholds are affected by the time constraint whereas the drift rates and biased starting values are constant estimates for the pooled employer sample reveal a large and significant effect of race beliefs on the decision drift indicating a strong bias against hiring workers with blacksounding names that accumulate with decision time as expected productivity beliefs also affect the decisions through a strong positive drift in line with ddm predictions the information threshold of 142 for decisions not subjected to time constraints is reduced by 042 when employers are under time pressure 31 we also estimate that employers require about 043 seconds on nondecision time for our task estimating the ddm separately by employer subgroups reveals substantial heterogeneity in how beliefs influence decision drift rates for black employers and white employers supporting aa productivity drift parameters are six to seven times larger than the black drift parameters indicating that decisions are mainly determined by their productivity beliefs by contrast the productivity drift is only twice the size of the black drift for white employers opposed to aa suggesting that they are more influenced by race beliefs we also find that race beliefs do not have a significant impact on the starting values in the pooled sample or for any of the subgroups we next relax the assumption of constant drift rates across experimental treatments by estimating the ddm separately for short and long decisions results reported in panel b and c of table 8 show that productivity drift parameters remain relatively constant across decisions times and employer groups by contrast the race drift parameter is more than three times larger in the short compared to long decision time in the pooled sample this confirms the hypothesis that employers focus more on race early in the hiring decision and then gradually shift their attention to other worker attributes that are less salient but more relevant for hiring decisions we again find large heterogeneity in this pattern across employers going from short to long decisions the ratio of productivity to race drift changes from 22 to 12 for white employers supporting aa and from 25 to 68 for black employers by contrast this ratio of only increases from 14 to 23 for white employers opposing aa these estimates help explain the large variation of the effect of time pressure across employers 32 figure a9 visualizes the changing role of the race drift across decision time and employers by plotting how expected relative decision values evolve we can use these structural estimates for counterfactual analyses and calculate hiring probabilities for candidate pairs with different combinations of race and productivity differences figure 10 plots the hiring probabilities calculated separately across decision times and employer subgroups differences in productivity beliefs are plotted on the xaxis hiring probabilities on the yaxis and differences in beliefs that the worker is black are presented by different lines in the pooled sample lines have a steeper slope for long than short decisions reflecting that productivity beliefs have a larger effect on hiring probabilities in decisions without time pressure the bottom three panels visualize heterogeneity in responses to time pressure across employers for black employers and those favoring aa the productivity profile becomes much steeper for long 31 a threshold of 142 should be interpreted as 142 standard deviations of the accumulated noise of mental computations after a second of decision time 32 we also find that the starting point is significantly biased against black workers for some employer subgroups in the long decision frame and that this bias appears to favour black workers in the short decision frame for all employer subgroups the fact that our estimates do not support the assumption of constant drift rates across experimental treatments combined with a lack of observations near the intercept means that we should guard against interpreting the starting point estimates as heuristic biases decisions capturing that these employers are more likely to override their heuristic bias and hire more productive workers when given time figure 10 simulated hiring probabilities the vertical difference between the highest and lowest lines in the graphs indicates the hiring penalty experienced by black workers at varying levels of productivity differences notably this penalty is larger for short than long decisions and peaks for black workers with moderate to large productivity advantages 33 these estimates also provide insights into the necessary productivity advantage required by a black candidate to have an equal chance of being hired as indicated by the horizontal difference between races at the 50 hiring probability threshold in the pooled sample this premium amounts to 203 pp for long and 390 pp for short decisions for white employers who oppose aa these figures increase to 528 for long and 442 pp for short decisions for white employers favoring aa the productivity premium is sizable at 341 pp for fast decisions but decreases to 101 pp for long decisions black employers require a more moderate productivity premium of 258 pp for short decisions which decreases to 130 pp for fast decisions the results in this subsection confirm that the ddm provides a useful framework for understanding the observed relationship between response times and hiring decisions and helps explain seemingly contradictory responses to productivity beliefs and hiring decisions although variations in hiring decisions across short and long experimental treatments can not be completely accounted for in a single ddm with constant drift rates the structural estimates from separately estimated models indicate that race beliefs have a strong effect on short hiring decisions but becomes much less important when hiring decisions are longer we also document important heterogeneity across employer subgroups in how attention to race and productivity beliefs shifts between short and long decisions the results suggest that while all employer subgroups exhibit some degree of racial discrimination in their hiring decisions the cognitive processes driving these decisions may vary significantly alternative mechanisms uncertainty and risk aversion an alternative explanation for the race gap in hiring is that firms may be more hesitant to hire black applicants due to uncertainty regarding their productivity levels 34 that is in addition to differences in expected productivity differences in the variance of productivity beliefs may also influence decisionmaking 35 to test this hypothesis we ask employers to rate their certainty about picking the more productive worker in each choice after they completed the ten hiring decisions 36 in line with the ddms prediction that people facing time pressure reduce the information threshold we find that employers in the short time frame report being 32 pp less certain about their choices if employers are indeed less certain about productivity of black workers race differences between candidates would also reduce certainty however our findings suggest the opposite perceiving one candidate as black and one as white increases levels of certainty by 53 pp even after controlling for productivity and other beliefs we observe a similar pattern where perceived race differences increase levels of certainty by 02 34 race differences in the variance of productivity beliefs can create spurious evidence from audit studies 35 one theory proposed in the literature for why firms may be more uncertain about black candidates is that the majority of hiring managers are white and people tend to be more effective at evaluating applicants from their own race group 36 we ask you hired name over name what do you think is the probability that you picked the more productive person to 03 sd this suggests that race differences reduce uncertainty in the hiring decision which is consistent with findings from the ddm that employers use race beliefs to reach an information threshold we conduct subgroup analysis levels of risk aversion to further test whether uncertainty is a driver of the race gap in hiring riskaverse employers may be more hesitant to hire candidates with unfamiliar names which could disproportionately harm black candidates contrary to this hypothesis we find that the race gap in hiring does not widen among more riskaverse managers this result provides further evidence against uncertainty as a driver of the race gap in hiring37 concerns about worker payouts last we explore the variation in whether workers obtain a chance of winning a large bonus for being hired this offers a clean test of how much employers care about worker welfare in our setting as it does not affect their own payouts the directional effect on the race gap is unclear exante if employers prioritize the wellbeing of white workers over black workers it may increase the race gap on the other hand if employers care about equity or are averse to inequality it may reduce the race gap we find that the bonus does not change the race gap in hiring one explanation is that the bonus has heterogeneous effects that offset each other some employers may prioritize the welfare of white workers while others may be concerned about reducing inequality and thus favor black candidates to investigate heterogeneity of the bonus effect we analyze the effect on different subgroups of employers interestingly we find that the effect of the bonus does not vary depending on employers support for racebased affirmative action political views or race we interpret this as evidence that concerns about worker welfare including explanations related to tastebased discrimination are less relevant in our setting this may be unsurprising since workers and employers do not interact in our study context however preferencebased discrimination may still factor into belief formation and help explain why employers hold incorrect beliefs about the productivity of black workers conclusion we explore the influence of names on hiring decisions drawing on data from both actual workers and an incentivized hiring experiment in a nationally representative sample our analysis reveals racial disparities in beliefs based on workers names and that these beliefs contribute to a race gap in hiring these results shed light on one of the fundamental challenges in studying the effect of names namely that names are not randomly assigned people hold many other associations that may be correlated with race and it is unclear to what extent these racial disparities reflect discrimination we find that other beliefs explain some of the variation in the hiring gap but that much remains unexplained especially in rushed decisions in addition most of the race penalty remains when we look only at the variation in beliefs for the same name and when we drop the most distinctly black names these results address the criticism that discrimination detected through audit studies mainly reflect associations other than race or are driven by the choice of certain names however our findings also highlights the importance of measuring race beliefs to correctly interpret differences in employer behavior measured by audit studies an important question is how much namebased discrimination documented by our and previous studies matter for situations outside of experimental settings especially as other studies using large administrative data sets find that black names are not correlated with educational and other life outcomes after controlling for other factors leading fryer jr and levitt to conclude that carrying a black name is primarily the consequence rather than a cause of poverty one explanation for this disparity in findings is that once people have more information eg through frequent interactions in the classroom they are less likely to judge others by their name yet there are many situations where namebased discrimination can prevent people from collecting additional information about a person as they may decide not to interview a candidate accept as a renter or offer credit esponda et al show how biased beliefs reduces peoples attentiveness to new information and prevents correcting beliefs learning requires that people are willing and able to adjust their behavior in response to information this can refer to new information and feedback or it may refer to thinking harder about a decision our findings show that perceiving someone as black substantially shortens the time people dedicate to considering other qualities of that candidate biased beliefs thus prevents learning from ones own memory being willing and able to learn also requires that one considers other characteristics than race that may be less salient and harder to retrieve when spending more time on a decision we find substantial heterogeneity in what beliefs people use in their decision for rushed decisions race beliefs are a key determinant of their decisions across all employers when given unlimited time some employers put more weight on their productivity beliefs while others are guided by the same beliefs as in rushed decisions in our data we identify support for aa as a predictor of who is considering other beliefs than race support for aa is also the single biggest predictor in who is holding biased race beliefs which is consistent with esponda et al s conclusion that inattention can prevent people from correcting beliefs one widely proposed strategy to reduce discrimination is to force people to slow down decisionmaking and thus reduce the role of heuristic biases associated with system 1 our results suggest that for some employers this strategy is highly effective in reducing discrimination however our results highlight two reasons that limit the effectiveness of these policies employers may be unwilling to consider other factors than race in their decisions and they may hold biased beliefs about these other characteristics in our sample these two tendencies are correlated which makes it particularly challenging to reduce discriminatory behavior for these employers echoing recent papers documenting substantial variation in discriminatory behavior across employers policies need to address the underlying source of this heterogeneity to be effective f π c exp vcw v 2 t 2 × ∞ n1 k exp k 2 π 2 t 2c 2 sin this is a defective probability in as far as it integrates to the conditional probability of crossing the lower threshold rather than one the probability density for the upper boundary can be obtained by setting v equal to v and w equal to 1 w calculating these density values is complicated by the presence of an infinite sum which needs to be approximated as discussed in however recent contributions have improved the efficiency and speed with which these calculations can be performed we use the fddm package in r to calculate the density values and the partial derivatives of the individual densities with respect to the model parameters our implementation of this model allows both race and productivity beliefs to determine the drift v θ 1 θ 2 in addition the starting value is allowed to depend on the difference in race beliefs across workers α α 1 this requires adding another parameter to the model so that the parameter vector is effectively this does not add any complexity to the estimation process beyond the application of the chain rule to calculate the relevant partial derivatives we start the estimation process by dropping all decisions with missing choices or productivity or race predictions this is represents about 98 of the total sample as is typical with such models we also omit a small share of observations with implausibly quick or slow response times specifically we drop 394 decisions with response times shorter than 05 seconds or longer than 20 seconds these decisions comprise 23 of the sample which is consistent with the the 2 to 3 of responses that is common for such models the maximum likelihood estimates are obtained by using a sequence of numerical optimization routines to identify the parameter values that maximize the likelihood value this happens in three steps first we use the bayesian global optimization routine implemented in r through the mlrmbo package the optimization is warmstarted by preevaluating the model over a 200 initial parameter values drawn using a spacefilling latin hypercube design these estimates are then used in a sequential optimization procedure across 100 additional iterations with kriging models as surrogate learners and the expected improvement infill criterion the terminal point of this global optimizer serves as the starting point for our second numerical optimization step which uses the neldermead method on both the calculated likelihood and gradient values this method was found to be more efficient and robust in approaching the same terminal point across different starting values than other methods we experimented with finally we use the berndthallhallhausman algorithm with starting values determined by the previous estimation step both the individual loglikelihood vector as well as the gradient matrix are used which allow us to cluster standard errors by employer using these methods are implemented in the maxlik package a2 tables figure a6 geographic variation in race gap notes the map shows how the race gap varies geographically we estimate our main specification separately for each state we limit the analysis to states for which we observe at least 100 hiring decisions affirmative action is measuring level of support from 0100 scale coded as con mid and pro racial diversity refers to zip code level racial fractionalization divided into terciles hiring experience refers to whether the respondent has reallife experience in hiring a appendix a1 estimation in the ddm a decision is reached when the relative decision value z t crosses either of two thresholds b or b in the most common version of this model this process evolves with constant drift v and is subject to random perturbations e t z t z t1 v e t this process is sometimes called a wiener diffusion process due to the common normality assumption of the error terms e t ∼ n ormal we also can allow this process to have a nonzero starting point α the total response time to cross a decision threshold t consists of both decision time t d and nondecision time t n this process produces pairs of observable decision outcomes and response times that are random variables whose distributions depend on four model parameters it is often more convenient to reparameterize this model so that c 2b and w αb 2b and to work with the parameter vector the probability density of the response time for decisions that cross the lower threshold can be expressed as

economists whose research aims to provide answers to the global labor market challenges of our time our key objective is to build bridges between academic research policymakers and society iza discussion papers often represent preliminary work and are circulated to encourage discussion citation of such a paper should account for its provisional character a revised version may be available directly from the author

within local government to support their ability to create and synthesis the evidence needed for preventative and public health interventions most research systems exist outside of the local authority and are based within health community and academic partnerships 1 in england local government has become a key constituent for addressing health inequalities and influencing the health of individuals and communities 2 while this has been lauded as an effective approach to tackle the multiple determinants of health there are concerns that generating and utilising research evidence to inform decisionmaking and action is a challenge 34 this situation is not isolated to england and international reviews have shown various ways in which local government access and acquire evidence for decisionmaking one review suggesting six models and approaches between local government and research systems 1 indeed evidenceinformed decisionmaking is complicated and involves integrating the best available research evidence with contextual factors including community preferences local issues political preferences and public health resources 5 with this backdrop this paper reports research which sought to understand the capacity to collaborate deliver and utilise research across one metropolitan district council the research explored current assets within local government in relation to research development and evidence implementation and how these could be further harnessed moreover the research identified limitations and shortcomings which prevented research use and activity from flourishing the paper draws out implications more widely for local government and how to reconfigure the relationship between research evidence and decisionmaking in public health the transfer of public health functions in england from the national health service to local government in 2013 aimed to bring about improvements to population level health and to reduce health inequalities while the delivery of public health can vary in local authorities 6 this reorganisation saw a change in culture from a narrow focus on health care pathways to one of a politically led environment with opportunity to influence the wider determinants of health and wellbeing as part of this health and wellbeing strategies are a vehicle for local governments to act on the wider determinants of health and wellbeing and provide an opportunity to adopt an evidencebased approach to local decision making and prioritisation of limited resources across local government nonetheless the use of evidence and published research within these strategies is not common practice analysis of health and wellbeing strategies by beenstock et al 7 identified that only five out of 47 health and wellbeing strategies referred to published research evidence and only three cited national institute for clinical excellence guidance barriers to the use of research and evidence to guide decision making include the questioning of the credibility of the evidence 34 and the transferability of evidence that is out of context and not generated in the local setting 3 studies exploring how evidence in local authority public health practice is used have highlighted the disconnect in understanding between policy makers and academics especially in regard to what constitutes robust and useful knowledge 8 indeed locally generated data are viewed by decision makers as fitting the political context having more transferability and thus having a bigger influence on their local decision making 9 in addition a systematic scoping review exploring the use of evidence in local public health decision making concluded that researchers need to develop a deeper understanding of evidence requirements from the perspective of decisionmakers 10 the local government association 11 further reiterated the value of research in local government settings the lga recently highlighted that local government needs practical research providing solutions that can be applied in real world situations councils can benefit from engaging in research partnerships the report suggests the need for increased capacity and development of the local authority research system other reports have also signalled the importance of taking a population level nonclinical and transdisciplinary approach to public health interventions and research 12 how that vision translates into practice and work on the ground is relatively underexplored and understood so while the rhetoric is strong it is clear that there are significant challenges based on the daily rush to support frontline delivery of services with a lack of resources in local government this means that time expertise and space to use or generate research is a struggle 13 in the uk the national institute of health research funds health and social care research that aims to improve peoples health and wellbeing the nihr recognised the position that local government can have to improve population health and set out a funding call to identify how local authorities could be developed into locally based research systems and to shape future investment the research presented here was conducted following a successful application to the local authority research system funding call the research was based in one local authority in the north of england where qualitative methodology was employed operationalised through interviews focus groups meeting observations and documentary review this paper focuses specifically on interviews and focus groups with a range of local authority personnel to enable greater understanding of the capacity of the local authority to collaborate and deliver research methods the research was undertaken between augustnovember 2020 the overarching aim was to explore the current research assets in the local authority and to determine how these could be nurtured and replicated within the organisation to foster a stronger research culture in addition the research sought to identify any perceived barriers that exist to the local authority working with academic partners in particular to establish research capacity and opportunities and explore with key members of the organisation how a sustainable research system could be developed to impact on local residents health reduce health inequalities and identify the most important research outcomes the theoretical underpinning of the research was the research capacity development framework 14 the study adopted a collaborative approach throughout from the funding bid development to outputs and dissemination a project steering group was established which included representation from the local authority at strategic operational and political levels neighbouring local authorities who had also received nihr funding local academic intuitions nhs research infrastructure support networks and the local nhs hospital trust this steering group supported with the study design recruitment and data analysis and following the study knowledge transfer and dissemination the study was chaired by an elected member in the uk an elected member is chosen to represent their local area and inform and influence the decisions and running of the local authority elected members may have key responsibility for different portfolios such as health childrens services planning and transport data collection was undertaken by an embedded researcher who was based within the local authority for the study period the er model is becoming increasingly highlighted as allowing a joinedup approach to creating and using knowledge by placing a researcher in a nonacademic organisation to better link research and practice 15 the decision to use an er in this study was so that it could potentially provide greater depth and insight within an organisation through having a researcher integrated within the culture and environment however this was compromised during the covid19 pandemic and the er became digitally rather than physically embedded in the local authority as part of the er process a coapplicant of the study facilitated access for the er to attend to attend online team meetings at the operational and strategic level with various departments across the local authority in order to meet employees develop a rapport with teams and raise awareness of the study this included attending team meetings and formal committees the er was introduced to strategic directors by another coapplicant of the study who was also a member of the local authority leadership team prior to the study starting the strategic leadership were informed and supportive of the study this helped with rapport building in preparation of the interviews while the research team conceded that the original intention was for the er to be colocated in situ with staff in the local authority there was still methodological learning and value from a digitally er working within the organisation this is reflected upon later setting the research focused on a single local authority in the north of england the area is one of the largest metropolitan districts in the country and is one of the largest cities in the uk without its own university with levels of educational attainment below average the area is in the top twentypercent of the most deprived districts in england and on average people die younger than in other parts of england cardiovascular cancer and respiratory illnesses are in high levels in the district resulting in people becoming ill at a younger age having to live with their illnesses longer compared to most of the rest of the country sample purposive sampling was used for both identifying individuals for the interviews and focus groups the sampling was conducted with support of the project steering group in which a discussion was had to identify the key strategic roles and groups from across the authority that would need to be included the steering group also identified groups of people who were research active roles within public health where research was considered to be used in practice on a regular basis and elected members who had responsibilities for different portfolios across the local authority participants were recruited via email invitation all participants were provided with a briefing paper written by members of the project team and coapplicants employed by the local authority and a participant information sheet prior to data collection to ensure informed consent was gained consultation with the study steering group informed the sampling of three focus groups which were conducted with focus group 1 elected members focus group 2 public health officers and focus group 3 officers with research interests across the local authority interviews were conducted by the er with corporate directors and service managers purposively sampled to enable the research questions to be explored fully all data collection was undertaken online using microsoft teams due to social distancing restrictions of the covid19 pandemic all aspects of the study received ethical approval from both leeds beckett university and sheffield hallam university and access permissions were gathered from the local authority via the strategic leadership team interviews and focus groups were conducted in parallel due to the short time frame in which to conduct the research and lasted between 30 and 60 minutes interviews and focus groups explored a range of issues which were informed through the research capacity development framework developed by cooke 1416 the rcd works at individual organisational and systems levels with a purpose to develop research that is useful and impactful to society 1718 assessing both the assets and potential for rcd of an organisation can help articulate what a partner may bring to a collaboration and can be considered an important aspect of winwin research partnerships the rcd framework has been applied in a range of contexts and in developing of organisational research strategy 16 using the principles of the rcd framework 18 the interview schedules and focus group guides covered linkages and partnership skills and confidence in the workforce and wider community infrastructure of the council and wider partnerships research use and dissemination experience and assets of coproduction in projects and ownership leadership and sustainability of research activity data analysis interview and focus group recordings were transcribed by an external transcription company anonymised and shared as a secure online file which was accessible by three members of the research team all transcripts were coded on nvivo 12 by the er and two members of the research team cross checked a sample for coding accuracy data were analysed using framework analysis 19 framework analysis was used as an expedite method given the short timescale for the project funding and was deductively informed following the rcd framework 14 specific elements of the rcd framework were used in the development of the matrices a core aspect of framework approach this seemed pragmatic in deductively analysing the data set given the rcd framework was used to inform the data collection tools given the limited timeframe set by the funder for the research delivery the data was analysed sequentially with interview analysis being completed first followed by focus groups this was based on pragmatics but also was beneficial in refining analytical categories and themes during the process and supported the triangulation of the two sets of data inductive coding and inductive thematic development was also part of the analytical process to enable specific local issues within the local authority to be represented results the analysis revealed a range of thematic areas relating to the focus of the research this section presents these to highlight the barriers and potential in local authorities for improved researchled decision making to address health inequalities barriers respondents identified challenges to improving researchled decision making to address health inequalities the political and cultural context respondents described a duality in the use of research and evidence within local authority decision making and how the essential political nature of a local authority led to unavoidable tensions sometimes politics and research meet in a way thats positive and constructive and sometimes it collides and sometimes research and objective factual information is inevitably used politically or influenced by politics pressures arising from the four yearly election cycle were acknowledged as election time draws closer elected members may begin to look to research for insights into or solutions for complex problems such as health inequalities but the time required to complete the research process and a need for prompt answers is incompatible the political landscape may have moved on before research can provide answers or political priorities changed many respondents highlighted the challenge in balancing the need to undertake robust research and the need to complete it quickly with a tension between academic rigour and the political need to get things done the constraints of the four yearly election cycle also meant that where research and evidence was used to inform decision making it may be focused on popular shortterm solutions and immediate response rather than engaging with the root causes of health inequalities and a longerterm view the political leaders within the local authority were also felt to be more reluctant to deal with complex problems such as health inequalities as they may be viewed as a signal that something isnt working rather than as an opportunity for identifying potential solutions respondents felt this could lead to decisions being made because they would be popular with voters but that these decisions were made quickly and without establishing what the most appropriate course of action may be theres a lot going on that you have to do bang bang bang its a bit like that political you know this is what we have to do and we have to do it now but when do we actually have time to step back and ascertain whether weve done the right thing and what have we learnt from it respondents also described how it was politically expedient to be seen to be operationally focused and pragmatic with a strong focus on day to day delivery of services research could therefore be something which was a distraction from business as usual and be a less attractive option for the use of resources but historically i think theres a view that research is not doing so weve become a council that is overly focused on action rather than consideration and careful development of those actions so across the organisation i would say its kind of frowned upon as being a little bit academic and a little bit of nondelivery the expectation for the local authority to be seen to be focused on delivery also led to constraints on those who had taken on formal training or qualifications such as an msc or phd on their return to the workforce they are fully committed back into delivery and had little opportunity to use their newly acquired skills i think theres a lot of people within the named department who are doing their masters or they have done their masters but then its incorporating that into the everyday job and i think sometimes you just revert back to the day job rather than what youve actually learnt through doing that programme barriers arising in the wider political landscape were also identified by respondents the impacts of austerity and the financial restrictions within which a local authority must operate were widely acknowledged time and resource for developing or using research skills and capabilities were limited but again its about how you actually make that happen in terms of resourcing because as the workforce has shrunk we have less flexibility to enable that to happen without then having to backfill posts respondents also suggested that the policy and practice of the wider research system was felt to be set up to support academic and nhs organisations conduct research rather than local authorities so im caveating i suppose that i think academic researchers go through professional network nationally to then reach individual local authorities what we dont do and there isnt a system for is us saying individually or collectively as local authorities heres an area that we think would benefit from some research and some research expertise could we collectively put that out to see whether we might find an appropriate research partner to work with us on this so its a oneway system this potential lack of dialogue could then leave those within the local authority feeling that researchers collected data from the organisation or community and then disappear with it for a couple for years without useful outputs coming back into the organisation furthermore the language used by academics and researchers was not always helpful or useful and the perceived elitist world of academic research was not considered accessible to the delivery focused local authority lack of organisational strategy local authorities as with any organisation have flux in terms of leadership and strategic direction variability in the leadership around researchled decision making presented a number of challenges to tackling health inequalities respondents explained that where individual officers within a service had a personal or professional background or interest in the use of research then a researchled response to health inequalities may develop but the use of research was not yet an overarching strategic vision of the organisation this patchy and sporadic approach to research was problematic even where there was a growing interest in the use of researchled decision making amongst practitioners senior management may not share this position as senior managers control the service budgets and resources this could then preclude any further action being taken its also then about getting buyin from the highest level because whats the point in even trying to look at solutions for a problem if you dont have buyin from senior management the lack of a coordinated organisation wide approach to researchled decision making was seen to lead to a culture of research as somebody elses responsibility with services within the local authority providing policy and intelligence functions seen as responsible for providing relevant updates and insights rather than researchled decisionmaking being embedded within the organisation facilitators respondents identified several opportunities for research led decision making within the local authority recognition of the value of evidence respondents described the growing support for research already present within the organisation and the recognition that the tighter financial constraints required more careful targeting of limited resources for the greatest returns research was seen as spending a little more up front to make sure your finances are focused in the right area in addition there was a willingness across senior leadership to engage with the culture shift required to take on board the insights available from research with a growing interest in a bit more thinking about how we could deliver it in practice external research findings were felt to bring the additional advantage of being both instructive for changes to policy and practice while remaining uninfluenced by the possible biases present within the local authority the advantage would be purely that independence because i know very much im sure im definitely guilty of it and im probably sure other people are quite often we maybe have a solution in mind before we even start so were trying to do research that will fit our solution so youve got that inbuilt bias in the research that youre doing so how you ask the questions who you ask them to what the content is youre almost trying to fit the solution that youve got in mind whereas somebody completely external is probably starting more with a blank piece of paper and is just supplying the evidence that leads you then to a potential solution for a local authority with the requirement for public consultation and feedback evidence inherently incorporates the local voice the value of intelligence generated locally was in the immediate geographical or cultural relevance which fed more easily into any decision making process as such respondents reflected the value of coproduction to inform decision making around health inequalities listening to the voices of the community and understanding that the use of these insights could result in better service provision and a more efficient use of resources was driving the focus on evidence based decision making higher up the agenda within the organisation i think theres also something about leaders understanding what the national agenda and national conversation is around that and engaging with people with lived experience and the value that that can bring to an organisation while acknowledging the cultural differences between the local authority and academics respondents highlighted the opportunity to drive the use of research when addressing health inequalities by tailoring research findings to the needs of both the elected members and officers separately i think it would be to managers to me that it will aid decision making that if youve got the right information its much easier to make decisions on policies and for politicians as well the way forward it would be to me about helping make decisions overall respondents were clear that the challenges of using research in a political organisation were not insurmountable and any research into health inequalities that could bring that strategic and operationalness together would be well received building existing networks though a divide between the culture and practice of academic nhs and local authority organisations was described by respondents it was also clear that this divide was already being bridged and with further work could be mitigated further the perception of a divide was manifested in a belief that local authority employees simply did not do research but some respondents suggested that this was not wholly the case and that was a comment that came back from one of my service managers was no we havent done any academic research as such and i said that wasnt the question that i askedcertainly i had to prompt them to sort of say actually you have done a lot of research and youve used that research to put options and recommendations to elected members to inform their decisions the national move towards greater integration between local authorities and nhs organisations was also described by respondents as a facilitator of the move towards greater use of research so i think were working on it and were trying because there are two very very different cultures so its about understanding each others worlds and how we can come together and what we could share what research we can share thats applicable to both of us potential to improve researchled decision making was also felt to lie in the networks around the local authority membership of professional networks provided exposure to new ways of working and allowed for the dissemination of research findings i would to some extent try and find out that myself by attending some public lectures at places like the university who get a lot of guest speakers in from the office for national statistics and the like to talk about some of the cutting edge stuff that theyre doing respondents also identified how relationships and networks need to be built with the local voluntary and community sector groups not just with professional or academic networks for improved decision making these groups understood the context and lives of the communities the local authority served and could therefore provide greater insight to help target resources more effectively championing a research infrastructure a champion for research at a senior level was felt to be an important actor to facilitate the growing momentum within the local authority for research and evidenceled decision making a senior leader would be able to identify where challenges remain in addressing health inequalities and how to develop services often as a result of their own background interest or simply by being curious senior leaders could potentially make decisions to fund and support more research in addition they need to manage the tension between the timescales within which the local authority operates with the timescales of a research process which seeks to create new intelligence greater understanding and tolerance of any delays could ultimately lead to the organisation being better informed and able to make more effective decisions about action its understanding the timescales and its sometimes you may be asked to look at a problem and theyre expecting a solution very very quickly whereas for quality research its going to take a prolonged period of time obviously within local authority we tend to work in fouryear cycles really if that coming towards elections and things like that so its understanding that things dont happen overnight and that if you want quality information quality data its going to take time to collect before the solutions can even be dreamt up the economic constraints within which the local authority must operate are unlikely to shift and limitations on the formal funded routes to developing research skills within the workforce are likely to remain however respondents identified the informal pathways within the organisation such as mentoring or secondment that were available these could be used more effectively as an organisation and while acknowledging the impacts on resourcing would bring the benefits to the organisation so likewise again if a member of my team said do you know what id love to spend a day a week with an academic institution researching this as long as we can make it work in terms of you know the pressures that we have work pressures then i would really support that discussion this paper sought to understand how research evidence could be more effectively used to inform decisionmaking in a local authority focusing particularly on what strengths and assets are currently embedded in the organisational makeup and to identify any potential areas for development uniquely the research design was underpinned by an er model which has high utility in gaining depth of information and recognising contextual and local factors we argue that such an innovative methodological approach offers a new contribution to understanding the use of research and evidence in local government while this er was largely digitally integrated there were particular benefits with adopting a model whereby rapport could be developed with individuals within the local authority to foster rich data gathering this is discussed again later in this section influenced heavily by evidencebased medicine evidencebased public health is a longstanding principle of great importance in research and practice this principle has been amplified by the movement of public health into local authorities with the increasing emphasis on economic rationalism and the need to justify expenditure and ensure that funds are deployed to maximum returns 20 with the political dimension that local authorities hold economic rationalism and evidencebased decision making is crucial to ensure democratic legitimacy but to date little research exploration has focused on this matter if local authority personnel are to successfully implement change then they must draw on the evidence base to aid and support decisionmaking 21 by elected officials indeed this rhetoric was well understood in this study and the practical challenges were also recognised by participants this study showed the significant challenge for local authority practitioners and policymakers using evidence to good effect some of these issues are unsurprising and have been noted elsewhere 7 it is perhaps axiomatic that busy practitioners working in local authority do not have the space or time to engage in research evidence generation or assessment and this study reenforced that this situation has not necessarily changed over time while this is understandable it can be a fundamental shortcoming for effective evidencebased decisionmaking there is also a strong ethical imperative to adopt the principles of evidencebased practice to ensure that health promotion and public health activity does no harm either directly or indirectly by wasting limited funds on ineffective or inappropriate interventions or by raising unrealistic expectations about what might be achieved similar to the findings of the study reported in this paper in a study by li et al 20 p196 health promotion practitioners stressed the value of evidence for this reason one participant in their study noted i do firmly believe that we need some evidence before we launch into things i think the prospect of doing harm is too great to not have some inkling of where it is going to go the context of public health within a local authority a political domain is also interesting for research and evidence utilisation lifestyle drift is the inclination for policy that recognises the need to act on upstream social determinants only to drift downstream to focus on individual lifestyle factors 22 in a culture where lifestyle interventions are significantly easier to evaluate and are facilitative of political cycles it is understandable why more entrenched determinants of health which takes years to address are often ignored 23 this strikes to the epicentre of the tension between academic rigour and expedient decisionmaking and was highlighted here as a common issue in local government public health is a very evidencefocused arena and some have suggested that english local authorities are not a natural home for traditional evidencebased practice local government systems are political systems with key decisions needing locally elected officials approval 6 this has direct relevance to research leadership in local authority and having individuals who subscribe to research and evidencebased principles at the pinnacle of local authority structures the research demonstrated that where this was in place it fostered stronger commitments to research and evidencebased decisionmaking within teams and services it has been suggested that training for practitioners in interpreting research evidence is a necessary competency to aid professional judgements 24 both li et al 20 and owusuaddo et al 24 have demonstrated that practitioners in health promotion value evidence from researchers that is contextbound and relates directly to their own practice rather than evidence which is more abstract or outofcontext this was shown in this study where decisionmakers had a preference for contextspecific evidence yet in reality this can be difficult and extracting useful evidence from various contexts is critical and does require advanced skills and understanding the research showed a strong appetite for individuals and groups within the local authority to improve their research skills and moreover suggested viable ways to do that through training and qualifications and strong connections with academic organisations and institutions the need for research competency and capacity in local authority is something that is commonly known both nationally and also internationally 25 owusuaddo et al 24 highlighted that training programmes which build and maintain common skill sets and language among local public health practitioners in ghana was necessary to accomplish evidencebased public health goals the literature highlights the benefits and challenges associated with utilising an er approach to gather data 15 our experience was overwhelmingly positive in terms of accessing rich and detailed data for analysis and interpretation the er approach drew on ethnographic principles including interviews and observations but was fundamentally premised on being responsive and agile to opportunities that were presented within the local authority while the er was digitally embedded and not physically embedded as a result of the pandemic this did not pose significant disadvantage indeed as discussed earlier in some cases it facilitated expedient access to key personnel who may have otherwise not have been made available there were however some limitations with the study access and rapport building with employees at the local authority was limited through attendance at prearranged meetings and the methods of data collection with limited opportunity for informal conversations such as those that take place in an office environment the shorttime frame set by funders to set up deliver and report on the research meant the study team and er had to focus on ensuring that data collection was prioritised with less time to establish the er into wider teams across the local authority the skillset of the er was crucial in being able to navigate both the local authority processes and also the academic collaborators making up the study team where challenges arose they were mitigated by strong partnerships between the research team and the local authority staff as well as the project steering group this collective partnership between all constituents worked exceptionally well and enabled data gathering on barriers and facilitators to be conducted relatively smoothly the er approach offered the opportunity to gather insight from within the organisation that we are confident would not have been uncovered using other approaches to data gathering conclusions the study utilising a unique er approach has explored and shed further insight into the decisionmaking processes and evidencebased decisionmaking in local government public health practice and practitioners are accustomed to the use of evidencebased decision making yet this study showed how the democratic and organisational structure of local government challenges how effectively evidence is used in practice furthermore increasing demands limited capacity and resources impact on even the most research engaged practitioners ability to do research the research highlighted the criticality of research leadership to challenge the status quo in the process of policy development and decision making in local government and move it to one that uses evidencebased principles and prioritises the use and development of research undertaken within local government organisations the er model has high utility in gaining depth of information and recognising contextual and local factors which would support research capacity development in local government local government place based collaborations and academic institutions should explore and develop opportunities for ers to bridge the organisational divides in doing so developing trusted relationships continued staff development and research capacity abbreviations competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

background local government has become a key constituent for addressing health inequalities and influencing the health of individuals and communities in england lauded as an effective approach to tackle the multiple determinants of health there are concerns that generating and utilising research evidence to inform decisionmaking and action is a challenge this research was conducted in a local authority situated in the north of england and addressed the research question what is the capacity to collaborate and deliver research the study explored the assets that exist to foster a stronger research culture identified barriers and opportunities for developing research capacity and how a sustainable research system could be developed to impact on local residents health and reduce health inequalitiesthis was a qualitative study utilising semistructured interviews and focus groups the study used an embedded researcher er who was digitally embedded within the local authority for four months to conduct the data collection senior managers were purposively sampled from across the local authority to take part in interviews three focus groups included representation from across the local authority framework analysis was conducted to develop the themes which were informed by the research capacity development framework results tensions between research led decision making and the political and cultural context of local government were identified as a barrier to developing research which addressed health inequalities research was not prioritised through an organisational strategy and was led sporadically by research active employees a recognition across leaders that a culture shift to an organisation which used research evidence to develop policy and commission services was needed building relationships and infrastructure across local government placebased collaborators and academic institutions was required the embedded researcher approach is one method of developing these relationships the study identifies the strengths and assets that are embedded in the organisational makeup and the potential areas for developmentresearch leadership is required in local government to create a culture of evidencebased principles and policy the embedded research model has high utility in gaining depth of information and recognising contextual and local factors which would support research capacity development

the language used to discuss aging has been criticized for its poverty reflecting and reinforcing instrumentalist and reductive approaches to aging that do not convey the nuances and lived experiences of a complex process lived in time we argue that the same could be said for language used to discuss intergenerational relationships the term has become ubiquitous across academic policy and media discourses and is often used as a shorthand to describe different generational cohorts finding no adequate synonym we use the term ourselves but we seek to broaden the vocabulary and deepen understandings of what we mean by intergenerational relationships we do so using the concept of lived ambivalence and a creative qualitative methodology of analyzing participants responses to novels we argue that novels that depict characters whose experiences and relationships are portrayed in a narrative form over time can be a useful way of opening up discourses of lived ambivalence rather than dichotomous discourses that imply a crosssectional approach to intergenerational relationships in which each generation is fixed in time fiction can facilitate more nuanced processual human and fundamentally more meaningful understandings of how intergenerational relationships are lived in time and what they mean to people intergenerational dichotomies we argue that there are two main discourses of intergenerational relationships both of which reinforce a sense of rigid generational boundaries instrumentalism and reductivism and neither of which are helpful in facilitating a more nuanced understanding of relationships between people of different ages the first discourse can be understood as generationalism a mindset that instigates artificial confrontations between the generations in a simplified and exaggerated way perpetuating a narrative of generational injustice and ongoing crisis that divides generations this discourse relies on a conflict solidarity binary that frames intergenerational relationships as sites of antagonistic zerosum battles between different generational cohorts most currently typified as boomers and millennials it is often found in the media and social media where the assumption of an economic and political conflict between the two generations has become an established trope these conflict narratives often invoke the future with calls for intergenerational justice to address what are framed as future threats caused to todays children and younger people by todays older people in response to this there have been calls for a greater intergenerational solidarity that puts generational divisions aside and comes together for the sake of a more broadly imagined humanity the conflictsolidarity discourse is related to a second dichotomous discourse that identifies intergenerational segregation as a problem that needs to be addressed through increased intergenerational integration examples of this include interventions and calls for policies intended to facilitate greater intergenerational interaction in housing educational settings workplaces and communities in general a desire for greater intergenerational solidarity and integration is understandable particularly as intergenerational relationships have been centered on discourses concerning several recent political and environmental issues however seeking solidarity in intergenerational relationships can be limiting as it requires a consensus that minimizes the diversity of different experiences and risks ignoring how age intersects with other social divisions such as class gender race and ethnicity an uncritical emphasis on solidarity can paper over the tensions and contradictions inherent in personal and social relationships and render the term intergenerational relationships anodyne to gain a more meaningful understanding of why and how intergenerational relationships matter to us we must go beyond dichotomous discourses that mask the messiness of lived relationships to find a way to expand the discourses of how people of different ages relate to each other we argue that the concept of ambivalence can be helpful in this regard ambivalence and intergenerational relationships ambivalence has been used in aging studies to cut through simplistic dichotomies for example in understanding conflicting feelings toward the future in people living with dementia it has also been used in research on intergenerational relationships as a bridging concept between social structure and individual action that also has a dynamic transformative and temporal dimension as such ambivalence allows for differences of opinion and reflects the way personal relationships can often be sticky and difficult to shake free from… at an emotional level even when conflict is present around topics where values may differ relationships still survive defining ambivalence as the coexistence of mixed or contradictory emotions attitudes or ideas about the same person object or situation by an individual subject it can offer a mature step toward acknowledging a more complex world of multiple perspectives and emotional resilience lüscher conceptualizes ambivalence as a useful counterpoint to a desire for solidarity which while appealing can imply an idealized and static worldview that can ignore function and process the concept of ambivalence allows us to get closer to how intergenerational relationships are lived within kinship and social networks the significance of aging as a process and of how relationships are lived coheres with calls from scholars of aging studies to draw on approaches from the humanities to better understand these deeply humane processes and experiences baars argues that our experiences of living and aging through time cannot be reduced to the eitheror dichotomies he identifies as being prevalent in academic and public discourses on aging and so advocates for a lived ambivalence that can cut through these one way to better understand the complexities of aging is through cultural and literary texts free from the conventions of policymaking and scientific research that often reduce human experience to empirical data fiction is better equipped to explore the ambiguities contradictions and richness of the relational and processual nature of aging there is a substantial body of work by humanities scholars who draw on fictional texts to better understand aging as a process and experience demonstrating how aging is a lifelong process informed by cultural social and material forces fiction has also been used by health care professionals in geriatric medicine to communicate and explore the emotional aspects of aging with patients sociologists have used fiction as an alternative source of knowledge to provoke new perspectives on the social world and as a spark for theoretical rumination within literary studies felski has argued that identification with fictional characters can provide access to shared experience without negating difference and enhance a readers sense of self in society alongside character narrative emotion encourages readers to become empathetic cocreators of fictional worlds by respond ing to the techniques of storytelling with curiosity suspense and surprise a growing body of work in the social sciences and literary studies demonstrates the value of using literary criticism as an empirical device to investigate social issues and ambivalences and to elicit lay reflections on cultural narratives of aging addressing a perceived hierarchy and disconnect between professional and ordinary readers the relationship between novelists and aging scholars also works the other way the british author margaret drabble acknowledges that her novel the dark flood rises was partly inspired by helen smalls the long life there is less of a tradition of using literary texts to understand the diversity and complexity of intergenerational relationships in gerontology yet there is scope to use fictional representations of intergenerational relationships to relate and understand their social impacts literary texts have been used to facilitate and study intergenerational relationships be that exploring the nature of play and connectivity and highlighting the mutual learning benefits that emerge in intergenerational reading groups intergenerational reading groups offer a fruitful ground for analyzing complex attitudes to relationships between people of different ages as together readers make meaning both individually and as a collaborative group drawing on experiences across life spans methodology the findings presented here are part of an economic and social research councilfunded project reimagining the future in older age which aimed to examine the relationship between older age and future time the project received ethical approval from the university of stirling we undertook a qualitative study that brought together adults of different ages to analyze and reflect on dominant narratives of aging and intergenerational relationships by discussing novels that depicted these themes we chose novels as a literary form because of their accessibility to a range of readers who might differ in confidence and because we judged their typical length and narrative structure conducive to portraying aging and relationships as processes in keeping with the projects focus on temporality the project team drew up a long list of novels which participants were then invited to choose from and add to only one novel was selected solely by participants the novels were primarily chosen because they depicted themes of aging time and intergenerational relationships that were central to the project we purposively sought novels from a range of genres and eras in order to represent different intergenerational relationshipsfrom the historical to the contemporary and from the realist to the speculativeto give readers a range of imagined societies life spans and fictional worldbuilding scenarios to respond to sparking imaginative conversations about readers own experiences for more information on the novels and the intergenerational relationships foregrounded please see supplementary material reading groups and book clubs have been found to encourage rapport and relational links particularly in an intergenerational context where adults of all ages can develop a mutually advantageous understanding of one anothers situation using literature as a creative method provided a way to engage with participants lived experiences as they compared their social worlds with those in the novels specific genres such as speculative fiction are driven by a goal that returns us to our own world enlivened with deeper understanding and insight… and fresh perspectives on how to build our age world in meaningful and just ways as such fiction can be used as a provocation to prompt thoughts ideas and feelings on reallife topics as well as a springboard to imagine different solutions and scenarios in the real world although originally planned as facetoface meetings due to coronavirus disease 2019 the reading groups were facilitated online by m lovatt and v wright and this digital element allowed us to recruit participants from across central scotland participants were recruited via social media and the project website and through snowball sampling in an attempt to recruit a diverse sample of participants across different social characteristics we also sent targeted invitations to a range of community and thirdsector organizations representing minority groups in scotland despite this the majority of participants were white womena bias that reflects the typical composition of reading groups reflecting on our recruitment strategy in meetings with our project advisory group we wondered if we might have been more successful had we been able to make inperson visits to organizations representing minority groups in order to explain the project in more detail build relationships and elicit suggestions for novels however these opportunities were denied us due to social distancing regulations in place at the time in the end 28 participants were recruited to four reading groups although not everyone attended all of the discussions due to a range of reasons including changing commitments and personal circumstances related to the pandemic we tried to ensure age diversity in each group the groups met monthly from june to october 2020 each group was made up of adults of different ages to allow for reflections on the novels from a range of perspectives the reading group sessions lasted approximately 90 min and usually began with the participants and researchers checking in with each other providing a type of informal emotional support network as we shared how we were feeling under lockdown conditions and as things began to open again we then invited participants to give their initial reflections on the novel followed by a semistructured conversation based on prompting questions circulated in advance the questions were based on m lovatts and v wrights readings of the novels and related to the research interests of aging time and intergenerational relationships although the questions were useful as a starting point discussions often spiraled out to a range of related topics raised by participants and they shared their own stories and experiences outside of the reading group all discussions were videoand audiorecorded and transcribed verbatim participants were further invited to keep diaries in which they could record their thoughts on the novels outside of the discussions and situate the readings in the contexts of their everyday lives and any other reflections they thought were relevant the data comprised transcripts from 19 reading groups and 43 diary entries in the first stage of analysis v wright and m lovatt read the transcripts uploaded them to nvivo 13 and conducted open coding which resulted in several themes of relevance to the project j e french then led a further round of analysis which focused on the theme of intergenerational relationships and which was guided by the question how can fiction expand our understanding of intergenerational relationships as j e french was not present for the data collection she supplemented her analysis of the transcripts with watching video footage of the groups and sharing interpretations of the data with the other authors j e french refined the themes using a mindmapping approach to create a thematic map of the data and to further search for relevant patterns using an inductive analysis approach this flexible approach was taken due to the breadth and depth of the discussions in order to capture as much richness of the conversations as possible that the analysis was conducted by researchers who were present during data collection and a researcher who was not increased our confidence that our claims to knowledge were justified and yielded insights that we may not have otherwise had in a manner similar to what james calls the analytic imagination not all novels are featured in this paper reflecting this papers focus on intergenerational relationships rather than aging and time more broadly which are covered in the other novels findings our analysis identified three key ways participants discussions opened up new understandings of intergenerational relationships a greater understanding of what intergenerational relationships are who they involve and what they ought to be a more nuanced understanding of emotional connection between generations and a desire for more authenticity in fostering intergenerational interaction a greater understanding of what intergenerational relationships are while the novels featured relationships between characters of different ages none of these were explicitly defined as intergenerational relationships the fictional representations opened up lines of communication with the generational other and the narration of complex characters entangled in relationships in a range of scenarios perhaps helped participants to talk about relationships in ways that transcended dichotomies this was revealed in the ambivalence that participants expressed about their own relationships with people of different ages how they felt intergenerational relationships might change with increased life expectancies and the relationships between ancestors and descendants intergenerational caring relationships within families were discussed in relation to the last children of tokyo a dystopian speculative fiction novel depicting the relationship between 108yearold yoshiro who has an increased vitality and life expectancy and his ailing greatgrandson mumei who will die young because of a variety of environmental and social disasters participants reflected on the extended life expectancy of the older characters in the novel and the implications of this for the nature of intergenerational relationships jen said i think it challenges us to think about what we mean by grandparents greatgrandparents i think sometimes when you use the words like grandparents and greatgrandparents we all have an image in our mind of what we assume that person to be that age to be but theres such a variety in society nowadays participants felt that the greater involvement of greatgrandparents in caring for younger relatives was not unlikely with kitty suggesting this might be the first generation where its not unreasonable to assume that greatgrandparents will have a caring role with their greatgrandchildren my grandchildren range from 18 months to 30 years old i think for me the kinda realisation that greatgrandparents now can be looking forward to actually having active roles i hadnt thought about that before when asked about what she felt about this extension of caring responsibilities she expressed ambivalence saying i have to be honest deep down you want to help your children but there is a bit where you think ive already done this obviously theres lovely bits to it but physically i dont feel equipped really she later added that while she was still working and active when her first grandchildren were born by the time the next tranche came along the middle ones and the wee ones ive been doing it just enough to really enjoy them but i am exhausted with it i really am this shows the ambivalence of caring for grandchildren but also the processual nature of the relationship as one that is lived through time as part of the aging process participants also expanded understandings of intergenerational relationships to include ancestors and descendants duine interpreted the decreased life expectancy of children in last children of tokyo as a message to society that when you live for today and to hell with consequences for tomorrow it is building up untold harm for your children grandchildren and following generations jamie echoed this arguing that the author has created this scenario as a kind of parable about each generations responsibility over the generations to come its not as simple as living innocently and then being cared for in your old age but living with a radical responsibility frankie also felt that maybe we should be looking back itd be interesting to look back seven generations and say right thats what i need to be making amends for or you know what happened seven generations back from me what horrors were carried out that might give a different perspective about it the novel sixteen trees of the somme uses the genre of a family saga to grapple with this exact question as edvard searches for meaning in the past 100 years of family history to decide the future of his farm the novel prompted differing responses in our readers jamie reflected personally i think that we owe more to future generations than our ancestors because they are the ones who are going to inherit the world sanny added that we have a responsibility to our ancestors as well as to future generations our ancestry is a major player in who we are values are passed down from generation to generation it can sometimes take a considerable time before we realise this but that does not detract from it being a truth this implies an awareness of change and continuity in intergenerational relationships where it is possible to identify different generations while acknowledging how each is shaped by and shapes others for participants intergenerational relationships included familial social and public relationships happening now but also placed generations in dialogue with ancestors in the distant past and descendants in the near future this perception of intergenerational relationships as one of mutual concern and responsibility occurring over several human lifetimes diverges from schefflers argument of a contemporary temporal parochialism the participants temporal framing of intergenerational relationships also runs contrary to the binary antagonistic generationalism represented in contemporary dominant discourses and is instead more akin to the longerterm reciprocal relationships rooted in environmental time as articulated in indigenous discussions of aging commitments to future generations in particular were evident in the emotional responses to the novels which we discuss next ambivalent emotions that complicate the conflictsolidarity binary several novels prompted discussions of the environment and participants of all ages acknowledged emotions of guilt responsibility and blame relating them to intergenerational relationships this is unsurprising considering that the climate crisis is typically framed as an issue of intergenerational justice however participants articulated these emotions in more complicated and ambivalent ways than attributing blame and victimhood to discrete generations in a zerosum fashion first many of the older participants felt annoyed with what they perceived as being personally blamed for environmental crises for example trouble with lichen prompted discussions of the environmental impact of extended life expectancies christine felt she was being judged by her family on the topic i mean even my daughter was saying oh its you thats ruined everything personally so already theres a bit of blame going on discussing last children of tokyo rebecca similarly expressed that her children were also blaming her for ruinin g the planet although some of the older participants expressed some guilt and responsibility they contextualized this within the socioeconomic political and technological practices and innovations experienced during their life course christine said im far more aware of the climate emergency i am more keen to do things i utilise things trying to stop using plastic i dont think that my generation is responsible for all the plastic waste per se but then that was the scientists at the time invented that and we all used it thinking that it was okay greta agreed with this saying i always have this argument with people when they start talking about plastic and ill go excuse me not my generation we get the sort of label youre the previous generation so you must be responsible for all of that participants used the discourse of generations but stressed the necessity to understand individual action within wider social practices second participants of different ages invoked a temporal aspect to guilt rather than seeing it as the preserve of particular age groups or generational cohorts they projected themselves into the past or future to consider what else they could have doneor could dodifferently to take more responsibility one example of this is a discussion about generational guilt in group 3 which was prompted by the environmental dystopian setting of the last children of tokyo clare began by saying i think of when im older and theres younger generations in my head im like they wont be resentful towards me ive done my bit but then like i am very much susceptible to causing climate change but i do think that element of guilt will always be there responding to this jen said when we were seeing all the climate change marches that were going on cause they were kind of the next generation down from me and i feel really guilty that i didnt do enough when i was their age when i was younger it was all about the hole in the ozone layer and stuff like that and it kinda felt like thats the only thing we concentrated on and then once wed solved that we stopped doing anything else so i think theres definitely a generational element to that guilt downloaded from by hochschule luzern user on 19 february 2024 kirsty agreed to some extent although believed that the generations that came before us that developed the technology to have everything disposable did so with the right reasons so i can see why there would be guilt but its up to us what we do with the technologies and the products that we have and i dont think weve made the right choices i dont think thats my mum and my grandparents fault discussions such as these were common across the groups elizabeth had a similar reaction to jen and resisted the idea that her generation was ignorant of the environment in the circles i was in it was very much about the environment climate rachel carson and silent spring protests of all sorts however she also felt that its kinda like then we got to a certain level and everybody went ooh we could have a holiday now time for champagne and opera jonathan thought that the characters in the last children of tokyo were just resigned to a state of hopelessness and… it felt like there was a massive amount of guilt on the part of yoshiro reflecting on the novel he projected himself into the future stating im going to be one of the older people so im going to be the one feeling guilty even though now i feel like im a younger person who gets to be like well it wasnt my fault and i guess it just goes to prove a point that i dont think guilt is a very helpful reaction to it a temporal dimension was also expressed in some participants invocation of an understanding of generations in a broader sense akin to that of the ancestors and descendants understanding discussed in the previous theme jess found the last children of tokyo shocking for its clarity in describing a world in which a child might only know of animals through his great grandfathers memories she said of mumei him drawing all of the animals and never getting the opportunity to see them it just reallybrought home quite what were doing to the planet and that that could be our future and i dont think were quite ready in this generation to admit it i dont think weve all everyone thats alive now has really accepted that climate change is a real thing here she implies a definition of generation as everyone thats alive now and in doing so suggests a shared responsibility regardless of age this was also suggested by jamie who argued i think that if we are going to make any kind of advance on this then there needs to be a rallying together rather than throwing stones at each other this can be interpreted as a desire for solidarity in the face of conflict but we argue that the lengthy discussions devoted to generational guilt and other emotions complicate this and reveal underlying tensions that cannot necessarily be resolved in a desire to address environmental disaster authenticity and ambivalence in fostering intergenerational contact participants welcomed relationships between people of different ages in the books and regarded intergenerational interaction as something to be valued and encouraged however they resisted what they saw as contrived attempts to bring people of different ages together instead they called for authentic intergenerational engagement this was prompted particularly when discussing the summer book and young art and old hector both of which foreground the relationship between older and younger characters set in the highlands of scotland in the first half of the twentieth century young art and old hector by neil gunn tells the story of 8yearold art and his older neighbor hector participants loved the depiction of the relationship for what they perceived as its warmth and empathy between people across age groups kitty praised the novel for showing life through an older persons eyes and a young person it was just that much clearer and i just felt like it just fitted somehow you know hectors experience as if he really could connect with art it felt like he could see easily the issues there for the kid angela agreed i think its just a lovely relationship that both of them really valued participants across the groups reflected on the relationships in the novels in the context of their relationships with younger and older people in family and wider networks and spoke of the value of these experiences agnes recounted her own experiences of working with children and older adults in schools and the joy she took in this ive got one photograph in particular of a lady who was in her eighties talking to a child of about eight or nine and the look between the eyes of these individuals is a connection over all these years talking about school teachers and to me thats the magic of it it doesnt matter how old you are youve got a shared experience although participants in all groups felt that these relationships were important for fostering empathy and learning across different stages of the life course several participants felt that these interactions were rarer for reasons including increased geographical mobility and a lack of time outside work and education they called for new policies and practices that could encourage intergenerational relationships focusing in particular on a desire for more free time however participants also articulated an ambivalent desire for authentic relationships they desired authentic community connection free from political interference at the same time as they articulated a need for new policies that would free up time and space to build such communities participants offered practical suggestions on how to use time more effectively kirsty felt having more time could encourage friendships across age groups and she wondered if a younger retirement age might change that if there was a wider span of people enjoying the same activity together this type of shared activity across ages was a motif of the summer book where many readers across different groups found the grandmother and sophias time together enviable as they are free to stay curious and organize their own time on the island the novel inspired them to imagine new possibilities for organizing time differently jonathan translated this desire for time into a potential policy solution we have the resources for like 3or 3day weeks for everyone and i think that would massively free up people to do what sophia and her grandmother are doing which are you know exploring and playing and being creative together elizabeth suggested that a universal basic income would free people up to do more voluntary work or even change careers across their life course where some might power on some might want to change direction alongside desiring more time a desire for more accessible intergenerational space was also important to participants responding to the summer book eleanor wrote in a diary entry do not keep elders and children apart compartmentalising their experiences into ageappropriate ghettos even if at times the relationship seems fraught or indifferent living and learning together improves our understanding of each other builds stronger relationships and teaches compassion participants were aware of existing projects that sought to bring different generations together including intergenerational coliving spaces nursery and care home exchanges and integrated dementia villages the space of the island in the summer book was seen to naturally encourage intergenerational connection prompting jonathans idea to build a care home something thats kind of a lot more open to the community where people can just interact rather than kind of you only visit a home if youre visiting a relative participants imagined new spaces where intergenerational mixing could happen with calls for community centers to be reopened and devolved to communities equally participants said that they did not want these spaces to be contrived or inauthentic the relationships between characters such as the grandmother and sophia or art and hector were praised for being genuine reflecting on young art and old hector jane shared a story about a local man who was a stalwart in her community once he moved to a care home he became more isolated and what would have been a natural everyday occurrence of seeing his neighbors became reduced to visits that were something you have to arrange katherine also craved more real example s of directly interacting with the older generation such as intergenerational house sharing where people would be not forced to but encouraged to mix and mingle angela cautioned against coercing participatory involvement noting you ant force someone to take part in something you know that takes away what oure trying to do i think thres only so much you can do and its about sometimes focusing on what groups are a success … not everythings going to be a success and it hasnt been but i think youve just got to try havent you participants hoped community would naturally occur and lead to active intergenerational communities based around reciprocity shared values and sincere connections discussion and conclusion in this paper we have shown how fiction can be used to humanize and add nuance to the term intergenerational relationships notably the novels read by the groups did not explicitly mention intergenerational relationships and made no reference to cohorts such as boomer or millennial instead they presented readers with complex emotional and ambivalent examples of relationships between people of different ages that readers could relate to the paper makes a number of key contributions to how intergenerational relationships can be engaged with more meaningfully beyond simplistic and reductive dichotomies first it expands dominant definitions of intergenerational relationships beyond fixed crosssectional cohorts of people of different ages alive today to include relationships that are lived and which transition over time second it identifies greater complexity and ambivalence in the articulation of emotions relating to generations and generational identities relating to environmental crises than is depicted in conflictsolidarity discourses third it presents ambivalent desires for on the one hand policies that foster greater meaningful intergenerational interaction while cautioning against interventions that are contrived and inauthentic the paper contributes to gerontological understandings of intergenerational relationships and ambivalence through its use of fiction and reading groups existing scholarship has identified ambivalence as a useful concept in resolving rivalry and moving beyond generational oppositions and to circumvent conflictsolidarity binaries by using a methodology of readers responses to novels we show how fictional representations of intergenerational themes can elicit more meaningful reflections on the ambivalences and complexities of relationships across age groups notably the ambivalence expressed by participants was rooted and revealed in reflections on their own lived experiences and their reactions to relatable fictional characters and scenarios this is closer to the lived ambivalence that baars although baars used the term more in relation to aging rather than specifically intergenerational relationships the experiential temporal and processual dimensions invoked by the word lived help us to make sense of the findings presented here we endorse baars insistence that time be given more attention to understanding the aging process but extend this to specifically include intergenerational relationships in reflecting on the novels participants spoke about intergenerational relationships as ambivalent processes lived in time this temporal dimension was evident in participants discussions about past existing and anticipated caring responsibilities extended definitions of intergenerational relationships as encompassing middle generations and ancestors and descendants personal regrets and anticipated guilt contextualized within historical processes and a desire for more time to allow for authentic intergenerational connection in addition to showing how fiction can deepen understanding of gerontological issues we suggest that our paper also offers insights into how gerontological concerns can inform interpretations of fiction although we argue that the very absence of terms such as intergenerational relationships or intergenerational segregation in the novels freed participants to express more nuanced and ambivalent thoughts than might otherwise have been the case their awareness of these issuesin part but not wholly prompted by our questionsguided their reading whether in speculative fiction such as trouble with lichen or the last children of tokyo or more realistic representations in young art and old hector and the summer book participants responded enthusiastically and ably to our invitation to read them with a gerontological lens and were well versed in the vocabulary of dominant discourses of intergenerational conflict inequality and justice in their discussions even as they expressed more ambivalence these interdisciplinary pathways between gerontological concerns and imaginative reader responses suggest that both approaches are needed to develop new ways of thinking through the complexities of intergenerational relationships and the transitional experience of livingaging through time a number of policy implications arise from this study given the marked ambivalence expressed by participants across different subjects and their desire for authenticity we agree with biggss suggestion that policymakers would be wise to embrace ambivalence to acknowledg e and negotiat e solutions promoted between generational groups participants echoed concerns about age segregation and valuing what they perceived as the genuine intergenerational connections depicted particularly in the novels the summer book and young art and old hector called for more time and space in being allowed to develop these relationships the ambivalence expressed here was one where participants wanted policymakers to facilitate greater intergenerational connection without necessarily labeling interventions as such accordingly the policies they endorsed were not explicitly targeted at addressing age divisions therefore organizations that work with intergenerational groups might consider how present policies currently being trialed such as the 4day week ubi urban design and climate action intersect with lived experiences of aging and what intergenerational communities can contribute to these ideas this paper addresses calls to mythbust generational conflict but also calls for nuance and complexity in invoking intergenerational solidarity the findings presented in this paper are underpinned by a methodology that uses fiction to provide a platform for ambivalent discussions and feelings where novels can open up new worlds and allowing for recognition to forge connections across difference and offer new vocabularies for discussing intergenerational relationships in doing so we offer a way to avoid the pitfalls of a flattening generationalism and bring more insight into what intergenerational relationships are and why they matter data availability for the purpose of open access the authors have applied a creative commons attribution license to any author accepted manuscript version arising the data supporting the findings reported in this paper will be available via the uk data archive repository from april 2023 this study was not preregistered supplementary material supplementary data are available at the gerontologist online conflict of interest none declared

background and objectives the term intergenerational relationships is widely used in gerontological literature and agerelated policies however discussions of the term often tell us surprisingly little about what it means or why it matters we suggest that this is due to a reductivism and instrumentalism in 2 main discourses within which intergenerational relationships are usually discussed first intergenerational relationships are often conceptualized through a binary conflictsolidarity lens reinforcing an entrenched generationalism second they are predominantly constructed as a problem to be addressed within debates on how to tackle intergenerational segregation neither of these discourses provides much room for a more nuanced understanding of how intergenerational relationships are experienced or why they are meaningful in this paper we discuss how fictional narratives can introduce imagination and a richer vocabulary into discourses concerning how people of different ages relate to each otherwe present findings from reading groups where adults discussed novels depicting themes of older age intergenerational relationships and timein discussing the fictional narratives and characters participants reflected on the significance and meaning of intergenerational relationships in ways that went beyond dichotomous and instrumentalist discourses drawing on the concept of lived ambivalence we argue that fictional representations of intergenerational themes can elicit more meaningful reflections on the complexities and contradictions of relationships across age groupswe conclude that a more nuanced understanding of intergenerational interaction can inform gerontological discourses and policy but also that gerontological awareness of social challenges concerning age relations can inform interpretations of fictional narratives

background in mexico 573 of the population do not have access to employment paid health care insurance 1 this situation represents a scenario of vulnerability where social capital could play an important role to solve health related issues to understand the association between social capital and health it is necessary to understand that the healthcare system conditions and access to healthcare services are marked by deep socioeconomic political and cultural inequalities it is also important to note that healthcare includes more than the possibility of getting healthrelated services it incorporates access to knowledge about how to navigate the healthcare system health education efficient and highquality medical care and material and emotional support to deal with illness 2 3 4 the national mexican council for the evaluation of the social development policy 5 defines the lack of healthcare access indicator as the population percentage that does not have healthcare insurance in public or private institutions the indicator expresses the degree of compliance with the provision of the social right to health access listed in the mexican constitution although the gap in access to healthcare has decreased in recent years 1 the prevalence of mexicans without access to healthcare coverage is still relevant in mexico health services are provided by differentiated subsystems 6 most of the medical services provided under a healthcare insurance coverage are delivered by the by the popular insurance which covers 422 of the population who lack of medical insurance as a job benefit given that its beneficiaries do not have permanent job positions the second most important healthcare provider is the mexican institute of social security which provides medical services to those employees working in private companies who cover the premiums as a benefit at the formal sector the recipients of this coverage represent 364 of the population other healthcare providers are state owned as the institute of social security and services for state workers which covers 55 of the population that receives this benefit as government officials other healthcare services are delivered through government managed hospitals who covers benefits to government employees at the national oil company the ministry of national defense the ministry of naval forces state level issste also as healthcare special programs as the imssprospera who provides primary healthcare in low income communities the remaining population receives medical under the private healthcare insurance indirect insurance and other medical institutions 7 despite the positive trend in healthcare access mexico has some of the highest outofpocket expenses among all of the nations belonging to the organization for economic cooperation and development 6 the quality of service and the satisfaction level explain why individuals covered by public institutions prefer to access to private healthcare providers where there is a larger amount of available facilities some of the most common reasons for not demanding services at the public healthcare systems are the long waiting times the lack of available medications the distance from the household to health providers the lack of money and the poor service delivered by healthcare workers at the clinics 8 people covered under the seguro popular medical insurance reported to have faced more difficulties to receive medical care at its facilities compared to have received assistance at other health systems 9 this is a remarkable disadvantage considering that most of the beneficiaries of the seguro popular are in the first four income deciles and the most economically limited data concerning the conditions of mexicos healthcare system suggest a scenario where social capital could play an essential role under this premise we selected four states with differentiated levels of social welfare and healthcare access to conduct our research 10 which can see in table 1 mexico city and oaxaca have the highest population percentage without access to healthcare and are above the national average the state of mexico has the same percentage than the national level while tamaulipas has the lowest proportion of individuals without access to healthcare 11 as it can be seen in table 1 states with higher marginalization levels have more individuals covered by the seguro popular and less beneficiares of formal jobs insurance either from private companies or government agencies data suggest a potential association between formal employment the marginalization index of the state and the number of individuals covered by the seguro popular considering previous statements we hypothesize that social capital is a relevant asset to manage health problems in mexico however in the case of illness support varies according to the conditions of marginalization according to several scholars families and friends social capital can become a crucial option to deal with health issues in the least developed countries where healthcare systems are inadequate 12 networks provide assistance trust reciprocity and support in case of illness therefore individuals with more social capital are more likely to be healthier 1314 social capital and health social capital is based on strong and weak ties cultural dynamics of production and social articulations such as a norms obligations and commitments b trust c expectations of reciprocity and c support and cooperation practices 15 16 17 18 19 social capital operates at the micro meso and macrosocial levels 19 the microsocial level employs networks of relations that can be understood as bonds with relatives and friends and belonging to groups of similar interests 20 according to granovetter 17 these networks of relations play a decisive role in the solution of particular problems and are the main sources of social and emotional support the mesolevel refers to the strength of the relations within secondary groups it comprises neighborhood and the sociocultural institutions of the community as a whole 19 therefore social capital is part of each communitys sociocultural system its management and its sanctioning structures the macrolevel includes a feeling of belonging to society and describes the degree of consensus and intensity of social bonds besides trust and institutional legitimacy it includes participation in social civil or political organizations 20 previous research has reported an association between social capital and health selfperceptions 21 22 23 there are also references to the influence of norms and attitudes on healthy behaviors and psychosocial networks that increases access to medical attention and mechanisms that improve selfesteem 24 25 26 social capital is also associated with community participation and mental health 27 28 29 physical and psychological health 30 and number of years lived 143132 some authors have described a relationship between informal relations and mental health 33 in this regard social capital represents a strategy to mitigate the effects of social isolation and social disconnection on health and quality of life 3435 this is particularly relevant for older adults because it has been found that social capital has positive effects on slowing mental illnesses 3637 indeed regular family contacts have positive impacts on loneliness among older adults 38 due to the value of social influence social support norms and the flow of information and resources 3940 in addition social capital is considered a relevant concept in public health because it helps to identifying the importance of the links or bonds that individuals create throughout their lives 2 family neighborhood and identity relationships shape the source of social control family support and creation of benefits through extrafamilial networks 41 42 43 several authors have suggested a positive association between social capital and health 4445 links that individuals build throughout their lives are valuable assets that can be tapped into for personal or community profit 46 bondingtype social capital includes trust and cooperation relationships among members of a network that compare themselves as similar because they share a social identity 47 this form of capital acts as a connector where trust and respect for norms are built but where intolerance and mistrust toward members outside of the group can also grow these circles include family members and very close friends 1848 as a consequence networks are a support system for solving healthrelated issues 49 however behavior that is harmful to health might be reinforced or reproduced because they are ruled by habits norms and customs legitimized by the group 17 bridgetype social capital includes acquaintances in social groups or networks where information is shared and exchanged 41718 regarding access to health care bridgingtype social capital relationships create more opportunities to get information individuals can ask friends and other groups to get access to other networks and potentially earn valuable information 50 weak links turn into bridges among two or more networks that offer access to information resources and health services beyond the intimate circle 51 the linkingsocial capital type includes norms concerning respect and trust it also comprises networks among individuals who interact through different levels of explicit formal or institutionalized powers within the society 4648 several studies show the association between social capital components and health depend on the context 4 the consequences of such a relationship can be observed in populations that are socially excluded to the detriment or support to the wellbeing 43 social capital highlights the potential of social bonds and interactions regarding disparities in access to health services 5253 and other social economic and cultural inequalities 54 considering the above some analyses have included income disparities 125455 and the implications of these interactions 256 however the positive effects of such associations do not limit the states responsibilities concerning public health and social welfare 57 social capital is used as an asset in the absence of an efficient healthcare system nevertheless the association is not homogeneous and can differ according to the characteristics of individuals and the context 4 mostly in populations that are socially excluded 43 for this reason our purpose is to answer what role does social capital play when people with different levels of marginalization and access to health services get sick in mexico methods municipal marginalization index this study employs the municipal marginalization index 58 as a measure of socioeconomic comparison among contexts the index includes four areas with nine types of exclusion which are measured by percentages of the population that have no access to basic services the four areas and nine types of exclusion are education housing population distribution and income each of these categories has an indicator expressed as a type of deficiency which is used to create an index that classifies marginalization in five levels very high high medium low and very low 59 in comparison to other similar measures as the human development index the municipal marginalization index represents conditions of high marginalization as more vulnerable because they accumulate the highest percentages of indicators therefore in low marginalization populations there is a very low proportion of exclusion indicators we labeled the marginalization values as follows i ii iii iv and v sample data were collected through semistructured interviews in four states with different degrees of social wellbeing 10 mexico city tamaulipas the state of mexico and oaxaca interviews were carried out in different municipalities according to the type of municipality municipal marginalization index 59 and population size the total number of municipalities selected was 71 and distributed in the following way 16 in mexico city 6 in tamaulipas 31 in the state of mexico and 18 in oaxaca a total of 247 semistructured interviews were conducted 78 in mexico city 44 in tamaulipas 53 in the state of mexico and 72 in oaxaca interviewees were chosen through nonprobabilistic sampling considering variables as socioeconomic level educational level age and gender to achieve heterogeneous profiles according to previous research 60 interviewees with different sociodemographic profiles support saturation of categories which produces more sound and consistent results access to the communities was done with the help of several gatekeepers who were residents in the area they were the starting point to the snowball technique to find individuals with the desired profiles information gathering interviewers were trained in ethical research issues as well as in the use of the protocol to handle respondents information every interviewee was informed that all of their responses would be confidential and agreed to sign informed consent the interviews lasted approximately thirty minutes major the social capital and health section answers were recorded with the interviewees permission and later transcribed literally on a text processor analysis data analysis was iteratively deductive and inductive based on the grounded theory 61 that lies on fieldwork as the main knowledge source to come to conclusions based on empirical evidence 62 coding was concurrent with data analysis and interpretation first it helped to observe to record and to classify answers during fieldwork second coding helped to disaggregate information and to group and to synthesize it from multiple associations and cognitive inferences 62 this procedure was helpful to the interview analysis at different stages such as understanding synthesizing and theorizing phases the understanding stage enabled us to approach to the beliefs values and ways of life of the different contexts and to see the experience from the participants perspective 63 during the synthesis stage we read the transcripts of the interviews the purpose was to identify and codify the emerging trends in each category to that end we used the qualitative nvivo software version 11 the following codes emerged from this process in general this codebook guided us to clarify the association between social capital and health in specific the codebook was also helpful to distinguish central discourses and meanings associated with the role of social capital in health according to the informants levels of marginalization and access to health services 1 finally the theorizing stage allowed us to contextualize and to explain the relationship 63 authors discussed the findings in several meetings interpretations of categories in each level of marginalization and their link with the theoretical framework were examined during these meetings results municipalities and interviewees in this study municipalities were grouped into levels of marginalization and type as shown in table 2 table 2 shows a potential relationship between the municipal marginalization level and the interviewees socioeconomic profile data suggest most of the individuals with elementary school education attainment in very low and low marginalization areas live in rural and semiurban areas in contrast those participants in areas with very high and high levels of marginalization with undergraduate and graduate studies attainment live in urban areas social capital and health issues regardless of the level of marginalization social capital represents an essential tool to deal health issues for the interviewees low trust in health institutions turns social capital into a critical component to optimize the individuals economic resources bridgetype social capital contributes to the choice of medical service providers by obtaining information from previous experiences and recommendations from neighbors friends and family moreover interviewees indicated that belonging to networks of friends relatives or neighbors provides information that allows a better choice of hospitals specialist doctors and administrative procedures regarding medical insurers regardless of the marginalization level findings show that the exchange and dissemination of health information are central resources for the closest networks emotional support is also fundamental to face and solve healthrelated problems still there are some differences in how it works because it depends on the level of marginalization and access to health services participants living in very low or low marginalization areas have health coverage in 965 of the cases such coverage includes access to private health care providers as well as access to specialist doctors at this level participants have access to healthcare coverage due to their membership to a larger number of networks which include extended family workgroups or religious groups besides strong links the interviewees socioeconomic level and their health coverage influence the function of social capital in this case it provides an emotional support system that leads to feelings of security and support for instance people accompany or visit a sick person they give them fruit they accompany them to the doctor or they help with the housework i feel very very supported i mean ive known my friends for a long time and i have no doubt that they would help because at least with what we have shared thats how they make you feel dont they and concerning my relatives well the time we spend together when i see them um lets say that they make me feel sure that that they would give a hand whenever it might be needed right and … well economically id do it because i have the insurance that would cover all their expenses individuals that live in high or very high marginalization areas are covered mainly by the seguro popular or lack of healthcare insurance seguro popular has limited coverage of services quality of the infrastructure and care provision of medicines and very high waiting times for these reasons 729 of interviewees mentioned that they had insufficient infrastructure for the number of individuals covered regarding funding for medicines 545 of respondents stated they rely on generic medications which affects the quality of the treatment meanwhile 756 of respondents indicated to be unsatisfied with the quality and access to health services therefore they would prefer to use private doctors services home remedies selfmedication traditional therapies praying or drinking when they do not have enough money respondents pray with the aim of tolerating the pain or healing at these levels of marginalization relatives and friends networks are valuable assets that individuals can use to transform into alternative and additional resources to solve health issues bondingtype social capital integrates the material and emotional support to deal with health situations in the case of accidents or illnesses these networks are useful to raise funds for the patients treatment likewise networks provide necessary emotional support to improve the health of a sick person my family well my brothers and my parents i feel that in a strong need yes i have support from them we have the support of the whole family these individuals socioeconomic situation and their vulnerable position regarding health coverage emphasize the essential role of social capital according to our findings support networks establish a critical resource for health emergencies such as access to medicines home remedies or to transfer the patient to the nearest health care center we have helped each other in the good and the bad times if someone passes away or get ill we collect money and we help to my friends and family i would help them with actions because i do not have much money participants who have experienced these situations expressed they felt supported and grateful simultaneously they felt guilty for being a burden to their loved ones with such moral and material responsibility they also expressed constant feelings of vulnerability well i feel very very bad because i cant even find a way to pay for it so that i can take care of it by myself or take care of my own accidents or illnesses so you feel bad i think anyone feels bad dont they that someone has to pay hisher expenses and not out of pride but because to have to say i cant pay it by myself i mean its hard isnt it the microlevel of social capital is essential in high or very high marginalization levels because networks provide the patient with information to navigate the healtcare system and to have accurate information about doctors and alternative health care centers likewise people in networks recommend home remedies to the patient or donate medications that they did not consume in previous illnesses to respondents the support of these networks facilitates the transportation of the sick person to the health centers in emergencies private cars are a frequent alternative to the lack of ambulance and medical emergency services in the middle level of marginalization respondents present heterogeneous healthcare in coverage and how social capital works in different ways in case of illness on the one hand for individuals who have major medical health insurance social capital is similar to very low and low levels of marginalization in situations of illness on the other for those who have the services of imss issste and popular insurance and do not have major medical health insurance social capital works similarly to those interviewed at high and very high levels of marginalization finally 51 of respondents indicated that they have a low level of trust in health institutions although the main criticism targets at public institutions individuals also mistrust the private ones results suggest that regardless of the marginalization level there are specific codes about the support levels the type of support and its length in mexico in the case of disease or long term health problems the commitment level and the possibilities of material and emotional support are stronger in the family nucleus regarding friends and neighbors networks commitment and support are usually temporary discussion the most vulnerable socioeconomic levels are the most affected in the access to health services behind these issues there are deficits in health subsystems for instance there is a reduced number of doctors and nurses in the system including those that work in the private sector 6 in addition the public system usually provides less time for each patients visit which has negative consequences on the quality of medical service delivery also only some of the seguro popular imss and issste medical centers have emergency rooms 6 finally 33 of prescriptions in the seguro popular were not wholly fulfilled because the medicine was not in stock while at the imss 14 of the prescribed drugs were not available 6 regardless of the municipal marginalization level and the healthcare access health system conditions could explain why most respondents mentioned that they do not use the basic or emergency services from public institutions most individuals indicated that these services are not efficient or effective this perception is the result of sick individuals that must travel long distances to reach the health care centers long waiting times perception of poor quality medical services delivery and there is a lack of funding for prescribed medications disparities between levels of marginalization suggest another source of inequality findings evidence that the participants at the poorest condition are in a very vulnerable situation regarding their right to health disparities in access to and quality of health services explains the role of social capital to address health related problems the evidence here supports that the microlevel of social capital has an essential role when individuals get sick however unlike other studies 63 the relevance of social capital can be explained by the precariousness of medical services the poor health infrastructure and the problems of access to medical care 68 the low levels of trust in physicians and health institutions make bridgingtype social capital an essential component to select a good quality medical service according to the individuals budget however the respondents socioeconomic level and health coverage influence the role of social capital or in other words the type of support they provide and receive each social capital type has different functions the bridgingtype social capital helps to provide information about physicians or homemade remedies bondingtype supports emotional and instrumental provision to manage health problems 2551 regardless of the level of marginalization and interviewees socioeconomic level bridgingtype social capital provides information based on direct experiences these networks help in search and choice of healthcare insurance economical and reliable hospitals medical specialists and advice for the followup and care of diseases 25 findings also evidence the value of emotional support in health situations 6465 in the low and very low marginalization levels support networks are broad and include strong links religious groups and extended family in the very high and high levels of marginalization networks are limited to the nuclear family and closest friends in specific respondents in very high and high levels of marginalization indicated that family close friends and neighborhood are essential to face accidents or severe illnesses these networks not only provide the necessary emotional support for the recovery of the patient but they also articulate instrumental support 5166 namely medicines homemade remedies taking the patient to the nearest hospital and funding for health services at medium marginalization level social capital is broader most of the participants mentioned they could count on extended family and friends networks also help in raising funds for more extensive medical services and better hospitals for individuals in the low and very low marginalization levels support networks include strong bonds that also extend to other groups and act as emotional support in addition the links are broader and a positive relationship between social capital and income is developed 66 considering most of the participants at this last level have private healthcare coverage social capital operates mostly as emotional support conclusions mexican constitution guarantees that every person hast the right to health protection health is a social right according to interviewees the delivery of the healthcare services is deficient mainly at the primary care level as well as at the emergency room services provided by the state operated hospitals as the seguro popular imss and issste the access to this right should not be conditioned by any socioeconomic political and cultural inequalities in mexico employment status and socioeconomic level define the access to the health care system and subsystems the imss and issste relate to formal employees in the private sector and the federal government respectively meanwhile the seguro popular focuses on individuals in the informal sector not covered by the benefits of a formal job or permanent position medical insurance evidence suggests a positive association between informal work socioeconomic vulnerability and access to healthcare services the population proportion covered by the seguro popular seems to be associated both to the municipalitys informal employment level and its marginalization index participants indicated low levels of trust in healthcare institutions due to the poor infrastructure and quality of services although the main criticism is focused on public institutions individuals also did not report to not trust the private ones either these facts related to the access and quality of medical services and transform social capital into a significant asset besides strong bonds or links are valuable resources that individuals can tap to solve healthrelated issues however the use of such resources is not homogenous and is modified by specific factors that were represented in this study through the municipal marginalization index we can observe that at low and at very low levels of marginalization the interviewees socioeconomic conditions and health care coverage impacts on the role of social capital social capital acts as a type of emotional support and as a way of companionship that explains the positive feelings of security and support at high and very high marginalization levels networks are limited to the nuclear family and the closest friends these individuals access to healthcare defines social capital as an essential resource and an emotional support system when dealing with medical issues for this reason participants reported contradictory feelings on the one hand they feel supported and grateful but on the other they feel guilty about burdening their loved ones with such moral and material responsibility one of the implications of this study is that in mexico the use of social capital could be a valuable asset in health education access to information and health resources and services besides it could help to foster norms for respect and trust between medical healthcare providers and patients as a sine qua non for the quality and efficiency of health services the second implication of this study is that although we found that social capital is an essential resource for solving healthcare issues the positive effects of the relationship do not exonerate the responsibility of the mexican government to guarantee the quality of the healthcare services provided by the government we should emphasize the importance of ensuring access to healthcare and quality medical services it means to reduce waiting times to increase prescription medicines availability and having a more balanced ratio of medical staff in comparison to the number of individuals covered finally there are some limitations to this study first the imm is an indicator that provides measures at the context level conditions and not at the individual level second the highest percentage of people interviewed were located in urban areas even in the locations under study there are no rural areas at the very low level of marginalization third the results are not generalizable to the entire mexican population given that a qualitative analysis approach was used despite the sample cannot be considered as representative the selection of the interviewees considered the heterogeneity and diversity of socioeconomic cultural and geospatial aspects of the participants in order to improve learning possibilities and the reliability of the results in this regard the coding procedure used allowed the incorporation of emerging nuances and interpretations which contributed to the consistency of the findings despite these limitations the qualitative approach used in our research can be appropriate to any context where health services have been stratified according to population socioeconomic conditions or employment status it could also be useful in those countries where noncontributory health services cover individuals living in poverty because it shows how functional social capital can be in healthrelated situations availability of supporting data datasets used and analyzed during this study are available from the corresponding author on reasonable request competing interests the authors declare that they have no competing interests

background social capital is employed as an asset when there is a lack of an efficient healthcare system however this relationship is not homogeneous and can differ according to the characteristics of individuals and their context in this paper we aim to analyze the role of social capital in the solution of healthcare problems among individuals with different levels of marginalization and unequal access to health services methods this qualitative study examines the role of social capital in the demand for healthcare among mexican individuals with different levels of marginalization the research draws data from semistructured interviews n 247 that were collected in four mexican states with different social welfare benefits mexico city tamaulipas the state of mexico and oaxaca the interviewees were selected using the snowball method and other eligibility criteria such as education age and gender results findings suggest that social capital is a relevant factor in solving healthcare problems depending on the level of marginalization the role of social capital can be explained by the precariousness of medical service delivery the poor health infrastructure and the difficult access to health care in mexico networks are the main resource to deal with health related issues food medicine and outofthepocket medical expenses in contexts of high levels of marginalization in the middle level of marginalization networks also help in raising funds for morespecialized medical services and higher quality hospitals in the leastmarginalized levels social capital is used as companionship for sick individuals while support networks act as emotional relief at this level most individuals have private health insurance and many of them have major medical healthcare coverage conclusions participants reported low levels of trust in the health care system because of the poor infrastructure and quality of medical service delivery although the main criticism is focused on public healthcare institutions there is a lack of trust in private medical services as well these facts are related to the access and quality of medical service delivery and turn social capital into a significant asset despite that social bonds or links are valuable resources that individuals can use to solve healthcare related issues the use of social capital is not homogenous indeed it can be influenced by several factors that were represented in this study through the municipal marginalization index

in lowincome areas with limited access to healthful foods are more likely to consume foods with poorer nutritional quality when compared to those living in higherincome higheraccess areas 18 studies show that living in a food desert is associated with risk for obesity 19 and nutritional deficiencies 20 few studies have assessed the relationship between food deserts and metabolic health during pregnancy however one study showed that living in a food desert was associated with increased likelihood of morbidity during pregnancy 21 including metabolic disorders and another suggested decreased risk for gestational diabetes mellitus in areas with more grocery stores 22 food desertmediated differences in dietary quality may be responsible for these associations among pregnant populations some studies show that consumption of a more proinflammatory diet is associated with increased risk for gdm 2324 however another study observed that a more proinflammatory diet is associated with decreased risk for gdm 25 this heterogeneity may be related to differences in dietary data collection methods with one study using selfadministered food frequency questionnaires in the united states 25 while the others utilized ffqs completed with the assistance of trained dietitiansinterviewers among people in iran and china 2324 while living in a food desert likely informs dietary quality whether the inflammatory quality of the prenatal diet is related to living in a food desert during pregnancy has not to our knowledge been previously examined the influence of socioeconomic status on metabolic health in pregnancy lower socioeconomic status an important correlate of health inequalities 26 is associated with poorer health outcomes for pregnant people compared to those with higher ses pregnant people with lower ses show an increased risk for gestational diabetes 27 gestational weight gain 28 obesity 29 and metabolic syndrome 30 the mechanisms by which low ses influences metabolic health are complex and multifaceted lower ses is associated with both reduced access to affordable healthy foods 32 and more proinflammatory diets 3334 which have been linked to metabolic health in nonobstetric populations including increased risk for obesity 35 hyperglycemia 36 and metabolic syndrome 37 low ses is also associated with inadequate prenatal care 38 and chronic stress 39 as well as insufficient access to specific nutritive foods 40 or food altogether 41 whether living in a food desert mediates the association between ses and metabolic health for pregnant people has not yet been articulated socioeconomic status food desert severity and their interactive impact on metabolic health in pregnancy identifying contributing factors that help explain the relationship between ses and metabolic health during pregnancy is important for optimizing intervention strategies for pregnant people with lower ses as well as for reducing the burden of poor metabolic health during pregnancy on offspring living in a food desert may be one mechanism underlying the relationship between variation in ses and metabolic health during pregnancy we seek to extend studies showing that lower ses is associated with reduced access to affordable healthy foods 1832 and with increased pregnancy morbidity 27 28 29 30 42 by examining food desert severity as a potential mediator of the relationship between ses and metabolic health outcomes during pregnancy for example access to fewer financial resources may lead to reduced access to a healthful diet which may in turn impact metabolic health by increasing adiposity promoting peripheral inflammation andor disrupting glucose regulation current study we propose that in addition to being mechanistically linked both ses and food desert severity may play a role in metabolic health and nutrition during pregnancy an association that has not to our knowledge been formally tested while many other studies of food deserts utilize a dichotomous assessment of food desert status 43 the use of a categorical variable does not capture the degree to which healthful and affordable foods are accessible and may limit the ability to detect meaningful differences thus in the current study we calculate the degree of food desert severity for each participant relative to others in their neighborhoods allowing us to draw inferences about pregnancy metabolic health according to the spectrum of resource accessibility we examine three outcomes related to metabolic health and nutritional quality in pregnancy adiposity glucose regulation and the inflammatory nature of the prenatal diet as these outcomes are linked to one another 44 and provide complimentary but distinct information unlike previous work we control for their interdependence using structural equation modeling furthermore as there is a graded positive linear association between maternal hyperglycemia and risk for adverse perinatal outcomes 45 we examine a continuous measure of glucose regulation as both low ses and living in a food desert are associated with consumption of a less healthful diet 4647 we also examine the effects of low ses and food desert severity on nutrition during pregnancy while the relationship between food desert severity and ses is complex and likely interrelated elucidating the interacting role of each of these is critical for both practitioners and policymakers as we work together to address disparate access to resources among pregnant individuals our analytic strategy is key to disentangling the unique role of ses and food desert severity on the metabolic and nutrition variables as sem allows us to simultaneously estimate the effects of ses and food desert severity on the metabolic and nutrition variables of interest while controlling for their interdependence thus we are able to examine the significance and strength of the different relationships in the context of the complete model our use of sem also limits the risk of multicollinearity impacting our results as sem is known to be robust to multicollinearity 48 sem also allows us to reduce measurement error by explicitly modeling shared variance thus more valid coefficients are obtained importantly sem also allows us to examine how ses may impact metabolic health and dietary intake during pregnancy by assessing the mediating and mechanistic role of food desert severity in the current study we examined whether food desert severity mediates the relationship between ses and metabolic health during pregnancy this study had three hypotheses 1 ses will have a negative relationship with metabolic health during pregnancy with lower ses associated with increased adiposity higher glucose concentrations during a routine glucose tolerance test and consumption of a more proinflammatory diet during pregnancy 2 food desert severity will have a positive relationship with adverse metabolic health with higher food desert severity associated with increased adiposity higher glucose concentrations in response to a routine glucose tolerance testing and consumption of a more proinflammatory diet during pregnancy 3 food desert severity will mediate the relationship between ses and metabolic health and diet during pregnancy such that lower ses will lead to a higher degree of food desert severity which in turn leads to worse metabolic health during pregnancy methods procedure data measures glucose regulation as part of their routine prenatal care participants were screened for gdm via an oral glucose tolerance test onehour plasma glucose concentrations were utilized in analyses as they are a common metric for predicting health outcomes 49 including whether further gtt testing is necessary as participants were assessed at varying times during pregnancy the number of weeks gestation at the time of assessment was included as a covariate in all analyses that included gtt data see supplementary materials for more information adiposity to measure body composition at 22 weeks gestation air displacement plethysmography was utilized via the bod pod © body composition tracking system 5051 as an excess of body fluid is typically observed during pregnancy 52 estimates of fat and lean mass in the body were adjusted using previouslydescribed equations 53 and second trimester pregnancyadjusted percent fat mass was utilized in analyses see supplementary materials for more information nutrition second trimester dietary intake was measured by three nonconsecutive 24h diet recalls conducted by trained dietitians using the multipass method 54 and the nutrition data system for research software see supplementary materials for more information to capture the inflammatory nature of participants diets dietary inflammatory index scores a metric of dietary quality that may be particularly relevant for metabolic health 55 were calculated from the 24h diet recalls positive values indicate a more proinflammatory diet 56 see supplementary materials for more information socioeconomic status selfreported information including years of education completed total annual combined household income adjusted for number of people in the household and amount of savings after adjusting for debt was utilized to capture information about ses see supplementary materials for more information food desert severity score geographic information system mapping was utilized to identify food deserts this method offers advantages over others because it provides a more comprehensive characterization of community resources when determining if an individual lives in a food desert participant addresses obtained at study enrollment were converted to latitude and longitude coordinates and mapped onto census tracts using data from the 2010 census of the population using the food access research atlas published by the economic research service of the united states department of agriculture and census data lowincome and lowaccess census tracts were identified detailed information about the sources of the data used to characterize census tracts as food deserts can be found online briefly income data came from the 20142018 american community survey urban or rural designation was from the 2019 urbanized area geographies and two 2019 lists of stores were combined to produce a list of stores with affordable and nutritious food approximately onequarter of participants in this study met criteria for living in a food desert a higher percentage than the us population 58 in order to capture the range of access to healthy and affordable foods we calculated the degree of food desert severity for each participant relative to others in their census tract by dividing the number of individuals in a tract living more than 05 mile or 10 miles from the nearest supermarket supercenter or large grocery store by the total number of individuals living within the tract food desert severity index was used as our primary analysis variable covariates as advanced age of birthing parent increasing parity and minoritized race or ethnicity are risk factors for poor metabolic health during pregnancy 5960 these variables were considered as covariates in analyses due to their relationships with ses and metabolic health 61 62 63 we also examined alcohol use during pregnancy as well as the use of prenatal vitamins see supplementary materials for more information analytic plan structural equation modeling was conducted in mplus sem was selected because it allows us to simultaneously model the complex associations between multiple predictors and multiple outcomes while controlling for their interdependence furthermore this approach allows us to test for mediation all data utilized in analyses were first screened by qualified experts including a trained nutritionist to assess normality and plausibility with the exception of percent adiposity during the second trimester nearly all variables of interest were nonnormally distributed thus a robust maximum likelihood estimator was utilized to accommodate for nonnormal data distributions using a sandwich estimator mediation was tested using the model indirect command in mplus as the use of conventional tests of significance are unreliable when testing indirect effects we utilized the recommended asymmetric confidence intervals based on bootstrapping methods 64 to incorporate the nonnormality of the data into the model test statistics estimates and accompanying confidence intervals were calculated based on 10000 bootstrapped samples missing data were handled using full information maximum likelihood 65 model fit was assessed by examining the comparative fit index the tucker lewis index the standardized root mean square residual and the root mean squared error of the approximation 6667 nonindependent observations were accounted for using the mplus cluster command see supplementary materials for more information a stepwise approach to increasing model complexity was utilized 1 data reduction prior to hypothesis testing a confirmatory factor analysis was used to assess the appropriateness of considering our indicators of ses as a latent variable 2 covariate selection covariates were examined and any that were significantly correlated with the indicators of ses maternal metabolic variables or food desert severity were included in the more complex models as described below 3 hypotheses 1 and 2 regression analyses to test hypotheses 1 and 2 a series of regression models were run where food desert severity was regressed on ses pregnancy adiposity glucose concentrations and dii values were regressed on ses and pregnancy adiposity glucose concentrations and dii values were regressed on food desert severity 4 hypothesis 3 structural equation mediation model to test whether food desert severity significantly mediated the relationship between ses and each of the pregnancy metabolic variables an sem was estimated in which each of the pregnancy metabolic variables were simultaneously regressed on ses and on food desert severity in the same model food desert severity was also regressed on ses pregnancy metabolic variables were allowed to covary allowing for control of their interdependence each metabolic variable and food desert severity were regressed on each covariate and ses and each covariate were allowed to covary to preserve model parsimony nonsignificant paths from covariates were removed from the final model beta weights and pvalues are reported for each of the paths as well as bootstrapped confidence intervals for the indirect paths institutional review board statement informed consent statement informed consent was obtained from all subjects involved in the study results sample description bivariate correlations bivariate correlations among the focal variables suggest that higher food desert severity scores were associated with greater adiposity and lower ses variables related to lower ses were associated with greater adiposity and with proinflammatory dietary intake but not with glucose concentrations adiposity glucose concentrations and dii scores were all positively correlated age of birthing parent was positively correlated with variables associated with ses and negatively correlated with dii scores minoritized racialethnicity status was positively correlated with glucose concentrations multiparity was significantly correlated with total household income proinflammatory dietary intake and age endorsement of alcohol use after pregnancy was known was positively correlated with food desert severity and using prenatal vitamins was positively correlated with years of education table 1 descriptive statistics for study variables gtt oral glucose tolerance test dii dietary inflammatory index lmp last menstrual period higher food desert severity scores indicate that a greater percentage of individuals living in a census tract characterized by lower income and lower access to healthy and affordable foods a pregravid weight status is based on pregravid body mass index scores b percent of census tract living in a food desert c 0 primiparous and 1 multiparous d 0 white nonhispanic and 1 racialethnic minority participants selfidentified as asian black multiracial native american pacific islander white other or prefer not to answer participants also selfidentified as hispanic nonhispanic or prefer not to answer e 0 did not use alcohol after pregnancy was known and 1 used alcohol after pregnancy was known f 0 did not use prenatal vitamins and 1 used prenatal vitamins g 1 less than 5000 2 5000 to 11999 3 12000 to 15999 4 16000 to 24999 5 25000 to 34999 6 35000 to 49999 7 50000 to 74999 8 75000 to 99999 9 100000 to 199999 10 200000 to 299999 11 300000 and greater h 1 less than 500 2 500 to 4999 3 5000 to 9999 4 10000 to 19999 5 20000 to 49999 6 50000 to 99999 7 100000 to 199999 8 200000 to 499999 9 500000 and greater 76 sf 77 and ggmaps 78 table 2 bivariate correlations for study variables gtt oral glucose tolerance test dii dietary inflammatory index higher food desert severity scores indicate that a greater percentage of individuals living in a census tract have lower income and lower access to healthy and affordable foods a total household income adjusted for household size b 1 less than 500 2 500 to 4999 3 5000 to 9999 4 10000 to 19999 5 20000 to 49999 6 50000 to 99999 7 100000 to 199999 8 200000 to 499999 9 500000 and greater c percent of census tract living in a food desert d 0 primiparous and 1 multiparous e 0 white nonhispanic and 1 racialethnic minority f 0 did not use alcohol after pregnancy was known and 1 used alcohol after pregnancy was known g 0 did not use prenatal vitamins and 1 used prenatal vitamins bolded values indicate significance p 005 ses measurement model a latent variable for ses was created using the measures described above all factor loadings were significant and greater than 040 in magnitude confirming that this is an appropriate way to consider these data the variance of the latent variable was significant suggesting interindividual variability in ses scores see table 3 for detailed results of the measurement model regressions used to test hypotheses 1 and 2 table 4 reports the results of the regressions used to test hypotheses 1 and 2 consistent with the results of the bivariate correlations lower ses was associated with greater adiposity greater dietary inflammation and greater food desert severity scores greater food desert severity scores were associated with greater adiposity and glucose concentrations sem used to test hypothesis 3 figure 2 displays the results of the sem used to test hypothesis 3 lower ses was associated with higher food desert severity scores increased adiposity and higher dii scores ses was not associated with glucose concentrations higher food desert severity scores were associated with greater adiposity but not with higher glucose concentrations or with dii scores food desert severity scores significantly mediated the relationship between the latent ses variable and adiposity however they did not mediate the effect of ses on glucose concentrations or dii scores this model simultaneously tested the relationships between ses and food desert severity and each metabolic variable adjusting for their interdependence ses was also associated with age of birthing parent such that higher ses was associated with older ages using alcohol after pregnancy was known was positively associated with food desert severity and prenatal vitamin use predicted higher adiposity and higher ses racial ethnic minority status significantly predicted glucose concentrations such that individuals from minoritized backgrounds had higher glucose concentrations adiposity significantly covaried with glucose concentrations and dii scores glucose concentrations significantly covaried with dii scores sensitivity analyses are described in supplementary materials table 3 measurement model for ses latent variable the measurement model for ses was justidentified meaning that no fit indices were produced but that model estimates are reliable a total household income adjusted for household size b 1 less than 500 2 500 to 4999 3 5000 to 9999 4 10000 to 19999 5 20000 to 49999 6 50000 to 99999 7 100000 to 199999 8 200000 to 499999 9 500000 and greater latent ses variable indicator β ± se 95 ci p total household income a 0 discussion metabolic health during pregnancy is an important determinant of health for pregnant people and their infants 1 2 3 4 5 6 8 10 11 12 13 14 15 16 17 low ses is one risk factor for impaired metabolic health during pregnancy 272830 but the mechanisms through which ses influences metabolic health and nutrition during pregnancy remain relatively underexplored here we assessed whether food desert severity mediated the relationship between ses and adiposity glucose regulation and inflammatory level of diet during pregnancy the findings of this study provide overall support for a relationship of both ses and food desert severity on metabolic health during pregnancy results suggest that food desert severity is a mechanism by which ses influences adiposity during pregnancy such that individuals with lower ses tend to experience more food desert severity which leads to increasing adiposity during pregnancy consistent with earlier work 28 32 33 34 results from main effects models indicated that lower ses was significantly associated with greater adiposity greater food desert severity and consumption of a more proinflammatory diet as adiposity glucose concentrations and the proinflammatory nature of participants prenatal diets were all positively and significantly correlated we account for their interdependence through our model design it is interesting to note that the proinflammatory nature of participants prenatal diets was significantly correlated with glucose concentrations while dietary quality likely impacts glucose regulation and adiposity during pregnancy it is also possible that overall metabolic state informed by gtt results and body composition may impact diet for example an individual atrisk for gdm may alter their diets in response to their gtt results or at the instruction of their physician particularly if their physician recommends trying to limit pregnancy weight gain 68 after adjusting for adiposity glucose concentrations and dietary inflammation as well as the interdependence of these variables and for relevant covariates the effect of ses on food desert severity survived we also found that higher food desert severity was associated with higher adiposity and poorer glucose regulation during pregnancy the effect of higher food desert severity associated with increasing adiposity during pregnancy survived accounting for the effect of ses the interdependence of metabolic health measures and relevant covariates these findings are consistent with work in nonobstetric samples showing that living in a food desert is associated with obesity 19 while living in a food desert is certainly related to ses our results indicate that they are not equivalent constructs or metrics for example it is possible that some individuals living in a food desert may have the financial resources necessary to access healthful foods or vice versa results from our study suggest that after accounting for food desert severity ses is not independently related figure 2 food desert significantly mediates the relationship between ses and adiposity food desert severity scores significantly mediated the relationship between latent ses and adiposity after adjusting for age of birthing parent parity status and racialethnic minority status as well as for weeks gestation at gtt use of alcohol after pregnancy was known and use of prenatal vitamins food desert severity did not mediate the effect of ses on glucose or dii scores p 005 p 001 p 0001 cfi 0965 tli 0947 srmr 0039 rmsea 0024 90 ci 0000 0049 p 0957 51 to glucose concentrations during pregnancy our findings also suggest that living in a food desert is not associated with increased circulating glucose concentrations in response to the gtt which is consistent with other work suggesting that living in a food desert is not associated with increased gdm risk 69 but in contrast to work suggesting reduced gdm risk in areas with more grocery stores 22 we posit that these discrepancies may be due in part because past work has not simultaneously accounted for the interdependent effects of ses and food desert severity food desert severity scores significantly mediated the relationship between lower ses and greater adiposity even after accounting for the proinflammatory quality of the participants diet their glucose concentrations during pregnancy and relevant covariates this important finding offers a mechanistic explanation of how ses impacts metabolic health during pregnancy consistent with our initial hypotheses lower ses was associated with greater food desert severity scores and food desert severity in turn was associated with increased adiposity during pregnancy this is the first study to our knowledge to simultaneously assess the effects of food desert severity and ses on adiposity glucose concentrations and dietary inflammation during pregnancy notably the effect of ses on adiposity via food desert severity was independent of the inflammatory nature of diet which was not associated with food desert severity in this model this is in contrast to other work in nonobstetric samples showing that living in a food desert is associated with an unhealthy diet 46 future research should consider other mechanisms through which food desert severity may impact pregnancy adiposity for example individuals living in food deserts may experience chronic stress associated with poverty which may be independently associated with dysregulated gestational weight gain 39 it is possible that measuring specific microor macronutrients in the dietary intake of pregnant individuals living food deserts rather than the overall proinflammatory quality of their diets may be more informative however we did not find that either total caloric intake or percent of total calories from fat during the second trimester had a significant relationship with ses or food desert severity it is also possible that physical activity contributes to this relationship however we did not find that selfreported physical activity during pregnancy explained our findings thus future work may benefit from targeting other differences in specific nutrient consumption by pregnant populations as well as from exploring the influence of physical activity on pregnancy adiposity further we note that our physical activity measure was selfreported physical activity during pregnancy rather than a more robust objective measurement of physical activity during pregnancy such as via accelerometry this study had a number of strengths to our knowledge this is the first study to examine whether food desert severity mediates the relationship between low ses and poor metabolic health during pregnancy whereas most other studies of food deserts utilize a dichotomous assessment of food desert status 43 in this study we utilize a continuous measure of food desert severity the continuous measure of food desert severity allowed for quantification of the linear association between food desert severity and metabolic health and may be useful for drawing inferences relevant to individuals in lowincome low access areas but who do not meet the threshold for living in a food desert as well as for individuals who do not reside in food deserts but have lower access to healthy food this study was also strengthened by the detailed characterization of participants diets via repeated 24h recalls conducted by registered nutritionists which may have increased the reliability of the dietary information moreover rather than using selfreported weight gain we utilized air displacement plethysmography to assess body composition allowing us to distinguish between the percent of fat and lean mass during pregnancy limitations and suggestions for future research this study also suggests several directions for future study results suggest that factors beyond the proinflammatory quality of the diet may be responsible for the relationship between higher food desert severity and greater adiposity during pregnancy future studies should assess other factors relevant to the metabolic health of those living in food deserts for example neighborhoods with low access to healthful and affordable foods may also have poor incorporation of features that encourage physical activity such as sidewalks and greenspaces 71 neighborhoods with higher crime rates may also be associated with lower physical activity due to safety concerns 72 physical activity during pregnancy alone is unlikely to explain these findings however as analyses conducted with selfreported physical activity as an outcome measure did not show a relationship between physical activity during pregnancy and ses or food desert severity furthermore food deserts may have more pollution which can contribute to poor cardiometabolic health 73 due to our specific interest in mechanisms associated with metabolic health during pregnancy we focused on adiposity during pregnancy in our primary models this focus allowed us to temporally align our various measures of metabolic health and to control for their interdependence an approach that strengthened our ability to make inferences relevant to this unique developmental period however it is important to note that the effects of ses and food desert severity are not likely to be specific to pregnancy and may predate pregnancy andor persist after birth it remains clear that while variation in ses and food desert severity may not be specific to understanding metabolic health only during pregnancy ses and food desert severity contribute unique importance to identifying risk for poor metabolic health during pregnancy a developmental period with longterm significance for the parent and child furthermore while geospatial coding is a novel means of collecting objective data about the food desert severity there are some limitations associated with this technique for example individuals within the same census tract may have different access to healthful foods depending on where in the tract they reside although food desert severity provides a sense of proximity to healthful foods this is of course not deterministic future research should explore other factors related to food access for example individuals may live in a food desert but have access to healthful foods via grocery delivery or other means future studies may benefit from triangulating access to healthy and affordable foods via multimodal data collection including geospatial coding and surveys concerning accessibility to healthful and affordable foods given the growing literature on food swamps areas where convenience stores and fastfood restaurants outnumber retailers with healthier options the relationship between food swamp severity and pregnancy metabolic health should also be assessed an additional and important limitation of this study is that the usda food access research atlas data from which the food desert measures were calculated utilized data from the 2010 census of the population the pregnancies in our study occurred between 2018 and 2021 it is possible that census tracts may have changed since 2010 additionally average incomes in particular census tracts may have changed between 2014 and 2019 and new supermarkets may have been constructed between 2018 and 2019 thus areas that were considered food deserts based off of these earlier data sources may no longer be considered food deserts while these were the most uptodate udsa fara data available at the time of this study future studies should utilize updated usda fara data when it is released finally while our sample characteristics are consistent with the demographics of the portland oregon metropolis the majority of our participants were white nonhispanic and of higher ses future research should validate these findings in a larger more diverse sample that is more representative of the united states population conclusions the finding that food desert severity significantly mediates the association between low ses and adiposity during pregnancy is an important step toward identifying targets for interventions aimed at improving metabolic health during pregnancy and by extension offspring birth outcomes and longterm health identifying food desert severity as a mechanism by which ses impacts adiposity during pregnancy lends important credence for supporting certain interventions aimed at improving metabolic health during pregnancy over others for example improving access to healthful and nutritious foods may be a step toward improving metabolic health during pregnancy for groups at increased risk for adiposity which may in turn improve offspring outcomes as individuals with higher percent adiposity during pregnancy may not have exceeded clinical cutoffs for unhealthy pregravid bmis 68 understanding the mechanisms responsible for increased body fat during pregnancy may be a useful means of identifying which individuals may be most liable for metabolic risk during pregnancy results indicate a critical need to focus on making healthful and affordable foods accessible in all communities this can be implemented via micro mezzo and macrointerventions which may include providing community gardens or encouraging healthful dietary habits via trainingeducation on food preparation and nutrition enrolling eligible residents into federal supplemental nutrition assistance programs or encouraging participation in food system planning or enacting legislation and policies to incentivize the addition of fullservice grocery stores and supermarkets to underserved communities and improving the quality of food available at existing convenience stores data availability the data set described in this manuscript will be publicly available on the national institute of mental health data archive under study 2069 doi doi org 10 15154 15287 86 the study page provides instructions on locating the data competing interests the authors declare no competing interests additional information

poor metabolic health during pregnancy is associated with health concerns for pregnant individuals and their offspring lower socioeconomic status ses is one risk factor for poor metabolic health and may be related to limited access to healthful and affordable foods eg living in a food desert this study evaluates the respective contributions of ses and food desert severity on metabolic health during pregnancy the food desert severity of 302 pregnant individuals was determined using the united states department of agriculture food access research atlas ses was measured using total household income adjusted for household size years of education and amount of reserve savings information about participants glucose concentrations one hour following an oral glucose tolerance test during the second trimester was extracted from medical records and percent adiposity during the second trimester was assessed using air displacement plethysmography information about participants nutritional intake during the second trimester was obtained by trained nutritionists via three unannounced 24h dietary recalls structural equation models showed that lower ses predicted higher food desert severity β 020 p 0008 and higher adiposity β 027 p 0016 and consumption of a more proinflammatory diet β 025 p 0003 during the second trimester of pregnancy higher food desert severity also predicted higher percent adiposity during the second trimester β 017 p 0013 food desert severity significantly mediated the relationship between lower ses and higher percent adiposity during the second trimester β indirect 003 95 ci 0079 0004 these findings indicate that access to healthful and affordable foods is a mechanism by which ses contributes to adiposity during pregnancy and may inform interventions intended to improve metabolic health during pregnancy metabolic health in pregnancy metabolic disorders during pregnancy are associated with serious longterm health complications to the pregnant individual including cardiometabolic disorders 12 renal disease 3 and urological conditions 4 they also predict a host of birth and longterm complications for offspring including preterm birth 5 stillbirth and neonatal death 6 altered birthweights higher in the case of gestational diabetes 78 and lower in the case of preeclampsia 9 and macrosomia 10 poor metabolic health at birth 11 longterm obesity 1213 metabolic conditions 1415 and an increased risk for neurodevelopmental disorders 1617 defining the determinants of metabolic health during pregnancy is critical to improving perinatal and longterm health for pregnant people and their children the impact of nutrition and living in a food desert on metabolic health data from nonobstetric populations suggest that access to healthy and affordable foods is associated with metabolic health those living

introduction fake news has been defined as fabricated information that imitates news media content in form but not in organizational process or intent which overlaps with other information disorders such as misinformationfalse or misleading informationand disinformation which is false information that is deliberately disseminated to deceive people 1 the impact of fake news in social media is a major concern in public health as it can reduce or increase the effectiveness of programs campaigns and initiatives aimed at citizens health awareness and wellbeing the advancements in the methodologies related to social media analysis provide new insights to unveil how citizens share health information and the ways in which fake news influences public health social impact in social media constitutes a novel methodology in both social media analytics and the evaluation of the social impact of research 2 this article applies the sism methodology to the specific case of fake news in health to identify the type of interactions related to the information shared in social media impact of fake news on public health fake news concerning health on social media represents a risk to global health the who warned in february 2020 that the covid19 outbreak had been accompanied by a massive infodemic or an overabundance of informationsome of which was accurate and some of which was notwhich made it difficult for people to find reliable sources and trustworthy information when they needed it 3 the consequences of disinformation overload are the spread of uncertainty fear anxiety and racism on a scale not seen in previous epidemics such as sars mers and zika therefore the who is dedicating tremendous efforts aimed at providing evidencebased information and advice to the population through its social media channels such as weibo twitter facebook instagram linkedin and pinterest as well as through its website the mit technology review highlights that social media are not only being used to spread false news and hate messages but are also being used to share important truthful data and solidarity with all those affected by the virus and hate messages 4 we are in what some have called the second information revolution 5 the first information revolution began with the spread of the written word through the press now in this second information revolution a digital transformation is shaping how citizens around the world interact with each other we are facing an unprecedented global expansion in the ways we share access and create information that is presented in many formsone of which is social media from diverse fields of knowledge linked to health issues it can be stated that social media can have both a positive and a negative impact on public health 67 on the one hand the combination of artificial intelligence and big data can help public health providers identify pandemic diseases in real time improving the coordination of the response of public health systems through information sharing and improving surveillance and diagnostics furthermore research shows that social media information and social media responses are effective strategies to gain feedback on potential public health policy proposals this positive impact of social media in health has been demonstrated in a recent study about heat protection policy for australian schools which through the analysis of public comments posted on a national australian broadcasting corporation website identifies the themes to support a national heat protection policy for schools 8 there is evidence of the negative effects of using social media to spread misinformation which produces harmful consequences to global health and wellbeing becoming one of the greatest challenges for public health systems today 59 the most extensively studied topics involving misinformation in health are vaccination ebola and the zika virus as well as nutrition cancer the fluoridation of water and smoking 5 10 11 12 disinformation spread by the antivaccine movement has led to episodes regarding vaccination provoking easily preventable disasters such as the measles epidemic in washington state the spread of false information also explains a decrease in immunization behaviors with respect to measlesmumpsrubella vaccinations explaining the drop in the demand for this vaccine in the uk and the usa between 1999 and 2000 13 furthermore research related to the negative impacts linked to the authenticity of social media and identities has increased in recent years 14 this includes the analysis of the problems surrounding social media messagesposts regarding privacy posts ending with unintended users concerns on how to use social media platforms who to follow and how people portray themselves in an inauthentic manner 1415 spreading fake news on health in social media the context in which fake news is spread never before in human history has the role of globalization processes had the impact that it currently has in decisionmaking processes and societies because of the speed of communication 5 globalization also plays a crucial role in the spread of health news including social media influencing the way users receive such news 1617 in this arena it is important to highlight that in a globalized world health content information can be perceived differently depending on the target group or context 18 therefore fake news may reach citizens in different ways depending on their age culture and other factors 19 moreover research shows that social media and related global digital media content influence discourses about professions and how citizens perceive them including public health professionals 20 for instance many public health programs aimed at children and youth have physical education at the core of their initiatives 2122 the teaching profession is often portrayed in digital media in relation to unhelpful physical crisis messages 23 or discourses related to bullying in movie scenes in a similar vein social media has also been demonstrated to influence the perceptions of adolescent students with regard to their sexual and reproductive health learning 24 as a result health professionals may recognize that social media channels such as facebook offer possibilities to support their activities research on the role of mass media and messages and dominant discourses that are communicated to the public is an emerging topic of interest in scientific works that requires further investigation the influence of social media discourses may differ depending on age culture or gender 19 for example young people build their identities construct knowledge and acquire information from digital media including social media beyond formal education and classroom learning which is an approach resonating with public pedagogies 25 other authors such as ulmer 26 argue that mass digital media provides the public an entry point into the debates the fact is that digital and social media contribute to the strength or undermine the diversity of points of view influencing the development of specific health public health policies and interventions 2728 such influence of the media has been defined by some authors as the fourth state 29 taking into account these contextual considerations it is important to face fake news related to health in social media to support public health policies instead of trying to reverse them fake news health and social media in a globalized world the spread of fake news content on healthrelated topics in social media and the ways in which it spreads have recently been discussed in depth 1030 misinformation and disinformationmisinformation as inaccuracy and errors and disinformation as a falsehood created on purpose and the spread of it by malicious individuals gain momentum from the desire to find a solution to a particular disease or illness by patients or their relatives who inadvertently contribute to spreading misleading information globally the narratives of misinformation are dominated by personal negative and opinionated tones which often induce fear anxiety and distrust of institutions once misinformation gains acceptance in such circumstances it is difficult to correct and the effectiveness of interventions varies according to the personal involvement of each individual and his or her literacy and sociodemographic characteristics 10 however other studies have shown that ignorance rarely leads to strong support for a cause for example those who most strongly reject the scientific evidence of climate change are also those who believe that they are best informed about the issue peoples preexisting attitudes often determine their level of belief in misinformation 31 with respect to globalization processes evidence suggests that false information spreads globally more pervasively and farther and faster than the truth spreads in social media in examinations of possible explanations for this global phenomenon it has been found that novelty is a pervasive component of false rumors which are significantly more novel than the truth however data cannot support the contention that novelty is the only reason or the main reason for the spreading of falsehood 1332 however other studies that have focused on the analysis of fake news in social media have reached different conclusions 3334 a recent study that analyzed the credibility of sources publishing articles online that may reach global audiences concludes that for the specific case of online health information and content on social media people are more concerned about the veracity and credibility of the information source and tend to spread less misinformation about health one possible explanation given by the authors is that people generally do not read health information for entertainment but rather search for information useful to their health or that of people close to them furthermore in these cases they are less likely to have a preexisting opinion about health information than are those who share fake news stories about other topics 34 a similar conclusion came from a factchecking study of twitter and sina weibo developed 24 hours after the whos declaration of the ebola outbreak as a public health emergency of international concern in august 2014 in a globalized world this declaration by the who had diverse impacts on the definition of private and public strategies to combat the virus it contended that only 2 of the posts created on twitter and weibo were fake news or disinformation while the rest were outbreakrelated news and scientific health information mostly coming from news agencies reporting information from public health agencies this study was able to confirm that these two social media sources contributed to spreading the news of the ebola outbreak which was the key message of the who 33 research on fake news on health in social media covers a variety of channels including twitter facebook reddit and weibo 35 36 37 the analysis of twitter has gained special attention and research shows the reach of twitter codes and the manner in which information spreads on twitter this occurs in diverse fields related to public health from physical education 38 to healthy eating habits or healthy lifestyles 39 identification of social media interactions as key to spreading or combating healthrelated fake news social interaction appears to be the main method of understanding how disinformation or fake news spreads over social media different studies have been conducted to identify by who and how health disinformation content is promoted in social media in the case of twitter different types of malicious actors covering both automated accounts and human users mainly trolls have been identified it is very difficult to detect whether there is a human or a bot behind a profile however all of them produce distorting effects that may be critical to messages from public health systems 12 one of the studies in the case of vaccines identified three types of profiles that had a special probability of spreading vaccinerelated disinformation 12 the first profile is trolls or twitter accounts with real people behind them identified from lists compiled by us authorities these trolls use the hashtag vaccinateus and spread proand antivaccination messages often with the apparent aim of encouraging people to believe that the medical community is divided the second profile called sophisticated bots is artificial intelligence that automatically spreads content via twitter with the same objective of making people believe that the medical community is divided the third group of profiles is comprised of content polluters who use antivaccine messages to pique users curiosity and lead them to click on links such that every click leads to more income for those behind the website some studies have suggested the need to increase social media literacy provide strategies and instruments to check the reputation consistency and evidence of any information and avoid selfconfirmation 4041 combating fake news on social media several approaches have been proposed in recent years to automatically assess credibility in social media most of them are based on databased models ie they use automatic learning techniques to identify misinformation based on these techniques different applications have been developed with different objectives and in different contexts such as detecting opinion spam on review sites detecting false news and spam in microblogging and assessing the credibility of online health information 64243 these techniques include both human intervention and algorithms to verify the veracity of information across technologies such as artificial intelligence and natural language processing 44 other mechanisms developed as a remedy against fake news on social media are source ratings that can be applied to articles when they are initially published such as expert ratings user article ratings and user source ratings 34 according to the literature social media is an interaction context in which misinformation is spread faster but at the same time there are interactions focused on health that are evidence based furthermore it is important to highlight that social media users share the social impact of health research however less is known about what these interactions are or what type of recommendations we can identify from them the main aim of this work is to contribute to advancing methods of overcoming misinformation or fake news in health through social media data analysis in this sense we have applied the methodology of social impact in social media 2 to identify which type of interactions spread misinformation and which type of interactions contribute to overcoming fake news or misinformation related to health the main research questions are as follows rq1 how are social media messages focused on fake health information or misinformation rq2 how are social media messages focused on health evidence with potential or real social impacts and rq3 how do interactions based on health evidence with potential or real social impacts help overcome misinformation or fake health information the results indicate that messages focused on fake health information are mostly aggressive those based on evidence of social impact are respectful and transformative and finally deliberation contexts promoted in social media overcome false healthrelated information materials and methods the method used and the sample selection are described in detail in the following sections the method used is social impact in social media methodology 2 which combines quantitative and qualitative content analysis of the sample selected considering the contributions of the social impact of the research 45 according to elo et al 46 there are trustworthiness issues in the preparation phases of the data collection method the sampling strategy and the selection of a suitable unit of analysis according to the way in which the research goals are defined in this sense the following sections develop in detail how the sample was selected and how the data collection and extraction were developed the data analysis is explained in detail in the corresponding section along with an explanation of the unit of the analysis used regarding ethical considerations the present research adheres to international ethical criteria related to social media data collection and corresponding analyses in particular we have followed the ethical guidelines for social media research supported by the economic and social research council 47 and ethics in social and humanities sciences of the european commission 48 furthermore we have perceived the risk of harm to and conserved the anonymity of users additionally we have read the terms conditions and legalities of each of the social media channels and we have used only public information without identifying any user likewise the data were appropriately coded and anonymized to avoid the possibility of traceability sets of data have been secured saved and stored the dataset analyzed and the calculations performed are available in the supplementary materials we cannot share all raw data due to the current terms of the social media channels and the general data protection regulation sampling social media data collection and extraction the first step to develop this study was the selection of a suitable sample of social media channels to collect the data the social media channels for the analysis are facebook twitter and reddit and their selection corresponds to three criteria relevance of the number of active users in millions according to statista 2019 data facebook twitter reddit availability of public messages and suitability for online discussion there are other social platforms with millions of users but these three have been selected because they are more suitable for our research study the chosen sample is exploratory and selective and is based on the following criteria criteria 1 selection of suitable searchable keywords we selected the word health as a general topic and the specific keywords vaccines nutrition and ebola the use of these specific keywords is based on the findings by wang et al 10 in which the authors identify vaccines nutrition and ebola as topics with more misinformation in social media specifically we used the hashtags vaccines nutrition and ebola to extract twitter information in relation to facebook we selected two public pages with more audiences in relation to the topic health with regard to reddit we selected the topic vaccines in a community focused on this topic and an askscience ama series focused on vaccines criteria 2 data extraction the data extracted from twitter contain tweets published under the hashtags selected in the last ten days in the case of the facebook page the data are extracted from the last 100 posts published and the corresponding comments of the two facebook pages selected finally in reddit we selected the comments published in two conversations in two different communities table 1 shows the data collected data analysis the strategy for data analysis aims to unveil the nature of interactions focused on misinformation or fake health information and the nature of interactions based on health evidence of potential or real social impacts to do so we have designed the following steps and strategy the unit of the analysis is the full message published by the user which means that the information provided in the external links included in the messages is also analyzed steps step 1 to identify which tweets and facebook posts have received more attention in the case of twitter this identification depends on likes and retweets in the case of facebook this identification depends on likes on the posts of the facebook pages selected and the public comments with more likes in the case of reddit this identification depends on the total number of interactions of 4 conversations in the vaccines subreddit and the 100 mostvalued comments by the community and each comment receives points given by different members of the community on the askscience ama series for the case of the askscience ama series of one of the conversations we selected the last 20 comments sorted by reader preference such that each comment receives points according to the preferences of different members of the reddit community table 2 shows the data selected step 2 development of qualitative content analysis for each message selected researchers apply a classification of messages according to the codebook and interactions received the social impact coverage ratio will be applied for each source of social media selected which identifies the percentage of tweets and facebook posts providing information about potential or actual social impact in relation to the total amount of social media data found 2 the elaborated codebook has four categories defined a priori as a result of the literature review performed the categories classify messages analyzed regarding evidence of social impact false news misinformation opinion and facts while the research team performed the first analysis with these four categories two new categories emerged from the analysis these two categories were messages that ask for evidence of social impact and messages that contain misinformation but search for dialogue to contrast with the informationboth messages search for deliberation step 3 indepth analysis of interactions containing evidence of potential or real social impact classification four categories defined a priori code definition esism the message is an example of evidence of the social impact shared in social media this means that there is evidence of improvement in relation to the topic selected this evidence could be a potential or real social impact of research results that is linked with societal goals for instance the un sustainable development goals and that contributes to improving the specific health issue concerned this information is useful in connecting citizens with trustworthy information the message offers a link to evidence of contrasting information or sources of the evidence with possible contrasts misfa the message is an example of misinformation or fake information in health both situations have negative consequences for public health and personal health it does not offer a contribution in order to contrast but rather presents the message as evidence or trust information or the source of the information offered is not scientific opinion the message is an opinion and the message is presented as opinion not as evidence info the message is an event or fact for instance news two codes emerged from the analysis esism d the message is formulated as a question to ask for evidence of scientific results that ensure social impact or that are a starting point for deliberation misfa d the message contains misinformation or fake information but it contains questions that open dialogue in order to contrast ones own assumptions with the scientific evidence delivered by other persons or to begin a deliberation interrater reliability the analysis of social media data collected for the second analysis was conducted following a qualitative content analysis method in which reliability was based on a peerreviewed process the sample was composed of 453 messages each message was analyzed to identify whether it contains evidence of potential or real social impact if it was a message of misinformation or fake information in health if it was an opinion or if it was information the researchers involved were experts in the social impact of research and fake news each researcher was provided with the codebook before starting to code the messages once the analysis was finalized the messages were coded and compared we used interrater reliability in examining the agreement between the two raters on the assignment of the categories defined using cohens kappa the result obtained was 079 considering the interpretation of this number our level of agreement was almost perfect and thus our analysis was reliable in cases where no agreement was achieved the raters decided to exclude the results results before answering the research questions there are initial steps to determine whether among the messages selected in the sample there are more messages and interactions based on misinformation or on the contrary there is more evidence of potential or real social impact for this purpose we first classified the messages and second we calculated the sicor in relation to the twitter sample analyzed we found that tweets with a higher percentage of esism were those that were published under hashtag ebola followed by nutrition in the case of vaccines a lower percentage of esism was found but misfa had a higher percentage the higher percentage of three hashtags selected is the node of info and opinion is higher in the vaccines hashtag with 29 in relation to the data analyzed on facebook the lower percentage is under the code of misfa and the percentage of info is higher on facebook page 1 than on facebook page 2 however opinion is higher on facebook page 2 the case of esism is only present in the case of facebook page 1 with 15 in the case of subreddits we selected examples focused on vaccines because this topic was the most controversial on twitter one of the results indicates that the percentage of esism was higher than the misfa code info had the highest percentages in the subreddits and opinion had the secondhighest percentages if we analyzed the total amount of data collected we obtained the following sicor for each social media channel selected as shown in table 5 the sicor calculation 2 is a ratio that calculates the percentage of esism found in the full sample selected in this case the sicor is the percentage of tweets with evidence of social impact in relation to all the tweets collected the same applied to facebook posts and comments and subreddit comments as we can see the selected subreddit comments have a higher percentage of sicor followed by tweets and facebook posts and comments in the case of misfa the percentage of total amount for each social media channel selected is shown in table 6 according to the results the misfa percentage is higher in tweets followed by subreddit comments and facebook posts and comments fake health information social media messages are mostly aggressive regarding the research questions the nature of the social media messages focused on false health information is that they are mostly aggressive in the sample analyzed this result is mainly concerning the messages on vaccines in which the possibility of dialogue does not exist there is no option and the messages contained an affirmative closed sentence first we have detected hostility to arguments based on science and even defamation of scientists who have contributed to advances in the field of vaccines one of the examples of fake news in vaccines said the following vaccines have a long history of damaging the brain from day one followed by thesocalled father of vaccination left his first son braindamaged by vaccinating him jenner was smart enough not to vaccinate his second this is an example false of information that has negative impacts on the truth first jenner devoted his life to overcoming smallpox jenner even freely treated poor people to save them from smallpox his discovery had a substantial social impact and his sons died due to tuberculosis not due to smallpox vaccines this scientific article explains in detail the contribution of edward jenner 49 and concludes how his discovery and the promotion of vaccination facilitated the eradication of smallpox thus spreading false information about this crucial discovery with defamation of real history harms citizens lives because this lie could damage their health another example found that parents should be encouraged to boycott doctors who recommend vaccinating their children there is an active antivaccine movement that is continually sharing this type of message in social media the negative consequences are that some children who are not vaccinated have contracted diseases that could be avoided in addition to adults who have done the same for instance in 2019 there were 1282 cases of measles in an outbreak in 31 states 50 this number was the highest number of cases reported in the us since 1992 most cases occurred among those who were not vaccinated against measles 50 the negative impact of this type of interaction affects the public health of cities and villages where people decide to follow these antiscientific arguments for this reason these types of messages are also aggressive as they do not to follow scientific arguments related to health and cause physical damage and disease among children and those who share a common space regarding the examples of the type of misfa we found some messages that contain false information or misinformation but contain questions to open dialogue that may pose contrasts to ones own assumptions with scientific evidence delivered by other persons or the beginning of deliberation for instance one of the examples begins with i would be interested in a healthy and respectful conversation saying that he is a vaccine agnostic sharing his opinion that he believes there are more risks than benefits however he is open to dialogue this message is based on opinion not scientific evidence however he is honest saying that it is an opinion and he is not assuming that he knows the truth this is a first step towards dialogue this case reflects another type of message found people who are influenced by false information but open to having a conversation nevertheless this opinion also has negative consequences as he stated that his children are not vaccinated and thus they are also at risk potential or real social impact social media messages are respectful and transformative messages that contain the potential or real social impact of health are respectful and transformative they deliver quantitative or qualitative evidence of the social impact that contributes to knowing health is being improved some of the illustrative examples of this are those published under the ebola topic one of the examples analyzed was the impact that the ebola vaccine was finally approved ebola is a health concern especially in drc due to the number of people affected and who die due to this disease one of the examples shares quantitative evidence of the social impact of this vaccine and congratulates the people that made this result possible mercks ebola vaccine which has been given to more than 258000 people in the current outbreak in drc another example of this type of message said that the ebola vaccine is the best of 2019 this discovery offers hope and optimism for overcoming ebola in drc by offering qualitative evidence of the potential social impact of this vaccine for example a survivor of ebola who took part in the vaccine trial was quoted as saying i can convince other people in my town that there is a treatment available for ebola and that they can get better and a link was added to the who article with the full testimony of this survivor 51 similarly another example of qualitative evidence of social impact is delivered by a message that contains a documentary of ebola through different testimonies such as jophet kasere who survived ebola however his family did not he works as a nurse caring for children whose parents have been infected with the virus the documentary recorded by frontline shows how treatment delivered by who was improving the health of different members of the community but at the same shows how people who were against this international help tried to stop this improvement and leave people at risk 52 in deliberation contexts messages with evidence of social impact overcome fake information in health one of the results found is that deliberation contexts in social media promote the possibility of contrasting information and open dialogue based on valid claims this example has specially been observed in the reddit conversations analyzed the social network allows conversations abiding by the rules of the communities for instance one of these rules states that conversations should be based on scientific information and not on false information we have found examples of people with doubts or concerns regarding vaccines using reddit to share their views and learn in reddit we found misfa d and esism d because the common goal is to dialogue for instance one of the examples found was a conversation initiated by a girl who was not vaccinated she said my parents never vaccinated me and she was concerned about this and her health her questions were addressed to the community seeking help with regard to her situation she received replies focused on helping her for instance she was told to visit her gp in order to receive an appropriate catchup schedule and the importance of talking to a doctor was stressed this is not something you should be deciding yourself or asking the internet about just ask your doctor the second example selected was a conversation initiated by a person who holds antivaccine views but was searching for some answers to vaccine questions this person affirms that there has never been a vaccinated vs completely unvaccinated study to extract reliable conclusions about whether it is better to vaccinate or not this person received replies with evidence of social impact focused on comparative studies between people who were vaccinated and not vaccinated where those who were vaccinated exhibited better health than those who were not direct links to these studies were also provided some of the information detailed the following german study on lower rates of asthma among the vaccinated comparing unvaccinated and vaccinated people who do catch the fluvaccinated people are protected from the most serious effects vaccinated versus unvaccinated children how they fare in first five years of life nigerian study of 25 unvaccinated and 25 vaccinated children one vaccinated child had a mild case of measles unvaccinated children 3 dead plus 11 nonfatal cases of measles the second reply selected detailed cases of measles in the us and explained how the number of cases increased due to unvaccinated children and this was then compared with romania providing scientific sources where the data are published the result of this conversation is that the person who began this conversation read extended replies that were wellargued based on evidence of social impact and official data replying enthusiastically thanks ill read these and think on the issue thus a transformation was possible due to arguments based on evidence of social impact another example selected is from the ask me science conversations this is a conversation where scientists are available for dialogue with citizens about different topics in this case vaccines were used one of the conversations selected was concern around andy wakefield and his researchthat is an exphysician who became an antivaccine activist among those responsible for purporting a link between vaccines and autism the clear and overwhelming consensus among scientists is that his malevolent influence on the vaccine world was terrible and we have still not fully recovered even though his publications and ethics have been debunked because of his paper millions of people were not vaccinated and thousands have died what a legacy to live with furthermore the final example selected was regarding the negative impact of a community that opts to remain vaccinated this dialogue was started by someone sharing the concept of herd immunity this concept details that in a community there are people who cannot be vaccinated such as due to allergies or those who are immunocompromised and they depend on herd immunity to protect them this was followed by highlighting that if too many people who could get the vaccine but choose not to it does not just affect the individual but can compromise others in the community as well this person explained that in hisher county a large population chose not to vaccinate and consequently there was a measles outbreak further an emergency was declared heshe has a friend who is immunocompromised and needed to stay home for fear of contracting the measles it was terrifying and preventable if people who could get the vaccine would choose to do so it is a choice that does have an impact on others this conversation opens a dialogue on how our decisions based on false information can have a negative impact on the health of others thus it is crucial to apply the evidence of social impact in collective matters to guarantee in this case successful public health discussion the previous studies reviewed have been useful in clarifying how health information is spread in social media identifying the positive and negative impacts 67 regarding the adverse effects of using social media to spread misinformation there is evidence of the harmful consequences to global health and wellbeing becoming one of the most significant challenges for public health systems today 59 some of the studies have advanced the identification of the types of profiles that spread vaccinerelated disinformation 12 and this helps to identify whether the profile that is posting could be a trusted source or not our study contributes to advances in the direction of overcoming false information in health through the analysis of how the messages and interactions are based on false healthrelated information and the transformative dimension of those messages based on evidence of social impact this identification has made it possible to apply the sism methodology which is focused on evidence of social impact the three social media channels show that there is a public online discussion regarding the object of study the detailed analysis of the selected sample allowed us to identify deliberation contexts in the three social media channels for instance in reddit the open conversations encourage people to search for a dialogue based on valid claims moreover in this context messages based on evidence of social impact overcome false information even among those with previous antivaccine ideas but with an openminded attitude and respect however it is not possible to engage in dialogue with those who have an aggressive position against science this finding is especially crucial because it allows us to identify whether citizens have access to evidence on social impacts and whether they can share this evidence in conversations in which false information is spread the evidence of social impact is the vaccine against false healthrelated information future research lines could replicate this analysis in other topics in which false information is damaging nevertheless civil rights movements could also promote these findings to quickly overcome false healthrelated information that is causing deaths in adverse but avoidable situations on the basis of the research findings there are several practical implications and recommendations for public health professionals first the results allow public health professionals to determine the type of health information with evidence of social impact that is most shared in social media second the results also contribute to understanding the types of fake news with a stronger presence in social media that can reduce the effectiveness of public health social media campaigns third this knowledge can be useful in the design of strategies in the public health sector to reverse fake news fourth this knowledge can also be useful to narrow efforts to disseminate evidence of social impact in health to deactivate fake news finally this study contributes to identifying discussion forums in which debates are occurring around health information to contribute to the dialogue providing health information with evidence of social impact conclusions this article demonstrates that sism is a replicable methodology that has been successfully applied in social media analytics in relation to health and fake news contributing to the further exploration of the possibilities of this methodology this study offers the possibility to identify on the one hand evidence of social impact shared in social media and on the other hand misinformation or fake information related to health furthermore the results show how the interactions in social media depend on the type of information shared or commented upon by diverse actors the analysis of twitter facebook and reddit unveils the different types of interactions regarding evidence or fake news but they all have the common pattern of showing more messages of events or factrelated information about ebola nutrition and vaccines furthermore in most cases the existence of interactions regarding evidence is higher than that of interactions regarding the misinformation of fake information although the percentage is much higher for the misinformation of fake information than for evidence in the case of twitter vaccines with regard to opinions the results indicate that they are much more frequent on facebook and on subreddits than on twitter moreover the percentage of tweets and facebook posts providing information about potential or actual social impacts in relation to the total amount of social media data is higher in tweets and subreddit comments than in facebook posts and comments another relevant finding is that messages focused on false information regarding health are mostly aggressive and messages based on evidence of social impact are respectful and transformative finally deliberation contexts in social media allow for the transformation of even those who have false information but who are open to dialogue when they participate and access evidence of social impact the findings provide insights into the way in which public health initiatives can support the presence and interactions of evidence as an effective strategy to combat fake news two main recommendations are suggested for public health professionals among others on the one hand we narrow the dissemination strategies to reverse and deactivate fake news regarding health considering that the percentage of misinformation on fake news is much higher than that observed for twitter vaccines on the other hand the design of concrete interventions for discussion forums in which health information is discussed can provide health information with evidence of social impact this research contributes to including citizens voices into research from a bottomup approach in line with the need to support science and social dialogue in relation to public health including vulnerable groups 53 or the role of patients to overcome barriers to health access 54 the possibilities of social media analysis have been widely explored in very diverse fields from gender to digital protests 5556 and this work contributes to advancing knowledge in social media analysis and fake news in public health future investigations can use sism to analyze the interactions in social media regarding other public health issues to further explore how citizens use and share information supplementary materials the following are available online at table s1 dataset kappa

one of the challenges today is to face fake news false information in health due to its potential impact on peoples lives this article contributes to a new application of social impact in social media sism methodology this study focuses on the social impact of the research to identify what type of health information is false and what type of information is evidence of the social impact shared in social media the analysis of social media includes reddit facebook and twitter this analysis contributes to identifying how interactions in these forms of social media depend on the type of information shared the results indicate that messages focused on fake health information are mostly aggressive those based on evidence of social impact are respectful and transformative and finally deliberation contexts promoted in social media overcome false information about health these results contribute to advancing knowledge in overcoming fake healthrelated news shared in social media

introduction in the last few decades the rate of remarriage has grown rapidly in china as illustrated in figure 1 the annual number of people registering remarriage increased from fewer than 1 million in 1990 to more than 28 million in 2010 while remarriages accounted for approximately 8 of all marriage registrations in 1990 nearly 23 of marriage registrations in 2010 involved at least one remarrying spouse the importance of remarriage in china lies not only in its numerical increase against the backdrop of drastic socioeconomic cultural and institutional transformation in modern china the rise of remarriage serves as a kaleidoscope reflecting dynamic changes in the chinese family and the shifting landscape of intimate relationships moreover the institution and practice of remarriagedeeply embedded in complex family relationsraise a number of issues that have long interested social scientists care provision stepparenthood inheritance and family finances although a number of studies have been conducted on remarriage in the chinese context prior researchers have either focused on populationlevel trends or drawn on smallscale regionspecific qualitative evidence in this study we aim to fill the gaps in existing research by providing an uptodate nationally representative individuallevel analysis of remarriage in modern china figure 1 about here the study of remarriage requires the consideration of linked lives the incomplete institutionalization of remarriage is vividly reflected in the state of existing research on remarriage which relies heavily on the opportunitypreference framework developed for the study of first marriages as individuals make decisions on remarriage in the wake of preceding lifecourse events and previous marriages often entail indisposable ties with people such as children and inlaws theories based on first marriage are unlikely to fully capture the distinctive features of remarriage the need to consider family relations is particularly pertinent to the study of remarriage in china where marriage is largely a family rather than an individual affair as a result the presence of nuclear and extended family members may play crucial roles in configuring the probability of remarriage furthermore the dynamic social interactions sustained by such family relations may also differ between remarried individuals and those who remain single after marital disruption in the chinese family women and men are also known to assume differentiated gender roles and relate to other family members in distinct ways therefore the first objective of this research is to explore the gendered relationship between family relationsboth their structure and the dynamic exchange associated with such relationsand remarriage it is also crucial to differentiate and compare distinctive lifecourse trajectories that lead to remarriage few previous researchers have distinguished between remarriage after divorce and remarriage after widowhood however divorce and widowhood may entail drastically different life experiences emotional contours and circumstances although a small number of researchers have distinguished between remarriage postdivorce and postwidowhood they have tended to focus on one or the other not both only a few have compared postdivorce and postwidowhood remarriage in western societies therefore it is our second objective to explore the similarities and differences in the relationship between family relations and remarriage after divorce and after widowhood in china analyzing data from the 2010 wave of the china family panel studies we examine the roles played by a diverse array of family relations in configuring the probability of remarriage after divorce and after widowhood as well as how the dynamic care exchange sustained by such family relations differ between remarried and single divorcé or widows we further supplement and elaborate on our quantitative findings using qualitative evidence from 13 indepth semistructured interviews with respondents who have remained single and respondents who have remarried since divorce or widowhood background and theoretical considerations changing context of remarriage in china remarriage is not a new phenomenon in china in the feudal and imperial eras remarriage was common among widows from less welloff families despite the thendominant moral ideal of the chastity widow which obliged widows to remain faithful to their late husbands a lack of inherited assets made remarriage a viable strategy for subsistence for socioeconomically disadvantaged women especially given womens limited participation in the labor force at this time due to the rarity of divorce in feudal and imperial china most remarriages followed widowhood rather than divorce the establishment of a socialist regime in 1949 and chinas subsequent socioeconomic reforms brought about considerable and gendered changes in the context of and motivation for remarriage as well as its sociocultural and symbolic meanings first the socialist revolution boosted womens laborforce participation to more than 90 in the socialist era enabling chinese wives to enjoy unprecedented economic independence therefore economic deprivation is less likely to encourage remarriage for the sake of subsistence as it did in presocialist china second the 1950 marriage law conferred on chinese men and women equal rights to marry and divorce according to personal will third the opendoor policy implemented in late 1978 exposed chinese people to western ideals of individualism the resulting prevalence of divorce particularly in big cities has created a major path to remarriage along with widowhood furthermore as cultural and legal changes erode the ideal of the chastity widow traditional moral imperatives may no longer impede women from remarrying indeed it is widely argued that the growth of individual autonomy in modern china has contributed greatly to the individualistic pursuit of intimate relationships and therefore remarriage linked lives family relations and remarriage given the ongoing influence of family relations on marital decisions the individualization of remarriage remains an empirical question existing scholarship has consistently shown that nuclear and extended families continue to play an active role in events such as matchmaking mate selection and the sanctioning of marriage in china today although prior research has focused on the relationships between individuals and particular family members such as children parents and relatives investigating their respective influence on the probability of remarriage research comparing distinct sets of family relations is scarce it thus remains unclear whether and how different family members influence individuals remarriage in distinct ways furthermore family relations are experienced not only through the structural presence or absence of family members but also through complex and dynamic care resource and emotional exchange sustained by such structure therefore it is crucial to provide a systematic assessment of the ways in which the presence or absence of distinct family members may configure the probability of remarriage and whether and how the patterns of care exchange differ between those who have remarried and those who have remained single since marital disruption in china family relations have two major dimensions intergenerational between parents and children and horizontal between extended family members such as siblings and relatives as gender roles are highly segmented between men and women in the chinese family both dimensions of family relations are gendered intergenerationally parents were traditionally considered to be a major impediment to remarriage whose presence was believed to reinforce ones sense of filial obligation as well as the traditional ideal of chastity this might not still be the case in modern china in the wake of divorce or widowhood parents may often serve as the first resort of help and support in the modern era the traditional moral ideal of chastity wife is being replaced by a rising sense of individualism that locates personal fulfilment in intimate relationships this concurs with recent evidence that some parents are seen to encourage divorcés and widows to seek a fulfilled personal life and oldage security through remarriage the presence of children was considered as another major impediment to remarriage under the influence of patrilineal traditions minors were often considered to be undesirable baggage that may diminish ones chances in the remarriage market particularly for women in addition the widespread vilification of stepfamilies for harming childrens development has led to an image of remarriage as an option for selfish parents however recent research suggests that the rising divorce rates may have contributed to a decline of the negative stigmas attached to stepfamilies in postreform china particularly in urban areas moreover single parents especially those with young children are increasingly challenged by the soaring costs associated with childcare and childrearing to consider remarriage the legitimacy of marriage in modern china is sanctioned by law as well as by the recognition of a broader circle of extended family members compared with those operating intergenerationally care and resource exchanges between extended families and relatives are far less intense however social recognition from extended families as a generalized reinforcer may play an important symbolic role in legitimizing and reinforcing social norms pertaining to remarriage because marriage is considered an integral part of a fulfilled personal lifeparticularly for womenin modern china marital dissolution and widowhood may generate anxiety among extended family members who may consequently pressure divorcés and widows to seek personal fulfilment through remarriage therefore the presence of extended family members is likely to facilitate remarriage comparing remarriage postdivorce and postwidowhood the need to differentiate postdivorce and postwidowhood remarriage is motivated by three major considerations first divorce and widowhood represent distinct lifecourse trajectories a comparative analysis may yield important insights into the implications of the two major types of marital disruption for subsequent lifecourse developments second divorce and widowhood tend to occur at distinct stages of the life course whereas divorce usually takes place in midlife in china widowhood is more likely to occur later in life this means divorcés and widows may have very different personal concerns over issues such as financial dependence and oldage security and divergent life aspirations for intimacy and marriage third divorcés and widows are also likely to have family members who are at different stages of their life course in turn this may demand divorcés and widows to respond to the needs that are specific to the lifecourse circumstances of their family members for instance due to the absence of state welfare for childcare single parents with young rather than adult children may particularly view remarriage as a source of care and resources although we are prevented by the scarcity of prior research from deriving systematic hypotheses our key aim is to explore whether and how the interrelations between family relations and remarriage differ between divorcés and widows method in this research we adopted a twostage mixedmethods exploratory design we first analyzed nationally representative survey data to identify the relationship between the structure of family relations and the likelihood of remarriage after divorce and after widowhood respectively and to examine the patterns of association between remarriage and careexchange activities to further elaborate on our quantitative findings we drew on indepth semistructured interviews to explore how individuals make sense of their remarriage considerations quantitative data and sample our quantitative data were drawn from the adult panel of the 2010 wave of the china family panel studies the cfps was conducted by the institute of social science survey at peking university in collaboration with the population studies center at the university of michigan multistage probabilityproportionaltosize sampling was used with samples weighted in proportion to population structure at the administrative levels of county village and household the survey covered 33600 adults from 16000 households from 25 provinces the response rate was 8128 at the household level the 2010 cfps data are suited to the current research for a number of reasons first the survey contained a large nationally representative probability sample of remarried individuals in china second the survey is representative of households from the eastern coast to the western hinterland which is crucial given the considerable regional variation in remarriage rates across china third the cfps collected event history data on both marriage trajectories and family relations to construct our analytical sample we first excluded 30382 nevermarried respondents those in first marriages and those who had experienced both divorce and widowhood we then deleted 23 higherorder remarriages and 126 cases with missing values for our variables we used the mcartest package in stata to identify any potential biases resulting from our listwise deletion of cases with missing values as the littles test was not statistically significant at the 10 level the results confirmed that the listdeleted cases were missing completely at random our final analytical sample comprised 3069 individuals who had experienced either divorce or widowhood of whom 722 had remarried for the first time based on the event history data from the cfps we restructured the crosssectional dataset into the personyear format following the method recommended by singer and willet the data were structured such that the first personyear record represented the year in which the divorce or widowhood took place and the last personyear record represented the year of remarriage for those who had remarried by 2010 or the year of survey for those who had not remarried as of 2010 this restructured dataset contained a total of 33964 personyear observations ie each respondent was observed for an average of 1107 years table 1 presents descriptive statistics for the analytical sample table 1 about here measures marital history based on the respondents current marital status and marital history we distinguished between divorcés who had remained single and remarried divorcés and between single widows and remarried widows in our analytical sample 830 respondents had previously divorced of whom 492 had remarried and 2239 respondents had experienced widowhood of whom around 14 had remarried the proportions of divorcés and widows in our analytical sample are consistent with evidence from the divorcés accounted for around 14 of the chinese population we also derived a variable recording the year of divorce or widowhood the respondents experienced divorce or widowhood between 1958 and 2010 with the average marital disruption occurring in 1997 on balance divorce and widowhood occurred when the respondents were 3337 and 5367 years old respectively the previous marriage lasted an average of 902 years for divorcés and 3281 years for widows the average time between marital disruption and remarriage was 403 years for divorcés and 424 years for widows structure of family relations based on the respondents marital history and their childrens demographic information we derived a series of timevarying variables to capture the presence or absence of preschool children aged 06 school children aged 717 and adult children respectively for each personyear observation we coded the presence of children as binomial categorical variables because only a small number of respondents had more than one child in each category at any given time our further checks indicated that no respondent had a child with their remarriage spouse prior to their remarriage as no change was noted in the sibship status of the respondents in our observation window we captured the presence of sibling using a timeconstant dummy variable due to the lack of detailed life history data on parents and extended families we coded the presence of living parent and the size of the extended family as timeconstant variables based on the information in 2010 although the presence of parents and extended family members tends to predate the event of remarriage we are careful to interpret the results for these variables in terms of association rather than causality due to the use of timeconstant proxies care exchange activities we also measured the respondents provision of care to their children and their reception of care from children in the six months prior to the survey we defined care in a broad sense to include financial assistance financial management domesticity and childcare we coded the respondents as active care providers if they provided their children with one or more types of care similarly we coded those who received one or more types of care as active care recipients due to cellsize considerations we coded care provision and reception as binomial categorical variables because the proportion of respondents who received or provided each specific type of care is relatively low unfortunately the cfps did not measure care exchange between the respondents and other family members and only current but not event history data on care exchange were collected this means our analysis only provides a correlational snapshot of whether and how the patterns of careexchange activities differed between single and remarried respondents after marital disruption collecting and analyzing finegrained longitudinal data on care exchange should be an important agenda for future research on remarriage covariates we controlled for the respondents gender and 62 of the respondents were female we included respondents age as a linear regressor as preliminary work showed this to be the most parsimonious specification the respondents ranged between 29 and 82 years old with a mean age of 6099 and the divorés were considerably younger than the widows whereas the remarried divorcés and single divorcés were similar in age the remarried widows were significantly younger than the single widows we controlled for the respondents years of schooling as younger cohorts enjoy more educational resources than their predecessors in china and the divorcés were substantially younger than the widows it is not surprising that the divorcés had received more education than the widows we took account of whether a respondent had ever held a formal job for more than 6 months and 25 of the respondents had never worked in the absence of event history data on the respondents income we necessarily relied on the timeconstant measure of individual income in 2010 as a proxy of ones socioeconomic status we also included a timeconstant dummy variable distinguishing between residence in a rural area affiliated with a village committee and residence in an urban area under the jurisdiction of a neighborhood committee in 2010 due to the lack of data on the respondents migration history this timeconstant measure may not have captured the respondents geographical mobility in our observation window nevertheless we also controlled for ones hukou origin using the hukou status of the respondents parents distinguishing between rural and urban types which predates the event of remarriage and is unlikely to change over time in china hukou origin plays a prominent role in determining ones family values and marital mobility irrespective of ones location of residence in rural or urban areas hukou origin is a major cause of segregation in the marriage market in contemporary china statistical analysis in our analytical sample 193 of the cases included more than one respondent from the same household and the households were further nested within provinces to account for the hierarchical nature of the data and unobserved heterogeneities at the household and province levels we fitted all models using a multilevel framework with random intercepts at the household and province levels first to examine how the structure of family relations configures the probability of remarriage we fitted separate multilevel cox proportional hazards event history models for remarriage postdivorce and postwidowhood using the long personyear dataset the cox specification was used because it makes no assumption about the underlying distribution of event time our key focus is on the predictors rather than the timing of remarriage and the specification provides a more parsimonious solution given our long window of observation our additional tests using the discretetime specification yielded results consistent to those reported here in model a we included the structure of family relations and all control variables we then added the interactions between gender and the structure of family relations in model b we then nested model 1 and model 2 to conduct crosssample comparison of the regression coefficients second to compare the patterns of care exchange between the single and remarried respondents we fitted multilevel binomial logistic regression models predicting the odds of care provision to children and care reception from children in 2010 using the wide dataset the models were first fitted only with the main effects of all variables and we then included the gender interactions for the care exchange measures notably we used the respondents remarriage status in 2009 rather than 2010 to ensure the key predictor predated the dependent variables given the dynamic and timesensitive nature of care exchange we are also careful to report and discuss the results in terms of association rather than causality in both sets of models the variance inflation factor test was conducted and the vif values were well below the conservative threshold of 25 for all our key variables qualitative data collection and analysis to elaborate on our quantitative findings and explore how individuals make sense of remarriage considerations we drew on qualitative data from indepth semistructured interviews the interviews were conducted between 2015 and early 2016 snowball sampling was used to recruit 13 single and remarried divorcés and widows with distinct experiences of remarriage from a number of cities in southern china the interviewees ranged from 42 to 66 years old with a mean age of 52 of the 13 interviewees 10 were female 5 had experienced widowhood rather than divorce and 5 had remarried since divorce or widowhood with an overarching focus on peoples considerations and decisions pertaining to remarriage the interviews explored the respondents family relations and biographical trajectories since their divorce or widowhood lasting for an average of 47 minutes the interviews were conducted in chinese audiorecorded where possible and transcribed a combination of selective and axial coding was used to analyze the qualitative data as the main purpose of our qualitative procedure was to illustrate and enrich the interpretation of our quantitative findings our initial coding of the qualitative data was necessarily guided by the patterns identified in our quantitative analysis here we paid close attention to the occurrence of themes that corresponded to our key variables axial coding was then used to identify and establish potential relationships between different themes at this stage we paid particular attention to how the interviewees subjectively experienced and made sense of their family relations when considering remarriage results table 2 presents the results from the multilevel cox proportional hazards regression models predicting the transition into remarriage after divorce and after widowhood respectively coefficients are reported in table 2 as we report the results we also present the hazards ratios in the body of the text where a value greater than 1 indicates a greater likelihood and a value less than 1 indicates a lower likelihood of having remarried rather than remaining single after divorce or widowhood figure 2 depicts the marginal differences in the odds of care provision to children and care reception from children between the single and remarried respondents table 2 and figure 2 about here in model 1a the results show that there is a positive association between the presence of preschool children and the probability of remarriage after divorce in contrast the presence of schoolage and particularly adult children are associated with a reduced likelihood of remarriage after divorce in model 1b the results further reveal the gendered pattern of association between the presence of children and the likelihood of remarriage divorced men are particularly more likely to remarry in the presence of preschool children and divorced women are particularly less likely to remarry in the presence of adult children the presence of schoolage children has divergent influences on divorced women and men while divorced women are less likely to remarry in the presence of schoolage children divorced men are more likely to remarry in the presence of schoolage children as depicted in panel b of figure 2 the association between care exchange and remarriage after divorce is also gendered as remarried men but not remarried women are less likely to receive care from their children compared with their single counterparts the quantitative findings are further nuanced by our qualitative interviews as evident from the following excerpts i would be very concerned about my daughter if i were to remarry i watch all these news reports of men harassing their stepdaughters thats why very few women with young daughters remarry it would be ok if i had a son look at woody allen and his adopted daughter how can he touch her shes his daughter they married even his poor wife its very hard to find a man who can take care of you and your children youre old already citing media portrayals and popular stereotypes the divorcés particularly the females almost unanimously expressed concern about the adverse effects of stepfamilies on their childrens wellbeing this echoes the widespread perception of stepfamilies as detrimental to the development of children and young adults meanwhile children from previous marriages were widely perceived as burdensome and unwelcome baggage in the remarriage market due to the persistence of patrilineal traditions in china single mothers with children from previous marriages find it particularly difficult to remarry in the words of one interviewee who wants to foster someone elses bloodline nevertheless although our interviewees reiterated their preference as good mothers to stay single to protect their children they also hinted at an inner desire for remarriage as life would be so much easier if there were someone to share the parental responsibilities however despite the negative stigmas attached to single parenthood and stepfamilies remarriage may function as a source of economic support that allows divorced mothers with young children to spend time on childcare rather than paid work particularly in the absence of state welfare provision meanwhile divorced men may view remarriage as a viable source of care for their young children and themselves as women rather than men are expected to be the major care providers in china similar to the results for model 1a the results for model 2a indicate that the probability of remarriage after widowhood is negatively associated with the presence of schoolage and adult children similarly for women and men as shown in model 2b furthermore the comparison between model 1a and model 2a indicates that the negative association between the probability of remarriage and the presence of schoolage and adult children are significantly stronger among widows than divorcés different from postdivorce remarriage the presence of preschool children is negatively associated with the remarriage of widows the patterns of care exchange also differ considerably between single and remarried widows as depicted in panel c of figure 2 remarried widows are less likely to provide care to their children compared with their single counterparts as depicted in panel d both remarried widows and widowers are less likely to receive care from their children compared with their single counterparts the findings may have two possible explanations first remarriage may be a cause of the observed differences in the patterns of care exchange as remarried widows are closely involved in their conjugal lives they may have less time and space for care exchange with their children as ones spouse may serve as a source of care provision the need for care provision from children may also be lower among remarried than single widows second remarriage may be a consequence of preexisting care exchange activities in the absence of welfare legislation the concern over oldage security constitutes a major driver for remarriage in china therefore preexisting care with children may lessen widows need of remarriage moreover elderly widows in china often help their children with daily chores and look after their grandchildren the provision of care for family members may anchor care providers both functionally and emotionally in their family relations and thus decreasing the perceived need of remarriage while we are not able to determine the causality between care exchange and remarriage using crosssectional data our qualitative evidence reveals the concurrent existence of both mechanisms in the interviews some of the widows expressed their hope to relieve their children of the burden of oldage care provision through remarriage the other widows we interviewed were keen to enumerate their various forms of engagement with their offspring and described a sense of security in the knowledge that they had families to fall back on in old age they said grandma youre so outdated you dont know how to play video games they helped me download apps they gave me their stylus pen i said then you wont have one they said that their dad had given them three stylus pens so they were able to give me one my sons both come back for dinner every night they live with me i cook from 5 to 6 and then i am free to watch tv and listen to the radio and read i have no time to think about these things dating i follow my daughter wherever she goes we observed a positive association between the presence of living parent and the likelihood of remarriage for widows but not divorcés the positive association is stronger among widows than widowers parents are often the first resort for support in the wake of widowhood different from hans ganong and colemans finding in the usa that remarriage is associated with a lower level of attachment to parents our interview data vividly illustrate that parents provision of such support often creates a strong sense of emotional attachment and filial obligation in their children our interviewees were particularly vociferous in their gratitude to their parents for being a reliable cushion on which to fall back the resulting feeling of indebtedness to ones parents was also a prominent theme in the narratives of the divorcés moving on from marital disruption however it is also evident from our interviews that the elderly parents are closely concerned about the oldage security of the widows and thus encourage their children to pursue a fulfilled personal life and oldage security through remarriage we also found a significant positive association between the size of extended family and the likelihood of remarriage for both divorcés and widows these observations may be attributed to the widespread belief in modern china that marriage is crucial to a fulfilled personal life a belief that may be reinforced by extended family members indeed a number of interviewees reported that their singlehood was often questioned during gatherings with siblings and relatives extended family members customarily aired their concerns over the wellbeing of the singletons by encouraging them to move on to find happiness in a new relationship as indicated in the following extract before i got together with my current wife my family and particularly my brothers constantly prodded me to find someone with whom to start over they said things like look at the mess you are in you need a woman to sort you out…not to mention that your son needs a mother they told me to move on from the divorce and they went on and on the results reveal both similarities and differences in the patterns of association between family relations and remarriage after divorce and after widowhood particularly the differences must be considered in relation to the distinct demographic profiles and marital histories of divorcés and widows as shown in table 2 compared with women men are less likely to remarry after divorce but they are more likely to remarry after widowhood notably these gender differences are mediated and thus explained by the inclusion of gendered family relations in models 1b and 2b the likelihood of postwidowhood remarriage decreases with the age at divorce a longer previous marriage is negatively associated with the probability of remarriage for widows but not divorcés we found that both divorcés and widows of urban hukou origin are less likely to remarry than their counterparts of rural hukou origin although socioeconomically disadvantaged widows in feudal and imperial china relied on remarriage for subsistence a lack of economic activity and income today does not seem to be associated with an increased probability of remarriage we also found a positive association between ones years of schooling and the probability of remarriage after widowhood discussion and conclusions the increasing rate of remarriage is often considered to reflect broader social changes in modern china prior research on the aggregate population trends of divorce widowhood and remarriage in chinese settings has tended to attribute these phenomena to macro social trends such as socioeconomic development and the massification of education research drawing on nationally representative individuallevel data is scarce most individuallevel analysis has focused on remarriage either after divorce or after widowhood not both drawing on data from the 2010 china family panel studies and 13 indepth qualitative interviews we address these gaps by exploring the gendered relationship between family relations and remarriage in particular we compare divorce and widowhood as two distinct lifecourse trajectories leading to remarriage our findings suggest that remarriage is far from an individualized affair it is widely assumed that the prevalence of remarriage in modern china is caused by a trend of societal individualization however informed by the perspective of linked lives we find that remarriage is closely associated with indisposable ties with children siblings parents and extended families indeed we find that the probability of remarriage is closely shaped by the structure of family relations and that the patterns of care exchange vary considerably by remarriage status above and beyond the structural presence or absence of family members we find that the lifecourse circumstances of family members matter just as much in that children at distinct lifecourse stages were seen to configure the probability of remarriage in considerably different ways in addition distinct sets of family relations seem to play different roles in configuring the probability of remarriage and these roles also differ between divorcés and widows we argue and demonstrate that rather than considering remarriage as an institution it would be useful to conceptualize remarriage as a social practice that responds flexibly to the diverse constellations of lifecourse circumstances the relationship between family relations and remarriage may differ between widows and divorcés because they cluster at distinct stages of the life course and thus have very different life circumstances among divorés we find a strong sense of structural ambivalence resulting from conflicting ideals and constraints in chinas remarriage market the divorcés we interviewedparticularly those with young childrenexpressed a desire to remarry however the structural presence of minor and youngadult children was perceived as a formidable constraint on divorcés remarriage this is not only due to the widespread cultural stigma attached to stepparenthood but also because the odds are stacked against those with children from previous marriages in the marriage market compared with divorés the widows viewed the structure of family relations as an inhibiting constraint to a lesser extent and the remarriage of widows seems to relate more closely to their practice of family relations as vividly illustrated in our interviews widows were seen to actively provide care for their offspring such care provision often generates a sense of emotional attachment and fulfillment that seems to lessen the perceived need for fulfillment through intimate relationships moreover care provision might prevent widows from dating and getting remarried by consuming their available time and resources the results should also be interpreted with reference to the distinctive institutional features of modern china due to the absence of childcare subsidies and socialservice provision for single parents the lack of state legislation for oldage welfare and care and the persistence of patrilineality chinese families are often responsible for cushioning the repercussions of divorce and widowhood this is consistent with daviss finding that chinese marriages are being privatized from the states perspective paradoxically however due to the lack of alternative service and welfare provision which has obliged individuals to fall back on their families in the wake of divorce and widowhood remarriage and its considerations have become no less private from the individuals perspective in other words complex family relations continue to play a prominent role in shaping the institution of remarriage therefore the states privatization of the marital institution seems to reinforce the familialization of remarriages in china which embeds remarriage practices further in the traditional familial system instead of deanchoring it from traditional moorings as argued by individualization theorists the limitations of this research suggest several important directions for future research first the quantitative results yielded from the analysis of crosssectional data should be interpreted in terms of association rather than causality although the respondents are likely to provide accurate information on life events as important as marital disruption and remarriage it is possible that the event history data may be susceptible to recalling errors in future research longitudinal analysis will be crucial to unpack the lifecourse dynamics of remarriage postdivorce and postwidowhood second our qualitative procedure relied on convenience sampling therefore we cannot claim to have obtained representative narratives simply narratives that shed further light on our quantitative findings third while our analysis took place at the individual level it is important for future scholars to conduct dyadic analysis to address the tethered lives of remarried couples furthermore given the rapid sociocultural and institutional changes ongoing in china it will be crucial for future researchers to examine the overtime developments in the dynamics of family relations and remarriage 6638 27326 note reference category in parenthesis a femalemale betweenslope difference for remarriage after divorce statistically significant at the 10 level or below b difference between remarriage postdivorce and remarriage postwidowhood statistically significant at the 5 level or below based on model 1a and 2a for control variables p 10 p 05 p 01 p 001 note caculations based on threelevel logistics regression models with random intercepts at the province and household levels all models controlled for all variables listed in table 1 full regression results available upon request from the authors austerix star indicates statistically significant difference beteween postdivorce and postwidowhood remarriage significant at the 5 level or below

we are grateful for the helpful comments received at the conference we thank the anonymous reviewers for their constructive suggestions

introduction the trafficking of human beings for the purpose of organ removal is not a new phenomenon 1 with a shortage of legally sourced organs around the world it is estimated that the illegal trade of human organs generates about 15 billion dollars each year from roughly 12000 illegal transplants 2 thbor has serious consequences for human security particularly for the most vulnerable populations such as the unemployed homeless people and migrants for instance in 2017 a growing number of organ trafficking cases was uncovered in lebanon as syrian refugees were desperate to support themselves and their families 3 since the declaration of istanbul on organ trafficking and transplant tourism governments and nongovernmental organizations have begun to provide rough estimates about thbor and yet little academic attention has been devoted to the study of such a global phenomenon 4 in 2004 the who urged governments to take measures against organ trafficking and protect those who are the most vulnerable such efforts culminated with the declaration of istanbul on organ trafficking and transplant tourism where more than 150 scientific researchers from 78 different countries concluded that commercialized transplants organ trafficking and transplant tourism should be prohibited 4 in this paper we aim to shed light upon the current state of the literature on thbor and its relationship to migrants we employ a bibliometric analysis with a global sample for the 19902019 period to find the current trends and shortcomings in the literature in 2018 the international labor organization asserted that about 40 million people were victims of human traffickingroughly the population of iraq today 5 about 90 percent of all detected cases were for sexual exploitation or forced labour purposes 6 the remaining 10 percent of cases are often lumped together in the other forms categoryincluding organ removal organ trafficking is a 2 of 11 broad concept that includes several illegal activities of which the main goal is to profit from human organs and tissue for the sole purpose of transplantation these activities include thbor transplant tourism and trafficking in organs and tissues 7 8 9 despite international and domestic efforts about 10 percent of all transplants worldwide are believed to be illegalapproximately 12000 organs per year 10 while the number of reports on victims of trafficking in people has increased only 700 victims of thbor were detected from 25 countries for the 20062019 period 6 migrants are amongst one of the most vulnerable populations for organ trafficking 1112 many migrants often face poor socioeconomic and political conditions in their own countries however situations of vulnerability can occur while en route or in host areas as migrants are exposed to abuse and exploitation by smugglers and opportunists 11 for instance in 2015 pakistani refugees in lebanon escaping the syrian civil war were prevented from reregistering as refugees in a second country by the un in the words of an organ broker those who are not registered as refugees are struggling what can they do they are desperate and they have no other means to survive but to sell their organs 11 moreover a migrants individual vulnerability can increase due to personal circumstances such situations arise when migrants travel with children elderly people with disabilities and the like 13 the previously mentioned organ broker also acknowledged that one of his clients was a 17yearold boy who left syria after his father and brothers were killed he had been in lebanon for three years with no work and mounting debt struggling to support his mother and five sisters he agreed to sell his right kidney for us 8000 11 to summarize thbor is a global problem with health and human rights consequences for millions of people especially for those in vulnerable situations such as migrants the following research questions are relevant to our study to what extent is scientific research addressing thbor are migrants included in this research where is most of the published output from thbor and migrants being produced materials and methods study design we employed a bibliometric analysis to accomplish the goals of our study a bibliometric analysis consists of the application of quantitative analysis techniques to data concerning scientific production such as journal articles and their accompanying citation counts 1415 it is ideal to quantitatively measure the trends volume and scope of publications on thbor the use of a bibliometric analysis also allows us to find the geographical distribution of knowledge production about thbor and migrants as well as to explore the most frequently used methodological approaches in the study of organ trafficking therefore bibliometric analysis constitutes a useful tool to quantitatively explore the evolution and situation of thbor literature and particularly to find if and to what extent migrants as one of the most vulnerable groups are being included in publications dealing with such a relevant topic in conclusion it provides useful information for researchers and professionals to evaluate publication activity offering a basis for future research search strategy table 1 presents our search strategy iterations keywords and exclusions keyword selection is of great importance in bibliometric analysis as keywords searched will determine the documents retrieved and therefore the findings and results search keywords were selected from previous published literature relevant who documents such as resolution 4425 16 the who global glossary of terms and definitions on donation and transplantation 17 and the declaration of istanbul 4 the second column in table 1 presents the keywords searched among the topic field tags in web of science topic field tags include titles abstracts keywords and descriptors of every document although the search was not restricted to any language most of the results come from english language publications iterations with specific organs were also used as some publications do not address thbor as a general topic but focus on the trafficking or illegal transplantations of a specific organ or tissue the specific organs utilized in our search are presented in the first column of table 1 these keywords were selected for iterations because they are estimated to be the most frequently illegally removed 2 finally excluded keywords were selected to minimize the number of falsepositive results as a result of this iterated search we obtain a database of 482 publications which will be used for the following bibliometric analysis not ts not py 2020 note symbol includes all possible grammatical endings source of information data were obtained from the web of science database for the 19902019 periodno publications relating to organ trafficking were found prior to 1990 wos is a global citation search engine whose database concentrates ideas across disciplines and time from over 17 billion cited references from over 159 million records from leading academic corporate and government institutions over 115 years 18 wos includes the science citation index expanded social sciences citation index arts and humanities citation index emerging sources citation index book citation index conference proceedings citation index and current chemical reactions and index chemicus 19 20 21 22 23 24 25 26 the database was created by clarivate analytics an international wellknown enterprise dedicated to innovation and the delivery of critical data and information for among others scientific and academic research 27 furthermore as web of science has been indexing every piece of content and supplies a great variety of filtering options it is the most reliable database for bibliometric analysis bibliometric indicators bibliometric indicators measure knowledge production about a certain topic the number of publications and citations are the most useful and widely employed metrics as they quantitatively measure the volume of research output and the impact and influence of it respectively our bibliometric indicators are presented as a timeseries to show a trend in thbor research we are particularly interested in the most productive journals and institutions as well as their country of origin this will allow us to analyse the spatial distribution of global output in line with previous bibliometric analysis literature we utilize a threshold of ten when presenting our results 28 29 30 31 these indicators namely the number of publications and citations can be employed to further analyse research trends on the topic of thbor with the focus on which research approaches are being used especially on how migrants health has been included in organ trafficking research research approach and specificity the web of science categories show which research field a publication belongs to and which methodological approach was utilized bibliometric indicators are used to show the most common fields of study conducting research on thbor previous studies on human trafficking have found healthrelated approaches to be underrepresented in the literature 25 however thbor itself is a healthrelated issue therefore we cluster all healthrelated publications for the following research areas biomedical social sciences cardiovascular system and cardiology cell biology gastroenterology and hepatology general and internal medicine genetics and heredity health care sciences and services haematology immunology infectious diseases legal medicine medical ethics microbiology neurosciences and neurology nursing obstetrics and gynaecology pathology pediatrics pharmacology and pharmacy psychiatry psychology reproductive biology research and experimental medicine respiratory system surgery transplantation urology and nephrology publications that did not fall under these fields of study were classified as nonhealth related an additional analysis of the database metrics was conducted to classify publications depending on their specificity some publications focus their thbor research exclusively on the removal of a specific organ or address the different dynamics between trafficking of different organs organspecific documents are defined as those making the explicit mention of any organ in their title abstract or keywords we believe that this specificity will allow us to shed light on what kind of specific organs have researchers devoted most of their attention to as well as the spatial distribution of where these research specific clusters are taking place across the world publications that mention a specific organ are henceforth referred to as organspecific publications given that one of the main purposes of our study is to analyse thbor research that addresses migrants publications were classified depending on their inclusion of migrants we assume that when migrants are mentioned in the title or abstract of a document it means that the article takes into account these relevant groups as they may be the main research objects publications studying migrants are defined as those including the following words in the title or abstract migrants emigrants immigrants migration emigration immigration refugees asylum seeker results our results suggest four key findings first a lack of research on organ trafficking second the research that addresses the link between thbor and migrants is staggeringly scarce third most organ trafficking research originates from western countries finally the bulk of the literature comes from the medical sciences and there is a wide gap within the fields of social science and the humanities volume of publications temporal analysis in total 482 documents about organ trafficking were used in our analysis figure 1 shows an increase in the total number of publications pertaining to organ trafficking from 1990 to 2019 researchers have increasingly paid attention to this issue since the istanbul summit and the following publication of the declaration of istanbul on organ trafficking and transplant tourism in 2008 on average before the declaration of istanbul about 37 organtraffickingrelated documents were published per year after the declaration the average increased to 347 documents per year therefore we conclude that international attention to organ trafficking has led to a boost in publications about thbor the momentum created in 2008 can be also appreciated in the total number of citations received by organ trafficking research studies documents published in 2008 received more citations than those published in any other year and per publication received double the citations than the overall average the impact and influence of the declaration of istanbul of 2008 are clearly evident but the momentum may have slightly decreased in the last couple of years as suggested by the slight decrease in the slope of the curve in figure 1 spatial distribution the retrieved documents were published in 219 different journals as table 2 shows the most active journal in the field of organ trafficking was the american journal of transplantation with a total number of 45 publications closely followed by transplantation with 41 publications almost one in every five articles on organ trafficking was published in these two journals however documents published in the lancet and current opinion in organ transplantation received the highest number of citations per article as can be inferred from the journals titles most active journals belong to different medical research areas spatial distribution the retrieved documents were published in 219 different journals as table 2 shows the most active journal in the field of organ trafficking was the american journal of transplantation with a total number of 45 publications closely followed by transplantation with 41 publications almost one in every five articles on organ trafficking was published in these two journals however documents published in the lancet and current opinion in organ transplantation received the highest number of citations per article as can be inferred from the journals titles most active journals belong to different medical research areas a similar pattern unfolds when we look at authors institutional affiliations authors from the documents retrieved were affiliated to a total number of 859 institutions from 75 different countries table 2 also shows that harvard university and the university of california are the leading institutions in thbor research when measured in terms of total publications as was the case with most journals the leading institutions on organ trafficking are concentrated in anglosaxon countries four of them in the usa two of them in australia and one in canada n is the total number of publications figure 2 displays the most influential countries in thbor research when using the total number of cited papers as a proxy the geographical distribution illustrates that most of the literature is shaped and produced by western countries first 85 of all cited organ traffickingrelated articles are concentrated in the usa and uk second while the rest of the leading countries are not anglo saxon they tend to be economically affluent western democracieswith the exception of south africa and turkey 32 although such a trend is not unexpected we find important to point out that countries in latin america africa and asia that have the highest number of thbor victims are underrepresented within the current literature 2 ironically some rich countries that are amongst the primary organimporters are also shaping the discourse on thbor while poor countriesoften transit andor destination areasare largely underrepresented 2 19 20 21 a similar pattern unfolds when we look at authors institutional affiliations authors from the documents retrieved were affiliated to a total number of 859 institutions from 75 different countries table 2 also shows that harvard university and the university of california are the leading institutions in thbor research when measured in terms of total publications as was the case with most journals the leading institutions on organ trafficking are concentrated in anglosaxon countries four of them in the usa two of them in australia and one in canada int figure 2 displays the most influential countries in thbor research when using the total number of cited papers as a proxy the geographical distribution illustrates that most of the literature is shaped and produced by western countries first 85 of all cited organ traffickingrelated articles are concentrated in the usa and uk second while the rest of the leading countries are not anglo saxon they tend to be economically affluent western democracieswith the exception of south africa and turkey 32 although such a trend is not unexpected we find important to point out that countries in latin america africa and asia that have the highest number of thbor victims are underrepresented within the current literature 2 ironically some rich countries that are amongst the primary organimporters are also shaping the discourse on thbor while poor countriesoften transit andor destination areasare largely underrepresented 2 19 20 21 research areas and specific organs most of the publications in our sample address organ trafficking in broad terms and do not focus on the trafficking of a certain organ or tissue only 158 of all the organ trafficking studies retrieved mentioned a specific organ figure 3 illustrates the most common organs being addressed in the organ trafficking literature almost 85 of the publications make references to kidneys 16 mention liver and about 6 refer to the heart this ranking is consistent with the estimates of removals by organ as most of the frequent illegal transplants involve kidney liver and research areas and specific organs most of the publications in our sample address organ trafficking in broad terms and do not focus on the trafficking of a certain organ or tissue only 158 of all the organ trafficking studies retrieved mentioned a specific organ figure 3 illustrates the most common organs being addressed in the organ trafficking literature almost 85 of the publications make references to kidneys 16 mention liver and about 6 refer to the heart this ranking is consistent with the estimates of removals by organ as most of the frequent illegal transplants involve kidney liver and heart unexpectedly publications that cover heart trafficking have a higher impact receiving 212 citations per document well above the average impact heart unexpectedly publications that cover heart trafficking have a higher impact receiving 212 citations per document well above the average impact when we consider that 76 of all thbor research is done in the medical field it comes as no surprise that eight of the top ten research areas within the thbor literature belong to the medical field as figure 4 illustrates this is a logical conclusion considering that organ removaltransplants require medical professionals nevertheless it is surprising that such a transnational phenomenon and human rights issue is not being addressed by other fields such as international relations which comprises only 2 of all publications when we consider that 76 of all thbor research is done in the medical field it comes as no surprise that eight of the top ten research areas within the thbor literature belong to the medical field as figure 4 illustrates this is a logical conclusion considering that organ removaltransplants require medical professionals nevertheless it is surprising that such a transnational phenomenon and human rights issue is not being addressed by other fields such as international relations which comprises only 2 of all publications heart unexpectedly publications that cover heart trafficking have a higher impact receiving 212 citations per document well above the average impact when we consider that 76 of all thbor research is done in the medical field it comes as no surprise that eight of the top ten research areas within the thbor literature belong to the medical field as figure 4 illustrates this is a logical conclusion considering that organ removaltransplants require medical professionals nevertheless it is surprising that such a transnational phenomenon and human rights issue is not being addressed by other fields such as international relations which comprises only 2 of all publications thbor and migration is thbor research addressing migrants we find that migrants are not receiving proper attention within our main sample only 13 documents or 27 of 482 publications address migrants the omission of migrants from publications can be clearly seen in figure 5 migrants are not only neglected from research but when they are acknowledged in the literature the research focus is quite different publications that address migrants are less organspecific with just 21 of them mentioning any specific organ this is a third less than nonmigrantrelated documents int j environ res public health 2020 17 x 8 of 12 thbor and migration is thbor research addressing migrants we find that migrants are not receiving proper attention within our main sample only 13 documents or 27 of 482 publications address migrants the omission of migrants from publications can be clearly seen in figure 5 migrants are not only neglected from research but when they are acknowledged in the literature the research focus is quite different publications that address migrants are less organspecific with just 21 of them mentioning any specific organ this is a third less than nonmigrantrelated documents the gap becomes wider when we narrow our focus to examine how many of the 13 documents specifically address the health of migrants previously we established that the medical field was the most prolific on thbor literaturearguably due to its natural relationship to the field of organ transplantation however such prolific production abruptly drops when we include migrants in our search out of all 482 publications retrieved about organ trafficking only 5 specifically address migrants health that is to say about 1 of the entire thbor literature has considered the relation between organ trafficking and migration from a medical fielda problem given that migrants are a particularly vulnerable group discussion the trafficking of human beings for the purpose of organ removal is a highly relevant health and human rights issue that disproportionately impacts migrants the number of publications on thbor has been on the rise since the declaration of istanbul on organ trafficking and transplant tourism of 2008 which puts the issue on the agenda of both international organizations and researchers however the momentum created by the declaration of istanbul may have been slowing down in the last few years and thbor research has yet to catch up with the literature on other types of human trafficking despite the growth of scientific output on organ trafficking over the past decade this literature comprises only 7 of the bulk of human trafficking literature 25 the gap becomes wider when we narrow our focus to examine how many of the 13 documents specifically address the health of migrants previously we established that the medical field was the most prolific on thbor literaturearguably due to its natural relationship to the field of organ transplantation however such prolific production abruptly drops when we include migrants in our search out of all 482 publications retrieved about organ trafficking only 5 specifically address migrants health that is to say about 1 of the entire thbor literature has considered the relation between organ trafficking and migration from a medical fielda problem given that migrants are a particularly vulnerable group discussion the trafficking of human beings for the purpose of organ removal is a highly relevant health and human rights issue that disproportionately impacts migrants the number of publications on thbor has been on the rise since the declaration of istanbul on organ trafficking and transplant tourism of 2008 which puts the issue on the agenda of both international organizations and researchers however the momentum created by the declaration of istanbul may have been slowing down in the last few years and thbor research has yet to catch up with the literature on other types of human trafficking despite the growth of scientific output on organ trafficking over the past decade this literature comprises only 7 of the bulk of human trafficking literature 25 second although thbor disproportionately targets vulnerable populations such as migrants the literature has largely excluded them from the issue only 27 of the entire thbor literature in our sample acknowledges any direct or indirect relationship to migrants this gap leaves the most vulnerable groups out of the academic and policy discourses as well as the potential creation of any sociopolitical and healthcare policy agenda to tackle organ trafficking similarly publications that do include migrants in their studies are less organspecific which is problematic given that this is vital to understand the different dynamics of each organ being smuggled this exclusion is even greater from the perspective of the migrants health despite thbor being a health issue since it entails the need for surgery to remove the organs most publications about migrants in the thbor literature do not approach it from a medical field the health of migrants is currently being neglected by scientists of all stripes future research should address this blind spot in the literature such a limited number of publications can be attributed to a combination of factors first the differences in terms and definitions make it difficult to conduct research consistently and in a homogenous manner additionally the hidden and illegal nature of thbor poses serious challenges to research on this topic as it is complicated to gather reliable informationand often when the data is available it is suppressed for political expediency the lack of information is especially alarming in the case of quantitative data imposing severe methodological constraints to organ trafficking research future research should further address thbor in order to close the literature gap with other types of human trafficking research focusing mostly on increasing reliable quantitative data on a global level given the global complexity of thbor it is surprising that in most areas of social science research there is limited scientific knowledge pertaining to thbor being generated in the last 29 years just 10 publications have examined organ trafficking from an international relations perspective the phenomenon of organ trafficking and transplant tourism is a global problem as trafficking networks are usually transnationalespecially those targeting migrantsand often persist along the divide between rich and poor countries thus research on thbor should address this lack of attention from the angle of international relations and further analyse thbor in the context of international migration dynamics when mapping the country of origin of thbor research a remarkable bias is found first the skew highlights the presence of englishspeaking countries such as the usa the uk south africa and australia which are among the most influential countries in terms of the cited work on this topic second most of these countries are also net migration receiver countries however origin and transit countries for migration which suffer more from thbor are not the ones publishing research on the topic to be able to address organ trafficking research should also be promoted incentivized and funded in developing and transit countries research made by these countries can best consider the local and regional dynamics of organ trafficking as they are usually the victims country of origin or where the organ removal surgery is performed limitations of study while web of science is an internationally recognised group of databases which offers reliable information it also has limitations the main one is the language bias which results in englishspeaking countries being overrepresented this may explain why china india or germany are not as present as they should be regarding their number of publications in addition unlike many other bibliometric analyses this paper does not include grey literature as they are not included in the web of science thus these limitations need to be considered when studying the findings of the investigation furthermore the country of origin of the journal is not necessarily the same as the one of the editor or writers consequently the results only show the countries in which more resources are being allocated moreover we also acknowledge that it is possible that some of our retrieved literature could include the migrant population as well but without mentioning this subgroupperhaps due to legalethical constraints nonetheless the available research so far does not allow for a robust examination of the impact of organ selling on migrants conclusions the current study is to the best of our knowledge the first to assess publication activity relating to the topic of trafficking of human beings for the purpose of organ removal it has shown the huge quantitative impact the declaration of istanbul of 2008 had on stimulating research about organ trafficking however the literature on organ trafficking has yet to catch up with research on other typologies of human trafficking that are more established we conclude that there is a clear need for improving and increasing quantitative data on thbor particularly focusing on migrants who are usually the victims of organ trafficking and need to be included in the published articles currently migrants are being ignored by research on thbor and medical research about organ trafficking and migrants is all but completely neglected furthermore while academic publications mostly originate from rich countries poor and middleincome countries are actually the most vulnerable because they are either transit or origin areas for most international migrants future research should further address the relationship between migration migrants health and organ trafficking in order to develop efficient public policies against organ trafficking and transplant tourism this can be done by incorporating and advancing scientific output by developing countries author contributions jg and ig wrote the initial draft jg also undertook data collection and analysis as contributed as supervisor to the project by undertaking research data analysis and the revision of article content all authors have read and agreed to the published version of the manuscript funding this research received no external funding

the debate over trafficking of human beings for the purpose of organ removal thbor remains largely absent from policy debates as its crime is hardly detected reported and sparsely researched however criminal networks continue to exploit vulnerable populations particularly migrants to help bridge this gap in knowledge we employ a bibliometric analysis to examine whether the nexus between organ removal and migration is being addressed by the current academic literature our results indicate that 1 research exploring the link between thbor and migrants is relatively scarce 2 organ trafficking literature output is largely clustered in a couple of western countries and 3 despite the international nature of the topic most empirical studies on organ trafficking and migration lack representation within the social sciences and humanities taken together our results point to a huge gap on scientific publications between thbor and migration quantitative data is required to lift the current knowledge constraints and better inform policymakers

introduction quality sleep marked by adequate continuity duration and frequency is essential to human wellbeing sleep health is multidimensional adapted to contextual considerations and characterized by subjective satisfaction appropriate timing adequate duration high efficiency and sustained alertness during waking hours sleep disturbance defined as sleep that is inadequate in duration or quality is correlated with impaired functioning of multiple physiological systems sleep disturbance and related sleep disorders have been found to correlate with negative mental behavioral and physical health outcomes across all age groups investigators have identified many affective cognitive attentional and motivational correlates of and sequelae to sleep disturbance including posttraumatic stress disorder depression and anxiety sleep disturbance is considered a component feature of ptsd anxiety and depression investigators have sought to disentangle the temporal relations between sleep disturbance and mental health challenges multiple prospective studies in higherincome countries have demonstrated that sleep disturbance most commonly insomnia may predict higher incidence and symptomology of subsequent depression anxiety and ptsd many crosssectional studies have been analyzed in attempts to show causality between poor mental health and sleep disturbance potentially contributing to confusion regarding the temporal order of measured variables a 2021 metaanalysis of randomized control trials in highincome countries show improved sleep quality causally leads to improve mental health including symptoms of depression and anxiety and ptsd in addition to mental health sequalae of sleep disturbance poor sleep correlates with impairment to many social processes within mostly crosssectional data social correlates of poor sleep include increased physiological sensitivity to socialevaluative tasks worse identification of social cues and social isolation relationship strain intimate partner violence victimization and smaller social networks while there are few longitudinal studies assessing potential bidirectionality between social relationships and poor sleep quality poor sleep has been shown to predict feelings of anger and worsened perceived relationship quality nationally representative data from the united states demonstrate that sleep disturbance is more common among people who are socioeconomically marginalized and engage less in healthy behaviors raising concerns for health equity in promoting sleep quality given the wideranging correlates and consequences of sleep disturbance and emerging concerns for health equity in promoting quality sleep the global health agenda should include sleep quality as a potentially modifiable determinant of global population health yet the overwhelming evidence on sleep quality and health has originated from highincome countries and china extant research has identified associations between sleep quality and health correlates within lowor middleincome countries that parallel those found in highincome countries however research that has been conducted on sleep in lowand middleincome countries has been almost entirely crosssectional or limited to select clinic populations the dearth of longitudinal data on sleep quality mental health and social relationships from within subsaharan africa and other lowor middleincome regions has unfortunately led to continual reliance on findings from western cultures to drive global mental health program and policy planning global health researchers organizations and activists have increasingly sounded alarm regarding the real global increase in common mental disorders social support is imperative for mental health and promotes resilience to various threats to ecological social mental and physical health further underscoring the need to understand potential determinants of social support clarifying relationships between sleep disturbance social support and mental wellbeing is essential to promoting global health and development the estimated burden of mental health disorders within kenya and globally is increasing there is a need for a whole of society approach to improving mental health across kenya and other lowor middleincome countries given the demonstrated impact of sleep disturbance on mental health within highincome countries it is essential to understand how sleep disturbance may impact the population mental health within kenya study aim this study seeks to identify temporal relationships between sleep disturbance social support and common mental disorder symptoms among adults in semirural kenya across two waves of an interventional cohort briefly the intention behind the study intervention was to support the nurturing capacities of families and communities to which streetinvolved children are reintegrating and to support primary prevention of streetmigration of children methods study design and participant selection this study analyzes longitudinal interventional cohort data all participants in the program are 18 years of age or older though this is not an interventional requirement the intervention is an active program with open enrollment and no comparisons are made in this study between intervention participants and nonparticipants participants in this study were selected at random from among participants in a multisectoral multilevel communitybased empowerment program in meru county kenya the intervention design has been described more completely previously initial participants are recruited to the program through identification as a known family member of a child living on the streets index families the first within a village to join the program invite neighbors to form an internal microlending group comprised of 2530 participating families subsequent recruitment to the program within a village follows wordofmouth and is open to anyone interested in joining while all participants in the present study were intervention participants at the times of data collection not all participants were index families that is most participants did not have a child living on the streets at the time of the study potentially mediated by decreased loneliness and increased access to social resources additionally access to social resources available through the intervention moderates associations between prior adversity and future generalized anxiety among participants in the program random selection process with the aim of recruiting a representative sample of adult participants from participants recruitment from the program to this interview questionnaire was conducted by offering each willing participant the chance to select a piece of paper from an opaque bag the opaque bag contained folded pieces of paper with 1 representing being selected to this study and 0 representing not being selected to this study on the first interview day seven pieces of paper with the number 1 were included in the opaque bag and an additional 0 was added until there was an even number of willing participants and pieces of paper interviews were delivered in the location where the groups met removed from the remaining participants selected survey participants joined the program in late 2022 and completed standardized survey questionnaires in february or march 2023 and again in april or may 2023 inclusion criteria inclusion criteria required study participants to be active members of an internal lending group present at the weekly session from which data were collected 18 years or older and willing to engage in the interview survey conduct each survey was delivered by a local trained paid language expert most of whom were nursing students at a nearby university or recent graduates measures survey questionnaires utilized previously validated psychometric scales primary measures in this analysis included sleep disturbance depression anxiety ptsd and social support all primary measures were analyzed as continuous variables local language experts worked in separate teams to translate questionnaires into the local language kimeru and back to english comparisons between initial and backtranslated items were conducted by these two teams and an additional native english speaker items in conflict were resolved by agreement between these teams and administered to a small kimeruspeaking sample to assess psychometric properties items on all psychometric scales were averaged to contribute to a summative measure following inspection of factor structure and internal reliability sleep disturbance was measured using the 8item promis sleep disturbance scale 084 at t1 α084 at t2 yu et al 2012 the scale asks respondents to recall their sleep over the past 7days and respond to various statements about the quality and quantity of their sleep such as my sleep was restless using a 5point likerttype response the promis sleep disturbance scale previously showed associations with higher prevalence of ptsd following road traffic accidents in an ethiopia population depression was measured using the 21item becks depression inventoryii the bdiii asks participants to reflect on their current thoughts and feelings covering multiple domains of depression including negative or flattened affect loss of appetite and reduced motivation on a 4point response format the bdiii has been used and validated in diverse global populations generalized anxiety disorder was measured using the gad7 the gad7 is a 7item anxiety scale using a 2week recall period prompting respondents to report the frequency of experiencing nervousness worry difficulty relaxing and irritability the gad7 has previously been validated in kenya and other global populations ptsd was measured using the primary care ptsd screen for dsm5 while developed to screen for ptsd among veterans the pcptsd5 index has been shown to have excellent diagnostic accuracy among civilian populations within the present sample the pcptsd5 showed high internal reliability 20076 at t1 kr2008 at t2 the pcptsd5 screens respondents for the presence of any lifethreatening experience over the respondents lifetime countryspecific populationbased estimates of lifetime exposure to such events range globally from 29 to 83 respondents who indicate the presence of such an experience are then asked 5items documenting the presence or absence of ptsd symptoms over the previous month the pcptsd5 has previously been adapted for use in south africa zimbabwe and uganda and found to be associated with forced sex and risktaking in these contexts respondents who reported no prior lifethreatening traumatic event or who reported no symptoms from such an event were considered 0 within this analysis social support was measured using the brief 2way social support scale the brief 2way sss assesses the giving and receiving of emotional and instrumental support in the present with 12 items such as there is at least one person that i can share most things with and i give others a sense of comfort in times of need within multiple cultural contexts this relatively new measure of social support is associated with mental wellbeing as expected control variables to control for withinsubject variations potentially associated with sleep behaviors we included measures of wealth income marital status age and years of formal schooling wealth index was recorded as household asset ownership of 12 common items income was recorded as a continuous variable reflecting estimated household monthly income marital status was recorded as a binary variable married living with someone as though married vs not married not living with someone age was recorded in years since birth formal schooling was measured as an ordinal variable between no school 0 and finishing a tertiary program 14 statistical analysis descriptive analyses that included univariate mean and pairwise spearman rank sum correlations were conducted of all primary and control variables the correlation matrix included bonferroniadjusted significance levels wilcoxon matchedpairs signedrank tests were used to assess the statistical equivalence of all continuous measures between t1 and t2 the primary analysis for this study utilized crosslagged panel analysis with a full set of potential pathways between each of the 5 primary continuous variables at t1 and t2 this model was created using structural equation modeling using a backward modeling process removing correlations until only correlations under the alpha threshold remained in the model control variables were added to all pathways and further removed until only correlations under the alpha threshold remained correlations between variables at t1 and t2 were included and removed if under the alpha threshold to be considered significant path coefficients must be under a final alpha threshold sem correlation standard errors were calculated using robust variance estimators to account for variables with nonnormal distributions additionally we presented the standardized sem coefficients between control and primary variables at t2 to enhance understanding of these relationships all analyses were conducted using stata v16 ethical consideration data were collected following ethical approval from the institutional review boards at the kenya methodist university and the university of texas medical branch in galveston tx all participants provided informed written consent prior that emphasized the voluntary and confidential nature of the study to participating in the study compensation was given to participants microfinance group on behalf of each study participant following a practice designed by community members interested in ensuring equitable distribution of available resources following a random selection results the mean for each variable is shown in table 1 eightyseven percent of respondents reported experiencing a lifethreatening experience during their lifetime symptoms of depression anxiety and ptsd significantly decreased from t1 to t2 social support did not change significantly between the two waves the mean age was 412 years respondents owned on average 54 items on the 12item wealth index which did not significantly change between the two time points mean monthly household income significantly increased from 34 to 45 mean years of formal education was 52 and 75 of respondents were married or living with a partner as though married the mean number of weeks between two waves was 11 table 2 demonstrates the correlation matrix with significance between primary and control measures significant pairwise correlations exist between sleep disturbance and symptoms of depression and anxiety sleep disturbance is significantly correlated with symptoms of depression symptoms of anxiety and social support the crosslagged panel analysis displayed in figure 1 below indicates that more sleep disturbance at t1 predicts subsequently worse symptoms of depression anxiety ptsd and less social support after controlling for withinvariable and withintime correlations between primary measures more depressive symptoms were better predicted by prior symptoms of anxiety and sleep disturbance than by previous depressive symptoms anxiety symptoms also predicted symptoms of ptsd and later anxiety symptoms social support was significantly correlated with fewer symptoms of depression anxiety and sleep disturbance at t1 and with fewer symptoms of depression ptsd and less sleep disturbance at t2 social support was not predictive of any included variable table 3 shows the standardized correlation coefficients between included control variables and primary variables as shown more years of schooling predicted less sleep disturbance at t2 but no other control variable was statistically significant married respondents reported significantly higher social support and fewer symptoms of depression wealth predicted significantly fewer symptoms of ptsd discussion this unfortunately we were not able to identify many variables that predicted sleep disturbance in this study preventing meaningful nuance to subsequent investigations higher education attainment was found to predict less subsequent sleep disturbance though income wealth age marital status and gender were not bivariate correlation analysis between control variables at t1 and sleep disturbance at t2 provides little information that might otherwise nuance these null findings from the full sem model most bivariate relations between control variables and sleep disturbance were also nonsignificant more basic behavioral research is required to understand the cultural and contextual factors contributing to or potentially improving sleep disturbance prior research in higherincome countries has found stress management relaxation practice stimulus control sleep hygiene and physical exercise may improve sleep distrubance urban living has previously shown to be a greater risk for sedentary lifestyles one common predictor of poor sleep within higher income countries in the rural study context where only 13 of respondents reporting owning motorized transportation sedentary behaviors are less likely to contribute to poor sleep in our study pain has been identified as contributing to poor sleep and was unmeasured within the study data sleep disturbance as a predictor of reduced social support is an important finding social support and social functioning are essential to human flourishing and a central element within the flourishing community interventional model from which these data were collected this finding suggests the need for a deeper understanding of the processes by which social support is developed and maintained within the interventional context and the mechanisms by which sleep disturbance may both undermine and be alleviated by these processes economic modelling comparing productive work time between individuals with different durations of average nightly sleep finds that poor sleep contributes to a 1 3 reduction in potential national economic productivity in five organization for economic cooperation and development countries whether sleep contributes to economic functioning merits research within lowand middleincome countries and may be mediated by worse psychosocial functioning while we expected temporal relationships between sleep disturbance and poor mental health we did not anticipate depressive symptoms would be less predictive of depressive symptoms than were symptoms of anxiety ptsd or sleep disturbance this finding suggests perhaps that persistent depressive symptoms are mediated by mental and behavioral processes better registered by the sleep anxiety and ptsdrelated measures future research should add more waves of measurement and qualitative investigation with people experiencing persistent depression to better understand operative mechanisms and potential interventional points to reduce persistent depression at minimum these findings suggest improving sleep quality among participants may improve subsequent mental healthpotentially interrupting otherwise persistent mental health challenges the percentage of respondents reporting any experience of lifethreatening trauma over the course of their lives was slightly higher than national prevalence estimates in countries like the united states or south africa we find these differences credible as the sample population was selected due to identification of streetinvolved children migrating from those villages and socioecological risk factors of streetmigration of children may well increase the trauma risk for other individuals within the same villages future studies should adopt or adapt a life events checklist to improve the specificity of lifethreatening traumatic histories trauma research may reveal populationlevel nuances regarding stress responses to traumatic events the role of sleep in protecting against stress responses and sociocultural factors potentially providing resilience to diverse traumatic events we interpreted responses to validated psychometric scales in many epidemiologic studies as reflecting symptomatic severity rather than diagnosed mental illness as there are limited trained clinical diagnosticians within the study location and across kenya subsaharan africa and the world thus while this study is informed by practical constraints within the context these constraints are found globally to address the need for improved understanding and the development of public health approaches to community mental health therapeuticsthe national institutes of health has led the development of an alternative to diagnosticbased approaches to mental health that primarily serve the clinicianpatient relationship found within the diagnostic and statistical manual or icd10 diagnostic coding the nih research domain of criteria posits sleep quality as one essential component of mental and behavioral health our findings support the intent of the rdoc program by showing more sleep disturbance predict relatively worse future mental health symptomologies and less social support and provide a route to exploring mechanisms to improve populationlevel mental and social wellbeing by reducing sleep disturbance there is increasing recognition for the need to move beyond diagnostic criteria to support individual clinical encounters and towards a public healthenabled approach to mental health which is consistent with the rdoc program and our aims in this study finally these data were not collected from a random sample of the population but rather randomly limitations this analysis relies on intervieweradministered selfreported data using interviewers was necessary to include participants with low or no functional literacy selfreported data are subject to reporting biases such as social desirability bias and recall bias respondents influenced by social desirability bias would need to indicate worse than average sleep but average or better mental and social wellbeing at t1 and average sleep but worse than average mental and social wellbeing at t2 for social desirability bias to contribute to observed correlations we think it is unlikely social desirability bias would lead to this differential reporting between time points if social desirability bias leads to differential reporting between time points it seems just as likely that misclassification could occur in the opposite direction we believe findings are robust to influence by social desirability bias though assert they are not evidence of causation only of temporal relations controlling for other betweenand withinpanel correlations future research should investigate whether sleep quality is causally related to subsequent mental health as found in other contexts research in any context is required to establish causal relationships between sleep and social variables a review comparing reliability of objective measures of sleep to selfreported sleep quality found comparable reliability is lower than one may expect

sleep quality is essential to biopsychosocial functioning yet there remains limited longitudinal research on sleep and mental or social wellbeing within lowor middleincome countries this study utilizes longitudinal cohort data from a communitybased empowerment program in meru county kenya to assess crosslagged correlations between sleep disturbance social support symptoms of depression anxiety and posttraumatic stress participants n373 92 women age range 1886 years who reported more sleep disturbance at t1 reported significantly more symptoms of depression anxiety and ptsd and significantly less social support at t2 average 11 weeks later controlling for all withintime correlations across measures withinmeasure correlations across time and sociodemographic background characteristics findings are consistent with research across highincome countries underscoring the need for more contextualized research into sleep behaviors across lowand middleincome countries findings may inform interventions to increase mental and social wellbeing within kenya

drinkaware began as a website set up in 2004 by the portman group an alcohol producerfunded organization which has attempted to influence the evidential content of policy debates through a range of tactics including attempts to pay academics to write anonymous critiques of world health organization sponsored evidence reviews 1 2 3 the portman group featured prominently in the previous uk governments 2004 strategy for reducing alcoholrelated harms being responsible for the provision of information on alcohol to the public 4 this was strongly criticized at the time 56 in 2006 drinkaware was established as a separate charity with the objective of positively changing public behaviour and the national drinking culture to help reduce alcohol misuse and minimise alcoholrelated harm following a memorandum of understanding between the portman group the department of health the home office and the devolved administrations for scotland wales and northern ireland 7 globalization has concentrated alcohol production among a small number of large multinational companies the alcohol market was worth us 979 billion in 2007 40 of which is controlled by just 10 producers 8 large corporations invest heavily in a range of activities to foster national and international policy environments which favour their interests 9 access to internal tobacco industry documents resulting from us litigation including those concerning the jointly owned miller brewing company and phillip morris 1011 shows that companies in both industries use corporate social responsibility activities to hone their reputations which in turn helps them to access and influence policy makers 12 social aspectspublic relations organizations central to the alcohol industrys csr activities are social aspectspublic relations organizations set up to manage issues that may be detrimental to its interests particularly in areas that overlap with public health 2 sapros divert attention away from populationlevel strategies that limit the availability price and promotion of alcohol and thus threaten corporate profits towards those focused on individual responsibility 13 sapros operate in policy and research by disseminating consensus statements and codes of practice 14 they have grown very rapidly over the last decade and drinkaware and the portman group are among more than 40 alcoholrelated sapros now operating in at least 27 countries 1 there has not been a systematic review of sapro activity 15 so we draw upon experience with the australian sapro drinkwise to compare its modus operandum with that of drinkaware drinkwise was established in 2005 by the alcohol industry and funded later by the federal government of australia in 2006 it describes itself as an independent notforprofit organisation focused on promoting change towards a healthier and safer drinking culture in australia when given public funding critics argued that it should advocate evidencebased public health policies 16 instead drinkwise lobbied the government for ineffectual information programmes while opposing evidencebased policies not in industry interests 17 in 2009 57 health experts and scientists wrote to the medical journal of australia opposing further public funding and declaring that they would not accept funding from drinkwise 18 drinkwise responded by writing individually to selected signatories including two of the present authors suggesting that the letter was defamatory and implying possible litigation in the manner of the tobacco industry 19 what does drinkaware do drinkaware is not publicly funded although its activities are very similar to those of drinkwise it is the mechanism in england for governmentindustry partnership on public education campaigns 7 its sophisticated multimedia website is promoted widely on alcohol packaging and marketing although much less prominently than the core content drinkaware and drinkwise have similar forms of governance annual budgets and stated aims both have doctors and corporate members on their boards and claim to provide independent evidencebased advice to the public particularly to help individuals make informed decisions about their drinking minimum unit pricing is a key proposal in recent british alcohol policy that was opposed strongly by sectors of the industry 20 aside from the commitment to mup the uk government strategy placed partnership with industry at the heart of policy 21 the result has been an energetic public debate about the evidence supporting mup however the drinkaware website despite being promoted as the place the public should go to for the facts 22 did not acknowledge the existence of any evidence supporting mup during the debates which followed the release of the government alcohol strategy it suggested that happy hours would also become slightly less cheerful and refers wistfully to the days of the £10 crate of beer among other negatively toned outdated contentsee box 1 the websitelinked tweets in box 2 sent by drinkaware include content that normalizes alcohol use and provides cues to drink on occasions when it may not be planned for example there is no british tradition of halloween parties involving alcohol drinkaware claims that its founding memorandum of understanding 7 precludes its involvement in policy issues yet when mup was debated in scotland 23 drinkawares written evidence to the 200910 health select committee alcohol enquiry argued that behavioural change is a process which cannot happen quickly the uk drinking culture can be changed if educational initiatives receive sufficient investment over a long enough period 24 in the 2012 hsc alcohol enquiry these claims of noninvolvement in policy were repeated in the face of several examples to the contrary and incredulity among hsc members concerns about drinkaware the 2012 hsc 25 noted significant concerns about industry influence on drinkaware and the content purposes and value of its activitiessee box 3 a longdelayed review of drinkawares effectiveness which the hsc hoped would address the perceived lack of independence from industry influence was published early in 2013 the review undertaken by an integrated creative communications agency 26 was overseen by a fivemember panel including jeremy beadles corporate relations director of heineken uk and former chief executive of the wine and spirit trade association who oversaw a vigorous wsta effort to dissuade the scottish government from introducing mup 2728 the drinkaware website also describes as independent research an evaluation of the website by a brand and communications research company who see their role as helping our clients build stronger brands through the use of better and more relevant communications 29 both advertising agencies have histories of working with the alcohol industry the review identifies a perception of industry influence resulting in a suspicion that drinkaware is not truly eight out of 10 people dont know the correct amount of units recommended in government guidelines sir liam donaldson proposed that the minimum price for a unit of alcohol should be 50p per unit to curb binge drinking for example a 13 bottle of wine containing nine units of alcohol could not be sold for less than £450 cheap supermarket promotions on bulk quantities of alcohol would also get pricierlong gone would be the days of the £10 crate of beer happy hours would also become slightly less cheerful minimum pricing could bring an end to some drinks promotions in pubs and bars for instance a pint of lager with an alcohol content of 5 contains nearly 3 alcohol units so with a minimum pricing of 50p per unit it couldnt be sold for less than £150 what exactly is a unit so with all this talk about alcohol units what exactly are they unfortunately its not as simple as one drink equalling one unit a unit is 10 ml or 8 g of pure alcohol to put this into context you would consume one unit of alcohol if you drank a 25 ml single measure of whisky or a third a pint of beer or half a standard glass of red wine many people dont have a realistic idea of how much theyre drinking in fact drinkawares research shows that eight out of 10 people dont know the correct amount of units that are recommended in government guidelines its recommended that men should not regularly drink more than 34 units a day and that women should not regularly exceed 23 units a day you can use our interactive drinks calculator tool to work out whether you might be drinking above the government guidelines and also get tips on cutting down your daily intake if the results take you by surprise so is minimum pricing far away whether or not the chief medical officers recommendations to put a minimum pricing of 50p on every unit of alcohol become reality remains to be seen gordon browns immediate reaction to the proposal was that putting a minimum price on alcohol would bring additional burdens on moderate drinkers the minimum pricing headlines ensure that the debate around the uks alcohol culture continues to be in the spotlight at drinkaware our sole aim is to provide people with the information to decide for themselves about what role alcohol plays in their lives whether it be helping consumers understand units or allowing them to keep track of their alcohol consumption we will continue to provide all the facts this page was created on 160309 was last updated on 100512 and was accessed on 211112 it has since been removed as part of a major redesign of the website independent of the alcohol industry and criticizes a lack of clarity about the mission and purpose of drinkaware it finds no evidence of undue industry influence although recommending the building of an evidence base it is not clear how industry actors can contribute to this when they promote information alone as sufficient for bringing about behaviour change both industry actors and the authors of the review treat funding as investment and see the drinkaware brand as having explicit value for the companies associated with it for example complaining of industry bodies that do not provide funding for drinkaware one funder suggested too many organisations that get to use the drinkaware brand get to benefit from what drinkaware offers without actually having to put any cash up box 2 tweets from drinkaware why does drinkaware matter alcohol problems in the united kingdom continue to increase while they decline in most of europe 31 drinkaware has hitherto avoided concerted public health attention as an alcohol industry body its centrality to policy has seemed unremarkable because it merely continues in the public information role fulfilled previously by the portman group 4 despite the growing problems alcohol causes british health and society lobbying has successfully positioned the alcohol industry very close to successive uk governments 32 henry ashworth the chief executive of the portman group moved into that role directly from the uk government cabinet office behavioural insights team interestingly a different situation pertains in scotland where the implementation of mup is most advanced there the current government is not formed by a westminsterled party and does not have close relationships with the alcohol industry 23 it has been observed that the chapter on working with industry in the march 2012 uk governments alcohol strategy eschews any enhanced regulatory stance concrete recommendations are absent corporate friendly content on the importance of alcohol to the economy and the need to cut red tape ie deregulation 21 are emphasized instead the intent of this material became apparent in late 2012 when the government launched its consultation on the implementation of the strategy 33 impact assessments described various options for extending the availability of alcohol to places such as florists and motorway service areas early in 2013 it was reported that mup would not be implemented and industry lobbying was the reason according to a conservative member of parliament with a health background 34 what to do about drinkaware because of high levels of support from successive uk governments drinkaware has attracted medical and academic colleagues to support and work with it and its materials are used in the national health service in addition to examining drinkawares specific activities the wider economic context needs to be considered both drinkaware and the portman group belong to a global network of sapros corporations are legally required to protect shareholder interests and any expenditureincluding that on sapros or any other csr activitywill necessarily be servant to this obligation the alcohol industry has to find a way to reconcile pursuit of profits through increased sales and thus consumption with the needs of governments to act to reduce the attendant increases in health and societal costs one possible strategic direction is an aspiration to exercise soft power in the form of subtle forms of steering and control constraining and limiting the options available for political choice 35 this requires a postpolitical style of partnership in which sapros work with governments in order to draw attention away from fundamental conflicts between economic with social and health interests 35 sapros are especially useful as they can claim not to have any economic interests themselves box 3 2012 parliamentary health select committee views on drinkaware 25 chris sorek stressed that drinkaware is an independent charity 80 but its role is seen by some as compromised because of its links with the alcohol industry the british medical association told us that the involvement of the drinkaware trust in providing public health communications is a significant area of concern this form of industry social marketing is counterproductive because industry responsibility campaigns are less effective than ones from other sources keep messages in a commercial comfort zone and distract attention away from more effective measures to regulate alcohol use industryrelated messages about alcohol have been found to subtly enhance sales and company reputations this is despite the fact that the public is cynical about the motives of corporate sponsors and that nongovernmental organisations make a more effective and credible source the hsc recommended that if drinkaware is to make a significant contribution to education and awareness over the coming years its perceived lack of independence needs to be tackled and as part of the review that is to be held this year the committee recommends that further steps are taken to entrench that independence we encourage nhs commissioners public health practitioners and academic colleagues to reconsider their relationships with drinkaware most would not engage with the portman group and we suggest that there is no obvious basis for viewing its offspring drinkaware any differently importantly the review of drinkaware laments its isolation within the alcohol harm reduction community and drinkaware is actively seeking to recruit scientists to support it the british public health community should bear in mind whos recommendation that alcohol industry bodies only be engaged in their roles as producers distributors and retailers 36 key corporate tactics in influencing policy include the manufacture of doubt about unfavourable evidence 37 and creating divisions among researchers 2138 the evolving international literature provides new frameworks for understanding sapro and other csr activities 1 these are needed to address the historically unparalleled levels of concern about the international activities of the global alcohol industry 3940 sapros work with and learn from each other the portman groupdrinkaware operational model whereby a public information role is assumed by the latter sapro and the former more obviously promotes industry positions on alcoholrelated issues may well be replicated in other countries national governments and their policymaking processes are key targets for the alcohol industry 41 the addiction and public health research communities should examine industry influence on alcohol policies 42 drinkaware like other sapros appears to us to be an industry vehicle to subvert evidencebased public health policy we propose that it is not worthy of any form of support in the past the portman group divested itself of a public information function so sapros may also be dispensable to the alcohol industry if they do not further its strategic objectives we urge policymakers to address industry influence on global and national alcohol policies 394344 more assertively to reverse the mounting toll of alcohol on population health and social wellbeing declaration of interests the authors have no sources of funding direct or indirect nor any other connection with the tobacco alcohol pharmaceutical or gaming industries nor any body substantially funded by one of these organizations

in 2006 drinkaware was established as a charity in the united kingdom following a memorandum of understanding between the portman group and various uk government agencies this debate piece briefly reviews the international literature on industry social aspects organizations examines the nature of drinkawares activities and considers how the public health community should respond although the british addiction field and the wider public health community have distanced themselves from the portman group they have not done so from drinkaware even though drinkaware was devised by the portman group to serve industry interests both longstanding and more recent developments indicate very high levels of industry influence on british alcohol policy and drinkaware provides one mechanism of influence we suggest that working with and for industry bodies such as drinkaware helps disguise fundamental conflicts of interest and serves only to legitimize corporate efforts to promote partnership as a means of averting evidencebased alcohol policies we invite vigorous debate on these internationally significant issues and propose that similar industry bodies should be carefully studied in other countries

based on the identified risk factors the highest area under the receiver operating curve and accuracy of the best classification model were 0758 and 0761 respectively adding various associated lifestyle factors to the baseline model resulted in an average increase of 0159 and 0135 in auroc for classifying weight underestimation and overestimation respectively introduction obesity is a complex and multifactorial disease that is a major public health issue the prevalence of obesity has been epidemically increasing worldwide being overweight and obese affects over onethird of the worlds population and it is expected that 38 of the worlds adult population will be overweight and 20 will be obese by 2030 excess weight and obesity are wellestablished critical risk factors for comorbidities of chronic diseases such as type 2 diabetes hypertension dyslipidemia cardiovascular events or premature mortality obesity represents a challenge in public health given its high prevalence increasing trend and accompanying health risks issues of obesity and its related health problems have generated an increased attention to the perception of and satisfaction with body image and shape body image distortion can lead to inappropriate diet restriction eating disorders and excessive weight loss which in turn give rise to reproductive function issues such as menstrual irregularity hypothalamic dysfunction infertility and bone loss due to impaired sex hormone metabolism moreover body dissatisfaction is linked to adverse psychological consequences such as poor selfesteem depression and anxiety existing studies report certain factors associated with the discrepancy between perceived and actual body shape and size significant gender and age differences have been reported for this discrepancy males and younger individuals tend to underestimate their weight studies have explored comprehensive lifestyle factors ranging from healthrelated behaviors to socioeconomic status however most of this research used crosssectional designs highly selected cohorts or populations with specific age groups in addition there is growing attention on how to identify the target populations with weight misperception and only a few studies have performed predictive analytics based on the associated behavioral and social factors that lead to body weight misperception this study investigated the perceived body weight andor its disturbance and trends across age groups in korean women using large population data from the national registry to determine the associated femalespecific and agespecific risk factors for the discrepancy between actual body size and selfperceived body weight one of the main purposes of the present study was to predict the future occurrence of body weight misperception with a machinelearning approach by providing data that could be used by the public health branch management for preventive interventions materials and methods study population sociodemographic and lifestyle variables the knhanes survey questionnaires assessed a wide range of lifestyle factors ranging from healthrelated behaviors to socioeconomic status data on age education level income level marital status selfperceived health status alcohol consumption and employment status were obtained using structured survey items education level was categorized as elementary school or lower middle school high school and college or higher income level was classified according to monthly income quartiles for each member in the household low middlelow middlehigh and high participants consuming more than 12 alcohol drinks per year were classified as alcohol drinkers the following clinical or healthrelated information were collected past medical history of chronic diseases experience of anxiety and depressive mood degree of chronic pain days of anaerobic workout per week days of walking per week exercise for weight loss weightcontrol practice gravidity and menstruation condition past medical history of chronic diseases was defined as having been diagnosed from a physician which was dichotomized into present and none for each disease including diabetes hypertension hyperlipidemia or depression weightcontrol practice was divided into the following categories weight loss management weight maintenance management weight gain management and never tried to control weight gravidity was defined as the number of pregnancies the woman has ever had including all live births stillbirths miscarriage and abortions the menstruation condition of the participants was assessed whether they were menstruating or were amenorrheic due to pregnancy lactation or menopause the full list of the variables used in this study is provided in supplementary table 1 assessment of objective weight status and classification of body weight perception to assess the objective weight status anthropometric indices including height weight and waist circumference were measured and the body mass index was calculated using the formula bodyweight in addition information on the selfperceived body image was collected based on the following questionnaire do you consider yourself as very thin a little thin average a little obese or very obese based on a comparison between the subjects actual weight status by the world health organization asianpacific criteria and their selfperceived body image two categories of mismatched body images were generated overestimation defined as women who had normal weight or were underweight who perceived their body as a little obese or very obese and underestimation defined as women with a bmi ≥ 23 who responded that their body size was average a little thin or very thin the control group was defined as women with normal perception who were not belong to either of overestimation or underestimation categories statistical analysis first chisquare test was performed to examine linear trends in proportions of weight misperception among age groups then we fitted multivariate logistic regression models to examine the associations between overall weight misperception and a range of lifestyle factors for all the participants the main null hypothesis of our logistic regression model was that there is no association between specific lifestyle factors and weight misperception among the tested factors gravidity was the only continuous variable and we replaced its extreme outliers with median values to explore agespecific differences in lifestyle factors associated with weight misperception we classified the participants into three age groups and repeated the analysis as follows early adulthood middle adulthood and late adulthood for agespecific analysis different subsets of healthrelated and lifestyle factors including age alcohol consumption anxiety and depressive mood chronic pain days of anaerobic workout days of walking per week education level exercise for weight loss gravidity income level marital status selfperceived health status and management of weight were tested the bonferroniadjusted significance level of 00055 for multiple comparisons was applied all the analyses were performed in the r environment using the svyglm function in the survey package accounting for the knhanes sampling weights predictive analysis we trained an ensemble of decision tree models to classify the participants selfperceived body weight status based on the identified lifestyle factors from the aforementioned regression analysis we hypothesized that several behavioral and social lifestyle factors would account for the misperception of body weight for the model training and evaluation the data were split into training and test sets among which the normal controls were randomly undersampled the baseline model was constructed only including bmi and its result was compared with our combined model that additionally incorporated significantly identified lifestyle factors the model performance was evaluated using the heldout test set by computing the values of the area under the receiver operating characteristic curve the 95 confidence interval and accuracy results demographic characteristics and overall misperception patterns of body weight we analyzed multivariate data from 22121 korean women who participated in the knhanes between 2010 and 2016 table 1 presents the demographic characteristics of the participants a wide range of socioeconomic lifestyle and healthrelated factors were included in the analysis ranging from selfreported questionnaire data reporting the individuals environment or daily behaviors to objective healthweight measurements or clinical diagnosis history the overall proportions for the correct and mismatch types of perceived body weight by age groups are shown in figure 1a where the age categories were 1945 years 4659 years and ≥ 60 years the proportion of participants who correctly perceived body weight was similar for early adulthood and middle adulthood but lower for the late adulthood group as only 682 were correctly matched moreover there was a trend towards an increase in the underestimation of weight with increasing age in contrast the proportion of overestimation decreased with age we identified several lifestyle factors that were significantly associated with the overall misperception of body weight age alcohol consumption days of walking education level marital status selfperceived health status effort of weight management were negatively associated with misperception patterns whereas exercise behaviors for weight loss was positively associated with misperceived body weight agespecific factors associated with misperception of body weight status based on the factors associated with misperception patterns we analyzed the data using categoryspecific variables in the early adulthood group women who tended to consume less alcohol had a lower education level were married and perceived themselves as unhealthy were significantly more likely to underestimate their body weight on the contrary women who tended to consume more alcohol had chronic pain did fewer anaerobic workouts perceived themselves as healthy made less effort for weight gain and more effort for weight loss were more likely to overestimate their body weight for the middle adulthood group women who did more anaerobic workouts had fewer episodes of depression had a lower education level had lower gravidity and were not menopausal state were significantly more likely to underestimate the body weight women who did less anaerobic workouts were not in menopause made less effort for weight gain and more effort for weight loss and who perceived themselves healthier were significantly more likely to overestimate their body weight in the late adulthood group less alcohol consumption fewer days of walking lower education level more exercise for weight loss lower income no menopause and perceiving themselves as unhealthy were associated with an underestimation of body weight among the variables of chronic medical diseases the presence of diabetes and the absence of hyperlipidemia were significantly associated with an underestimation of body weight women who perceived themselves as healthier with less effort for weight gain and more effort for weight loss were significantly associated with an overestimation of body weight predictive performance the bagging tree ensemble model that included the previously identified lifestyle features showed a moderate overall performance for assessing weight overestimation and underestimation the feature included in each model were presented as footnote of supplementary table 2 across the tested models the highest auroc and accuracy of the best classification model were 0758 and 0761 respectively with the 5fold crossvalidation adding various lifestyle factors to the baseline model resulted in an average increase of 0159 and 0135 for auroc when estimating weightunderestimating and weightoverestimating behavior respectively the classification models for the weightoverestimating behavior did not show any improvement compared to the baseline model which only included bmi the feature important analysis revealed the most useful relevant variables for classifying weight underestimation which were bmi weight management status and selfperceived health discussion in this study we investigated the agespecific trend of selfperceived body weight in a large population of korean women and observed that the incidence of mismatch of body weight increases with age and is highest in late adulthood weight overestimation patterns were more commonly observed than weight underestimation in early adulthood and late adulthood in our study existing studies have reported that race gender age and behavioral factors influence the misperception of ones body weight to date most of these studies were conducted in the us or on western populations which have limited application to women in other countries unlike western populations where an underestimation in overweight obese women is the main issue women in asian countries tend to overestimate their body weight and attempt weight control more than western women our work represents one of the few studies examining the overall trend prevalence and agespecific patterns of body weight perception in asian populations similar to the findings of other studies we observed that young adults are likely to overestimate their body weight or image and this phenomenon is frequently reported across countries and ethnicities young adults are often exposed to unrealistic body ideals portrayed in mass media that are regarded as the norm of societal standards of beauty accumulated studies have shown a high prevalence of misperception among the young population however data on older adults are currently limited the results of the present study revealed that the proportion of individuals with a mismatch in body image was highest in the late adulthood group in our cohort notably underestimation was more prevalent than overestimation in this age group a possible explanation for this finding is that agerelated changes in overall cognitive function or reduced interest in ones body image affect ones perceived body image the importance attributed to body image and physical appearance decreases with age and this reduced emphasis on appearance may be protective against negative selfevaluations associated with body image it is also possible that becoming feeble or caredependent with age may cause the person to feel weak and misperceive themselves as underweight more importantly an awareness of this phenomenon of the misperception on body images is necessary because chronic diseases such as diabetes hypertension metabolic syndrome and health issues related to obesity may be overlooked because older women do not feel the need for weight management in this study we identified several sociocultural habitual healthrelated and femalespecific factors that were significantly associated with misperceptions of body weight in korean women our regression analysis revealed that age education level days of walking and efforts for weight management were negatively associated with a misperception of body weight of note selfperceived health status was negatively related to the misperception of body weight across all age groups indicating that women who perceived themselves as unhealthy tended to underestimate their body weight also making specific efforts toward weight loss was associated with weightoverestimation patterns in all age groups these results support earlier observations that dieters are more likely to overestimate their weights even though their weights were within a healthy range and those bias could be risky as weight loss effort are a wellknown risk factor for reduced nutritional state mortality risk or significant health problems it can also be suggested that dieters particular attention to their body weight are associated with biased estimates of weight status and this is likely to influence their subjective perception of healthiness or the evaluation of healthinessunhealthiness might be closely related to ones selfperceived weight status further work is required to clarify which of these two factors weight loss efforts or selfperceived health status is more important for the weight misperception behavior and if there is an interference or interaction between them one of the strengths of our study is that a large nationally representative sample was collected from a centralized dataset derived from a national registry cohort existing studies have reported that women tend to be more sensitive and overestimate their body weight than men our study aimed to demystify femalespecific risk factors that might influence the weight misperception including gravidity menopausal status or pregnancy history in addition we sought to identify women with weight misperceptions to quantify the extent of variance that the identified risk features could explain to our knowledge this is the first study with a machine learning approach to classify an individuals weight misperception based on their demographic and lifestyle data even though we showed a slightly improved prediction model compared to the baseline model we believe that the inclusion of more lifestyle and behavioral features will identify social determinants for weight misperception and could address some crucial public health concerns by estimating the relative feature importance within the prediction models we confirmed that an individuals perceived health and weight management s t a t u s w e r e i m p o r t a n t a n d d i r e c t i n d i c a t o r s o f weight misperception our study had several limitations first most of our lifestyle features were derived from selfreported questionnaire from the knhanes dataset even though selfreported features enable deep curation of the environment surrounding an individual they are inherently biased by an individuals subjective feelings and do not comprehensively cover every part of the human lifestyle aside from the selfreported features if other types and ranges of objective measurements were available to describe an individuals lifestyle better the findings would have been strengthened by identifying more reliable and valid risk features associated with weight misperception in addition we observed a significant casecontrol imbalance in our dataset especially for weight underestimation hindering the performance of our weight misperception prediction models based on a machinelearning approach we attempted to address these challenges by undersampling the training data however for future studies the use of a large population will strengthen the classification models and unveil meaningful outcomes lastly even though the bmi is the most common anthropometric index to estimate general adiposity it does not provide accurate information for distinguishing between fat and lean mass or fat distribution thus the use of bmi index alone might be insufficient to determine whether or not an individual is at her proper weights future studies should consider incorporating other anthropometric indices that can better identify the adiposity and fat distribution to validate our findings further conclusion our study identified several sociocultural habitual healthrelated agespecific and femalespecific factors that are significantly associated with misperceptions of selfperceived body weight in a large sample of korean female adults our prediction models revealed that an individuals perceived health and weight management status are important and direct indicators of weight misperception to the crucial discussion and manuscript revision and approved the submitted version 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 institutional review board korea university ansan hospital written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at fendo20221007129full supplementarymaterial

background misperception of body weight is associated with various psychological and health problems including obesity eating disorders and mental problems to date femalespecific risk factors including socioeconomic or healthrelated lifestyle features or their indicative performance for the misperception in asian women according to age groups remain unknown objectives to investigate the prevalence and associated risk factors for the mismatch in selfperceived body weight and evaluated the classification performance of the identified risk factors across age groups in female adults methods we analyzed data of 22121 women age 1997 years from the 7year korea national health and nutrition examination survey dataset 2010 2011 2012 2013 2014 2015 2016 we evaluated selfperceived body weight of the participants with their actual weight using the body mass index cutoff and grouped them by age early adulthood 1945 middle adulthood 4659 and late adulthood ≥60 logistic regression was conducted in each age group based on their weight misperception the classification performance of the identified risk factors was evaluated with a bagging tree ensemble model with 5fold crossvalidation results 222 n4916 of the study participants incorrectly perceived their body weight of which 141 n3110 and 82 n1806 were in the underestimated and overestimated groups among the age groups the proportion of participants who misperceived their body weight was highest in late adulthood 318 and the rate of overestimation was highest in early adulthood 141 we found that a lower education level absence of menopause perception of themselves as unhealthy and efforts for weight management were significantly associated with the overall misperception overestimation or underestimation of body weight across age groups

61 de gruchy backg rou n d recently calls have been made at a global level for policies at all levels of government to be migration and health aware research from the south african context has shown that local responsesor a lack thereofcan contribute to either exacerbating or mitigating the experiences that migrants have of accessing healthcare one kind of local communitybased response to issues of health is programmes that train and equip community members to facilitate access to healthcare within the community this approach has received renewed attention in south africa as well as in other lowand middleincome countries since the mid1990s as the under resourced south african public healthcare system is faced with multiple challenges in addressing the four colliding epidemics of hiv and tuberculosis chronic illness and mental health injury and violence and maternal neonatal and child health however although the state increasingly recognises the role that these programmes can play in addressing unmet health needs at the local level policy responses have largely been fragmented and highlight that while the state sees these programmes and their cadres of workforce as important they remain peripheral to the health system itself and their training and management is byandlarge left up to nongovernmental organisations this reliance on external nonstate actors has implications both for the sustainability of these programmes and for the security and wellbeing of these workers additionally it has also meant that there is little uniformity in the structure of these programmes for the purposes of this paper these individuals will be referred to as communitybased healthcare workers however within specific programmes they have different titles varied responsibilities and levels of training are sometimes volunteers and at other times are remunerated this paper explores two programmatic interventions that independently developed cadres of communitybased healthcare workers in order to improve the access that migrant farm workers in the area around the south african town of musina had to healthcare ten kilometres from the zimbabwean border musina has always seen the coming and going of zimbabwean nationals some of whom have traditionally found work both seasonally and more permanently on the farms surrounding the town in 2007 and2008 in response to an increase in the number of zimbabweans crossing the border to escape electoral violence and a cholera outbreak in zimbabwe several international organisations including the international organization for migration and médecins sans frontières set up projects in the area by 2009 this crisis had largely dissipated and both organisations moved their focus to migrant farm workers on the commercial farms surrounding musina as vulnerable groups whose access to healthcare was limited and could be improved globally while migrant farm workers are key to many commercial farming industries more often than not structural barriers ensure that this workforce bears an undue burden of both communicable and noncommunicable diseases south africa is no exception while legislation covering rights to collective bargaining basic conditions of employment social security benefits and workplace health and safety exist the access that migrant farm workers have to these rights including to healthcare is limited subject to low wages and poor living and working conditions within a context in which the public health system is severely under resourced and programming is not migrationaware migrant farm workers are known to have one of the highest hiv prevalence rates in the country in musina at the time that msf and the iom were developing programmes the department of health had a mobile clinic programme that was meant to visit farm worker communities on rotation however it was severely under resourced and importantly unable to provide any form of hiv care or support furthermore continuity of care for hivand other chronic conditionshas historically been very difficult in this area as patients move regularly and south african health systems are yet to respond to the realities of patient mobility both crossborder and internal médecins what is known about this topic • increasingly calls are being made for migration aware policies and programming at all levels of governance • in south africa health policies do not consider the realities of migration which affects the access that migrants including migrant farm workers have to care • south africas approach to communitybased interventions is fragmented and characterised by a reliance on nonstate actors what this paper adds • original empirical insights into communitybased interventions and their potential as migrationaware responses to health • an analysis of why communitybased interventions are unsustainable in south africa • urgency to the call for sustainable migration aware policies and programmes de gruchy sans frontières 2012 2013vearey 2014vearey et al 2017 to address these gaps msf implemented the musina model of care an initiative that included a mobile clinic programme that provided voluntary counselling and testing for hiv antiretroviral therapy and developed a cadre of community health workers to work alongside the clinic in 2012 10 chws were trained across 10 farms to work both with the mobile clinic and independently to test for malaria support hiv treatment run support groups and provide basic medical care within the farm compounds as msf was developing and implementing its chw programme the iom working with the centre for positive care a local nongovernmental organisation that acted as an implementing partner trained on many of the same farms 103 farm workers as peer educators referred to as change agents this was part of the organisations ripfumelo project a largescale regional project which looked to reduce hiv and tb vulnerability amongst migrants and mobile populations and the communities affected by migration across several areas in southern africa including musina the primary difference between the two groups being that change agents educate and mobilise workers to seek care while chws are able to provide some basic biomedical care both of these interventions were envisaged as supporting the provision of biomedical care through the mobile clinic at the height of the interventions success chws and change agents were part of a robust migrationaware response to the intricacies of healthcare access for this group of workers however neither msf nor iom could commit to sustaining the programmes for more than a few years msf had hoped that when they left the chws would be incorporated into the department of health however at the time of msfs exit the department argued that it was not able to take over the cost and the maintenance of the programme as such the programme was managed and funded by north star alliance an international ngo that provides health services to mobile workers for a year after which it was handed over to the cpc this time as an implementing partner of the department of health cpc at this time remained an implementing partner of the iom and involved in the training and management of change agents at the end of 2017 the iom brought an end to its migration and health related activities in the area including funding for cpc cpc have consequently left the area handing the management of the chw programme over to the local branch of a humanitarian organisation in the area but leaving no provision for the change agents this paper is based on research conducted as part of a broader project that has examined the role that nonstate actors have played in responding to migration and health in south africa and the longer term implications of their involvement with migrant farm workers around musina key issues on which the research reflects have included the nature of responses by both state and nonstate actors to migration and health this paper uses the chws and change agents to illustrate the ways in which such workers can form part of a sustainable migration aware response to health but the paper also demonstrates how this is undermined by both the timebound nature of nonstate interventions and the states reluctance to incorporate communitybased healthcare workers more formally within the health system material s and me thods several qualitative methods were used in this research including key informant interviews an analysis of grey literature and observation of the mobile clinic programme key informant interviews a total of 79 indepth key informant interviews were conducted the specifics of which can be found in table 1 to understand workers experiences of the interventions interviews were conducted across two farms on which the interventions had been implemented and where farm management were willing for researchers to conduct interviews during work hours most of these interviews were conducted by two research assistants who had received training on conducting interviews with farm workers and the ethics thereof and were able to conduct interviews in chishona the language of choice for many of the farm workers audio recordings of interviews that were conducted in chishona were sent to a translator who both translated and transcribed the interviews into english for analysis by the author individuals were approached as they stopped work for lunch waited for the mobile clinic to set up or leave or were introduced to the researchers by others who had already been interviewed informed consent was sought prior to interviews commencing interviewees were asked to provide either written or verbal consent data from interviews was thematically analysed using dedoose 8214 74 codes were identified through the initial analysis of the data and these were then examined in relation to one another as themes f i g u r e 1 observation it proved challenging to formally interview many of the department of health employed healthcare professionals who work on the mobile clinic given the constraints of their work as such observation of the mobile clinic was undertaken between may and july 2017 time was spent in the mobile clinic offices travelling with the mobile clinics and observing how the healthcare workers related to workers when they arrived on the farms observations and informal conversations were recorded as field notes which were subsequently thematically analysed no treatment or care itself was observed grey literature in addition to supplement a review of published literature a thematic analysis of 76 documentsincluding policy directives meeting minutes memos project reports policy documents and emails relating to the projectswas undertaken byandlarge these documents were collected as interviews took place and participants indicated that a particular document might be of interest or use documents were thematically analysed in conjunction with interview data to triangulate information and provide details that may have been forgotten by participants use of these data were limited however as key informants had to be relied upon to send the author documents that they had deemed sufficiently relevant to keep the details of this study were reviewed and approved by the university of the witwatersrand nonmedical research ethics committee ethical clearance was given under protocol h160810 re sults in this section the two programmes are presented together to highlight their differences as well as the ways in which the two workforces interacted and continue to interact against a fragmented policy and programmatic landscape the change agents on the other hand were trained to act as community leaders facilitate dialogue educate farm workers on issues of healthcare dispense condoms and plan weekend activities so that farm workers use their free time in sports rather than engaging in unprotected sexual activities and abusing alcohol and drugs improving access to care given this broader range of potential roles that change agents could and can play these individuals are not exclusively regarded as healthcare workers by community members most farm workers interviewed reported positive experiences of both chws and change agents and importantly that they know who these individuals are and the work that they do however across the two farms three farm workers reported that they would only be able to identify the chw by face rather than by name and three reported that they were unaware of the chw while these are not large numbers they do highlight the limitations of communitybased workers even within a confined farm there are those farm workers who for whatever reason are beyond the chws reach motivations and status while the experiences that farm workers had of the chws and change agents are important the experiences that these individuals 65 de gruchy across the two farms there is however one salient difference in the chws role and status on one of the farms the chw is very clearly regarded as an important part of farm life she grew up on the farm and is married to the head change agent who is a senior employee and has a closer relationship with farm management than many of the other workers in one interview referred to by a farm worker as our leader she is very present on the farm and the lives of the workers describing herself as motivated to fulfil her role as chw a fulltime job on the second farm however the importance of the role of the chw is acknowledged but the chw is regarded with some frustration and irritation as she is often absent from the farm the problem that we have is that she cannot be found easily … if you are lucky to find her she can help you the role that this chw plays on this farm is markedly different from the previous example here the chw indicates that while she has a room on the farm this is not her home and her role is to be present every second weekcoinciding with the mobile clinic visits when interviewed this chw often deferred to change agents and indicated that in her opinion the role of the chw and change agents this is what i have seen happening in this compound frustrations and insecurity the frustrations expressed in relation to the chw on the second farm are part of a broader set of frustrations that both change agents and chws expressed during the research although the change agents continue to have some status within the community the benefits that the change agents derive this frustration spills over into resentment over the lack of more formal recognition of their work while change agents acknowledge that they signed up as volunteers the apparent promise of compensation at some future point appears to have been a motivating factor cpc for their part acknowledge this expectation but express the view that change agents should have become formalised within and compensated through farm structures although there is no evidence that this was ever discussed with farm management however while chws are remunerated for their work they remain financially insecure chws are paid their monthly stipend through whichever organisation is acting as the states implementing partner at the time however contracts between the state and these ngos need to be renewed annually regular delays in this process lead to delays in the payment of chw stipends for example in 2017 the chws around musina were not paid until july as cpc waited for their contract with the department of health to be renewed in regardless of this lack of support and the irregularities around remuneration however the fact that chws are remunerated while the structural differences in the programmes specifically around remuneration pose a barrier to the two cadre of workforce happily coexisting when additional social factors exist as on the first farm this barrier is overcome however in the absence of these factors as on the second farm tension is a reality in addition regardless of their migrant status workers enthusiastically took part in these programmes and byandlarge felt that the programmes had positively affected the health and wellbeing of their community however the sustainability of the programmes has been undermined as reflecting much of the literature the key software underpinning the efficacy of these cadre of workforcemotivation and supervisionas well as their integration within the broader health system have been neglected by the state d iscuss i on while the disparity in financial remuneration between the chws and the change agents emerged as a key tension in this case both the research presented here and the literature highlight that financial remuneration is not the sole motivation that individuals have for becoming communitybased healthcare workers a desire to learn as well as to improve the lives of loved ones and the general health and wellbeing of the community are also key factors that motivate individuals to participate in such programmes however as greenspan et al note a strong volunteer spirit … does not preclude a desire for financial rewards as many chws and change agents saw these programmes as an opportunity to upskill and improve their status within the community the lack of continued engagement by and support from external actors is keenly felt this echoes findings by akintola the lack of supervision and integration of the programmes within the broader state healthcare system are two additional factors that undermine the sustainability of these programmes supervision and integration have both been identified as key enabling factors or barriers to the sustainability of communitybased programmes kok et al argue that communitybased workers need to be seen as social actors that trusting relationships with both the communities that they serve and the healthcare system are pivotal to their efficacy and sustainability the role that the former plays is illustrated here by the different responses to the chws on the two farms which also highlight the importance of community fit for sustainability and perhaps the lack of care that was given to community fit in the selection of the chw on the second farm gilson and others highlight the importance of workplace trust in health systems this research indicates that communitybased healthcare workers can have a good working relationship and trust one part of the health system in this case the mobile clinic staff and local emergency medical services while simultaneously not being integrated into or trusting the broader structures of the health system research on the relationship between communitybased healthcare workers who are able to provide some biomedical care and nurses indicates that nurses often feel threated by these workers and are prone to enforcing professional hierarchies in counterproductive ways when forced to work together the good working relationship between the chws and nurses documented here contradicts much of this this may be because in this case chws are isolated on the farms and as such have a very clearly demarcated roleproviding support and care to farm workers between mobile clinic visits consequently they are of no direct threat to the nurses who leave the farm after each visit regardless trust in the broader health system is limited and may in fact be compounded by the fact that mobile clinic staff themselves indicate little trust in the broader department of health the nuances of which are described in de gruchy and kapilashrami finally theories of sustainability point to the importance of integrating interventions into broader structures here implementing organisations were unable to secure this integration prior to their departure due to the states fragmented interest in and response to such interventions characterised by a lack of sufficient attention to or support for this workforce 67 de gruchy this paper shows how communitybased healthcare workers can and do play an important role in health systems however as it makes clear within the south african system the fragmented approach to these workers undermines this potential the findings from this research support the call for migration and health to be prioritised within policy and programmatic responses to wellbeing and highlight the role that communitybased healthcare workers can play within this however it raises important questions about the development of these cadre of workforce within a context in which factors enabling their sustainability are limited as such ensuring that the ways in which migration and health are included in policy making are sustainable emerges as a necessary element to be included in global calls ack n owled g em ents the author thank all who agreed to participant in this research co n fli c t o f i nte r e s t there are no conflicts of interest to be declared o rci d thea de gruchy r e fe r e n c e s

reflecting global trends migrant farm workers in south africa experience challenges in accessing healthcare on the commercial farms in musina a subdistrict bordering zimbabwe medécins sans frontières and the international organization for migration both implemented migrationaware communitybased programmes that included the training of communitybased healthcare workers to address these challenges using qualitative data this paper explores the experiences that migrant farm workers specifically those involved in the programmes had of these interventions a total of 79 semistructured interviews were completed with migrant farm workers farm managers ngo employees and civil servants between january 2017 and july 2018 these data were supplemented by a review of grey and published literature as well as observation and field notes findings indicate that participants were primarily positive about the interventions however since the departure of both medécins sans frontières and the international organization for migration community members have struggled to sustain the projects and the structural differences between the two programmes have created tensions this paper highlights the ways in which local interventions that mobilise community members can improve the access that rural migrant farming communities have to healthcare however it simultaneously points to the ways in which these interventions are unsustainable given the realities of nonstate interventions and the fragmented state approach to communitybased healthcare workers the findings presented in this paper support global calls for the inclusion of migration and health in government policy making at all levels however findings also capture the limitations of communitybased interventions that do not recognise communitybased healthcare workers as social actors and fail to take into account their motivations desires and need for continued supervision as such ensuring that the ways in which migration and health are included in policy making are sustainable emerges as a necessary element to be included in global calls k e y w o r d s community health workers communitybased responses migrant farm workers migration and health south africa sustainability how to cite this article de gruchy t responding to the health needs of migrant farm workers in south africa opportunities and challenges for sustainable communitybased responses

background in 2014 zambia rolled out a new and ambitious framework for comprehensive sexuality education targeting children and adolescents enrolled in grades 512 in schools across the country 1 2 3 4 in zambia sexual and reproductive health knowledge is inadequate and unevenly distributed leading to considerable srhrelated problems among zambian adolescents 5 6 7 aimed to address such unequal access to knowledge about srh the development of a cse programme was heavily supported by unesco 34 in zambia as many as 25 of married girls aged 1519 have an unmet need for family planning and about 30 of girls aged 1519 have begun child bearing 578 moreover zambia has high rates of early marriage with as many as 31 of those aged 2024 reporting to have married before the age of 18 589 while abortions in zambia are allowed on the broad grounds spelled out in the termination of pregnancy act of 1972 the same law also severely restricts access to safe and legal abortion services by demanding written consent of three medical doctors including a specialist for a legal abortion to take place 1011 this is problematic in a country with critical shortage of health workers data on abortion in zambia is scarce but recent policy documents from the ministry of health estimate that 3050 of all acute gynecological admissions are caused by abortions and that as many as 6 per 1000 women in reproductive age die from abortionrelated causes annually 1213 the problem affects teenage girls in particular approximately 80 of women taken to health facilities for abortionrelated complications are adolescents 914 studies in botswana nigeria and south africa have shown that sexuality education may contribute to overcoming the adolescents srh challenges that zambia and other countries face 15 16 17 at the core of the zambian sexuality education policy is the idea that there is a substantial need to support adolescents in delaying their sexual debut to reduce the number of sexual partners and to increase safer sexual practices 15 16 17 backed by evidence on its positive effects on adolescents level of knowledge skills attitudes and values related to sex and sexuality cse has been promoted in a series of global policy guidelines and recommended to be integrated into ordinary school curricula 3 15 16 17 it is anticipated that the positive effects on knowledge skills attitudes and values will empower adolescents to realize their health wellbeing and dignity to develop respectful and pleasurable social and sexual relationships and to understand and ensure the protection of their rights throughout their lives 18 many low income countries have committed to international policies to roll out cse in their schools 3 15 16 17 together with 21 other countries zambia has signed the eastern and southern african ministerial commitment on cse and srh services for adolescents and young people which has shaped expansion and implementation of cse across the region 1 this agreement was in turn informed by the international technical guidance on sexuality education published by unesco 18 a guideline that grounds sexuality education within a human rights framework springing out of the cedaw and the icpd programme of action on sexual and reproductive health and rights 18 the coordination of the development of cse in zambia was done by unesco 23 and the zambian framework was developed with continuous reference to unescos guidelines document in retrospect it has been documented that the process of developing and disseminating the content and format of the zambian cse was done in a way that left key stakeholders including religious leaders civic leaders parents groups and youth without sufficient representation 23 this may have left the cse policy without much needed public support zambia has had reproductive health education since the 1990s but its original content was limited it did not cover central srh themes such as gender relations sexual behavior information on contraceptive methods as well as values attitudes and selfrealization life skills which have now been included in the new cse framework 4 a key feature of the revised framework is that it is not supposed to be offered as a standalone subject but is to be integrated in carrier subjects such as science and social studies 4 concerns that cse is incompatible with the religious and cultural norms have been reported to affect acceptability 18 in zambia this is commonly expressed as a conflict between cse and a tradition of grandparents providing sexuality education along with cultural norms condemning discussions about sexuality between the sexes except for in grandparentsgrandchild relations it is also a common concept that providing sexuality information to young adolescents should be avoided since it will trigger sexual promiscuity 19 similar difficulties in teaching sexuality education have been reported in other countries 2021 conflicting intergenerational discourses on sexuality between teachers and community members as well as taboos associated with discussion of sexuality 2223 and genderrelated challenges 23 24 25 have been reported to affect the acceptability of sexuality education in studies from south africa and botswana closely linked to cultural norms and moralization over sexuality are religious values zambia was declared a christian nation in 1991 a declaration that was included in the preamble of the national constitution 2627 this declaration has given christian morality a particularly prominent place in zambian politics and society it emerges in dominant discourses and weighs heavily in public health discussions about access to reproductive health services to homosexuals or contraception and safe abortion services to adolescents this contributes to the conditions causing unequal access to srh knowledge and services among adolescents 28 while quite a bit of documentation exists on the challenges of approaching sexuality education in schools in zambia there is inadequate knowledge about how teachers handle the task of teaching cse in schools this study aimed to investigate teachers experiences with the implementation of the cse curriculum in the zambian context we are particularly interested in teachers interpretations of their roles in teaching about sexuality love relations and contraception both vis a vis the pupils and their parents in the community in examining the teaching process we draw upon lipskys theory of streetlevel bureaucracy which relates to the role that frontline workers or streetlevel bureaucrats such as teachers play in concrete policy implementation 29 streetlevel bureaucrats are civil servants or others tasked with the ontheground implementation of policies they function as gatekeepers to services or reallife policy makers since any policy is dependent on health workers teachers social workers or others to convert the policy from paperwork to practice lipsky notes that in order to gain enhanced understanding of public policy implementation one needs to understand that the policy implementation process is dependent on the actions or discretion of those who carry out the policy in actual practice discretion which is the central tenet of the theory refers to the use of individual decisions or autonomy during policy implementation to vary the quantity and quality of services or information offered to citizens discretionary power can also take the form of inaction or resistance to delivering services or providing information 30 this discretion may be influenced by many issues such as difficulties in making complex decisions 31 limited availability of information and resources as well as when policies are deemed not to be fully compatible with the local context 2932 we used this theory as it is one of the most comprehensive and widelyused theories in understanding bottomup policy implementation process 3233 methods this study is part of a comparative research project named competing discourses impacting girls and womens rights fertility control and safe abortion in ethiopia zambia and tanzania funded by the norwegian research council and the university of bergen norway 34 we conducted the study in nyimba district in eastern province of zambia in 2017 the district was purposively selected as it is one of the provinces with the highest rate of early pregnancies and marriage in zambia primary data were collected by the first author of this paper together with a research assistant at the district level designed as a case study of teachers experiences of implementing cse in schools the study focused on the teachers of six schools conceptualized as cases and combined indepthinterviews of teachers with observation of the teaching process and classroom situations the semistructured interviews loosely followed an interview guide developed by the first author with input from coauthors after the first phase of data collection the results were discussed among all authors and the interview guide was further revised a total of 18 teachers were interviewed from six schools in nyimba district reaching a level of saturation we purposively selected the study participants to ensure inclusion of informants with diverse views and experiences about sexuality education an attempt was made to include teachers across different grades and subjects the average numbers of hours that the teachers teach varies from about 20 h per week in primary school to about 25 h per week in high school classes are made up of about 60 learners teacher expertise was largely grouped in two those who taught basic sciences including mathematics and those who taught social science related subjects such as social studies and religious education in conducting the recruitment process we informed the head teachers in the six schools that we were interested in interviewing the head teacher and two other teachers per school based on this criteria teachers discussed and agreed on who would be interviewed for the study the sample was composed of seven female teachers and 11 male teachers the male bias was caused by the deficiency of female teachers in some of the schools the age range of the study participants was from 27 years to 48 years the data did not suggest that gender seniority or age had an effect on their experience or forms of engagement with the cse the semistructured interviews varied in duration between 40 and 55 min and covered the teachers experiences with teaching cse and their thoughts and attitudes towards it in addition to the interviews we also reviewed the zambian cse curriculum and other relevant policy documents for documenting their content framing and approaches used we analyzed the material using thematic analysis 35 drawing upon lipskys perspectives on the use of discretion during policy implementation 29 we focused on developing key themes in decisions about what teachers teach and what shapes their decisions regarding teaching of cse in schools the analysis process started with transcribing audio interviews and reviewing the full data set after a thorough review of the interviews the development of a code sheet and later coding of the interviews took place coding was done using nvivo version 7 which is a qualitative software used to organize qualitative data the codes were merged into categories and then themes focusing on forms of discretion and drivers or sources of discretionary power were developed this was an iterative analytical process which involved moving between writing themes reading and analyzing the data and redrafting the analysis 36 37 38 the quotes presented in this text are based on the interviews with the teachers their experiences being the core focus of the paper ethical approval for the study was obtained from the eres ethics committee in zambia and the ministry of education informed consent was given by all participants before being interviewed for the study results this section presents findings on the process of integrating cse into the school curriculum for grades 512 in nyimba district while the first subsection describes teachers experiences and the dilemmas they encountered in teaching cse the second subsection presents teachers reflections on why their role in teaching cse is problematic teachers negotiating the comprehensive sexuality education curriculum we found that the cse curriculum was treated in an arbitrary manner leaving much room for the teachers to decide how when and what to teach as well as what to leave out with very little guidance these choices ultimately depended on the individual teachers judgement on what would be appropriate to teach considering the time available the age of the learners and the local norms about sexuality and sexuality education their decisions and how they reasoned around their choices is described below this framework does not provide guidance teachers were set to teach cse in grades 512 and to integrate the subject into science social studies civic education home economics and religious education the teachers we interviewed struggled with how this could be done in an appropriate and natural manner and without compromising the attention to and the learning outcomes in the core subjects although their knowledge of the content of the cse in general was incomplete the teachers shared a feeling of being overwhelmed by the comprehensive list of topics they were expected to integrate into existing subjects we are expected to teach relationships values attitudes and skills culture society and human rights human development and sexual and reproductive health these topics are the same across all grades 5 6 7 8 9 10 11 12 but as the teachers explained they were expected to provide different levels of detail for the different grades in the lower grades for example grade 5 on pregnancy prevention the focus should be on identifying benefits of abstaining from sexual activities while as you go up lets say to grades 8 9 and 10 we are also expected to teach how hormonal contraceptives are used the cse framework describes the expected learning outcomes for each grade but according to our informants and to our review of the framework it does not provide guidance on how teachers are supposed to integrate cse into the specific subjects this was experienced as both demanding and confusing so when i am teaching home economics or religious education when and how do i introduce sexuality issues in these subjects this framework does not provide guidance on such issues this makes teaching very difficult in this void between stated learning outcomes and lack of guidance on how to reach them teachers were left to solve the problem themselves and make decisions on the integration process on an individual basis as clearly illustrated in this quote i decide on my own on what to teach and how to teach it the lack of direction in teaching and integrating cse has thus implied dependence on individual teachers priorities and judgements and has entailed great variations in the content being taught when it is taught and how it is taught both within and across schools teachers stories show how they moved to amend the curriculum to fit what they perceived to be appropriate through holding back information emphasizing only some aspects of information or dropping classes on cse these tactics or strategies to cope with the problem are explored in detail below holding back information teachers reported being selective about which cse material they taught and what they left out i do not teach them everything i leave out some stuff according to our informants the concept that the school should teach pupils different ways of preventing pregnancy was highly controversial and teachers generally felt very uncomfortable about discussing the wide specter of contraceptive methods listed in cse and the myths associated with them with learners we are expected to discuss types of contraception such as oral contraceptive pill and depoprovera through injectable method implant but i do not teach them such things to develop the discussion in class into how the different types of contraceptives should be used and where they could be accessed was perceived as even more awkward and unacceptable why should i teach about the steps to using contraception its like teaching someone how to fish they end up always wanting to fish so in the case of sex what will happen when they do have contraception they will still have sex the topic on developing good relationships and attributes of a good relationship was seen as difficult to integrate since they did not fit well in subjects such as science and home economics when i am teaching science how do i bring in issues relating to differences between love affection and infatuation it does not work for me another reason for leaving this topic out was that teachers feared that it could be misinterpreted by learners as support from the school to engage in romantic relationships promoting abstinence only while some teachers would withhold a few selected pieces of the cse curriculum others would only agree to teach very limited fragments of it according to what they deemed to be appropriate for learners contrary to the philosophy of the cse curriculum of making information available to adolescents in order to prevent pregnancy some teachers believed that such information would be counterproductive and decided only to teach one method in the school setting when i teach about preventing pregnancy the main message is only about abstinence hence most of the time available was dedicated to abstinence and the benefits of abstaining from sexual activities the very strong moral message on abstinence was put across in several ways we have a song about the importance of abstinence we sing it before we start each session on cse i also tell them repeatedly that abstinence is the only method that can help them avoid teen pregnancies and stis including hiv this group of teachers saw their role as much as one of preventing sexual activity among their pupils as one of preventing pregnancy they reported to prioritize their time teaching about the importance of avoiding exposure to situations that could tempt pupils into sexual stimulations or encounters i tell them to avoid intimacy being with someone of the opposite sex in a secluded place or watching things that will make them think of the opposite sex dropping topics other teachers dropped topics or defined sessions in the cse altogether this took different forms within and between the schools interviews with teachers showed that some of them substituted the whole cse topic which they were not comfortable teaching with other topics which they believed were more appropriate for learners a teacher told us how he substituted a topic with another i skipped the whole topic on pregnancy prevention instead of teaching about condom use i moved to another topic i repeated sessions which i thought were good for learners such as communication assertiveness and decisionmaking skills in some cases when teachers had already taught the topics in the cse they were comfortable with or felt were appropriate they turned to teaching completely different subjects with little relevance to the cse curriculum when i realized that i had taught all topics that i was comfortable with instead of teaching topics on condoms or oral contraception use i decided to only teach social studies teachers that were most reluctant to teach cse could even took a more radical step to avoid teaching some told us that when it was time for them to teach cse they sent learners to do outdoor activities which were not related to cse i opt to send the students out for sport activities preventive maintenance work and other club activities instead of teaching cse interviews with teachers showed that teaching cse was not done on a routine basis and in a standardized manner and that the cse curriculum was treated haphazardly in the schools teachers could not state on average how often they taught cse and a few teachers reported that they had stopped teaching cse altogether and as one teacher put it all i can say that it is something that happens by chance lack of local ownership of the cse agenda the decisionmaking process among teachers regarding when what and how to teach comprehensive sexuality education was informed by a number of factors the reasons which we outline in detail in this section included perceived incompatibility of cse with the local culture teacherparent role dilemma concerns about the legitimacy of the cse concept and practical challenges related to lack of training and access to manuals incompatibility with the local culture comprehensive sexuality education was seen as incompatible with the local culture and religious values as it confronts local ideas about sexual morality there were concerns that some topics were too sensitive as they were believed to promote premarital and casual sex among learners we are a christian country so the message for us is no sex before marriage another teacher explained how provision of cse information would promote casual sex many children avoid sex because of fear of pregnancy no if they know that they can prevent pregnancy by using contraception children may get too excited and confident and start getting involved in casual sex teachers further reported that parents were against the teaching of some components of cse in schools as they considered cse topics to be sacred only to be taught by traditional counsellors at community level the controversy is also about the place where such information is delivered from not being culturally appropriate its taboo to teach sexuality education in a school at one school a teacher narrated an event which had caused uproar from the community in an effort to implement the cse curriculum the teacher had asked learners to do an exercise at home on initiation ceremonies for girls when they reach puberty having seen the assignment which i gave to the learners parents came in numbers to the school in the morning and demanded to see the headmaster i was called to attend the meeting the parents then complained to the headmaster that the initiation ceremony is something special which should not be handled at the school the notion of sexuality education as sacred and belonging to arenas of learning very different from the school surfaced strongly and placed teachers in some squeeze vis a vis the parents a complicating factor was gender mixed classes it was highly uncustomary to discuss sexuality and reproductive health issues specific to female or male learners in the presence of the opposite sex adding to the problem was age customarily sexuality education was not supposed to be introduced to children in the lower grades it should be introduced only during the initiation ceremony taking place later after girls attain puberty and many teachers shared this understanding with the community and had difficulties discussing sexuality issues and using sexuality terminology particularly with the youngest learners as the young students were not conversant in english the classes on cse had to be provided in the local language which was experienced by the teachers as more challenging since the local terms emerged as more insulting than the english ones in order to cope with the embarrassment teachers used different strategies as one of them explained i close my eyes when i mention the sex organs the taboo related to mentioning sex organs in the local language in teacherstudent discussions was clearly expressed in the practice of giving the teachers insulting nicknames as a way of avoiding antagonism with the community teachers reported leaving out or omitting issues that they perceived as inappropriate from the community perspective teacherparent role dilemma the dissenting or opposing views from the community about teaching sexuality education in the school coupled with cultural and religious values about morality presented a professional challenge for teachers on the one hand they were supposed to convey knowledge and stimulate reflections as described in the curriculum on the other hand teachers were expected to have a broader role vis a vis their pupils bringing them up according to social and cultural norms and values teachers reported that they struggled to strike a balance between teaching sexuality education to their pupils and maintaining the broader parental role of shaping them into responsible adults it is very difficult for me as a parent i need to promote abstinence but as a teacher this curriculum wants me to talk about the importance of using condoms one topic for example requires us to describe the steps that one has to follow when using a male or female condom now how do i demonstrate such steps to learners who are almost the same age as my child no thats like teaching children to be sex experts this situation was even more challenging for teachers who had biological children in their class and bolstered the tendency to skip cse sessions on sensitive topics i think about my children so when i know that the topic is not good for them i skip the topic because of this role dilemma other teachers suggested the need to think about other approaches to delivering cse one recommendation was to engage other actors to deliver cse some topics can be taught by teachers and other topics can be taught by people outside the school such as health workers or community health workers concerns about the legitimacy of the cse concept concerns about the legitimacy of the cse concept also emerged throughout the interviews many teachers reported not being comfortable teaching cse as they considered it to be something that was externally driven with little relevance to local needs when we asked one teacher why some teachers have stopped teaching cse he seemed to perceive it as a foreign agenda you mean this donor funded program some teachers have sidelined sexuality education its just extra work for us in addition to cultural incompatibility the inadequate involvement of actors at the district level during the development validation and dissemination process affected the legitimacy of the curriculum some teachers argued that instead of offering cse the community would have preferred more topics that directly address povertyrelated issues they should have known that this one is a hot issue it is not as simple as introducing a new curriculum for social studies or science this one touches on what people believe in peoples culture and how people bring up children to make it even more complicated we did not cover it during the training process in college thus as people that are supposed to implement it we should have been consulted limited prioritization of sexuality education teachers reported that compared to other subjects cse implementation was weak and was characterized by several severe gaps including lack of adequate training of the teachers involved the headmasters attended a 2 days training in cse and then they briefed teachers in schools on cse for only one to two hours so how do you expect us to effectively teach lack of teaching aids or images and reading materials in schools was another gap and was seen as particularly important for explaining complex and sensitive topics we also need images to explain for example topics on unsafe abortion cancer stis for now we have to borrow images from the health facility teachers also had challenges accessing the manuals as only one manual was given to each school the headmaster locks the only copy in his office so how do we teach furthermore the topics in cse were not reflected in the common scheme of work which all schools in the district were supposed to teach after the schemes were completed then we just realized that we accidently left out comprehensive sexuality education while some kind of teaching of cse is going on in the schools in the district many teachers were grappling with the puzzle of why cse was introduced this was primarily related to the weakness that has surrounded the implementation of cse compared to other subjects we have been teaching social studies for a long time and at no point did we see parents come and protest about the topics so why should we continue teaching something that the community has concerns over the decision by the government to implement cse without providing adequate support in schools made some teachers question the timing of the implementation process my question is about why they decided to implement cse when they were not ready i always wonder what caused this rush the puzzlement among teachers about the rationale for introducing cse made them question why they have to teach cse this lack of appreciation of teaching the new cse framework by teachers is best illuminated in the following question raised by a teacher when we her asked why she had stopped teaching sexuality education if i may ask why do they want us to teach sexuality education discussion the study has examined teachers interpretations of their role in teaching sexuality love relations and contraception during the early phase of implementation of cse in a rural district in zambia we have noted that what when and how to teach is dependent on the individual teachers decisions in line with lipskys 29 call for the need to move beyond the topdown approach to policy analysisand consider other contextual realities that shape policy implementation our study strongly demonstrates how the settings within the schools in which the cse framework was implemented influenced how teachers made decisions about the curriculum and subsequently the pattern and nature of the implementation of cse this studys findings revealed that the lack of clarity in the cse framework on how to integrate cse teaching into existing subjects coupled with contextual challenges left teachers involved in cse with a great room for discretion in this context extensive use of discretion resulted in arbitrary and unequal management of the cse curriculum in the district lipsky notes that unclear or vague policy guidance as well as features of work settings or context in which streetlevel bureaucrats or workers act can make the bureaucrats interpret and implement the policy content in different ways 29 according to the theory of streetlevel bureaucracy the differential policy interpretation happens because the lack of clarity in the policy gives the implementers space and power to exercise individual discretion in interpreting the content and direction of the policy 33 in this study some of the features of work settings that shaped decision making among teachers were sociocultural factors these factors included incompatibility of cse with the local culture and religious ideals for example while the cse framework required teachers to discuss different ways of preventing pregnancy religious and cultural values expected teachers only to focus on abstinence such incompatibility created teacherparent role dilemmas in the classroom setting teachers tended to see themselves in a parental role with the obligation to shape their pupils into responsible or morally upright adults abstinence was a key message in this regard the setting had inadequate support for cse such as inadequate training materials and tools for teaching as well as insufficient leadership and guidance in the implementation process these gaps made some teachers question the extent to which cse is prioritized within the education system and why they have to teach sexuality education we note that such doubts among teachers potentially provided more space for discretion and subsequently enhanced the power teachers had to skip some aspects of cse or not teach it at all these study findings like other studies that have discussed the concept of discretion agrees that the application of discretion or autonomy during policy implementation is potentially also motivated by the availability or otherwise of resources 29323940 as a way of dealing with these dilemmas and the gaps in support teachers modified their teaching of cse a practice that is articulated in streetlevel bureaucracy theory according to this theory when they are faced with challenging situations bureaucrats use their discretion to modify how they understand and execute their tasks or responsibilities 2933 lipsky 41 notes that this invention or modification of modes of decision is done in order to serve the workers agency or purposes this modification of policy content which is also known as coping can happen in three forms the forms include bureaucrats adjusting or moving towards clients through bending policy options in order to meet the needs of clients moving away from clients or rationing services and moving against clients through rigid application of rules 42 in our case study the modification process adopted by teachers in relation to their clients was moving towards clients by bending the cse policy this study further showed that the use of discretion to modify what to teach was justified by teachers as the best way to protect the children from sexual harm teachers feared that some information would motivate learners to engage in sex as they would no longer have to worry about pregnancy they argued that the situation had the potential of turning the learners into sex experts putting them at risk of pregnancies in cases where there is no contraception or contracting an sti if condoms were not available this process of exercising discretion among the teachers in the district was motivated by paternalism as they viewed or defined learners as children in need of protection rather than as young people who have the right to relevant information about their own bodies and their sexuality 43 p 36 as described above teachers justified adopting paternalistic values as they perceived themselves as parents of all children in the class it is important to note that paternalism was further articulated through resistance towards teaching cse teachers resisted teaching cse as they viewed it as something that was externally driven with little relevance to local needs as well as incompatible with the cultural norms and values the actual policy that is realized vis a vis clients depends more on those who carry out the policy than the policy makers 39 in the context of this study implementing cse is a negotiative process between the teachers and the contextual realities such as the broader educational system sociocultural and community dynamics as well as the experiences and values of individuals we note that the agency and power among the workers in this case the teachers coupled with interactions between teachers and the school environment influenced the implementation of the policy 4445 which resulted in unequal access to cse among learners in our case these powers included holding back some cse information teaching only abstinence and dropping classes these scenarios therefore make the outcome of the policy implementation process a result of the complex interplay or interaction between the frontline workers and the contextual realities lipsky 29 refers to this phenomenoninteraction and negotiating processas a gap between policy as written and policy as performed we further note like lipskyswords that as teachers interact and negotiate during the implementation process of cse the routines they establish and the devices they invent to cope with uncertainties and work pressure effectively become the public policies they carry out we therefore agree based on the findings on this study with gilsons 33 view that for all bottom uppers policymaking is still in progress at the moment of delivery meanwhile lipsky 41 cautions that negotiations during the policy implementation process and subsequent policy modifications may widen the gap between policy as written and policy as performed thus although discretion may promote teachers freedom to tailor and adapt their teaching to the needs of their pupils it may lead to widening the gap between policy as stated and practiced this widening gap between policy and practice may distort service ideals 33 for example adopting paternalistic approaches in delivering cse may affect the acquisition of skills about reproductive health among young people paternalism may affect learning learners may not be or feel able to ask questions freely on sensitive topics such as contraception use because of the limited interaction and lack of frank discussion between teachers and learners and the moralizing context of sexuality education 46 this may negate the very essence of establishing cse in such communities and perpetuate the absence of critical knowledge and life skills to prevent early pregnancy in a country with high pregnancy and early marriage rates this lack of knowledge is problematic our findings resonate with other studies that have examined the use of discretion in delivering welfare and prison services ie that nonconformity to prescribed policies by streetlevel bureaucracy can lead to disparities in access to services for some populations 3147 improving policy implementation requires paying attention to the contextual realities that reinforce discretion during this process 30 as we have discussed above policy as experienced by clients is a reflection or a product of the interplay between both the formal and informal practices of street level bureaucrats 48 enhancing the implementation of cse may require increased involvement of stakeholders at local level in developing and implementing cse policies and programs as well as providing comprehensive training in cse to teachers as observed in this study the limited involvement of local actors made teachers see cse as a foreign agenda which was not compatible with their local context or their mandate to teach other authors on cse in nigeria and a recent publication on international cooperation in sex education have also cautioned that limited involvement of local actors has the potential of developing cse which is insensitive to local collective concerns and networks 4950 we stress the need for giving stakeholders at the lower level a much bigger role in developing the content and implementation strategy of cse as they have better knowledge of the context networks and local support which they can use to negotiate or navigate micro level politics concluding remarks we conclude that the implementation of the cse curriculum in this setting was largely dependent on an individual teachers decisions on what how and when to teach this was related to lack of guidance lack of legitimacy of the curriculum and lack of local ownership of the agenda the big space left for teacher discretion in sexuality education resulted in arbitrary teaching of cse and great disparities within and between schools if the cse program is to be successfully integrated and taught there is a fundamental need to take local culture into account in terms of the curriculum content and teaching approaches and to secure local ownership of the curriculum the lack of such considerations can leave the learners at disadvantage in zambia there is rapidly increasing prevalence of early pregnancy which suggests limitations and failures in efforts aimed at addressing sexual and reproductive health challenges among adolescents to address this problem cse is needed but as this study has shown it requires repackaging of both the content and mode of delivery with the support of teachers and other stakeholders at district level authors contributions jmz kmm and ab contributed to the design of the study jmz collected the data and did the analysis and drafted the manuscript all the authors critically reviewed the manuscripts provided contributions and approved its final version competing interests the authors declare that they have no competing interests

background reproductive health problems such as hiv unwanted pregnancy and unsafe abortion among adolescents are closely linked to insufficient knowledge about sexuality and reproduction and lack of access to contraceptives supported by international agencies zambia has introduced an ambitious nationwide program for comprehensive sexuality education cse to be implemented into ordinary school activities by teachers the curriculum is firmly based in a discourse of sexual and reproductive rights not commonly found in the public debate on sexuality in zambia this paper explores how teachers perceive the curriculum and practice discretion when implementing the cse in midlevel schools in nyimba district in zambia methods using a case study design data were collected through indepth interviews with 18 teachers and analyzed thematically drawing upon theories of discretion and policy implementation results individual teachers make decisions on their own regarding what and when to teach cse this discretion implies holding back information from the learners teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether teachers choices about the cse program were linked to lack of guidance on teaching of the curriculum especially with regards to how to integrate sexuality education into existing subjects limited prioritization of cse in the educational sector was observed the incompatibility of cse with local norms and understandings about adolescent sexuality combined with teacherparent role dilemmas emerged as problematic in implementing the policy limited ownership of the new curriculum further undermined teachers motivation to actively include cse in daily teaching activities use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learnersthe cse had limited legitimacy in the community and was met with resistance from teachers tasked with its implementation in order to enhance ownership to the cse program local concerns about the contents of the curriculum and the parentteacher role dilemma must be taken into consideration not addressing these challenges may undermine the policys intention of increasing knowledge about sexuality and reproduction and empowering adolescents to access contraceptive services and avoid unwanted pregnancies

introduction dental caries is a dietrelated condition and is one of the most common oral diseases in china with almost half of the children and majority of the adults affected 1 despite the decline of dental caries in western countries in the past decades inequalities in oral health still exist in most of the countries 2 the highlevel of caries in china is mainly attributed to the increased consumption of sugars lack of dental services and socioeconomic factors particularly income and parental education 3 several studies found significant associations between lower socioeconomic position and higher risk of dental cavities 4 in china there were significant inequalities in the sum of decayed missing and filled teeth index by geographical location among 12yearold children 3 and in dmft index by income among 5yearold children 5 furthermore parental education was found to be inversely related to childrens caries experiences 6 parental education and income appear to affect childrens oral health through an impact on knowledge of oral health risk behaviors and attitudes towards prevention such as purchasing dental hygiene products toothbrushing habits frequency and patterns of health service utilization all linked to childrens oral health 7 furthermore parental level of education allows a better understanding of information that enables them to care for their children which may affect their childrens oral health 8 higher mother education and income may also affect childrens dietary habits which could lead to a positive impact on dental caries on the other hand the inequality in socioeconomic position might affect the dietary habits and nutritional intake of chinese children which could also affect childrens growth with the increase in income inequalities in china over the past 25 years it was argued that health inequalities in china are attributed to demographic and socioeconomic factors among which income occupation and education are the most important ones 9 yaos study indicated that there is an association between income inequality and bmi index 10 other studies also showed strong a socioeconomic gradient in stunting 11 and thinness 12 children from families with lower income are more likely to buy lowcost food and have a poor dietary intake thus decreasing essential nutrients intake such as protein and fat which increase the risk of being underweight and stunting 13 these apparent income inequalities indicate that a reduction in economic inequalities could reduce inequalities in undernutrition 14 given the common role of socioeconomic factors in both dental caries and undernutrition this longitudinal study set out to examine whether the same socioeconomic indicators are linked to changes in dental caries and childrens growth in the same population the objectives of this study are to examine socioeconomic inequalities in increment of dental caries and growth among preschool chinese children and to assess the strongest predictor of socioeconomic inequality for each of these conditions children whose parents agreed to participant were included at baseline and followup in this study the sample size calculation of 636 is based on a previous study among preschool children in hong kong 15 the number was increased to 1000 to account for dropouts materials and methods ethical approval was obtained for study population this is a longitudinal populationbased study and data was collected at two points in time the study recruited preschool children in the cities of shenyang liaoyang and fushun liaoning province china at baseline 15 kindergartens with 1111 participants were included in this study at followup the number of participants was 772 with a response rate of 70 at followup the participants who were lost at followup either left the kindergarten did not complete clinical examination or did not return a signed consent form mean ages of participants at baseline and followup were 5082 and 6055 months respectively median and mean followup times were 1012 and 973 months respectively data collection dental examination and anthropometric measurement were assessed at baseline and followup a structured questionnaire was used to collect information on demographic factors family income mothers education and childrens dietary habits the questionnaire was based on the who questionnaire 16 and modified following a chinese questionnaire used in national oral health surveys in this analysis baseline data from the questionnaire were in the analysis sex was coded as male and female and area was coded as urban and rural area income was collected using five options 03999 rmb 40005999 rmb 60009999 rmb 10000 rmb or above and undeclared income groups were based on the 4th chinese oral health survey 17 mothers education was grouped as primary and middle school high school and junior college bachelor or above and others the parents reported the intake frequency of five food or drinks of their children biscuitcakebread candychocolate fizzy drinks and fruit juice on 6point response scales weighted scores were calculated to reflect the frequency of consumption in each response category weighted scores of four snacks and drinks were then summed up to produce an overall score 3 which was used to reflect daily frequency of sugar intake frequency of fresh fruit consumption was calculated in the same manner and was used as a separate variable the survey team of oral examination included two persons a dentist and a recorder the dentist was trained on data collection using who standard criteria for assessing dental caries 16 eighty participants were reexamined in different days to calculate intraexaminer reliability agreement level was 072 indicating substantial agreement children with an urgent need for treatment were referred to a dentist the sum of decayed missing and filled teeth was used to examine the dental caries level of participants one health worker was responsible for assessing weight and height and was blinded to the dental condition of the participants height of the child was assessed with a weight and height scale to the nearest 05 cm similarly weights were assessed to the nearest 05 kg children wore light clothes and removed shoes before they stood on the scale ageand sexspecific percentile for weight and height was used to indicate body measurements of the children 18 the who growth standards for 2006 and 2007 were also used 1920 the who growth standards 2006 was utilized to convert weight and height measurements to weightforage and heightforage zscores among children aged 05 years old and who growth standards 2007 was used for children older than 5 years 1920 statistical analysis stata was used to analyze the data multilevel analysis was used to assess the association between baseline socioeconomic position and dental caries weight and height participants who had two clinical assessments were included in the analysis firstly the distributions of baseline demographic socioeconomic factors area and dietary habits were assessed then distributions of dmft index weightforage zscore and heightforage zscore at baseline and followup were assessed secondly multilevel analysis was used to explore the association between baseline socioeconomic position and changes in dental caries three models were constructed to assess the association between changes in dmft and each of income education and area accounting for time and sex the fully adjusted model included all socioeconomic indicators demographic factors and diet similar sets of multilevel models were constructed for each of change in height and weight results mean age of those lost at followup was 5115 months at baseline 5110 were boys mean dmft was 317 and means of actual weight and height were 1856 and 10626 respectively in these parameters differences between those who were lost at followup and those included in the analysis were minimal details of the study is published elsewhere 21 table 1 shows mean age at baseline and followup months the percentage of boys was 5142 and 6554 of children lived in the rural area only 14 of the participants were in the highest income group the highest percentage of mothers education was high school and junior college the mean dmft index was 318 at baseline and 421 at followup mean weight zscore was 058 at baseline and 066 at followup mean height zscore was 049 at baseline and 069 at followup table 2 shows results from the multilevel analysis for changes in dmft index area was positively and significantly associated with an increase in dmft 036 137 in the model adjusting for sex and age lower mother education was significantly associated with an increase in dmft score in the semiadjusted and fully adjusted models with coefficient 096 95 ci 018 174 and 086 95 ci 020 151 for the lowest and second lowest education groups only the highest income group was negatively and significantly associated with changes in dmft index in the semiadjusted model however the association was insignificant in the fully adjusted model table 3 shows results from the multilevel analysis for changes in weightforage zscore in the semiadjusted model higher income was associated with an increase in weightforage zscore after adjusting for all socioeconomic and dietary factors only the second lowest income group was significantly associated with weight table 4 shows the association between changes in heightforage zscore and socioeconomic factors the relationship between income and changes in heightforage zscore was positive and significant in the second highest income group in the semiadjusted model discussion in this study we assessed socioeconomic inequalities in both of childrens growth and dental caries in the same population of chinese preschool children the main findings showed that there was negative and significant association between income mothers education and changes in dental caries income rather than mothers education was positively and significantly associated with weight and height children from rural areas had a greater increase in dental caries a smaller increase in weight and height compared to those from urban areas the findings of the current analysis of dental caries inequalities among chinese children are consistent with studies from other countries dental caries is related to lower socioeconomic conditions such as parental education family income and area 22 untreated decayed teeth increase consistently as the family income decreases 23 which is consistent with the finding of this study the places where people live have also been reported as a factor that influence the association between health outcomes and related factors 24 education was considered as the most important indicator of socioeconomic inequalities in childrens caries 25 a finding consistent with this study in this study mothers education appeared to be a stronger predictor of childrens dental caries than family income or area this is probably because highly educated mothers are more likely to have better oral health knowledge and to provide better care for the children particularly related to behaviors such as diet oral hygiene and use of dental services furthermore mothers education is also linked to income which impacts on better living conditions and facilitates access to oral hygiene products better diet and preventive services 26 several studies demonstrated that the level of caries is associated with deprivation 27 mothers in lower socioeconomic positions are more likely to allow their children to consume unhealthy food such as sugary fatty and acidic food 2829 and to select food that optimizes quantity rather than nutritional quality compared to mothers in higher socioeconomic positions 3031 which may result in dental caries moreover children who belong to families at the bottom of the social hierarchy are more likely to have inadequate access to food food shortages and inadequate eating patterns these dietary patterns are likely to lead to an increased consumption of fermentable carbohydrate a risk factor for dental caries 3031 these dietary habits are implicated in the mechanism linking socioeconomic factors and dental caries 30 on the other hand children living in countries and communities with higher socioeconomic conditions are more likely to consume food with high calories snacks soft drinks and even fermentable carbohydrates 3233 this could also contribute to an increased risk of dental caries and weight gain in developed countries 34 socioeconomic inequalities in dental caries are not only attributed to different patterns of food and drinks consumption but also to other oral health behaviors such as toothbrushing habits 35 limited access to dental healthcare services poor oral hygiene and poor living conditions which could accelerate the development of decayed teeth 28 socioeconomic factors and material abilities are also strongly linked childrens growth 36 poorer families are more likely to experience poor dietary intake due to reduced access to healthy food containing less sugar and fat and rich in essential nutrients such as milk and protein 13 poor diet also impacts childrens abilities to concentrate sleep and attend schools which could also contribute to undernutrition 28 low income is also associated with poor sanitation and poor hygiene that lead to increased infections in children which detrimentally affect childrens development 37 in the current study there was consistent income inequality in weight gain than in height gain this was consistent with findings by wagstaff and watanabe 38 who concluded that inequalities in being underweight tend to be larger than inequalities in stunting 38 unlike in developed countries in china obesity and overweight are more common among those with a higher socioeconomic status factors such as overconsumption of food among children in higher socioeconomic families in developing countries leads to the risk of excessive weight gain 36 economic wealth and income inequalities also impact childhood development as they usually use private transportation rather than walking and engage in sedentary entertainment such as video games which influence their energy balance 39 sugar consumption is a leading risk factor for both caries and being overweight due to a higher energy intake 40 however in this study sugar consumption was significantly associated with dental caries but not with childrens growth the lack of significant association between sugar consumption and anthropometric measures observed in this study could be because sugar is not the sole determinant of childrens growth the nutritional transition in china has been linked to an increase in consumption of animal proteins 41 this increase of energy intake is considered as a key determinant of childrens growth 42 the strength of this study is in using longitudinal data to assess socioeconomic inequalities in both dental caries and childrens growth in the same population of preschool children in china there are some limitations worth mentioning approximately 30 of the participants were lost at followup mainly because the children were recruited from kindergartens and they could have moved from kindergartens as their parents changed jobs furthermore those who left the study were to a great extent similar to those included in the analysis in terms of clinical outcomes and sociodemographic characteristics secondly a longer time interval between the two assessments could have affected the findings this however was not possible given the short period children spend in the kindergarten thirdly only children who attended selected kindergartens were included in this study these children are usually from families with higher income who can afford kindergarten fees it is possible that if the study was conducted among the general population greater inequalities could have been observed conclusions the study demonstrated socioeconomic inequalities in changes in both dental caries and growth among preschool chinese children while mothers education appeared to be the strongest predictor of dental caries income was the only factor significantly associated with weight and height gain author contributions as ws conceived the research idea eb advised on the study design as conducted the analysis and wrote the first draft eb and ws advised on the statistical analysis and contributed to writing the manuscript all authors have read and agreed to the published version of the manuscript

background this study aimed at assessing socioeconomic inequalities in the increment of dental caries and growth among preschool chinese children and to assess the best predictor of socioeconomic inequality for each of these conditions methods this is a longitudinal populationbased study the sample data included preschool children living in three cities of the liaoning province china at baseline 15 kindergartens with 1111 participants were included and dropped to 772 with a response rate of 70 at followup mean ages at baseline and followup were 5082 and 6055 months respectively median followup time was 1012 months data were collected through structured questionnaire oral examination and anthropometric measurement the questionnaire collected information on sex age family income mothers education and childrens dietary habits the numbers of decayed missing and filled teeth dmft was used to indicate dental caries weightand heightforage zscores were calculated using the who growth standard multilevel analysis was used to assess the association between baseline socioeconomic position and each of dental caries and childs growth results mothers education was negatively associated with increments of dmft family income was not significantly associated with dmft in the fully adjusted model the association persisted after accounting for other socioeconomic and dietary factors higher income was positively related to an increase in the weightforage zscore the relationship between income and changes in the heightforage zscore was positive and significant in the second highest income group conclusions mothers education appeared to be the strongest predictor of increments of dental caries only income was significantly associated with an increase in childrens weight and height

introduction disability is a general term used to denote impairments activity limitations and an individuals restriction in participating in various activities which are the result of the interaction between human physical characteristics and the society in which adults with disabilities live 1 referring to the international classification of functioning disability and health disability mainly consists of functional impairments activity limitations and participation restriction the data released by the world health survey estimated that more than 1 billion people worldwide suffer from various disabilities accounting for 15 of the worlds population 2 as a developing country china has the largest disabled population in the world it was estimated by the china disabled persons federation that the number of disabled people had reached 8502 million in 2010 implying that 62 of the total population are suffering from various disabilities and this proportion is gradually increasing individuals with functional limitations and physical impairments are usually disadvantaged in their participation in society which is contradictory to fundamental human rights and affects their health and wellbeing 3 4 5 6 compared to the nondisabled population people with disabilities are at a higher risk for mental health issues due to the many challenges caused by poor health lower education levels employment difficulties lower income levels higher incidences of poverty and limited social participation 78 previous studies have found that people with disabilities suffer from more serious anxiety and depression owing to physiological diseases and nearly all disabled people have varying psychological problems for instance the quality of life of disabled people is significantly lower than that of healthy people 9 and they are more likely to experience symptoms of anxiety and depression 1011 which lead to the deterioration of their overall mental health status more importantly in the context of accelerating global population aging the number of disabled people in the older population will also rise which will limit their social participation and thus worsen their mental health level the data showed that nearly one out of every five older adults with adl disability is associated with depression in the united states and that the prevalence of depression among the elderly with disabilities reached 20 12 depression is more common among older people in republic of korea nearly 2070 of older people were affected by varying degrees of depression 13 the depression seen amongst disabled people in china is also not encouraging the detection rate of depression was 1740 in 2021 and this rate was even higher among middleaged and elderly adults with disabilities reaching 545 14 numerous studies have confirmed that depression was associated with increasing medical costs 15 mortality 16 a lower quality of life and lower levels of wellbeing 1718 how to encourage middleaged and older adults with disabilities to actively participate in social activities and improve their mental health status has become a significant issue that the chinese government has to address fortunately the development of the information society provides a convenient opportunity for individuals with disabilities to communicate and participate in social activities the basic manifestation of which is the popularity and widespread use of the internet according to the data issued by the china internet network information center the total number of internet users in china increased to 1032 billion in 2021 and the internet penetration rate reached 730 among older adults more than 119 million utilize the internet with an internet penetration rate of 432 middleaged and elderly people can receive massive amounts of information communicate instantly and use a variety of convenient services without leaving their home via the use of the internet internet technology is reshaping the form by which people with disabilities can participate in social activities and has excellent health spillover effects previous studies have showed that internet use has a positive impact on depression mental health social participation and the subjective wellbeing of the elderly 19 20 21 22 white mentioned that the use of the internet can improve the elderlys participation in online leisure activities and social activities and this is beneficial to reducing loneliness and depression 23 thereby improving their life satisfaction and subjective wellbeing 2425 cotten et al found that internet use was positively related to the mental health of retired adults which could reduce the risk of depression of retired elderly people by 2028 26 against this background some scholars began to focus on the impact of internet use on the mental health of disabled adults but existing studies have not reached a consensus on the health spillover effects of internet use most studies suggested that internet use can significantly reduce the risk of depression among older people with disabilities using a randomized controlled trial cotten et al found that internet use could significantly reduce the risk of depression symptoms among elderly disabled people 27 duplaga and szulc 28 held that internet use could decrease the loneliness experienced by individuals with disabilities by 40 birnie and horvath 29 found that those who were not active in the physical world may utilize the internet more frequently and benefit from it for those people with disabilities online communication may be regarded as a compensation for the lack of social interaction lee and cho 30 found that frequent internet use could significantly reduce the depression levels of disabled people and the use of social media could help them establish social support networks and healthy psychological tendencies a few scholars however have drawn different conclusions believing that there is a huge digital divide for disabled people the proportion of disabled people using the internet is significantly lower than that of the general population 203132 and internet use was found to be positively associated with depression levels loneliness and stress 33 overall the existing literature has some shortcomings first of all many scholars have discussed the effect of internet use on the mental health of the elderly in highincome countries but more empirical evidence is needed from middleand lowincome countries moreover although a few studies concentrated on the impact of internet use on the mental health and depression levels of disabled people they ignored that the different purposes of internet use may have different effects on depression risk and this has not been addressed in any previous studies third the digital divide caused by disabilities varies significantly with the types of disabilities so internet use may have different impacts on the risk of depression among older adults with different types of disabilities however few works in the literature have explored the possible differential effects of internet use on different types of disabilities finally there is a digital gap between urban and rural areas and the internet penetration rate in rural areas is only 576 far below the average of 730 which may have different impacts on the mental health of people with disabilities this article aims to respond to the above questions and the possible contributions are as follows first we used the nationally representative china health and retirement longitudinal survey to measure the internet use of middleaged and elderly people with disabilities from three aspectsinternet use frequency of internet use and social activities related to internet useand further systematically explored the association between internet use and the risk of depression among them in the information society we aimed to provide instant and verified evidence to allow the government to actively address the problem of ageing brought about by disability and disability caused by ageing in addition we classified the disabled people based on the types of their disabilities and analyzed the impact of internet use on people with different types of disabilities so as to provide evidence regarding maximizing the positive spillover effects of internet use on health finally we analyzed the possible age and urbanrural differences materials and methods data source the data used in our study were obtained from the 2018 china health and retirement longitudinal study charls is a national and continuous largescale social survey project conducted by the chinese social science research centre at peking university which aims to collect demographic internet access health status and other information from middleaged chinese people the database consisted of 7 modules including demographic information family cognition and depression healthcare insurance work retirement pension household income expenditures and house property according to the research purpose this study mainly used the demographic information cognition and depression and healthcare insurance modules of the 2018 charls to analyze the impact of internet use on depression risk among middleaged and older adults with disabilities we cleaned the data as follows firstly we matched all modules and removed the duplicate samples to obtain a sample size of 19816 secondly we only kept the samples with disabilities to obtain a sample size of 5329 finally after removing the samples with extreme values of household income and missing values of all controlled variables a final sample size of 5220 was used to analyze the association between internet use and depression risk in middle aged and older adults with disabilities figure 1 presents the process of sample selection variables dependent variables we used depression to represent the mental health level of middleaged and older adults with disabilities depression has been proven to be the most vital predicting indicator of mental health residents with depressive symptoms are more likely to suffer from serious psychological problems 34 in our study we adopted the 10item center for epidemiologic studies depression scale to assess the depression status of individuals the cesd10 included 10 questions and each question inquired as to the respondents mood during the previous week each respondent was asked to answer each question with one of four options after positive emotional responses were reversescored we finally obtained a summed score of 030 referring to previous studies the cutoff point of cesd10 was 10 and the respondents whose score exceeded 10 were deemed to be more likely to suffer from depression 35 therefore we generated a dummy variable of depression and when a respondents score exceeded 10 we assigned a value of 1 and 0 was valued when the score was less than 10 in this study the cronbachs alpha for cesd10 scale was 0802 which demonstrated sufficient reliability and validity in cesd10 table 1 shows that nearly half of the middleaged and older adults with disabilities had depressive symptoms independent variables according to the design of the 2018 charls questionnaire we selected three indicators internet use the frequency of internet use and social activities related to internet to measure the internet use status of middleaged and elderly adults with disabilities first we selected the question did you use the internet in the last month to measure the internet use of individuals and we assigned a value of 1 if the respondents answered yes otherwise the value was 0 we selected the question how often in the last month did you use the internet almost daily almost every week not regularly or never to measure the respondents internet use frequency we gave a value of 0 1 2 or 3 if the respondent chosen never not regularly almost every week or almost daily respectively finally we selected the question what do you usually do on the internet to measure social activities related to internet use there were four options for the response to this question in the questionnaire chatting watching variables dependent variables we used depression to represent the mental health level of middleaged and older adults with disabilities depression has been proven to be the most vital predicting indicator of mental health residents with depressive symptoms are more likely to suffer from serious psychological problems 34 in our study we adopted the 10item center for epidemiologic studies depression scale to assess the depression status of individuals the cesd10 included 10 questions and each question inquired as to the respondents mood during the previous week each respondent was asked to answer each question with one of four options after positive emotional responses were reversescored we finally obtained a summed score of 030 referring to previous studies the cutoff point of cesd10 was 10 and the respondents whose score exceeded 10 were deemed to be more likely to suffer from depression 35 therefore we generated a dummy variable of depression and when a respondents score exceeded 10 we assigned a value of 1 and 0 was valued when the score was less than 10 in this study the cronbachs alpha for cesd10 scale was 0802 which demonstrated sufficient reliability and validity in cesd10 table 1 shows that nearly half of the middleaged and older adults with disabilities had depressive symptoms independent variables according to the design of the 2018 charls questionnaire we selected three indicators internet use the frequency of internet use and social activities related to internet to measure the internet use status of middleaged and elderly adults with disabilities first we selected the question did you use the internet in the last month to measure the internet use of individuals and we assigned a value of 1 if the respondents answered yes otherwise the value was 0 we selected the question how often in the last month did you use the internet almost daily almost every week not regularly or never to measure the respondents internet use frequency we gave a value of 0 1 2 or 3 if the respondent chosen never not regularly almost every week or almost daily respectively finally we selected the question what do you usually do on the internet to measure social activities related to internet use there were four options for the response to this question in the questionnaire chatting watching news watching videos and playing games the specific definitions are presented in table 1 controlled variables to reduce potential estimation deviation caused by omitted variables four types of variables were controlled demographic characteristics variables including age gender marital status residence and ethnicity variables related to health including number of chronic diseases selfrated health smoking and drinking and socioeconomic variables including education condition household income pensions health insurance and work status considering that the differences in internet use in different provinces may have an impact on depression levels we controlled the provinces in which the middleaged and older people were located the definitions and descriptive results were presented in table 1 models because the dependent variable depression status is a dichotomous variable with values of 0 to 1 the logit model was used to estimate the impact of internet use on the depression risk of middleaged and older adults with disabilities the basic model was set as p log p 1 p β 0 β 1 internet i k ∑ i1 β k x ik ε i p represents the probability of experiencing depression risk among middle aged and elderly adults with disabilities β 0 is the intercept term internet i represents the internet use level of the i th individual β 1 is the correlation coefficient of the impact of internet use on the depression risk of middleaged and elderly adults with disabilities ∑ k i1 β k x ik represents a series of control variables and ε is a random error term results descriptive results table 2 shows the results of the chisquare test for depression symptoms and internet use among middleaged and older adults with disabilities as shown in table 2 there were significant differences between the symptoms of depression of disabled adults who used the internet and those who did not utilize the internet regression results the association between internet use and depression risk among middleaged and older adults with disabilities we used the maximum likelihood method to estimate the association between internet use and depression status among individuals with disabilities column of table 3 showed that internet use was negatively associated with depression in people with disabilities when we did not include any control variables column indicated that the marginal effect decreased to 0055 after controlling for other confounding variables columns and of table 3 reported the relationship between the frequency of internet use and depression in disabled adults the results suggested that compared to disabled people who never used internet those who used the internet almost daily had a lower depression risk which was consistent with the results of columns and among the controlled variables increasing age male gender individuals married with a spouse drinking wine higher education levels better selfrated health and higher household incomes were negatively associated with depression risk in contrast living in rural areas and having chronic diseases were positively associated with depression risk among disabled adults robustness test we used the substitute variable method to check the robustness of the regression results referring to the 2018 charls questionnaire design we selected the questions does your residence have a broadband internet connection and do you use wechat as substitute variables for internet use table 4 reports the regression results for the impact of having a broadband internet connection and wechat use on depression risk the results in column showed that disabled people who had access to broadband internet in their residence had a lower probability of depression risks column in table 4 suggested that using wechat was negatively associated with depression symptoms relative to those who did not use wechat the results in table 4 are consistent with those in table 3 in order to effectively reduce the potential selective bias between internet use and depression risk the psm method was used to estimate the association between internet use and depression risk the results of table 5 show that the att coefficients for knearest neighbor matching and kernel matching were 00838 and 00574 respectively which means that internet use was negatively associated with depression risk the att coefficients were consistent with the regression coefficient shown in table 3 which indicates that internet use could significantly decrease the probability of depression risk after overcoming the potential selective deviation the association between social activities related to internet use and depression risk among adults with disabilities columns of table 6 report the association between social activities related to internet use and depression risk among middleaged and older adults with disabilities the results showed that watching videos reading the news and chatting via the internet were found to be negatively associated with depression risk however playing games via the internet had no significant impact on depression risk due to space limitations the regression results of the controlled variables were not reported the association between internet use and depression risk among people with different types of disabilities table 7 reports the association between internet use and depression risk among people with different types of disabilities the results suggest that internet use had different effects on depression risk among people with different types of disabilities internet use had a greater impact on the risk of depression in adults with physical disabilities conversely in terms of hearingrelated visionrelated and other types of disabilities internet use had no impact on depression risk table 7 the association between internet use and depression risk for different types of disabilities due to space limitations the regression results of the controlled variables were not reported heterogeneous analysis columns and of table 8 report the age differences regarding the impact of internet use on the depression risk of disabled adults the regression results showed that internet use had a greater effect on elderly people with disabilities than on nonelderly people columns and of table 8 report the regional differences in the impact of internet use on depression risk the results suggest that internet use could significantly decrease the probability of depression risk among urban adults with disabilities by 81 but it had no impact on the rural group discussion previous studies have mainly explored the impact of internet use on the health of the elderly almost no studies have analyzed the potential association between internet use and depression risk among people with disabilities 2636 this study analyzed in detail the association between internet use and depression risk among chinese middleaged and elderly adults with disabilities by using the 2018 charls data we found the following internet use was negatively associated with depression risk and the higher the frequency of internet use the lower the probability of the depression risk different social activities related to internet use had different impacts on the depression risk the decline in depression risk was mainly related to watching videos watching the news and chatting via the internet but playing video games had no impact internet use was found to significantly reduce the risk of depression among middleaged and elderly adults with physical disabilities but had no impact on those with hearingrelated visionrelated and other types of disabilities the association between internet use and depression risk was mainly reflected in older adults with disabilities and those living in urban areas but had no impact on middleaged and rural disabled residents disability is an increasingly serious public health problem throughout the world especially for elderly adults 37 individuals with functional limitations or physical impairments are usually at a disadvantage regarding their health and subjective wellbeing 910 the advance of the information society has provided a chance for disabled people to participate more in social life the internet integrates multiple functional advantages such as humancomputer communication information sharing and leisure entertainment 38 people with disabilities can take part in social communication carry out information searches and enjoy leisure entertainment online through the internet which can reduce their risk of loneliness and depression 272930 a study from poland showed that internet use could reduce the loneliness of disabled people by 40 28 and cotten et al 39 drew a similar conclusion conversely some studies report that internet use has a negative impact on the mental health of disabled people in the information society and a significant positive correlation was found between internet use and depression loneliness and stress 3133 our study supports the first view we found that internet use could significantly reduce the risk of depression for middleaged and elderly people with disabilities and the higher the frequency of internet use the greater the reduction in depression risk a possible reason for this may be that through the internet people with disabilities can use social media to keep in touch with their relatives and friends enjoy leisure and entertainment search for health information and improve their health awareness and health literacy all of which can help them improve their overall health status 3840 for example some scholars found that during the prevention and control of the covid19 pandemic elderly patients with poor health received timely and effective treatment through online consultations moreover they also learned relevant knowledge regarding disease prevention through the internet and they decreased their depression risk through online leisure and entertainment during quarantine 41 in addition we found that the association between internet use and the risk of depression was constrained by different social activities related to internet use online chatting was found to help people overcome time and space barriers maintain a stable interpersonal network and obtain emotional support thereby alleviating their sense of helplessness and loneliness 42 watching the news and videos was found to not only help increase their leisure and entertainment activities but also helped them obtain healthrelated medical information which is helpful in improving their health level 38 one study found that the covid19 pandemic further increased the internet penetration rate and a large number of middleaged and elderly people acquired knowledge about infectious diseases and improved their health literacy through their use of the internet 41 however playing games was found to have a limited effect on reducing their depression risk because this would occupy the time that people should have spent on exercise or social participation some studies found that the frequency of playing games online was negatively correlated with ones level of happiness 28 compared with healthy people people with disabilities were more likely to indulge in the entertainment functions of the internet 43 which is also related to certain unhealthy behaviors and can decrease the positive spillover effects of internet use relating to health we also found that internet use had different effects on the depression risk in relation to different types of disabilities internet use had the greatest effect on reducing the depression risk of people with physical disabilities but had no effect on the those with hearingrelated visionrelated and other types of disabilities a possible reason for this may be that people with hearingrelated visionrelated and other disabilities experience a stronger digital divide and they may be unable to effectively communicate and participate in social life through the internet thus internet use has no impact on their depression levels in contrast people with physical disabilities are merely limited in their daily activities their disabilities do not affect their use of the internet moreover a relatively higher education level is conducive to building online interactions searching for information and enjoying the leisure and entertainment functions of the internet which can significantly reduce the risk of depression previous studies have shown that disabled people have strong heterogeneity and the digital divide varies based on the type of the disability 3144 our findings further confirm that the impact of internet use on the health of people with disabilities is affected by different types of disabilities finally we found that there were significant age differences and urbanrural differences regarding the association between internet use and depression internet use mainly reduced the risk of depression among older adults and people living in urban areas which is consistent with the findings of previous studies 36 the internet penetration rate in urban areas was found to be significantly higher than in rural areas so people with disabilities in urban areas have more convenient access to internet services as a consequence these groups are more likely to use the internet for social interaction learning participation in social activities and other activities contributing to a higher positive impact of internet use on their depression level 41 macro data also confirm this difference at present the internet penetration rate in rural china is only 576 far lower than the average rate of 730 therefore strengthening the internet infrastructure improving the penetration rate of the internet in rural areas and achieving the positive spillover effect of internet use on individuals health should be a core strategy of the chinese government conclusions in conclusion our study suggests that internet use can significantly reduce the risk of depression and the reduction effect in depression risk is significantly related to the frequency of internet use however the association between the internet use and depression risk of disabled people was affected by different social activities related to internet use and the type of disabilities watching videos chatting and watching the news via the internet was found to decrease the depression risk among disabled people moreover internet use mainly affected those with physical disabilities and it was found to have no impact on people with other types of disabilities finally we found that there were age differences and urbanrural differences in the association between internet use and depression risk internet use had a greater impact on the elderly and those who lived in urban areas this study had several limitations first of all the sectional data of 2018 charls were used to analyze the association between internet use and depression risk among middleaged and older adults with disabilities so this study essentially intended to elucidate a correlation relationship although we used the psm method to overcome the possible selective bias to some extent we did not address the endogenous problem caused by missing variables and reverse causality thus we failed to obtain a causal relationship moreover we used the frequency and social activities close to the internet to measure internet use among middleaged and elderly people with disabilities unfortunately we lacked indicators such as the duration of internet use which reflect the intensity of an individuals internet use and which may also have an impact on their depression level finally we explored the association between internet use and depression risk in people with different types of disabilities but disability severity was not fully considered it is clear that the impact of internet use on depression is affected by disability severity unfortunately we failed to take this indicator into consideration due to data limitations and we will continue to conduct related studies once the data are available data availability statement the datasets generated for this study are available on request to the corresponding author author contributions conceptualization xz and lz methodology xz and al software xz validation nc htak and bg formal analysis xz and al investigation bg and nc data curation xz writingoriginal draft preparation xz writingreview and editing htak and lz supervision htak and lz funding acquisition lz all authors have read and agreed to the published version of the manuscript

background globally nearly 15 of people suffer from various kinds of disabilities and china has the largest disabled population in the world the poor mental health status of people with disabilities has become an essential issue in most countries the main aim of this study was to explore the potential impact of internet use on depression risk among middleaged and older adults with different types of disabilities methods the data used in this study were obtained from the 2018 china health and retirement longitudinal study charls collected by peking university a binary logit model was used to analyze the impact of internet use on the depression risk among adults with disabilities and the substitute variable method and the propensity score matching method were used to examine the robustness of the results results 1 internet use was negatively associated with depression risk among disabled people and the higher the frequency of their internet use the lower the probability of their depression risk 2 different social activities related to the internet had different impacts on the depression risk and the decline in depression risk was mainly related to watching videos watching news and chatting via the internet 3 internet use reduced the depression risk of adults with physical disabilities but had no impact on those with other types of disabilities conclusions our study suggests that internet use may have a positive spillover effect on decreasing the depression risk of disabled people but the reduction effect is significantly affected by the social activities related to the internet and the types of disabilities

open access abstract outcome measures both absolute and relative measures were calculated first agestandardised mortality rates have been calculated directly standardised to the belgian population second mortality rate ratios were calculated using poissons regression adjusted for education housing conditions attained age region and migrant background results this study highlights inequalities in sitespecific cancer mortality both related to being employed or not and to the occupational group of the employed population unemployed men and women show consistently higher overall and sitespecific cancer mortality compared with the employed group also within the employed group inequalities are observed by occupational group generally manual workers and service and sales workers have higher sitespecific cancer mortality rates compared with whitecollar workers and agricultural and fishery workers these inequalities are manifest for almost all preventable cancer sites especially those cancer sites related to alcohol and smoking such as cancers of the lung oesophagus and head and neck overall occupational inequalities were less pronounced among women compared with men conclusions important se inequalities in sitespecific cancer mortality were observed by employment and occupational group ensuring financial security for the unemployed is a key issue in this regard future studies could also take a look at other working regimes for instance temporary employment or parttime employment and their relation to health introduction in industrialised countries life expectancy increased during the epidemiological transition with the most important causes of death shifting from infectious to chronic diseases such as cancer 1 this favourable longevity trend went together with an increase in socioeconomic health inequalities in general 2 3 and with cancer inequalities in particular 4 according to the fundamental cause theory inequalities result from the differential distribution of valuable resources that can be used to avoid adverse health outcomes 2 this implies that se inequalities in health will be larger for cancers that are more preventable either by avoiding risk behaviour or by access to medical interventions 3 5 than for less or nonpreventable cancers se inequalities in health are one of the most important challenges for public health policies therefore it is crucial to thoroughly document these inequalities up till now most sitespecific cancer mortality inequalities by employment and occupational groups a cohort study among belgian adults 20012011 studies assessing health inequalities have used only one indicator of socioeconomic position most often educational attainment or material wealth however detailed research on occupational inequalities in sitespecific cancer mortality is scarce 6 7 and even nonexistent in belgium yet many studies have shown that although these sep indicators are strongly related they may represent different aspects of sep 8 9 10 therefore it is important to establish the role of every single dimension of sep for every cancer site separately 9 11 12 hence this paper probes into se differences in sitespecific cancer mortality using employment and occupational group as measures of sep accounting for the other sep indicators by doing so we aim to estimate the net association between employment and occupational group and sitespecific cancer mortality in belgium which has not yet been studied our first research aim is to examine the magnitude of the association between sitespecific cancer mortality and employment group net of ones educational attainment and housing conditions the second research aim is to assess whether among the employed group occupational group is associated with sitespecific cancer mortality again net of education and housing conditions based on the fct we assume that we will observe inequalities by employment and occupational status especially for the more preventable cancer sites data and methods design and study population data are derived from a record linkage between the belgian censuses of 1991 and 2001 and register data on emigration and causespecific mortality for the followup period 01102001 to 31122011 this unique populationbased dataset includes information on mortality emigration cod sociodemographic and se variables of the total de jure population of belgium all sd and se variables are extracted from the 2001 census apart from occupational status for which the 1991 census contains the most recent detailed information all belgian individuals who are alive at the 2001 census and who were within the economically active age range at the census of 1991 are included in the study for these individuals we linked information on employment and occupational status stemming from the 1991 census irrespective of their employment status at the 2001 census the study population includes 2 333 479 belgian women of whom 49 are employed and 2 231 385 belgian men of whom 80 are employed age is included as a timevarying covariate to account for age changes during the 11year followup period to do so individual followup time is split into episodes of 5 years attained age groups using lexis expansions 13 consequently the age distribution of this population ranges from 35 to 85 years variables all cancer sites representing at least 1 of the total cancer mortality are included table 1 gives an overview of these cancer sites the corresponding icd10 codes and the level of preventability to classify the cancers by level of preventability we apply the criteria used in mackenbachs study 14 amenability to behavioural change and to medical interventions cancer sites are amenable to behavioural change if the combined population attributable fraction of mortality for overweight and obesity low fruit and vegetable intake physical inactivity unsafe sex smoking and alcohol consumption was larger than 50 for the european population in the global burden of disease and risk factors study 15 cancer sites are considered as amenable to medical interventions if the 5year relative survival rate for belgian women and men in the eurocare project was higher than 70 between 2000 and 2007 16 andor if effective screening is available in belgium 17 this study probes into cancer mortality inequality among the belgian population within the economically active age range by using employment and occupational group as a measure of sep both employment and occupational status are derived from the 1991 census and mortality is followed up for the period 20012011 employment status is divided in four categories employed unemployed and looking for a job unemployed and not looking for a job and disabled among the employed we additionally defined their occupational group based on the international standard classification of occupations 18 managers and professionals intermediate whitecollar workers service and sales workers agricultural and fishery workers skilled manual workers and unskilled manual workers we choose the employed as a reference category and among the employed the managers and professionals these choices have been made because of the size of these groups and because we assume lower cancer mortality for these groups which facilitates the interpretation open access statistical analyses to obtain a full picture of inequalities in cancer mortality we calculate both absolute and relative measures 19 using completecase analysis first directly agestandardised sitespecific mortality rates by employment and occupational group are calculated using the belgian population at the 2001 census as standard population second mortality rate ratios are calculated using poissons regression we aim to assess the net effect of employment and occupational group on cancer mortality therefore the poissons models are adjusted for educational attainment and housing conditions educational attainment is categorised using the international standard classification of education lower secondary education or less higher secondary education and tertiary education housing conditions is the result of a combination of ownership and comfort of the house resulting in six categories 20 sensitivity analyses are additionally conducted without adjustment for education and housing conditions these results are not shown but are available in online supplementary table 1 and 2 important differences between the crude and net model are mentioned in the discussion section as there is a strong association in belgium between mortality and region 21 as well as migration history 22 all poissons models are adjusted for region and migrant background all analyses are stratified by sex and are performed using stata 131 results description of the study population the study population consists of almost 5 million belgians within the economically active age range almost four out of five men are employed whereas in women about one in two has a paid job absolute cancer mortality rates by employment and occupational status for almost all preventable cancer sites men belonging to the employed category have systematically the lowest cancer mortality rates among the employed men whitecollar workers and agricultural and fishery workers have lower cancer mortality rates compared with manual workers these results hold true for all preventable cancer sites except for prostate cancer and malignant melanoma for which no inequality is observed for the nonpreventable cancer sites less inequalities are observed as expected based on the fct for the nonpreventable cancer sites inequalities generally represent differences between employed versus unemployed for women the absolute inequalities are less pronounced generally mortality from preventable cancer sites is largest for women who are unemployed among the employed women there are no inequalities except for lung cancer mortality which is somewhat more elevated for service and sales workers and manual workers compared with female managers on the other hand service and sales workers in this paragraph we present the results of the net relative models adjusted for education and housing conditions unemployed men and women have higher sitespecific cancer mortality rates compared with employed people this holds true for preventable and nonpreventable cancers and are especially observed among the unemployed who are not looking for a job to illustrate this with an example unemployed men who are not looking for a job have a three times higher chance of dying from bladder cancer compared with employed men for most cancer sites particularly unemployed men and women who are either not looking for a job or disabled have consistently higher cancer mortality rates compared with employed men and women within the employed population inequalities by occupation are also observed although more in men than in women in men managers appear to have higher colorectal and liver cancer mortality rates compared with men in other occupations furthermore lower mortality rates in favour of manual workers are observed for several nonpreventable cancer sites among others cancer of the pancreas and kidney compared with male managers skilled manual workers have a 7 higher lung cancer mortality rate another interesting observation is the mortality pattern of the agricultural and fishery workers compared with managers they tend to die less from preventable cancers such as head and neck and oesophageal cancers their liver cancer mortality rate is even 76 lower compared with managers in contrast agricultural and fishery workers show higher mortality from some nonpreventable cancer sites such as leukaemia and multiple myeloma female manual workers and service and sales workers have about 25 lower breast cancer mortality rates compared with female managers open access discussion and conclusion methodological issues the findings are based on a highquality and exhaustive dataset including the total belgian population within the economically active age range a numeratordenominator bias was eliminated through record linkage between census and register data this dataset provides very rich information on sd as well as se variables and mortality for a followup period of 11 years this enables us to give precise estimates of sitespecific cancer mortality inequalities at the individual level however these register data do not contain information on incidence or survival nor on health behaviours healthcare use or important aspects of the job which are all likely to be associated with cancer outcomes 23 therefore it is difficult to make solid conclusions on the relative importance of all these factors to explain the observed se inequalities in cancer mortality 23 24 we included the total belgian population that belonged to the economically active age group at the reference category is managers and professionals all analyses are adjusted for current age region migrant background educational attainment and housing conditions table 6 continued census of 1991 independently of their actual occupational status we decided so because we were interested in the association between cancer mortality and both employment and occupational group by doing so we avoided a selection effect due to including only the healthy workers 6 2528 our results indicate the importance of this issue showing highest cancer mortality among the unemployed groups nevertheless we cannot fully exclude a selection effect among the employed population because we can assume that unhealthy persons are less frequently employed in physically demanding jobs 26 27 a healthy worker effect might then be more likely in the groups of manual workers which could partly explain some of the observed mortality patterns in favour of manual workers on the other hand the whitecollar workers may have less physically demanding jobs which can counter this effect occupational information was derived from the census of 1991 which is the most recent source of detailed information since the census of 2001 does not contain detailed occupational information because of the lag time between some exposures and cancer mortality we do not consider this as a problem 29 due to the crosssectional nature of this information the occupation is not necessarily the longest job respondents were involved in nor do we have information on the duration of this occupation 25 however occupation was grouped into broad groups which leads us to assume that the bias due to transitions between occupational categories will be rather small 30 we decided not to use the robust distinction between manual versus nonmanual workers nor did we focus on one specific cancer site in relation to one or more job exposures these choices have been made in order to gain insights into the overall association between occupational status and cancer mortality 26 many studies assessing se inequalities in cancer mortality use only one se indicator at a time although the importance of including multiple indicators has already been pointed out 9 11 12 because different sep indicators tap into different pathways 8 9 10 housing conditions are related to material and financial resources and therefore to healthcare utilisation 31 education captures the human capital acquired early in life and may be related to the ability to adapt health education messages and hence to health behaviours 6 occupational status on the other hand reflects the ability to realise this human capital in the labour market and is rather a reflection of ones social class at older ages employment as well as occupation is likely to capture material resources access to healthcare as well as social networks and workrelated factors such as stress autonomy and occupational hazards hence we need to analyse all aspects of sep in relation to health outcomes although these indicators are closely related 6 in this paper we focus on the net effect of occupational status thereby adjusting for educational attainment and housing conditions the results indicate an association between occupational status and sitespecific cancer mortality independently of education and housing conditions open access finally we classified the cancer sites by their level of preventability we acknowledge that this classification does not exclude the fact that some nonpreventable cancers are also related to behavioural change andor medical interventions nor does it eliminate some possible overlap between these two criteria of preventability however to enhance the comparability with other studies we decided to adopt this oftenused classification theoretical considerations on the main findings this study reveals inequalities in sitespecific cancer mortality by employment and occupational groups generally se inequalities are less pronounced in women compared with men which is consistent with the literature 7 23 28 the unemployed group shows both for men and women higher cancer mortality rates compared with the employed which is in line with previous studies in france and the uk 23 32 possible explanations are financial insecurity which is related to a lower use of healthcare services and an unhealthy lifestyle 32 some studies suggest that part of this association between unemployment and health might be due to health selection 23 although others observed an ongoing effect after adjustment for preexisting morbidity 32 however it is very likely that for the unemployed that are not looking for a job as well as for the disabled group health selection will be at play also within the employed group inequalities by occupational group are observed in men these findings are in line with the fct which expects larger inequalities for more preventable cancer sites 3 5 the absolute results show that male manual workers have the highest sitespecific cancer mortality rates whereas whitecollar workers and agricultural and fishery workers have the lowest cancer mortality rates this discrepancy between manual and nonmanual workers is in line with previous findings in europe 6 33 these absolute inequalities are manifest for all preventable cancer sites with alcoholrelated and smokingrelated cancers being the main contributors to these inequalities as reported in previous studies 25 28 30 33 34 the excess mortality for cancers of the head and neck and lung are also observed for male service and sales workers which can be explained by the higher likelihood of occupational exposure to tobacco and alcohol in bars and restaurants 27 another interesting finding is the favourable cancer mortality pattern for farmers which might be related to their healthy life style with less tobacco and alcohol use and more physical activity 35 36 according to the fct the availability of valuable resources such as knowledge money power prestige and beneficial social connections are the social causes of health inequalities 2 when there is sound knowledge of the causes and cures of cancers those in high sep contexts with greater access to resources will disproportionally benefit from this knowledge several mechanisms have been suggested to explain this association such as a differential acquisition of knowledge on healthdamaging behaviours 6 7 10 23 26 37 also material factors are important having financial difficulties might be related to poor living conditions 7 23 30 or the inability to optimise the use of health services 10 33 37 both access to and quality of healthcare are crucial for health outcomes in all stages from prevention to treatment finally the social aspect of sep is associated with health for example stressrelated factors or the level of social prestige 25 since we cannot adjust for health behaviours or healthcare use it remains difficult to decide on the extent of inequalities due to each of these mechanisms 26 yet our findings showed that the inequalities were especially large for the preventable cancer sites related to health behaviours such as smoking and alcohol use previous studies indeed reported higher smoking prevalence among manual workers and people working in the catering industry 38 however studies mediating the observed gradients for smoking reported an attenuated but still significant relation between sep and mortality 7 24 30 which assumes that there might be other factors at play as well sensitivity analyses not adjusting for education and housing conditions showed both for men and women lowest lung cancer mortality among the managers compared with all other occupational groups however in the models adjusted for education and housing conditions the association reversed for women whereas for men lung cancer mortality only remains somewhat higher for male skilled manual workers which could be related to occupational exposures in contrary in the adjusted model higher breast cancer mortality rates were observed in female managers compared with all other occupations except sales and service workers this can be explained by differences in reproductive behaviour with less children and a later age at first birth for the whitecollar occupations 24 28 in the net model male managers had higher colorectal and liver cancer mortality compared with all other occupations yet in the unadjusted model the association between occupation and colorectal cancer mortality disappeared moreover compared with the whitecollar occupations manual workers do have lower mortality for several other cancer sites these results are counterintuitive suggesting that there are other factors at play such as an unhealthy and sedentary lifestyle of managers 39 40 we can assume that the results of the net model are more likely to be due to differences related to the job itself yet a healthy lifestyle may be induced by the social environment and therefore might not be excluded as a potential mechanism 6 specific occupational exposures and hazards may explain part of the association between occupational status and health 7 10 23 another important aspect of work related to health is the psychosocial aspect of the job such as the open access sense of control and autonomy the level of job strain or long working hours 7 23 25 30 41 this could be an explanation for the excessive colorectal cancer mortality among male managers colorectal cancer is associated with perceived stress and could therefore be related to the long working hours and work strain as perceived by managers 39 41 implications and conclusion this paper highlights important se inequalities in sitespecific cancer mortality by employment and occupational groups being unemployed and among the employed being employed as a manual worker or service and sales worker is associated with higher overall and sitespecific cancer mortality these unfavourable mortality patterns among the unemployed and manual and service and sales workers were especially observed for the more preventable cancers as we assumed based on the fct these occupational inequalities change when other sep indicators are adjusted for multiple sep indicators should be taken into account when studying se inequalities in health 9 11 12 because these allow for different causal pathways 8 9 10 yet it is difficult to identify to what extent the potential explanatory factors attribute to these inequalities because we do not dispose of data on incidence or survival nor on data on risk factors healthcare use or job characteristics future studies having access to these kind of data could help to unravel the complex interplay between incidence survival and mortality and to clarify at which steps the social differences operate 23 24 this study can be helpful in providing evidence for policy makers in order to reduce se inequalities in cancer mortality 37 our results prove that there is still a long way to go we observed for example that the unemployed groups are at a much higher risk of dying from cancer compared with the employed population ensuring financial security for the unemployed is a key issue in this regard 32 future research could also study other working regimes for example temporary or parttime employment and their relation to health finally there could be an important role for the general practitioner to make sure that the unemployed are getting the healthcare they need 32 also for the highrisks jobs regular health checks at the work floor are needed in order to detect cancers at an early stage competing interests none declared ethics approval this research as well as the data adhere to the ethical code of scientific research in belgium and all authors have signed the ethical code provenance and peer review not commissioned externally peer reviewed data sharing statement analyses are based on administrative data from the belgian census the belgian mortality register and death certificates provided by statistics belgium the availability of the data is restricted permission for analyses must be granted after verification of the research goals by the belgian commission for the protection of privacy

strengths and limitations of this study ► this paper probes into socioeconomic se differences in sitespecific cancer mortality using employment and occupational group as measures of socioeconomic position sep accounting for two other sep indicators education and housing conditions ► the findings are based on an exhaustive dataset including the total belgian population within the economically active age range which provides very rich information on sociodemographic as well as se variables and mortality for a followup period of 11 years ► these administrative register data do not contain information on incidence or survival nor on health behaviours healthcare use or important aspects of the job eg occupational exposures psychosocial factors

recent editorial in the international journal of epidemiology interpreted the psychosocial as a concept that operates at a mesolevel that is between macro and micro levels it described the mesolevel as encompassing such social formations as religious institutions the family the firm and the club… the editorial located the roots of psychosocial thinking in the influential definition of health originally recorded in the constitution of the world health organisation in 1946organisation in this defined health as a state of complete physical mental and social wellbeing and not merely the absence of disease and infirmity but the psychosocial is not only a medical theory and practice it also represents a form of politics this article addresses some historical elements of the psychosocial as a politics through an examination of the international congress on mental health held in london in 1948 the congress comprised international conferences on child psychiatry medical psychology and mental hygiene these were brought together under the organising umbrella of the mental hygiene movement with its conference playing the largest and most prominent role its theme was mental health and world citizenship this emphasised that healthy personality development was related to stages of growth and development which took place primarily within the family but that this process was mediated by wider cultural patterns and social institutions in apparent conformity with the international journal of epidemiologys claim regarding the origins of psychosocial thinking the 1948 congress used the whos 1946 description of health as a guiding definition however as this article shows through its examination of the mental hygiene movement the roots of the psychosocial in fact stem from earlier than this if the psychosocial is a form of politics what form does it take the sociologist nikolas rose has influentially described social psychology and the psychosocial as intimately connected with modern western liberal democracies he has argued that whereas the ideals of democracy are abstract and general respect for the individual personal autonomy social responsibility the control by the people over those who govern the power of social psychology is to enable these to be made congruent with specific programs for managing particular problematic areas of social life for rose …social and dynamic psychologies were to offer the possibility of making democracy operable through procedures that could govern the citizen in ways consonant with the ideals of liberty equality and legitimate power it is certainly true that midtwentiethcentury social psychology and representations of the psychosocial were replete with the terminology of democracy the 1948 congress was no exception however rose employs foucauldian conceptualisations of power and government in which power has no sovereign centre in society and indeed power relations appear to take place only between power and knowledge in roses hands these conceptualisations lead to the rather functionalist depictions of the psychosocial and its interaction with liberal democracy expressed in the above quotes this article contests such a rendition it suggests that prefoucauldian understandings of power government and authority common in the nineteenth and twentieth centuries need to be attended to in order to help appreciate the relationship of the psychosocial to twentiethcentury liberal democracy since this articles analytical stance might seem unfashionable in the face of currently popular theory driven historical work it is appropriate that the sociologist robert nisbets 1966 book the sociological tradition provides a schema for its analysis nisbet was a noted conservative and according to one obituarist so resolutely unfashionable that he regularly came back into fashion in the sociological tradition nisbet set out a group of paired concepts that he believed epitomised the conflict between tradition and modernity these were respectively community authority status the sacred and alienation on the one hand and society power class the secular and progress on the other nisbet emphasised that the archetype of community both historically and symbolically was the family and that the nomenclature of the family was prominent in every expression of it in fact although he did not draw it out fully the family clearly played a fundamental role for his thesis in general traditional social organisation was structured by authority relations that were deeply embedded in social institutions from the family through neighbourhood parish and guild and integrated throughout the social body the form of this authority was primarily personal whether it be that of the patriarchal head of the family or the sovereign it was characterised by personal intimacy emotional depth moral commitment loyalty and duty nisbet described how on this view the rationalist image of society along with associated philosophies of contractual relations and utilitarianism in the political and economic spheres separated the individual from deeper ties of community which had provided social cohesion and secure personhood nisbet added that when people are separated from long established social institutions there arises along with the spectre of the lost individual the spectre of lost authority these perspectives were informed by four aspects of the sociology of power associated with concerns about the growth of the rational and contractual state there were misgivings about the centralisation of power in the state this was often related to concerns about the political legitimacy of power becoming derived from a mass popular base a common view saw popular participation in power only leading to increased state centralisation through the dismantling of intermediate institutions of authority there was an associated fear of the totalism of power of its extension to the whole of peoples life and being along with this there were concerns about rationalisation as a facet of powerthe processes of measurement ordering and systematising in the name of rationality and efficiency nisbets rendition of each of his paired concepts as opposites is overdrawn it might be more accurate to view these pairs as coordinates that some social and political theorists attempted to place in new combinations in order to reconcile the traditional and the modern in this sense nisbets schema offers perhaps surprisingly a useful means to unravel some of the complexities of the psychosocial with reference to the mental hygiene movement and the 1948 congress it shows that through the interwar and postwar years of the twentieth century the psychosocial can be read as an uneasy and ambiguous attempt to reconcile the modern and the traditional the international congress represents one specific aspect of this engagement it was a means to both further professional aspirations and address a particular crisis of the relationship of individuals with the social order commonly perceived to have been revealed by the second world war relevance of nisbets thesis to the mental hygiene movement in england since the driving force behind the organisation of the international congress was the movement for mental hygiene this article will first of all look at how nisbets five paired concepts might relate to the movement in its prewar manifestation this will be discussed by looking at the movement in england four organisations formed the movements nucleus these were the central association for mental welfare the national council for mental hygiene the child guidance clinic and the tavistock clinic of these the earliest was the central association for mental welfare this had been set up with official government backing to assist in the operation of the 1913 mental deficiency act under this act all county and county boroughs in england and wales were to ascertain the local population of people deemed mentally defective provide institutional provision and arrange community supervision socalled mental deficiency was associated with what was termed social inefficiency and in turn to a host of social problems partly because of these connections the central association for mental welfare increasingly widened its scope to include people believed to be on the socalled borderline between apparent pathology and mental health through this it combined with the other three interwar organisations in the formation of a movement for mental hygiene although these other organisations included mental deficiency as important their concern with social inefficiency focused particularly on psychological disorders among individuals in the community the main aim of the movement therefore became the prevention detection and treatment of mental disorders in the population as a whole the main targets were people in society whose behaviour or experience appeared to mental hygienists to represent a failure of mental adjustment the central institution through which mental adjustment was to be achieved and maladjustment to be understood was the family the national council for mental hygiene and the child guidance council in particular promoted the family as a crucial element in the achievement of mental health this is important with regard to the movement for mental hygiene any reading of literature by the movement will show that the family was at the heart of its aim of preventing or detecting and treating mental maladjustment but it is here in fact that the ambiguous position of the movement to the modernantimodern polarities set out by nisbet is thrown into relief the essential elements of this position can be summarised in the following way for the mental hygiene movement unlike the social authority of traditional community characterised by nisbet the modern familys personal and hierarchical relations were not recapitulated across the social order from the realm of the family to that of the sovereign and all points in between instead straddling the modern and the antimodern the mental hygiene movement made the personal authority relations of the modern nuclear family the foundation of the rationally marshalled and moralised individual it is as if under the mental hygiene movement the authority relations of community as described by nisbet have been thrown back and compressed into those of the nuclear family and turned into a developmental process to adult adjustment authority relations embedded in personal relationships organised throughout the community which continually sustain personhood and social cohesion appear replaced by the nuclear family as forcing house of the rationally organised selfsustaining and moralised individual the individual of durable rationality and stability remains for mental hygienists the epitome of civilization but it is formed through the family it is not straightforwardly preordained as suggested in enlightenment thought how was this expressed by the mental hygiene movement its stance was of course structured by the theories that informed it two were prominent one was a theory of instincts drawn from the new psychology of the early twentieth century on this view humans were dynamic they inherited primitive instincts and these with their accompanying emotions constituted the basic impulses of human behaviour the other theoretical strand was psychoanalysis and its various popular reformulations with this the investigation of unconscious motivations became important these lay in the emotional substrates of the mind they were recalcitrant emotions but they could not just be suppressed by an act of will they required an expert knowledge of the development of personality and its emotional components with this emotionality could be nurtured and crafted to ensure mental adjustment the essential claim was that rational thinking had finally grasped the fact that emotional experience underlay all growth and adjustment the terminology of adjustment and maladjustment was important in mental hygiene theorising the nineteenthcentury concept of alienation suggested a failure of progress the mental hygiene use of the term maladjustment echoed this its terminology derived from biology in fact such terms had been applied to human psychology and social evolution since the midnineteenth century inherent in their use was the notion of progressive human and social history by using it mental hygienists were able to situate their outline of human development and mental health on preexisting depictions of the past as a process of progressive change much nineteenthcentury western thought had cast the past as a progression of stages in the development of the rational individual mind in association with an emerging civilisation of society the mental hygiene movement echoed this view but mental hygienists described it in terms of emotionality as well as intellect emmanuel miller the director of the east london child guidance clinic and a leading figure in child guidance provides an example of how in doing so mental hygienists prioritised the family and its personal relationships of authority as crucial to progress civilisation and the emergence of the rational individual according to miller primitive societies brought emotionality under rigid group control early on in a childs life consequently they thwarted individuality and freedom but miller described civilised society as having superseded the group mind with the individual mind under socalled civilised society the individual intellect now marshalled instincts and emotions this was achieved through the temporary and less rigid authority of the modern family j c flugel the psychoanalyst and senior lecturer in the department of philosophy and psychology at university college london expressed the same theme in his 1921 book the psychoanalysis of the family the book was later described by h v dicks the prominent postwar mental hygienist at the tavistock clinic as a work that had acted as a veritable bible in it flugel described a correlation between particular historical stages of development of the family and the relation of an individual to forms of social political and religious authority regarding the modern individual and family he wrote … it is i think abundantly clear that normal psychic development involves a gradual emergence from a state of dependence on parental authority and care to one in which the individual is dependent to a greater or less extent upon his own efforts as regards his livelihood and upon his own judgement as regards his conduct the sense of a transformation of the kind of traditional order described by nisbet into a developmental order within the modern family is summed up in a passage from a booklet published by the association of psychiatric social workers in 1932 the father image in family life in the community and in religion seems to be at the present time divesting itself of authority removing the protective guidance of a decalogue and asking of individuals instead of conformity and adjustment to a social norm the harder but more adult task of adjustment to the selfachievement of inner balance it was the psychic integration of instincts and emotionality that the parent child relationships of the modern family were understood to provide this required not unyielding domination but shaping based upon expert knowledge of emotional development the correct type of parental authority was crucial the child was not a blank space that could be directed and imposed upon without concern if we realize that the child is unique an individual dynamic organism then we are going to be a little more careful as to how we introduce authority wrote e graham howe one of the founding members of the tavistock emmanuel miller maintained that both mother and father … become part and parcel of a childs life not merely as persons from the outside world but as part of ones own sentiments of love admiration authority and selfcontrol this was why authority must not be overly dominant distant or rigid nor be overlyindulgent or utterly absent its aim must always be to assert authority in the interests of promoting the development of a selfgoverning mind parental authority must be wielded with the intention of making itself unnecessary flugel described a failure to become fully mentally adjusted within the relations of the family like this … one who has never progressed far from the infantile condition of dependence on the commands and opinions of others will be lacking in one of the character qualities which are essential for the attainment of any high degree of individuality or of social and economic responsibility … at best his morality will be one of hard and fast rules the dictates of parental ecclesiastical legal or social authority incapable of enlightened growth or modification to suit the ever changing flow of circumstances and the widening experience of life but if the mental hygiene movement seems thoroughly modern so far this impression must be tempered by mental hygienists assertion that primitive emotionality continued to reside in individual minds and mediate their engagement with society emmanuel miller put it like this … while the looser texture of civilized society has allowed for individuality it has also submerged those bonds which at one time visible in group conventions were strong enough to break the individual if at one time the individual was moored by a visible rope to the social quayside he is now anchored to the seabed by cables which though hidden are no less strong and binding hugh crichton miller maintained that on becoming a hospital patient the apparently civilised individual very soon reveals the fact that he is little more than a grownup child and that his reactions are for the most part those of primitive man once emerged in the circumstance of hospital this primitive man behaved much like flugels description of a person who had failed to become fully mentally adjusted he was dependent on authority craved security and relinquished his own initiative and responsibility it was here that mental hygienists expressed concerns about the coordinates of modern power described by nisbet in 1921 flugel wrote for example that the world war has taught us the necessity of implicit obedience to the state and its representatives military or civil the right of independent thought criticism and action being to a large extent suspended and the minute details of our lives being subject to order and inspection in much the same way as in our childhood they were subject to the supervision of our parents again modern socialistic thoughtespecially in its cruder aspects has produced a state of mind as a result of which the individual becomes to a large extent absolved from the responsibility for his own education progress and maintenance and for those of his children the adult individual is thus led to transfer onto the state that attitude of dependence which he originally adopted in relation to his parents … if our conclusions are correct there is a danger in too wide a ramification of state provision and state control inasmuch as it is liable to prevent that full development of individual power initiative and selfreliance which can only be obtained by a high degree of emancipation from the primitive attitude of dependence on the parents this is a classic example of concerns about forms of modern power centralised power has grown in the state and it is totalising and rationalising it inspects and structures the minute details of peoples lives in the name of rationality and efficiency fears about the legitimisation of state power through mass mandate are expressed in flugels relation of these negative aspects of modern power to the cruder versions of socialistic thought the mass political participation suggested by state socialism is depicted as in fact promoting more pervasive state control and this power merely serves to infantilise the masses while eroding the only institution in society that can successfully moralise the individual the family a class bias is clear in much mental hygiene writing sir maurice craig for example claimed in a speech that correct parental authority offered the best hope for combatting mental disorder but he made the general targets of this comment clear by adding that the stability and happiness of the mass depended on it he added that current ideas about equal shares for all might sound alright but they ignored differences in mental capacity the majority of people must therefore be content to remain in the social station to which they were most suited attempts to justify such a hierarchy were made by other prominent mental hygienists mental hygienists prioritization of the modern family as forcinghouse of the adjusted individual supported such attitudes to status and authority in the community flugel concurred with cyril burt that strikes and other crude forms of rebellion against authority in industry were the result of a displaced fatherhatred due to the primitive and repressive form of fatherhood common in the working classes similarly j a hadfield a leading figure at the tavistock clinic believed political disorders should be understood as manifestations of mass neurosis a conflict between spontaneous impulses of the masses and an authority that had failed to restrict and direct them adequately this led some to question whether the idea of political democracy should not be amended men have lately begun to wonder whether the principle of one man one vote is working quite as well as they hoped stated burt in a 1933 radio broadcast is it fair to count the number of heads without stopping to consider their contents hugh crichton miller the director of the tavistock clinic suggested that university graduates ought to be more independent thinkers and therefore more competent voters they should therefore have more weight and responsibility in a democratic society he claimed that one man one vote was sham democracy and that a community not educated in selfgovernment was much more likely to profit from a dictatorship than from the semblance of democracy which permits the demagogue to achieve autocracy the 1948 international congress on mental health the ambiguous position held by a prewar mental hygiene movement straddling the polarities of modernity and antimodernity set out by nisbet is clearly apparent at the international congress each of the conferences that comprised the congress continued their prewar mission of developing and publicising what they considered to be their expertise in understanding and preventing mental maladjustments but now faced with the catastrophe of the recent world war this took on a new salience with the onset of the second world war many leading figures of the movement in britain the united states and canada secured influential positions in the armed services it was from these angloamerican developments that ambitious plans for a postwar congress on mental health were developed j r rees a leading figure of the english mental hygiene movement was one of the principal instigators he had secured appointment as head of psychiatry in the british army during the war in the early 1940s he made two long study visits to the united states making close contact with leaders of the mental hygiene movement as well as leading psychiatrists including george stevenson frank fremontsmith harry stack sullivan and the canadian charles brock chisolm after the war rees collaborated with these people to plan an international conference on mental hygiene the ambitious aim was to promote the importance of applying knowledge on human personality and group relations for mental health and world citizenship through the coordinated work of the human and social science professions the introduction to this article referred to a recent editorial in the international journal of epidemiology that considered the roots of the psychosocial to lie in the who definition of health we have seen that its origins lie much earlier than this but nevertheless the world health organisations definition of health was certainly used as a guiding definition for the 1948 congress the first of the four volumes that recorded the congress displayed this extract from the whos constitution on one of its opening pages in fact leading figures in psychiatry and the mental hygiene movement were closely involved with the creation of the who and the drafting of its constitution several such as george brock chisholm the leading canadian psychiatrist and mental hygienist the us psychiatrist harry stack sullivan and j r rees were as i have noted key instigators of the international congress on mental health however the underlying orientation that had informed the interwar mental hygiene movement remains evident as we have seen the movements primary attention was on the family and the role of personal authority relations in mental development this concern with the role of human relationships in the creation of mentally adjusted citizens encouraged increasing engagement with the sociological and anthropological disciplines for example several of the important contributors to the 1948 congress such as the psychoanalyst franz alexander harry stack sullivan and lawrence k frank the director of the caroline zachry institute of human development had engaged with the anthropological and sociological professions between the wars additionally the anthropologist margaret mead played an important role at the congress she had joined the us national committee for mental hygiene in 1945 and became a member of the international preparatory commission for the congress in one of the prominent papers to the conference on mental hygiene mead argued that the family was mediator of culture and the individual franz alexander concurred for him psychiatry had established the fact that the factory in which human personality is moulded is the family he added that this knowledge had been extended by anthropologists such as mead and her onetime tutor ruth benedict they had shown that the personality traits characteristic of a nation were attributable to similarities in family influences prevailing in each culture meads speech at the congress on the theme of collective guilt is instructive regarding the integration of these views with mental hygienist thinking she argued that character structures were associated with different social arrangements family structures and political forms basing her analysis on contrasts in family socialization in various cultures mead argued that guilt was only one type of character structure used as a sanction in societies thus it was only one culturally specific mediator of the relationship between family training of the young and a nations government however she also described guilt as perhaps one of the more special developments and went on to say that … the capacity to experience guilt as a dominant psychological mechanism is a human capacity which may be either developed or neglected by any given society and cannot therefore be regarded as either universal or necessary however desirable it may be found in terms of contemporary ethics despite her caveats the idea that such mechanisms are either developed or neglected surely implies that they are morally superior the leading british mental hygienist hv dicks was more forthright he commented that some of the societies which dr mead had quoted as having little guilt and much shame or pride or just sheer external compulsion for the coercion of their members seem to stand on a psychologically less mature rung of the ladder mead also distinguished between character structures formed in relation to guilt these could be differentiated between guilt over the content of an act guilt over the form of an act and guilt over conflict between formally required acts she contrasted britain and the united states with germany and japan in this context the latter developed character formations built around the second two forms of guilt for instance she maintained that investigations had shown german character structure to be based around an emphasis on the moral necessity to discharge ones duty in the light of ones formal position in a family the army a government organization or the state… this she contrasted with britain and the united states where she asserted an emphasis was placed on the content of an act and whether it was to be judged good or bad right or wrong thus the construction of an internal authority overrode any external human authority according to mead this related to the fact that these countries allowed individuals free choice of those who govern them because of this freedom individuals therefore felt responsible for the content of the national behaviour in the context of our schema derived from nisbet such views suggest an assertion of the modern over the traditional the interacting hierarchical authorities of traditional community comprised of rigid status are rejected as inimical to mental health and social stability ives hendrick a harvard psychiatrist gave a similar rendition of german character to mead describing the culture as favouring feudal types of character dicks related character formation in germany to the continued influence of old testament authority according to him prewar germany had been a kind of paragon of old testament virtues and values by which he meant it was more rigidly ordered and insistent on the good behaviour of its children than most western countries toms however these presumptions apparently in favour of democracy were nevertheless mediated by a fundamental orienting principle of the congress this was the established mental hygienist claim that beneath the surface of apparently modern rational individuality lay primitive man under the sway of irrational prejudices and fears at the beginning of the six day mental hygiene conference david mitrany the adviser to lever brothers and theoriser of functionalism in international politics described human history as marked by the fact that humans had massively transformed their social environment and come to do so with increasing rapidity but understood biologically human nature had changed very little one consequence was that the chains of primitive taboos have gone but the complexity of modern life after freeing the individual from formal chains has wound round him a cocoon of distracting strains and conflicts others outlined associated features of modern societies mead summarised some of the common themes of the seventysix preparatory commissions she noted great concern about the insecurity and thus anxiety and hostility that was believed to be engendered by shifts from rural to city life firm religious backgrounds to loss of belief and from strong to loose family ties for mitrany this left individuals vulnerable to control and manipulation of their irrational impulses he maintained that whether one liked to admit it or not it was an unquestioned fact that most democratic devices intended as they are to widen participation in politics and government have added to the possibilities for appealing to mass emotions… likewise he continued new methods of communication had vastly increased the opportunities for mass suggestion a prominent theme at the congress was the extended power of the state and the general view of delegates about its deleterious effects on the formation of rational moralised individuals mitrany for instance described the modern state as an artificial organism that maintained itself through an alldemanding requirement of compulsive loyalty and unquestioning obedience it was a planned state able to use social institutions and instruments of material and of cultural life to gain submission and conformity… he feared that the military style discipline imposed through economic planning for wartime total mobilization was creeping into wider aspects of social life at the same time he asserted that however worthy the modern attempt to provide social security it had the effect of treating people abstractly and uniformly removing initiative and promoting passivity and frustration on mitranys view the state had become too strong to allow liberty but too weak to provide security a question raised remorselessly in the preparatory commissions reports on the subject of family problems and mental disturbance was is it likely that the family group is going to disappear completely and that all its functions will be taken over by the state the british mental hygienist dr maccalman appeared to concur with mitrany in his speech to the conference on child psychiatry he raised the apparent failure in function of the family vast numbers of individuals would appear to be growing up with insufficiently mature independence he claimed and he asked is the family unit surrendering its functions to the wider unit of the state which has not yet learned to exercise them adequately maccalmans speech in fact provides a useful template to represent the general view his opening remark rendered the aim of the congress this way … its goal is the more harmonious interpersonal relationships within the family group which in turn will give a greater security to the individual child and allow him to mature with a minimum of uncontrolled aggression if this takes place successfully he will be a more stable and efficient citizen of his community and the world displaying the modernist aspects of the mental hygiene movement maccalman maintained that too much aggression had been used against children in most cultures throughout most of history he maintained that the injunction spare the rod and spoil the child has been interpreted as an encouragement to lay the rod on lavishly this aggression had been accompanied he added by an interpretation of honour thy father and thy mother designed to crush any hint of retaliation maccalman concluded thus protected by biblical sanction parents and teachers have proceeded joyfully to knock hell out of the little blighters and what can the little blighters do but wait till they are big and strong enough to do likewise maccalman made it clear in his speech that he saw the role of psychiatrists psychologists and psychotherapists as to develop the power to influence mankind but how might they do this he drew the comparison between the influencing of childrens behaviour that took place in the family unit and the influencing of adults in wider society social scientists he argued emphasised indirect rationalistic techniques of influencing behaviour maccalman noted the antipathy of many psychotherapists to such large scale rationalised methods he pointed out however that psychotherapists themselves had played their part in extending such rationalizing power and its penetration of family group relations in terms of calculation objectivity rationality and efficiency in place of arbitrariness domination and patronage but maccalman clearly lamented along with the majority of congress delegates the perceived erosion in the role of the family and the gradual transfer of influence from small primary groups like the family to larger and apparently artificial groups maccalman looked to the small group as the main vehicle of influence in the introduction to this article we noted that the 2002 editorial in the international journal of epidemiology interpreted the psychosocial as a concept that operated at a mesolevel between sociostructural and individual levels of human activity it described this level as encompassing social formations such as religious institutions the family the firm and the club… maccalmans explanation of the small group relates directly to these social formations the significance of the small group was that it operated on the basis of personal ties and toms relations of authority echoing the traditonal elements of nisbets schema maccalman noted that it characterises small social units such as the family fraternities clans and communities he made plain that the modern family was the archetypal root of these groups it provided the primary medium through which intense interpersonal relationships could be worked out other postwar mental hygienists did much the same for example the psychiatrist t a ratcliffe was closely involved with the post war mental hygiene movement he maintained that the concept of mental health in a community would seem to demand two thingsthat individual members of that community should be themselves stable secure and settled and that the community pattern itself should be a mentally healthy one he argued that a community mental health service should be understood as a form of relationship therapy the model for this kind of therapeutic relationship was the family … just as the parentchild relationship should be the epitome of future relationships for the child and the path which leads him to adult maturity and independence of personality so the clientpsychiatric social worker relationship should be an experience which leads the client on until he can form his own mature adult relationships in his environment but ratcliffe also sought to promote small group work both for people considered maladjusted and also as a means to bring a wide array of professional groups in society together to work for mental health and his vision of such groups was that they would mirror the important elements of relationship therapy we should see an example of the importance of working out interpersonal tensions of understanding and accepting our feelings of aggression overdominance or overdependence towards each other and of the significance of interpersonal relationships in the sense that i have described we have here yet again an uneasy straddling of the modern and traditional if under the mental hygiene movement the authority relations of the traditional social order have been compressed and turned into a developmental process then the theme of development from childhood to adulthood lies at its heart in part this can be seen to uphold a form of liberal democratic political order the family creates autonomous responsible citizens capable of upholding a version of representative democracy but this developmental family model also informs critiques of the growth of state power under existing forms of democracy along with suspicion of popular political participation or protest and of movements towards greater egalitarianism they are either the causes or effects of dependence and infantilisation in other words in failing to echo the internal social order of the family they become elements in society that impact negatively on it and thus on the creation of citizens class bias inhibits democratic values and this bias is readily apparent in frequent mental hygiene pronouncements in general the vision of the mental hygiene movement was of a hierarchical ordering of society on the basis of measurements of intellectual capacity and the contents of personality the need for leadership was a common toms theme thus in respect of the mental hygiene movement the politics of the psychosocial might be less about how it acted as a conduit through which particular programmes for managing people could be made congruent with the values of democracy and more about the ways in which the movement attempted to reconcile its vision with democratic values biographical note jonathan toms has previously been postdoctoral fellow at the centre for the history of medicine university of warwick

the foucauldian sociologist nikolas rose has influentially argued that psychosocial technologies have offered means through which the ideals of democracy can be made congruent with the management of social life and the government of citizens in modern western liberal democracies this interpretation is contested here through an examination of the 1948 international congress on mental health held in london and the mental hygiene movement that organised it it is argued that in britain this movements theory and practice represents an uneasy and ambiguous attempt to reconcile visions of the modern with the traditional the mental hygienist emphasis on the family is central here it appears as a forcinghouse of the modern selfsustaining individual mental hygienists cast the social organisation of traditional communities as static with rigid authority frustrating both social progress and the full emergence of individual personality yet mental hygienists were also concerned about threats to social cohesion and secure personhood under modernity if the social organisation of traditional communities was patterned by the archetype of the family with its personal relations of authority mental hygienists compressed these relations into the private family situated here they became part of a developmental process of mental adjustment through which mature responsible citizens emerged this reformulation of the familys centrality for the social order informed mental hygienist critiques of the growth of state power under existing forms of democracy as well as suspicion of popular political participation or protest and of movements towards greater egalitarianismdemocracy michel foucault mental health mental hygiene psychosocial the notion of the psychosocial is highly influential in current mental health conceptualisation and practice however the term remains variously described and interpreted in its most general sense the psychosocial refers to a relationship of mind body and social environment in terms of mental health and illhealth this usually translates into assessments and interventions at various levels such as individual experience and behaviour the perceived dynamics of an immediate social context or a wider social environment dagnan 2007 3 the psychosocial refers neither to a purely reductionist or isolated notion of the individual nor to a primary focus on largescale social structures a

introduction due to the internal turmoil in syria the influx of migration started in 2011 and then it became an international social problem affecting the neighboring and regional countries as well as the eu member states türkiye the country with the longest border and historical ties with syria was most affected by this situation türkiyes opendoor policy adopting the temporary protection regime which includes the principles of nonrefoulement and meeting basic needs has also been effective in this which causes syrian refugees to see türkiye as a safe haven today türkiye has become the country hosting the largest number of refugees in the world hosting approximately 4 million syrian citizens since 2015 hosting such a large population also necessitated a comprehensive organization this organization requires the services of local government agencies as well as the support of international organizations and civil society on the other hand rightsbased organizations aidbased nongovernmental organizations and academia are also working to inform the public about the refugee crisis originating from syria to identify the deficiencies in the implemented policies and to offer suggestions one of the most important of these policies has been the provision of education to children and young people in order to ensure compliance with the fact that education policy is one of the most important tools in ensuring compliance multidimensional planning has been made the reason for this is the high young population and the unknown when the turmoil in syria will end this situation is a result of the fact that education is seen as a human right as well as laying the foundations for a longterm coexistence between local people and immigrants according to the december 2021 data of the directorate of migration management 1259435 of the 3734876 syrians under temporary protection in türkiye are schoolage children between the ages of 518 and 503128 are universityaged youth between the ages of 1924 in this respect it is seen that a total of 1762618 people are in the education age it is seen with the data that the number of schooling among syrian children in türkiye has increased over the years according to the data of the ministry of national education 230 thousand syrian children were enrolled in school in the 20142015 academic year 311 thousand in 20152016 and 492 thousand in 20162017 according to the may 2018 data of the migration administration 519980 of the 1150791 schoolage syrians aged 518 in türkiye attended temporary education centers and public schools however 630 thousand people in this age group did not go to school by 2019 while 680000 children were enrolled in school nearly 400 thousand children were still not enrolled in school according to the data of the ministry of national education 339541 out of 382357 schoolage syrians under temporary protection in türkiye in 2019 were enrolled in primary school therefore approximately 89 of primary school children continue their education considering that according to unhcrs 2019 data the primary school enrollment rate of refugees is around 63 it can be said 2460 atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 doi 1048146odusobiad1232477 that türkiye is successful in this regard however at the high school level the rate of enrollment and attendance is low this rate is 3255 the main reason for this is that boys have to work to provide economic support to the family due to economic conditions and girls are married at an early age despite all the arrangements and activities regarding the education of syrian refugee children the desired success has not been achieved in the participation of schoolage syrians in high school and higher education in türkiye in addition there has been a significant increase in the number of syrian students enrolled in higher education while the number of syrian students in the turkish higher education system was 608 in 2011 it increased to 27606 in the 20182019 academic year considering the syrians who were born married and set up a business in türkiye it is possible that they will be permanent in türkiye in the long run therefore it is important to integrate children into society and ensure their integration into society in order to achieve this an accurate and effective education policy must be established and implemented in this study the education policies of türkiye which is the country that hosts the most refugees with approximately 4 million people in the world since 2011 in order to ensure the integration of syrian children and youth will be discussed in this context the current situation regarding the legislative arrangements made the roles of local and international institutions and organizations in these policies and the results obtained after the researches on this subject will be revealed by document analysis method in this respect it is aimed to determine how education and integration policies develop in the case of türkiye which is the country hosting the most refugees in the world background legislation arrangements türkiye has published many legislation related to the education of syrian children and youth in addition various projects have been implemented in cooperation with the ministry of national education the european union and nongovernmental organizations in order to ensure the adaptation of syrian children to the turkish education system and their access to education disaster and emergency management presidency ministry of national education and higher education institution have established a cooperation regarding the determination and implementation of education policies for syrians under temporary protection in türkiye after the refugee influx that started in 2011 the policies followed on education were prepared only for the camp based on the assumption that the syrians would return first the first legislation on providing education to syrians was the circular titled measures regarding syrian citizens hosted outside of camps in our country dated april 26 2013 by the ministry of odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • national education with the cooperation of unicef and meb the guidebook for guidance services for individuals with temporary protection status was prepared and it was aimed to inform syrian refugees in this context by expanding the content of the first circular the circular educational services for syrian citizens under temporary protection was issued on september 26 2013 however these two circulars were not sufficient to eliminate the problems in the implementation of the education services provided to syrians therefore with the circular numbered 201421 published on september 23 2014 titled educational services for foreigners certain standards have been set for the education services to be offered to syrian children in addition to these temporary protection regulation was published in the official gazette on october 22 2014 with the 28th article of the circular the education of syrian children has been comprehensively discussed the circular titled execution of services for foreigners under temporary protection published by afad on 18 december 2014 also determined issues regarding the solution of the education problem of syrians it has been determined that the purpose of the education and training activities to be carried out for syrian students is to make up for the education they had to take a break and to ensure that they do not lose any years when they go to their country or any third country planning coordination and control of the educational services to be carried out is left to the responsibility of the ministry of national education it was decided that the need for teachers would be met by the ministry of national education when necessary by appointing people who can speak arabic in accordance with the conditions the 20152019 strategic plan published by the ministry of national education was the first document containing plans for the education of refugees the increase in the number of syrian students attending school between 2011 and 2020 is the result of strategic planning as well as legislative studies according to this for the first time the strategy document and national action plan for combating irregular migration was announced to cover the period of 20152018 with this document strategic targets were determined in türkiyes fight against irregular migration and studies were carried out for its implementation secondly the strategy document and national action plan for combating irregular migration covering the years 20212025 including the next period was prepared and entered into force the legal arrangements made in this process were carried out in parallel with the changes in needs over time for example yök initially admitted undocumented syrian students to universities with special student status but later provided the opportunity for lateral transfer to those with a certificate the ministry of national education announced that it was not possible to apply a curriculum other 2462 atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 doi 1048146odusobiad1232477 than the turkish education system curriculum at the beginning but in the circular it published later it was stated that the education program would be prepared by the syrian national coalition higher education commission under the control of the ministry of national education as a result of all these efforts although school enrollment has increased it is seen that a very high number of children are still out of school numerous researches and reports on this issue are presented and provide data for determining the necessary policies projects in addition to the legislative arrangements project activities for the education of refugee children are also carried out effectively project for supporting the integration of syrian children into the turkish education system organized by the ministry of national education within the scope of the pictes project the ministry of national education recruited personnel who teach in turkish stating that children aged 45 should attend preschool education in order to ensure the integration of syrian refugee children into society and language learning the first phase of the pictes project which is one of the most important studies to support the education of syrian children was started in 2016 and was completed at the end of 2018 after this date the second phase was started with the pictes ii project a contract was signed between the meb and the european union delegation to türkiye within the framework of the agreement on the financial assistance program for refugees in türkiye and meb activities began to be supported within the scope of this project the relevant general managers of the ministry of national education lecturers and school administrators who are syrian students in their schools attended the meb administrative personnel training meeting held in antalya between january 30 and february 3 2017 where the project was evaluated within the scope of the project it was stated that teachers and school administrators gained very important personal experiences in their communication and interaction with traumatized syrian children education policy application areas within the scope of the education policy for syrian children and youth in türkiye lessons have been started in five main platforms these are temporary education centers public schools syrianowned private schools open education institutions and higher education institutions temporary education centers in türkiyes border provinces with syria units affiliated to the ministry of national education and some nongovernmental organizations are working together to determine the education levels and equivalents of refugees through the commissions established within these ngos temporary education centers have been established in the cities whose education curriculum is compatible with syria refugees were provided with trainings by using the infrastructure of some schools outside of normal education hours there are also schools established for just this purpose odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • first of all training was provided through volunteer trainers and then with the joint initiatives of the united nations and the unicef teachers were paid a low wage ngos and afad took the lead in the establishment of temporary education centers under provincialdistrict national education directorates there is a syrian and a turkish administrator in the management of gem since the syrian curriculum is given here in arabic the majority of the staff consists of syrian teachers as a result of a research that included interviews with administrators in temporary education centers turkish and syrian teachers as well as syrian students it was seen that the correctly chosen curriculum various practices such as parent meetings and the appointment of syrian teachers at the center increased the sense of belonging to the school and supported the socialization of students on the other hand it was determined that the lack of opportunity for syrian students to communicate with their local peers at gems caused them to move away from the goal of integration in the 20162017 academic year policy changes were made and it was decided not to open new temporary education centers and to close the existing ones after a certain period of time in addition it is planned to enroll middle class students studying in these temporary education centers and registered in the foreign student information operating system to state schools in the upper class by providing effective turkish education in this context increased turkish education was started to a total of 25278 students in a total of 23 temporary education centers in adana adıyaman hatay and i̇stanbul in 2019 public schools public schools belonging to the republic of türkiye are a second alternative for the education of syrians within the scope of the ministry of national educations education and training services circular for foreigners syrian children have the opportunity to enroll in public schools by presenting the foreigner identification document they have received the language of instruction in these schools is turkish private schools syrians have been given the opportunity to provide education in accordance with the syrian curriculum in buildings that are suitable for education in türkiye either allocated to them by the state or found by them open education foreigners in türkiye have the opportunity to receive education in line with the relevant provisions of the regulations of open education institutions in this respect this opportunity is also valid for syrians atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 higher education at first the view that syrians would return to their countries in a short time led to the temporary planning of higher education discourse and policies in this context however not knowing how long the syrians will stay with the prolonged period and the increasing number of refugees have created the need to produce permanent and sustainable solutions at the first stage planning was made so that syrian students would not receive a diploma but would not fall behind in education in this context in 2012 syrian students were given the right to attend classes with special student status for one year in 2013 this limitation was removed and lateral transfer opportunity was provided for those who have a certificate in addition 460 syrian students were provided with dormitories and scholarship opportunities together with the university in this context many educational activities for refugee students were organized by state universities and foundation universities under the coordination of the council of higher education and support was provided to help them cope with financial and cultural difficulties despite the provision of these opportunities the problem of not knowing the official procedures or not being able to provide the necessary documents to benefit from this right to education has been the biggest obstacle for syrian youth to continue their university education the way to overcome this situation is to grant the right to register based on declaration however while the right to be a higher education student requires passing a difficult exam for turkish citizens it is likely to cause a reaction by the turkish citizens because of this right will be given to syrians by declaration the foreign academic information system project was initiated by yök in 2016 for the employment of syrian academics in türkiye at turkish universities 5 thousand academics from 31 different countries most of them syrian nationals were registered in the system however it has been determined that only 345 academicians are employed in universities in türkiye 320 of which are in theology and arabic departments in addition gaziantep university has founded different faculties for syrian students in the regions cleared of terrorism in syria by the turkish armed forces one of them is the faculty of economics administrative and social sciences in albab here 2 turkish and 7 syrian academicians teach students who are all syrians in addition the same university has an education faculty in afrin syria however the number of syrian academics employed except for the theology and arabic departments is considerably less than number of all the syrian academics in türkiye this situation was also expressed in the workshop the problem of arab academics and suggestions for solution held by the mediterranean research center as a result of the workshop it was stated that there were requests for the employment of syrian academics generally in arabic language and theology faculties of universities in türkiye there is a great potential for academics in other disciplines to work in their own fields of expertise for this it is necessary to be founded departments that teach arabic in odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • universities or to be founded a turkisharab university however there are bureaucratic obstacles to founding departments providing education in arabic studies conducted in different cities and universities about syrian higher education students starting education reveal that students experience difficulties in this process in a study conducted on syrian students studying at uşak university in 2018 it was revealed that students perceive social exclusion on issues such as economic spatial citybased education and health on the other hand it has been seen that syrian university students have multiple disadvantages as a result of the combination of the problems arising from being refugees with the educational problems they encounter at the university as a result of another research it was seen that syrian and other immigrant university students in konya tried to overcome difficulties such as communicating with academic and administrative staff being marginalized culturally and socially and understanding the thought system of another culture on the other hand it has been determined that they experience satisfaction problems such as stress psychological trauma financial dependence identity confusion language problems cultural shock inability to integrate into different social norms and values changes in the education system loneliness lack of social and spiritual support the media has a great role in the problem of marginalization and segregation of syrian university students the media produces wrong content about syrian students the media uses exclusionary rhetoric towards syrian refugees an example of this is the publication of false information such as syrian students being placed in the quota of turkish students at universities and scholarships given by the state for this reason in order to prevent disinformation on these issues it is necessary to provide accurate information to the public periodically by authorized institutions despite all the problems experienced it is seen that syrian university students under temporary protection move into the social cohesion process more easily and quickly than other syrians a study revealed that some of the most important factors affecting the social adaptation of syrians to türkiye are social and psychological support resources individual characteristics university education and social activities at the university problems in education policy implementation after the implementations made within the framework of the regulations some technical and social problems also caused a complicating effect in achieving success however since the regulations made are of a general nature they have also revealed different applications and results in different cities and schools within their original conditions in this context individual efforts and achievements towards solving problems are also observed in general technical issues difficulties in the registration process with the migration influx bureaucratic difficulties experienced in the school enrollment process for atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 doi 1048146odusobiad1232477 schooling the numerous documents required for school registration and the lack of any registration system for registration caused some students not to go to school in order to solve this problem the ministry of national education published the circular numbered 201421 educational services for foreigners in 2014 with this circular children in türkiye under temporary protection have the right to enroll in school only with a foreign identification document without a residence permit the information operating system for foreign students which was prepared to facilitate the registration process of foreign students reduced the difficulties experienced in the school enrollment process however although the ministry of national education enables syrian children to enroll in any public school with the foreign identification document given to them it is stated by the school administrators that there are some difficulties in the registration process when this document is not available equivalency and grade level determination difficulty one of the problems that syrian students face in education is the problem of equivalence the differences between syrian and turkish education systems and curricula cause problems regarding the grade levels that syrian children will attend in addition due to the fact that they take a break from education until they lead a regular and safe life during migration the time they spend without education is long after this long break it is a problem at which grade level they will be enrolled this problem arises when syrian students who do not speak turkish are enrolled in the first grade of primary school for language learning or they are enrolled in the upper classes appropriate for their age although they do not speak turkish at all access to education and participation problem lack of data on schoolage children transportation and service problems of students outside the camps intercity mobility caused by migration from the camp to the city can negatively affect the continuity of education for families the fact that the schools they will send their children to are far away can create various security concerns and may cause them not to send their children to school the transition to distance education during the coronavirus epidemic affected syrian refugee children more than other children children and their families who dont know turkish television broadcasts that are in turkish lack of television internet computer at home due to poverty crowd family population and obligation to children for taking an active role in housework negatively affected the education of refugee children these situations which affect the access to education information network courses have also caused the childrens level of benefit from the courses to be low on the other hand the fact that eba courses can be recorded and watched again reduced the problems experienced by children in expressing themselves in facetoface environments language issue in general in the adjustment of students at school factors such as the behavior of teachers and administrators friendship relations with their peers the rate of feeling safe and relations in and out odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • of the classroom are effective this is even more important for immigrant children from different languages and cultures in order to achieve this knowledge of language is the first requirement the majority of immigrants from syria except turkmen do not speak turkish in addition to the absence of arabicspeaking staff teachers the number and quality of teachers to teach turkish are insufficient therefore there is a communication problem between local teachers and students the continuity of teachers attendance is insufficient it is a quality problem for those who do not have pedagogical training and who are not teachers to teach in arabic in addition people involved in the education of refugee children should be equipped with education in emergencies all these situations negatively affect the education quality of syrian students especially in public schools the success of social integration has decreased as a result of the fact that syrian students attending school mostly prefer tecs due to language problems and social adaptation problems there is a wage problem due to the fact that syrian teachers working in temporary education centers cannot be paid directly by the ministry of national education syrians who work as teachers are paid a small amount by various international and local institutions and organizations such as türkiye presidency of religious affairs municipalities and unicef teachers who have syrian students in their classrooms suggest that these students should be taken to a preparatory class before being distributed to other classes and they should be taught turkish with the latin alphabet in addition in order to increase the motivation of students for language learning while providing this lecture care should be taken that the number of syrian students in the classrooms is not too high when compared to the number of general class students because students making groups among themselves and communicate in their own language as a result of this it has been determined that the level of need for turkish has decreased and the turkish language learning of syrian students has therefore fallen behind a second factor in the language learning and adaptation process is the family attitudes of refugee for their children however families who do not have sufficient knowledge of turkish may also be unable to communicate with the school in terms of families not knowing turkish or knowing turkish at a low level causes them to be unaware of their legal rights and duties and to have difficulty in handling their official affairs this situation can affect refugees at obtaining a valid identity document receiving services from the public benefiting from social assistance and social services etc not knowing the language causes women to participate less in society and therefore they cannot adapt to social life war trauma recovery challenges and need for specially educated instructors studies have shown that the mental health of the children of emigrant families is adversely affected due to the traumatic events they experience during and after the migration process problems such as forcing girls to marry at a young age not being sent to school being exposed to all kinds of violence lack of nutrition not being able to benefit from their health rights adequately and being forced into labor are the negativities experienced in this context those who have the right to go to school may have less chance of being affected by these negativities and traumas however the content of the education and the knowledge and attitude of the educator are important here the ability of refugee students who have survived great difficulties at an early age when basic knowledge and skills are learned and adapting to the country they live in is related to the approaches of their teachers the children of refugee families who came to türkiye by fleeing the war in syria need to see a different approach compared to the children of refugee families from other countries according to the teachers and administrators who participated in a study the reason for this was the death of syrians in their country and the fact that they came to türkiye to escape from the war after experiencing fear iranian afghan and iraqi students are in türkiye as a result of their families desire to have better living conditions and educational opportunities in türkiye the families of these students have better financial opportunities and higher education levels therefore they have fewer problems in adapting to türkiye in order to provide effective education to syrian students under temporary protection who have experienced war trauma it is important that school counselors are educated and experienced in working with children and adolescents from different cultures this education should include multicultural counseling advocacy and trauma in this sense it is important that not only teachers and school counselors but also nurses have special training on the education of refugee children and families in this context nurses should have knowledge about the chronic and infectious diseases of refugee children basic human rights and growth and development processes in addition nurses should work on providing safe playgrounds for children raising the awareness of the society about the effects of migration for children and families enabling refugee children to communicate with people and eliminating the prejudices of the society odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • i̇t is possible to say that a large number of professionals have gained field practice in the ten years since the syrian refugees first arrived to türkiye curriculum and teaching materials problems in terms of the quality of education the number of students per teacher should be 40 at most in addition to the building deficiencies there is a lack of tools and equipment in learning turkish educators suggest the implementation of level classes that will classify students according to grammar in turkish education and reinforcement courses for syrian children various aids are provided to syrian students by civil society and international aid organizations unicef and turkish red crescent are at the forefront of these organizations in this context besides a certain amount of financial aid stationery and clothing aid is also provided to the students who come to the school school needs and stationery sets are distributed to children by the association for solidarity with asylum seekers and migrants and mediation is provided for helping other aid organizations and charitable citizens current diploma issue in temporary education centers it is a problem that students studying in temporary education centers are not given a valid diploma because of this problem if the refugee student goes to his own country or a third country after education he cannot provide the equivalence of education in the solution of this problem especially international organizations should play a role due to the political crisis between türkiye and syria lack of coordination information and guidance first of all syrians and parents do not know about public school opportunities and their knowledge of their rights and responsibilities in education is insufficient this is due to the inadequacy of informing the public about the activities carried out by official institutions in the field of education for syrians in türkiye in order for the aid and training activities to be regular and effective coordination between public institutions and nongovernmental organizations should be improved social issues disadvantaged children children who do not have a parent or family or who are disabled need special education and rehabilitation socioeconomic disability and child labor due to factors such as the low education level of syrian families poverty lack of social security and cultural differences with the local people it makes it difficult for children to adapt to the society they live in in fact it can be seen that families make their children work and even beg money from the principal and teacher at school due to poverty atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 doi 1048146odusobiad1232477 the biggest victims of the war in syria are refugee children they are deprived of their right to education because they have to be partners in their families struggle for survival children are worked in fields and gardens in rural areas and in workshops and on the streets in cities in border provinces such as gaziantep kilis şanlıurfa and hatay syrian child workers can be found working in knitwear workshops textile factories dried fruit factories shoe manufacturing workshops and car repair shops agricultural labor and in the streets in jobs such as paper tissue and water sales social acceptance and adaptation problem it can be seen that syrian families do not want to enroll their children in school for fear of being bullied in order to prevent this situation it is necessary to carry out studies to ensure social integration before physical adaptation it is seen that syrian refugees who have economic opportunities and have established a business in türkiye easily rent a house their children continue their education and establish good relations with the local people through their workplaces this makes them more advantageous than syrians who do not have access to economic resources adaptation processes for themselves and their children are slow for those whose economic situation is not good it is important that the educated refugees contribute more to employment and the development of the country in order to solve the problem of adaptation to the society they live in this will enable them to benefit more from the countrys opportunities socially and economically and to be more accepted by the local people from this point of view considering that most of the syrian refugees who have been in türkiye for more than ten years will stay in the country in the next period it is important to plan an education that will ensure adaptation and employment for them schools and educational environments are important for refugee children to recognize the new culture that they met in the first place therefore it should be known that adaptation to school is the beginning of the cultural transformation process in addition to the correct planning of the educational content necessary measures should be taken to eliminate the obstacles to school attendance factors affecting success neglects such as not knowing the language adaptation irregularity uncertainty lack of planning absenteeism from school lack of boundaries health problems irregularity transition to higher education without examination family indifference differences in practice and mental chaos in the society on this issue lead to failure in education for syrian students in addition the tension created by the new life that comes with war migration and displacement all over the world negatively affects the inner world of children childrens longing for their homeland the differences between their old and new lives the physical and social deprivation of their new places the tension and hostility caused by cultural incompatibility social pressures such as discrimination exclusion and marginalization cause severe and traumatic consequences for children therefore the attitudes and behaviors they encounter at school are an important odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • tool in overcoming this trauma in this regard as well as trainers local peers and families who will motivate them to have a positive attitude are needed different city examples apart from these general problem determinations different practices and results have emerged for the education of syrians in different cities of türkiye in line with the efforts or the level of knowledge of the trainers and the conditions of the school and city the differences in this direction have been revealed by various studies in a study conducted in samsun which is located in the black sea region of türkiye it was determined that refugee children had difficulties in communicating with their teachers and peers as a result it has been observed that syrian students are largely deprived of the knowledge skills and attitudes provided by the school in addition it was determined that they could not socialize as a result of difficulties in getting along with their peers and they were mostly alone another finding is that syrian childrens inability to meet basic care skills such as cleaning due to socioeconomic impossibilities creates discomfort for other families it was observed that when teachers had the opportunity to meet with parents they could not establish a healthy dialogue as a result of the interviews held with teachers school administrators syrian students and parents in altındağ district of the capital ankara the issues of communication education process classroom climate physical structure of the school school attendance enrollment behavior cultural differences academic success bullyingexclusion and marginalization were discussed it has been revealed that there are problems on these issues in the research in nevşehir one of the cities of the central anatolia region the classroom teachers stated the problems encountered in the education of syrian students language problem registration bullying adaptation attendance cleanliness separation and being unwanted by turkish parents in a study conducted in afyonkarahisar province in the west of türkiye it was revealed that teachers are in need of professional development in terms of analysis of the content of the education to be given to refugee students teaching strategies lesson tools and materials development and evaluation of measurement tools it has been stated that this situation arises from the fact that teachers receive university education for education in monocultural and monolingual environments and gain experience in this context as can be seen in various researches conducted in different provinces from the north to the west of türkiye from the inner regions to the capital it has been revealed that the syrian students face many problems as a result of the trainings given to syrian students however there are other studies that show that the training provided has positive results or that different applications can be more successful atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 a study on refugee children who came for religious education in the beykoz district of istanbul in 2020 showed that the content of the education provided ensured the interaction and harmony of refugee children with the society they live in this result revealed that common religion courses are of a quality that will make syrian students feel like a foreigner in türkiye however it has been stated that the content of religious education in question aims to protect refugee childrens ties with their past without isolating them from the culture of their own country in a study based on the opinions of teachers working in the 20172018 academic year in i̇stanbul and bursa the important industrial cities of türkiyes marmara region it was seen that teachers believed that there was no cultural conflict between syrian and turkish students studying at primary school despite cultural and social differences considering that the problem in cultural cohesion stems from not knowing the language it has been concluded that teachers benefit from group work values education social activities and childrens games for language improvement as a result of the research in question the results in line with the prediction that the problem of adaptation will be solved with the solution of the problem of not knowing the language of the teachers were also revealed in a study conducted in i̇stanbul accordingly in the research conducted through interviews with some teachers working in primary schools in i̇stanbuls ataşehir district it was concluded that the attitudes and perceptions of syrian students friends towards them were prejudiced and exclusionary at the beginning but a supportive and sharing attitude emerged with the increase in communication with the efforts of the teachers and the development of the language in a study conducted in samsun it was seen that teachers carried out activities to strengthen the communication skills of refugee children to ensure their active participation and to facilitate their adaptation to the social order for this purpose it has been determined that they have developed methods such as using illustrated text language teaching with games setting concise rules exhibiting a moderate approach creating a need for turkish by creating a purposeful seating arrangement in addition it has been determined that teachers use techniques such as technology use repetition and concretization to make it easier for students to understand on the other hand there are opinions in the literature that sports activities can contribute to the positive development of the personality of refugee children accordingly since participation in sports is a means of socialization sports activities are helpful in the psychosocial development of children and in solving sociocultural problems it has also been demonstrated by other research results that being able to speak a common language and share in common social activities such as sports increases harmony between local and refugee students it has been determined that in the 20192020 academic year syrian students studying in the çarşamba district of samsun encounter a general acceptance within the school and their adaptation problems decrease it has been observed that as the duration of students going to school in türkiye odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • increases their sense of belonging to türkiye also increases this situation shows the importance of taking measures to ensure the attendance of more syrian students to school although it is thought that sharing on common religion and belief is effective in harmony it is not as effective as speaking the common language in the research conducted with the teachers of religious culture and moral knowledge who work in various cities of türkiye and have syrian students in their classes different results have emerged the majority of the teachers participating in the research stated that syrian children experience various problems due to language barriers and that they encounter problems such as labeling marginalization and violence in social cohesion this example has shown that although common religious education is unifying in terms of harmony in terms of content it still prevents being successful enough if there is no practice of speaking the same language on the other hand integration with local people can be more successful for syrians living in cities in türkiye which have linguistic historical and cultural even ethnic and kinship ties with their country a study conducted in ankara and hatay provinces is an important example in showing the effect of living in cities close to their own culture on adaptation in a study comparing the situation of syrian children living in ankara and hatay provinces it was determined that children living in hatay province which is at border of syria have less difficulties and have more freedom for example syrian girls living in hatay feel more secure and can go out of the home more it is thought that the reasons for this situation are that hatay is culturally and geographically close to syria that there is a large number of people who can speak arabic that there are kinship ties with syrians and that hatay is a smaller city it has been stated that the fact that syrian children in hatay experience their own language and cultural characteristics more intensely here facilitated the adaptation process of the children but on the other hand it made it difficult for them to learn turkish and to comply with the countrys rules conclusion and recommendations after the migration to türkiye that started in 2011 many legislations have been published regarding the education of syrian children and young people in addition syrian people have implemented various projects in cooperation with the ministry of national education the european union and nongovernmental organizations to ensure their adaptation to the turkish education system and their access to education within the scope of the education policy for syrian children and youth in türkiye education have been started on five main platforms these are temporary education centers public schools syrian private schools open education institutions and higher education institutions in this context despite the legislative changes and the opportunities provided in all kinds of training platforms technical and social problems arose in practice atıf citation ökten serkan educational policies and practices regarding the adaptation of syrians under temporary protection to türkiye odüsobi̇ad 13 24572482 doi 1048146odusobiad1232477 doi 1048146odusobiad1232477 technical problems are difficulties experienced in the registration process difficulty in determining equivalence and class level problems in accessing and participating in education language learning problems difficulties in overcoming war trauma and the need for specially trained trainers lack of curriculum and teaching materials valid diploma problem in temporary education centers the lack of coordination information and guidance social problems such as disadvantaged children without family or disabled children early marriage and child labor as a result of socioeconomic insufficiency social acceptance and adaptation problems uncertainty lack of planning absenteeism from school health problems irregularity transition to higher education without examination family indifference etc are other elements in the studies showing the results of the application it has been determined that solving the language problem in many different city examples generally ensures the social cohesion of the students and their success in education in conclusion the ministry of national education together with many international organizations in türkiye carries out important studies for syrian refugees in terms of adaptation to the national education system however in order to solve the problems and problems experienced decision makers should not only focus on the physical initiation of school for refugees but also develop multidimensional policies to ensure social cohesion in solving the problems here state institutions and ngos the joint work of syrian refugees and local governments will contribute there is a need for a culturally sensitive and inclusive education policy that will support the schooling of syrian children and support their education processes it is necessary to carry out childoriented studies that will take place in schoolfamilysociety cooperation in order to reduce the current problems of syrian students school social work practices should be carried out based on their needs individual differences and potentials and evaluating them with all aspects in a biopsychosocial framework also compliance is not a onesided situation therefore it requires the common will and practices of the local people and refugees therefore it is important that the social acceptance and adaptation process be carried out simultaneously and through policies that complement and support each other in this context while making policies and regulations regarding syrians under temporary protection in türkiye decision mechanisms should be established where their opinions will be taken in conclusion this study shows that the syrian refugees who were initially thought to be temporary were planned to continue their education in the camps and without obtaining a diploma or document and then with the prolongation of the war the necessary legal arrangements were made to include syrians in the turkish national education system and higher education despite the arrangements made it is seen that technical and social problems continue in practice and the desired level of participation in education after primary school cannot be reached however it has been revealed that the results of education policies for syrians under temporary protection vary with factors such as the odü sosyal bilimler araştırmaları dergisi issn 13099302 dergiparkorgtrtrpubodusobiad • cultural structure of the cities where syrians live in türkiye their geographical proximity to syria the population of arab origin in the city the status of schools and the qualifications and experience of teachers on the other hand it has been understood that the most important factor in ensuring success and harmony in education wherever it is is grammar it has been revealed in almost all researches on the subject that the efforts made to ensure sufficient success in this regard cannot provide the desired result to a large extent it has been determined that it is important to ensure that an increasing number of syrians receive education in higher education and that syrian academics take part in the academy even if it is not at the desired level the increase in this group as an educated and most adaptable group to contribute to employment has been found to strengthen the bond formation between both communities in this respect effective language learning in all age groups ensuring school attendance and increasing the number of academicians and students in the academy should be the priority policy issues for harmonization sosyal sorunlar ise ailesi olmayan dezavantajlı veya engelli çocuklar sosyoekonomik yetersizlik sonucu erken yaşta evlilik veya çocuk işçiliği sosyal kabul ve uyum sorunları belirsizlik plansızlık okula devamsızlık sağlık sorunları düzensizlik sınavsız yüksek öğrenime geçiş aile ilgisizliği vb diğer unsurlardır genişletilmiş özet eğitim politika uygulama sonuçlarını gösteren çalışmalarda birçok farklı şehir örneğinde dil sorununu çözmenin genel olarak öğrencilerin sosyal uyumunu ve eğitimdeki başarılarını sağladığı tespit edilmiştir bu kapsamda milli eğitim bakanlığı türkiyedeki birçok uluslararası kuruluşla birlikte suriyeli mülteciler için ulusal eğitim sistemine uyum açısından önemli çalışmalar yürütmekte olduğu söylenebilir ancak yaşanan sorunların ve sorunların çözümü için karar alıcıların sadece mülteciler için fiziksel olarak okul açılmasına odaklanması değil aynı zamanda toplumsal uyumu sağlamaya yönelik çok boyutlu politikalar geliştirmesi gerekmektedir buradaki sorunların çözümünde devlet kurumları ve stklar suriyeli mülteciler ve yerel yönetimlerin ortak çalışması katkı sağlayacaktır suriyeli çocukların okullaşmasına ve eğitim süreçlerine destek olacak kültürel açıdan duyarlı ve kapsayıcı bir eğitim politikasına ihtiyaç vardır okulailetoplum işbirliği içinde yer alacak çocuk odaklı çalışmaların yapılması gerekmektedir suriyeli öğrencilerin mevcut sorunlarının azaltılması için okul sosyal hizmeti uygulamalarının ihtiyaçları bireysel farklılıkları ve potansiyelleri temel alınarak ve tüm yönleriyle biyopsikososyal çerçevede değerlendirilerek gerçekleştirilmesi gerekmektedir ayrıca uyum tek taraflı bir durum değildir dolayısıyla uyum yerel halkın ve göçmenlerle ortak irade ve uygulamalarını gerektirir bu nedenle toplumsal kabul ve uyum sürecinin eş zamanlı ve birbirini tamamlayan ve destekleyen politikalar aracılığıyla yürütülmesi önemlidir bu bağlamda türkiyede geçici koruma sağlanan suriyelilere ilişkin politika ve düzenlemeler yapılırken görüşlerinin alınacağı karar mekanizmaları oluşturulmalıdır sonuç olarak bu çalışma uyum kapsamında eğitim politikası belirlenirken başlangıçta geçici olduğu düşünülen conflict of interest statement there is no financial conflict of interest with any institution organization or person related to my article titled educational policies and practices regarding the adaptation of syrian under temporary protection to türkiye

in 2011 after the internal conflicts in syria mass migration to türkiye started syrians entering the country are under temporary protection status in the face of this situation policies that required social cohesion were implemented and education became one of the most important cohesion policies in this context revealing how education is provided for immigrants in türkiye has been important in demonstrating the success of integration policies in this study it is aimed to reveal what are the policies and implementation results for the inclusion of syrians under temporary protection in the turkish education system in the method of the study official statistics legal regulations news and academic research were handled and document analysis was used in this context all dimensions of the subject from primary education to higher education were categorized when the findings were shared systematically it was seen that the syrians who were initially considered temporary continued their education in the camps without obtaining a diploma or document with the end of the war legal arrangements such as educational services for foreigners and execution of services for foreigners under temporary protection were made in order to include syrians in the turkish national education system and higher education in the field studies examined in the literature analysis it was seen that despite the legal regulations technical and social problems continued in practice and the participation in postprimary education was low in addition it has been revealed that the success of education policies for syrians under temporary protection is related to the cultural structure of the cities where syrians live in türkiye their geographical proximity to syria the population of arab origin in the city the status of schools and the qualifications of teachers as a result of the implications of the findings it is recommended to provide effective language learning to all age groups to ensure continuity in school after primary school by taking measures against situations that prevent participation in the lesson and to encourage syrian academicians and higher education students who are the most susceptible group

introduction with the emergence of feminism more and more people are becoming aware of the importance of gender equality however gender inequality still persists in visual culture that guides peoples mindsets the visual culture of gender inequality revealed in many films is subliminally reinforcing the cultural norms of the audience according to dowd cinema is a teaching machine especially the way in which it socializes people in a subtle way and provides informative representations of how people should behave 1 the messages of gender inequality and visual culture are implicit in many hollywood films which are becoming very popular with the audience based on the theories of feminism and visual culture this paper briefly explores how the visual culture of gender inequality is reflected in hollywood films focusing on three aspects namely the unequal representation of men and women in the films the imbalance of male and female film workers and their incomes and the predominance of male perspectives in hollywood films and the gender stereotypes hollywood has also focused on gender equality for a long time several scholars in academia have shown that in the early days of film history men and women were equal and women played a key role in the film industry stamp said that in the silent era of film history women occupied key positions like directors writers and producers 2 hills never did describes the various important tasks that women performed behind the scenes of the film industry in the beginning he argued that the persistence of feminized areas of labor in the film industry today such as work casting script supervision publicity and editing is mostly based on womens creative service in the early days of the film industry 3 smyth told that the heyday of the film business was run by women 4 despite the significance of women in the history of cinema and the gender equality they showed todays cinema still has many inequalities between men and women this exemplifies the changing positions of women in the film industry and the growing gender inequality this paper therefore examines the issue of gender inequality in visual culture focusing on a few representative hollywood films and using relevant statistics to demonstrate how gender inequality is reflected in the visual culture of hollywood films the inequality between men and women in hollywood films in todays innovative open and inclusive film industry women still possess fewer positions and achieve less income compared to men the unequal time distribution in hollywood movies the time male actors occupied is almost twice as long as female actors these data are obtained through the machine learning system the machine learning system is jointly developed by the university of southern california gina davis media gender research institute google charity and other organizations this system uses language recognition and faces recognition algorithms it can distinguish the gender of actors in a film and record their appearance time because of a lot of training the system can be accurate in seconds according to the statistics in the three years from 2014 to 2016 there were 100 liveaction films with the highest box office in hollywood and female actors only accounted for 36 of these films 5 in most films male actors occupy a dominant position in terms of the number of people and the responsibilities they undertake male actors occupy the dominant power so their discourse power is more and their importance is higher than that of women leading to the relatively low sense of the existence of female actors in films and the marginalization of female roles in hollywood there are many films with the theme of women for example antman and the wasp is a film that can be said that men and women have equal status 6 as a female superhero the hornet woman has the same ability as the male superhero her destiny is in her own hands and she does not need to rely on the protection of others this phenomenon is extremely rare in films antman and the wasp is also known as a film in which female characters in marvel have occupied the longest time however even so the heroine van danes appearance time in this film is only 35 minutes 7 therefore although gender equality is constantly improving with the development of the times it is still not the mainstream idea and gender equality is only reserved at the theoretical level not practical in hollywood movies most of the protagonists are male the study the film world of men using a sample of 2300 characters from the top 100 domestic box office films of 2013 found that 85 of the leading characters in hollywood films in 2013 were men 8 this is especially true in action movies in this genre movies like spiderman iron man and hulk all have male heroes 9 10 11 imdbs top 20 movies are almost exclusively male stacey smith a professor at the university of california santa barbara looked at the films of 2014 and found that only 21 of the top 100 grossing films had a female lead or colead 12 in hollywood movies the camera setting is usually dominated by the male protagonists and the angle of view is also guided by them male characters act as the gods of hollywood movies were women and there was only one female director in every 23 directors in the past 12 years the number of female directors did not exceed 10 each year in 2008 the number of female directors reached the highest accounting for 8 in 2018 female directors accounted for only 36 13 men also account for the majority of behindthescenes positions in photography editing props group film dubbing and so on this situation has not been improved compared with more than ten years ago the longterm gender discrimination has a negative impact on the female behindthescenes staffs even most people think that in the behindthescenes work of the film women will only act as assistants clothing designers and makeup artists according to the 2015 hollywood diversity report 83 of the senior executives of major hollywood film production companies are male and more than 6000 members of the academy of film arts and sciences are all male only 228 of hollywoods toplevel workers are women and less than 6 of them are nonwhite women 14 the ability of female behindthescenes staffs is equal to that of men they can even create greater value but the ability of women is often ignored this kind of thinking does not mean that women and men have physiological differences but that women are not able to undertake this job women are deprived of the right to obtain fair social distribution the income gap between male and female actors in hollywood movies the income gap between male and female actors is also incredible american actress natalie portman who won the best actress award at the 83rd academy awards said publicly after she starred in the film wireless love that her remuneration was only onethird of that of the actor ashton kutcher 15 in the 2013 film american hustle the remuneration of the female stars jennifer lawrence and amy adams was far lower than that of other male supporting roles in the film 16 during the films release the roles of actresses in propaganda were far greater than those of male actors but they still received much lower salaries than male actors in recent years more and more actresses have come forward to speak for the issue of equal pay for equal work for hollywood actors and actresses at the same time many films showing strong female images have emerged endlessly but they have not really changed the current situation of gender discrimination in hollywood gender stereotypes in hollywood films gender stereotypes can be reflected in the plots portrayed in many hollywood films women are often portrayed as inherently weak characters who are dependent on their men moreover they are also the representatives of sex dowd argues that sex and desire are central elements in the portrayal of women in the hollywood filmmaking system 1 denzin thinks that classic hollywood films have never been kind to women and women have always been given stereotypical roles either good women or bad women good mothers or bad mothers sinners or saints 17 das discusses that women are often depicted as traditional roles such as family members companions sex partners and janitors and their positions are subordinate to men 18 greenberg argues that women are also portrayed as thin and sexualized 19 this shows that gender stereotypes can be deeply reflected in traditional hollywood films however hollywood films do not really eschew gender stereotypes with the influence of feminism hollywood films have not directly portrayed women as completely dependent on men for survival but gender stereotypes and gender inequalities can still be seen in the films the portrayal of female characters is still bound by gender stereotypes in terms of dress and pursuits many people consider the film legally blonde to be clearly a feminist film and a big step forward in hollywoods portrayal of women as strong independent and critical thinkers however according to history in politics the film is still full of stereotypes of women 20 for example women like pink and the pursuit of love is a womans main goal in life and investing in fashion and beauty is a womans second goal in life while the film does attempt to attack the stupid blonde stereotype other stereotypes of women persist in terms of the plots that shape the destinies of women hollywood films still cannot escape gender stereotypes wartenberg states that an adventurous and independent woman in the first ten minutes of a hollywood film is likely to evolve into a more submissive and supportive assistant to the man over the course of the film 21 such plots are evident in classic hollywood films such as pretty woman in which the resourceful vivian is far more excellent in the early stages of the film than wealthy businessman edward but she gradually changes into a more traditional supporter of edward after she loves edward 22 in the film the maid of manhattan the female protagonist in the film named marissa is a single mother working as a maid in a fourstar manhattan hotel 23 despite the low status of her job marissa is resourceful intelligent and friendly and is admired by her peers she is also a loving presence in the life of her precocious young son things change however when she meets an upandcoming politician christopher marshall when he leaves her in the second act her world falls apart when her son intervenes with christopher and asks him to forgive his mother for her mistake the politician brings her back and marisa becomes a successful businesswoman the film embodies the default gender stereotype that womens success depends on the intervention of a male sponsor thus gender inequality persists in hollywood films women are always the objects of sight and behavior of male protagonists in movies the female figure is shown from the male perspective the audiences viewing angle is male because the frame of the film is always focusing on male protagonists the male gaze phenomenon is particularly prominent in hollywood films the male gaze refers to the view from the angle of heterosexual men through whom females are sexually objectified to please male audiences research published by the annenberg school for communication and journalism also found that female characters are more often used as sex objects in films than men nearly 28 percent of all female characters appeared in sexy costumes and only 8 percent of men did this only 91 percent of male characters showed nudity while 264 percent of female characters showed nudity 24 for example in the movies spiderman hulk and iron man the heroes rescue the female characters in trouble to show their strength and bravery the film world of men found that only 15 percent of hollywood films last year featured female protagonists the researchers said that female characters in films mostly exist to serve male characters and are rarely portrayed as leaders 8 overall the gender stereotypes portrayed in hollywood films did not disappear with the advent of feminism on the contrary gender equality in hollywood still has a long way to go conclusion this paper has argued that in hollywood films the visual culture of inequality between men and women is mainly reflected in the distribution difference between men and women and their representation in films by observing some hollywood movies a series of phenomena show that women are still treated unfairly in hollywood movies this shows that in hollywood movies there is still a long way to go to achieve real equality between men and women although the theoretical framework is not systematic this study can make more people aware of the unequal treatment women face some phenomena reflected in hollywood movies are closely related to mainstream ideology because women are in an unequal position in society the images of women in the movies are also unequal with the power of film culture more people can pay attention to the interests and situations of women future studies can look into female filmmakers who show and give play to their abilities contribute to the film industry and let the audience in front of the screen feel the power of women

the main content of this paper is to explain how the visual culture of gender inequality is reflected in hollywood films this paper refers to current research and reports about hollywood and analyzes some specific movies including antman and the wasp spiderman iron man and hulk the paper concludes that the visual culture of gender inequality is mainly reflected in the differences between men and women in the distribution of time work and income specifically compared to men women get fewer chances to play in a film have lower positions in the film industry and earn less furthermore it is found that most movies apply the perspective of men and repeat gender stereotypes therefore this paper hopes that more people can pay attention to the interests and situation of women

introduction since the emergence of the first case of coronavirus disease infection on december 31 2019 the severe acute respiratory syndrome coronavirus 2 has spread rapidly throughout china 1 there is no strong evidence that the coronavirus originated in china but the epidemic outbreak in china was found to exist in an epidemiological link to the wholesale seafood market in wuhan china 2 by march 26 2020 the number of confirmed cases in the city of wuhan had reached 50006 people and accounted for 6148 of all confirmed cases in the country 3 this made wuhan a highrisk region for the epidemic in china nearly all of the infected patients emerging from other regions had some sort of connection with wuhan either by having traveled to wuhan or by coming into contact with infected patients from wuhan 4 the chinese government implemented appropriate and timely response measures to contain the outbreak by quarantining wuhan city and setting up inspection points in other regions for people with a travel history to wuhan or its surrounding regions 2 this method of inspection relies on the public to submit reports voluntarily but its effectiveness does not appear to be satisfactory several cases of withheld information were uncovered subsequent to the onset of an individuals illness or an outbreak of covid19 in localized clusters for example a man from jinjiang fujian lied that he was returning from the philippines when he was in fact traveling home from wuhan he carried out regular activities and attended gatherings which resulted in the home quarantine of over 4000 people another individual from yaan sichuan became ill after returning from wuhan despite being repeatedly questioned by medical staff whether they had visited wuhan or its surrounding regions hou never admitted the truth exposure to this individual resulted in the quarantine of over 100 people including more than 30 medical staff another person in hebei who withheld their history died after missing the opportune time for treatment leading to 77 close contacts being quarantined tens of thousands of people have been forced to undergo quarantine and to shoulder the risk of infection resulting in a devastating outcome and consequences that still cannot be properly estimated the act of withholding travel history to highrisk regions is posing a difficult challenge for epidemic prevention and control and has greatly undermined epidemic response measures worse still the epidemic is no longer limited to china more than a hundred countries including the united states italy and the united kingdom have reported cases of the infection and the number of afflicted countries and cases continues to rise a study on the publics willingness to report on travel history to highrisk epidemic regions will provide support for countries that are facing or will possibly face the epidemic therefore this studys goals were as follows 1 to elucidate and analyze the publics willingness and beliefs associated with reporting travel history to highrisk epidemic regions 2 to provide effective suggestions and measures for encouraging the public to report their travel history in response to the world health organizations advocacy for nonpharmaceutical interventions methods questionnaire design after conducting the necessary literature research and receiving expert advice we developed a selfadministered questionnaire to confirm the effectiveness of the questionnaire we invited seven experts from fields such as health emergency epidemiology and public psychology as well as three health administration workers who are currently in charge of epidemic prevention and control to engage in two rounds of reviews of the questionnaire in addition we formed a team of 30 people to carry out a twoweek reliability retest the team was recruited voluntarily from harbin heilongjiang province china based on the principle of convenience they responded to the entire questionnaire and again two weeks later the data obtained was not used for the final analysis this questionnaire included the following parts sociodemographic information willingness and beliefs associated with reporting on travel history to highrisk epidemic regions cues that promote reporting on travel history to highrisk epidemic regions the dependent variable in this study was the respondents selfrated willingness to report on travel history to highrisk regions which was evaluated by the item supposing you have a travel history to wuhan would you report this to the designated department facility or personnel using a fivepoint likert scale ranging from 1 to 5 during analysis for the purpose of comparing respondents who had a positive willingness toward reporting with those who did not we sorted those who selected 4 and 5 into the category report and those who selected 1 2 and 3 into the category not report in the results of this study the number of respondents who chose each item of the dependent variable was as follows 15 213 373 4107 and 51146 sociodemographic data were collected including the respondents gender age education level marital status place of residence living arrangement and religious belief among them the religious belief data was obtained by the item do you have a religion using yes or no as the answer option in addition we used the macarthur scale of subjective social status to evaluate the respondents social status this scale yields comprehensive ratings for the level of income occupation and education 5 the scale contains two items respondents rated their perceived social status within their country and community from 1 to 10 with the total points falling within a range of between 2 and 20 respondents were divided into two groups according to the median ≤ 11 was lower class 11 was upper class the respondents beliefs associated with reporting on travel history was assessed through nine prompts to which they indicated their degree of agreement by selecting a rating between 1 and 5 the respondents overall perceptions of travel history and the covid19 infection were evaluated by the following prompt travel history has an impact on contracting covid19 the respondents perceptions of the benefits of reporting were assessed by two prompts reporting can confirm whether i contracted covid19 earlier and reporting can help discover earlier potential patients infected by coming in contact with me the respondents perceptions of obstacles to reporting were assessed by five prompts including reporting makes me feel stigma in addition another prompt judged respondents perception of the consequences of withholding travel history withholding travel history to highrisk epidemic regions will result in legal liability during analysis all responses to the prompts were converted into binary variables respondents who rated 4 and 5 were sorted into the category agree whereas respondents who rated 1 2 and 3 were sorted into the category disagree in the questionnaire we also designed an item to investigate which cues would promote respondents to report the item allowed multiple selections including cues such as persuasion by family or friends community public speaking and people around me showing potential symptoms of covid19 sample and data collection the crosssectional study was carried out in the format of an anonymous webbased questionnaire the questionnaire survey was conducted among residents of nine provinces with varying epidemic levels selected based on the cumulative data of confirmed covid19 cases publicized by the national health commission of china the health commissions of various provinces cities and districts and the governments of each province city and district as of february 11 2020 provinces where the epidemic was more severe were henan zhejiang and guangdong provinces where the epidemic was moderately severe were heilongjiang anhui and yunnan provinces where the epidemic was less severe were jilin inner mongolia and gansu based on the ranked cumulative numbers of confirmed cases of the cities within each province a city where the epidemic was severe and a city where the epidemic was relatively mild were drawn from each province using the method of convenience sampling questionnaire administrators were recruited from the sample cities who were undergraduates or postgraduates of harbin medical university and postponed their return to school due to covid19 in addition to recruiting two administrators in the three sample cities all the other sample cities recruited an administrator for a total of 21 administrators they sent a link to the questionnaire to the residents in their communities through social networking software such as wechat alongside an explanation of the studys intention and anonymity those who received the link could voluntarily decide whether to respond and we required at least 100 people in each sample city to receive the link the data were collected between february 12 and 19 2020 finally a total of 1965 people received the link in addition according to the questionnaire network platform 1823 people clicked on the link and 1481 people responded to the questionnaire the researchers carefully reviewed the questionnaires and eliminated those submitted by participants under the age of 18 years and participants who selected the same answers to every question a total of 1344 valid questionnaires were finally collected data analysis descriptive analysis was used to show the sociodemographic characteristics of the respondents their willingness and beliefs associated with reporting on travel history to highrisk regions and cues that could potentially promote reports chisquared test and fishers exact test were used to analyze the correlation between the participants willingness and beliefs to report spss 220 was used to conduct the analysis statistical significance was set at p 005 results characteristics of the respondents more than half of the respondents were women the ages of the respondents were concentrated between 21 and 30 years old among the respondents 6176 had an education level of undergraduate or above and 5603 were single more than half of the respondents normally resided in cities and a majority lived with family or friends almost all of the respondents were nonreligious the majority of the respondents perceived themselves to be lower class in social status 677 of the respondents chose not to report when they had a travel history to wuhan and 9323 of the respondents chose to report gender age educational level marital status place of residence and living arrangement were significantly correlated to willingness to report on travel history 935 of men chose not to report which was higher than that of women respondents under the age of 20 had the highest nonreporting rate while those aged 41 to 50 had the lowest rate in terms of education level the proportion of people who chose not to report was the highest among college graduates but the lowest among those with master degree and above single respondents had a higher percentage of nonreporter than married and widowedseparateddivorced in addition about onetenth of the respondents who live in countryside chose not to report which was higher than that of those who live in city the proportion of people who chose not to report among the respondents living with others was higher than living alone and living with family or friends beliefs associated with reporting on travel history to highrisk epidemic regions overall 8304 of respondents believed that having a travel history to highrisk epidemic regions would increase chances of contracting covid19 over four out of five respondents agreed that reporting on travel history can help to confirm whether they had contracted the infection sooner and discover potential patients who were infected by coming in contact with them earlier about half of the respondents believed that reporting would make them feel stigmatized other percentages of respondents believed reporting would result in high followup checks or treatment expenses did not know how to report and believed reporting was very inconvenient in addition 588 of the respondents expressed fear of potential quarantine after reporting on their travel history overall nearly onefourth of the respondents did not believe withholding information on travel history to highrisk regions would result in legal liability table 2 displays the factors that are significantly correlated with a willingness to report on travel history to highrisk epidemic regions cues that promote reports of travel history to highrisk epidemic regions figure 1 displays the cues that respondents perceived may encourage their reporting of travel history to highrisk epidemic regions hearing about cases where withholders of travel history were punished by law was the most selected option followed by people around me showing potential symptoms of covid19 and advocacy on television the internet and other media discussion our study evaluated the current willingness and beliefs associated with reporting on travel history to highrisk epidemic regions among the chinese public as well as the correlation between their willingness and beliefs a proportion of the public was found to be more inclined to withhold their history although the majority agreed to report nonetheless considering that any withheld history case can result in unpredictable outcomes this result already deserves great attention 7 8 9 after the emergence of frequent incidences of withheld history chinese authorities implemented more severe measures including restricting population movement in cities and communities rewarding those who provide clues to withholders and instigating systematic blanket searches in communities 1011 however in all of these actions the public plays a relatively passive role therefore research into the association between the publics willingness and beliefs to report on travel history is essential for promoting the publics voluntary reporting this study discovered several factors associated with the willingness to report on travel history to highrisk epidemic regions first is the belief of benefiting from reporting apart from being able to test whether one is infected as soon as possible a more valuable benefit of timely reporting on travel history is that it helps to identify other potentially infected patients the department responsible for epidemic prevention and control would be able to investigate the public transportation that reporters took the recent events in which they participated and the number of people that they had been in contact with this response would allow potentially infected patients to be examined and prevent them from further spreading the virus 12 the results of the study reflect that the proportion of the public that recognized these benefits demonstrated a greater willingness to report however our research cannot determine whether the reporting behavior of the public could be attributed to egoistic behavior or altruistic behavior emphasizing all the benefits of reporting in public advocacy may be the better option for promoting a willingness to report furthermore prospect theory in behavioral economics asserts that people have a mentality of aversion toward loss their level of sensitivity toward losses and gains are unequal and the pain they feel in the face of loss is far greater than the joy of gaining 13 thus instead of promoting the benefits of reporting the government can promote the risks of not reporting in public advocacy to activate the lossaverse mentality in the public and encourage action second considering the perceived obstacles to reporting the feelings of stigmatization that reporting brings and the fear of potential quarantine are factors that influence the willingness to report the proportion of the public that believed reporting would cause stigmatization and feared the quarantine that they may face after reporting expressed a lower level of willingness to report the stigmatization and discrimination of potential patients are phenomena that were present since the early stage of epidemic outbreak 14 reporting on travel history might cause the reporter to be labeled a potential patient which lowers their willingness to report 15 the exaggerated and arbitrary description of risk associated with having a travel history to wuhan provided by chinas official statements and media reports may also worsen the publics isolation of people with such an experience despite it not being the original intention thus social support and social policies should be available for potential patients including the reporter of travel history which would alleviate the social stigma attached to the travel history reporter and ease the discriminative atmosphere for example the objective open and continuous epidemic information publicity and communication with the public based on reliable medical investigation and experience as well as nondiscriminatory treatment to the travel history reporter by epidemic prevention and control departments and staff may improve the situation the government and media should also draw connections between regions and the infection with discretion to prevent the situation from worsening into regional discrimination in addition this study and past studies concur that the public fears restrictive epidemic control measures such as quarantining 16 17 18 on some level this fear is an extension of the underlying anxiety surrounding an infectious disease with an unknown cause and possible fatal outcome 19 members of the public with a travel history would generally be subjected to the prevention and control process of quarantine after reporting until the incubation period passes without incident fear of this has also become one of the factors that impact on the willingness to report therefore effective health education strategies and public risk communication are necessary to allay such fear third this study showed that the members of the public that agreed that withholding travel history to highrisk epidemic regions would result in legal liability demonstrated a greater willingness to report to combat covid19 china implemented class a epidemic prevention and control measures each province and city successively implemented firstlevel responses to the major public health emergency during this time all units and individuals were required to comply with epidemicrelated measures enforced by disease prevention and control facilities and medical facilities and truthfully provide relevant information deliberately withholding travel history to highrisk regions would result in a conviction for the crime of endangering public security by dangerous means based on the severity of the outcome 2021 shanghai even introduced chinas first covid19 legislation those who evaded quarantine by withholding their travel history would be diligently pursued for applicable legal liability based on the law 22 understanding that their action may result in serious consequences enforced by the legal system may suppress the publics desire to withhold information thus based on the existent legal framework on withholding travel history the government should further expand public campaigns to explain legal obligations to report on travel history and emphasize the consequences of withholding information in investigating the cues that may encourage the publics reporting of travel history we found various types of effective cues with the greatest number of respondents admitting to the effectiveness of hearing about cases where withholders of travel history were punished by law this outcome could enhance the publics acknowledgment of the illegality of withholding information as well as prompt public consideration of law enforcement dynamics however this study was unable to provide a conclusion regarding the publics sensitivity toward different penalties and frequency of hearing cases of people being prosecuted as well as the threshold that affects their ultimate actions this aspect would require further exploration in future seeing others showing potential symptoms of covid19 also encourages individuals to report their travel history as withholding information increases the concern of negatively impacting others epidemiological analysis from the chinese center for disease control and prevention shows that there are more than 1000 cluster covid19 cases in the country 83 of them are familybased or occurring in common gathering places such as medical institutions schools shopping malls and factories 23 another cue was the public speaking by communities thus far grassroots communities including rural communities have played a unique role in chinas epidemic prevention and control as well as in social governance 24 the power of grassroots leaders made it possible to manage residents of each jurisdiction systematically to monitor the epidemics advancement promote epidemic information and educate residents on healthy behavior the community is the publics direct recipient processer and promoter of travel history reports to highrisk epidemic regions and as such most members of the public report to their communities first if they have the willingness to report chinas leader xi jinping has commented as follows the community is the frontline in epidemic prevention and control and is the most effective line of defense in blocking external infectious sources and containing internal spread 25 under the current situation where the epidemic is spreading globally each country can consider mobilizing their communities for prevention and control as china has doneto place the power of prevention and control in the community nevertheless this study has the following limitations first the publics willingness and beliefs associated with reporting on travel history to highrisk epidemic regions may change with the course of the epidemic a crosssectional study is limited in its usefulness in capturing this type of dynamic change future research may consider a longitudinal design second this study only analyzed the effects that sociodemographic characteristics and beliefs associated with reporting travel history had on the willingness to report there may be other factors affecting the publics willingness to report third considering the cost and convenience of conducting research this study only selectively investigated a portion of provinces and cities based on the severity of the epidemic outbreak for more universal results a study on a larger scale may be necessary fourth this study only measures and analyzes the respondents subjective social status future research may need to consider the impact of objective social economic status which will contribute to more precise crowd intervention conclusions our study on the chinese publics willingness to report on travel history to highrisk epidemic regions showed an inclination to withhold travel history albeit in a small proportion of the public considering that any incident of withheld history can result in unpredictable outcomes this finding demands attention our study also indicated that the belief of the benefits of reporting obstacles to reporting and legal consequences of withholding travel history would affect willingness to report therefore on the one hand suitable public risk communication and public advocacy strategies should be carried out to reinforce the understanding that travel history reporting allows the individual and others to receive infection screening and treatment earlier and alleviate the fear of potentially being quarantined after reporting on the other hand social support and social policies should be made available to potential patients including the reporters of travel history to eliminate the feeling of stigma that may arise from reporting travel history the government and media should draw connections between regions and the infection with great discretion to alleviate the phenomena of stigmatization and discrimination to which potential patients are subjected finally reinforcing the legal accountability of withholding travel history and strengthening systematic community monitoring are measures currently taken by china to promote reports on travel history to highrisk regions these actions provide internationally relevant experiences to countries that are currently facing the spread of the epidemic and countries at risk of its potential spread in response to the whos advocacy for nonpharmaceutical interventions supplementary information supplementary information accompanies this paper at 1186s12889020092824 additional file 1 questionnaire questionnaire developed for this research abbreviations covid19 coronavirus disease 2019 sarscov2 severe acute respiratory syndrome coronavirus 2 who world health organization authors contributions mj ss and qw contributed to the conception and design of the study lw zs and yw contributed to the data collection lw zs and gz contributed to literature search and data quality control hj and sz did the statistical analysis and drafted the original manuscript yl revised the manuscript for important intellectual content yw cl and lw prepared the manuscript and supplementary material all authors contributed to data interpretation and rewriting the paper all authors have read and approved the manuscript lw zs yw contributed equally to this work mj ss qw are corresponding author competing interests none to declare

background the coronavirus disease 2019 covid19 that first occurred in wuhan china is currently spreading throughout china the majority of infected patients either traveled to wuhan or came into contact with an infected person from wuhan investigating members of the public with a travel history to wuhan became the primary focus of the chinese governments epidemic prevention and control measures but several instances of withheld histories were uncovered as localized clusters of infections broke out this study investigated the publics willingness and beliefs associated with reporting travel history to highrisk epidemic regions to provide effective suggestions and measures for encouraging travel reporting methods a crosssectional study was conducted online between february 12 and 19 2020 descriptive analysis chisquared test and fishers exact test were used to identify sociodemographic factors and beliefs associated with reporting as well as their impact on the willingness to report on travel history to highrisk epidemic regions results of the 1344 respondents 91 677 expressed an inclination to deliberately withhold travel history those who understood the benefits of reporting and the legal consequences for deliberately withholding information showed greater willingness to report their history p 005 conversely those who believed reporting would stigmatize them and feared being quarantined after reporting showed less willingness to report p 005

background globally intimate partner sexual violence a form of intimate partner violence has been declared as a public health issue considering its longterm physical biological psychological and neurological consequences on victims in society 1 2 3 ipsv is defined as sexual acts committed or attempted by an intimate partner without the consent of the victim or against someone unable to give consent 4 it involves rape unwanted pressured penetration intentional sexual touching and noncontact acts of sexual nature 4 ipsv is common among women globally although some men could also be victims an estimated 1 out of 10 men experience ipsv while 1 out of 4 women experience ipsv in their lifetime 4 also a recent literature review reported that the prevalence of ipsv among women range from 94 152 in several countries in the americas 5 several factors have been indicated to contribute to high levels of ipsv among women for instance it is established that cohabiting partners report higher rate of sexual violence compared with married women 5 furthermore sociocultural beliefs of women being recognized as the property of men and other sociodemographic characteristics such as poverty financial insecurity lower level of education and smoking among others have also been documented to be associated with ipsv 12 4 5 6 cigarette smoking is indicated to be prevalent among women who are victims of ipsv 47 several studies have established sexual violence to be one of the significant predictors of cigarette smoking among women 278 smoking is assumed to ease the stress women undergo in abusive relationships 124 a longitudinal study has found that women who smoke are likely to report sexual violence compared to women who do not smoke 4 papua new guinea is known to have high prevalence of sexual violence against women 910 about 41 of men admitted raping a woman while one third of women have suffered sexual violence 10 populationbased studies in png have demonstrated high prevalence of ipsv and ipv in general 910 however they have scarcely considered the influence of ipsv on cigarette smoking among women in union thus irrespective of the high prevalence of intimate partner violence in png studies linking ipsv and cigarette smoking among women in union are limited this study extends the present literature by examining the association between ipsv and current cigarette smoking among women in union in png this is an important public health issue for many reasons while ipsv has been associated with an elevated risk for physical and mental health problems cigarette smoking increases the risk of adverse health outcomes the aim of the present study is to examine the prevalence of ipsv and its association with cigarette smoking among women in union in png by controlling for demographic social and economic factors thus the study seeks to test whether ipsv is significantly associated with cigarette smoking and the role of sociodemographic and economic factors in the association this study focused on sexual violence because it is one of the most prevalent forms of genderbased violence in png 10 furthermore some studies have suggested that while sexual violence may include physical violence factors associated with each violence form could differ and as a result it is imperative to separately focus on each form of ipv 11112 methods data source sampling technique and sample size this crosssectional study used data from the papua new guinea demography and health survey conducted from october 2016 to december 2018 this is the first demographic and survey conducted in png the pngdhs aimed to generate comprehensive data on demographic maternal and reproductive issues such as fertility family planning awareness and practices breastfeeding practices health behaviors immunizations domestic and intimate partner violence among others through the demographic and health survey programme technical support for the execution of the survey was provided by inner city fund with the financial support of papua new guinea government australian government department of foreign affairs and trade the united nations population fund and unicef 13 the sample for the 201618 pngdhs was nationally representative and covered the entire population that lived in private dwelling units in the country the survey used the list of census units from the 2011 papua new guinea national population and housing census as the sampling frame and adopted a probabilitybased sampling approach specifically a twostage stratified cluster sampling procedure was followed the methodology and selection procedure details have been reported in the pngdhs final report in summary each province in the country was stratified into urban and rural areas yielding 43 sampling strata except the national capital district which has no rural areas the division paid particular attention to urbanrural variations samples of census units were selected independently in each stratum in two stages in the first stage sorting the sampling frame within each sampling stratum to achieve implicit stratification and proportional allocation using a probability proportionaltosize selection was done in the second stage of sampling a fixed number of 24 households per cluster were selected with an equal probability systematic selection from the newly created household listing resulting in a total sample size of approximately 19200 households to prevent bias no replacements and no changes of the preselected households were allowed in the implementing stages in cases where a census unit had fewer than 24 households all households were included in the sample a total of 17505 households were selected for the sample of which 16754 were occupied of the occupied households 16021 were successfully interviewed yielding a response rate of 96 in the interviewed households 18175 women age 1549 were identified for individual interviews interviews were completed with 15198 women yielding a response rate of 84 in this present study the sample comprised 9943 women who were in union during the survey thus our analysis used data only on women who were in union during the survey data availability and ethical consideration the data have been archived in the public repository of dhs the access to the data requires registration which is granted specifically for legitimate research purposes consent forms were administered at household and individual levels in accordance with the human subject protection the dataset can be accessed at dhspr ogram com data datas et papuanewguinea stand arddhs 2017 cfm flag 0 main outcome and predictor variables current cigarette smoking was the outcome variable in this study this was measured as having smoked cigarette in the last 24 h before the survey women in union were asked the question smoked cigarette in the last 24 h women in union current smoking status were classified as no no current smoking in the last 24 h or yes smoking in the last 24 h the key explanatory variable in this study was ipsv this variable was derived from the optional domestic violence module where questions are based on a modified version of the conflict tactics scale 1415 questions asked are in relation to physical sexual or emotional violence experiences in this study the focus was on the experience of sexual violence three standard items including whether the partner ever physically forced the respondent into unwanted sex whether the partner ever forced respondent into other unwanted sexual acts and whether the respondent has been physically forced to perform sexual acts she did not want to were used to generate the experience of intimate partner sexual violence for each of these items the responses were never often sometimes and yes but not in the last 12 months however for our analysis purpose we created a dichotomous variable to represent whether a respondent had experienced sexual violence in the past 12 months this was done by recoding the following responses never and yes but not in the last 12 months as no and yes often and sometimes as yes confounding variables theoretically and empirically relevant demographic and socioeconomic variables were included as confounders in all we included twenty socioeconomic and demographic variables to adjust for in the modelling these variables included age region religion place of residence highest educational level literacy marital status residing with a partner number of partners wives partners age partners education health insurance cover internet access mobile phone ownership watch television listen to radio read newspapermagazine occupation and wealth index the selection of these variables was informed by their statistically significant associations with sexual violence and cigarette smoking in previous studies 1241617 statistical analysis before the analysis all missing data were removed both descriptive and inferential analytical frameworks embedded in stata software version 130 were used the statistical analysis followed some essential steps we performed descriptive statistics such as frequencies and percentages to describe the sample the pearsons chisquare test was done to examine the differences in smoking cigarette by sociodemographic characteristics and ipsv a modified poisson regression adjusting for demographic social and economic variables was also performed to model the association between ipsv and cigarette smoking to estimate the relative risk of cigarette smoking 1819 the study used the modified poisson regression that incorporates the robust error variance procedure to optimize the accuracy of the estimates 18 as direct estimates of relative risk produce from modified poisson regression modelling may be a preferred method for estimating populationlevel risk 19 we fitted four regression models model 1 included dependent and independent results background characteristics of the participants the mean age of the participants was 3268 ± 008 years about 20 of the participants were aged between 2529 years 286 were from the highlands region 755 resided in the rural area 497 had primary level of education and 99 were christians again 83 of the participants were married 866 were currently living together with their partner and 338 had between 12 kids and 621 were not working distribution of cigarette smoking across exposure to ipsv table 1 shows the distribution of cigarette smoking across ipsv the results showed significant disparities in cigarette smoking and ipsv at p 0001 specifically 259 of women were exposed to ipsv while 268 of women who were exposed to ipsv smoked cigarette association between exposure to ipsv and current cigarette smoking among women in union in png table 2 shows the results of the association between ipsv and current cigarette smoking among women in union in png we found in all the four models that women who were exposed to ipsv were more likely to smoke cigarette in model 1 the study revealed that those who had experienced ipsv have a higher risk of smoking cigarette compared to those who had not experienced ipsv in model ii demographic variables were added to the variable in model i the study revealed that those who had experienced ipsv those from the highlands region those residing in urban areas those with no religion and those whose partners have 3 or more wives have a higher risk of smoking cigarette compared with their counterparts also participants aged 4549 years and those who are able to read a whole sentence have a lower risk of smoking cigarette compared to their counterparts in model iii when other social variables were added to all variable in model ii the study revealed that those who had experienced ipsv those residing in the momase region those living in urban areas those with no religion and those whose partners have 3 or more wives have a higher risk of smoking cigarette compared with their counterparts again participants aged 4549 years and those who are able to read a whole sentence have a lower risk of smoking cigarette compared with their counterparts in the final model when economic variables were added to all variables in model iii the study revealed that those who had experienced ipsv those from the momase region those with no religion those residing in urban area and those whose partners have 3 or more wives have a higher risk of smoking cigarette compared with their counterparts further participants aged 4549 years those who rated their wealth index as middle those who were clerical officers and those who are able to read a whole sentence have a lower risk of smoking cigarette the key take home message from the result is that after adjusting for diverse demographic social and economic characteristics at different levels of the model ipsv remained significantly associated with cigarette smoking among the participants as the direction of the association remained discussion this study examined the association between ipsv and cigarette smoking among women in intimate unions in png the present study adds to the current literature on ipv and cigarette smoking the study found that women who had experienced ipsv had a greater odds of smoking cigarette research on the association between ipsv and health risk behaviors especially cigarette smoking are well documented 20 and consistent with the findings of this study for instance in a crosssectional study that examined the association between intimate partner violence experience and cigarette smoking zhang and colleagues 20 found women experiencing intimate partner violence were more likely to smoke cigarette in the us a metaanalysis of 31 peerreviewed studies to evaluate the relationship between intimate partner violence victimization and cigarette smoking revealed victims of intimate partner violence are at greater risk of smoking with a composite side effect of d ¼ 041 21 thus across the collected and analyzed literature victims of ipv are significantly more likely to engage in smoking behavior than nonvictims sexual violence has been found to be more closely linked to activities such as cigarette smoking than other types of intimate partner abuses sexual ipv victimization exhibited the most pronounced connections with cigarette smoking according to a study done to investigate the health status and health risk behaviors related with experiences of psychological physical or sexual ipv among women getting care at a medical center 22 victims of ipv are more likely to smoke cigarette than offenders of ipv 21 it is important to also note that because of the circumstances surrounding intimate sexual assault it has great impact on victims psyches and the psychological repercussions last longer 21 studies have shown that victims of ipv experience mental health problems such as depression generalized anxiety disorder suicide risk and posttraumatic stress disorders 23 24 25 loneliness sleeping problem and short sleep 26 leading to variety of drug use disorders 24 these psychological outcomes associated with ipv are indicated to profound in women than in men 25 victims of ipv in most circumstances resort to health risk behaviors such as cigarette smoking as coping techniques against the stresses experienced 21 women who are victims of ipv also find consolation in smoking when they are unable to report the abuse to family members or law enforcement authorities 911 furthermore victims of ipv are sometimes forced by an abusive partner to use drug substances including smoking cigarette 27 a survey conducted by a national center on domestic violence trauma and mental health in the us found many victims of ipv are forced or coerced by abusive partners to use substances 28 our findings support the assertion that women are more likely to smoke as a psychological coping mechanism when they suffer stress anger or despair due to ipv and the association between stress and cigarette smoking has been reported to be stronger in women than in men 29 the present study also provides evidence to demonstrate that certain demographic and socioeconomic positions including age wealth index occupation partners number of wives region place of residence religion and literacy play a role in cigarette smoking among women in union evidently when compared to their counterparts those from the highlands region those who live in urban areas those with no religious affiliation and those whose partners have three or more wives had a greater odds of smoking cigarette wilson 30 posits that lower ipv is sometimes attributed with marriage urban residency and increasing age although all women can be victims of ipv regardless of their age marital status level of education income status place of residence and country of residence 31 bhona et al 32 found that women who have greater educational and socioeconomic levels are less likely to be victims of partner violence the findings of this study suggest that women between the ages 2529 years are mostly affected by ipsv and engaged in cigarette smoking as compared with other age group this supports the assertion that ipsv affects people of all socioeconomic backgrounds but youth from lower socioeconomic backgrounds are more likely to be exposed and suffer 24 moreover women of lower and higher socioeconomic status have more cigarette smoking tendencies as compared to those of middle socioeconomic status 33 as suggested by the findings of this study additionally the findings corroborate with a study which revealed that women with no formal education primarylevel or secondarylevel qualification have a larger chance of being smokers than women with a higher education 34 perhaps women with high education are more likely to have accessed information on the negative consequences of smoking some strengths associated with the present study need to be remarked the study utilized a nationally representative data to examine the association between ipsv and cigarette smoking in png thereby increasing the generalizability of its findings methodologically this study is also associated with some strengths the present study uses a relatively new analytical approach by applying the modified poisson regression that incorporates the robust error variance procedure to establish the association between ipsv and cigarette smoking the modified poisson regression approach can be regarded as very reliable in terms of both relative bias and percentage of confidence interval coverage 18 also extensive discussion in much of the literature has reached a consensus that the relative risk is preferred over the odds ratio for most prospective studies with binary outcomes as logistic regression modelling overestimates the odds ratios 18 35 36 37 38 in that regard the use of poisson regression has been a promising alternative of course there are some limitations that need to be commented our study does not explore any causal relationship between ipsv and smoking as pngdhs data are crosssectional in addition the present study relied on selfreported data which may be subjected to recall bias even accurate selfreported measures may reflect individual differences not associated with health per se also the ipsv variable was collected through an optional domestic violence module and as a result such type of sensitive information could not be reported or misreported by the participants moreover in this study current cigarette smoking was defined as smoked cigarette in the last 24 h before the survey this could have the potential to exclude women with a nondaily smoking pattern despite these limitations the research presented here is suggestive and represents important progress it calls attention to an association with scarce empirical examination in part due to limited research especially in the context of png public health and policy implications this study offers a number of policy implications that need to be acknowledged for the purpose of this study implications of the study have been grouped into three key areas 1 public health and practice implications 2 health policy implications 3 research implications first of all in relation to the public health and practice implications genderbased institutions and groups in collaboration with the png national department of health should organize health education and awareness creation campaign on cigarette smoking and ipsv in png the health education and awareness intervention should primarily center on health social and economic risks associated with smoking cigarette among women who experience ipsv based on the findings of this study the health education program should target more of women from the momase region those residing in urban area and those whose partners have three or more wives since they were having a higher log count on cigarette smoking in png also the proposed health campaign should target men and further educate them on the need not to expose women to ipsv because of the dangers associated with it again since our findings showed that cigarette smoking and ipsv are significantly associated increasing health campaign against ipsv could scale down cigarette smoking as part of this health campaign genderbased institutions and groups in collaboration with png health institutions should have a panel discussion with both men and women on why men expose women to ipsv to the best of our knowledge this form of discussion on experience of ipsv among women would help provide a framework to guide public health education on ipsv and its association with cigarette smoking concerning the health policy implications we propose that the developmentformulation of health policy that aims to reduce cigarette smoking among women who experience ipsv should include other significant demographic social and economic variables such as region of residence place of residence religion number of wives of partners age wealth index and nature of employment this is because aside from ipsv the above significant factors play a major role in cigarette smoking among women in png lastly in terms of the research implications since this study did not look at the following important research areas due to the nature of the dataset employed in this study future research should investigate the following areas 1 perpetuators of ipsv and associated factors 2 knowledge of women experiencing ipsv on the health social and economic risks associated with cigarette smoking 3 the moderating role of selfrated health in the association between experience of ipsv and cigarette smoking among women 4 enablers facilitators of cigarette smoking among women experiencing ipsv such studies can provide a comprehensive understanding of ipsv cigarette smoking and the association between these experiences capable of influencing policies and interventions conclusion the rates of ipsv and cigarette smoking among women in png in the current study were relatively high ipsv is shown to be a significant predictor of cigarette smoking among women in union in png understanding this association suggests that policymakers and relevant authorities in png can act to address ipsv to reduce cigarette smoking counseling to help victims of ipsv cope with stresses awareness creation service provision and program design on intimate partner violence are urgently required to minimize cigarette smoking among women in union in png additional file 1 authors contributions byaa performed the conception the design of the work the acquisition and the analysis eba pp and wad performed the design of the work and the creation of tables doo dv and pp performed the design and drafted the work all authors reviewed and edited the final version of the manuscript the author read and approved the final manuscript funding the current research received no specific grant from any funding agency commercial or notforprofit source no other entity besides the authors had a role in the design analysis or writing of the current article competing 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background intimate partner sexual violence ipsv is a prevalent public health problem affecting millions of people each year globally particularly in developing countries like papua new guinea png although over twothirds of women in png are estimated to experience some form of sexual violence in their lifetime empirical evidence is limited on the association between ipsv and cigarette smoking thus the present study aims to examine the prevalence of ipsv and its association with cigarette smoking among women in union in pngthis crosssectional study used data from the first demographic and health survey of png conducted between 2016 and 2018 a total of 9943 women aged 1549 years in intimate unions were included in this study we estimated the relative risk of smoking cigarette using modified poisson regression models with a robust variance and 95 confidence intervalsthe rates of ipsv and current cigarette smoking were 259 and 268 respectively the modified poisson regression results showed that ipsv was significantly associated with an elevated risk for cigarette smoking women with ipsv history were more likely to smoke cigarette relative to their counterparts with no ipsv history rr 133 95 ci 118150 in the absence of covariates after controlling for demographic social and economic factors the association between ipsv and cigarette smoking remained statistically significant rr 124 95 ci 108142 the rates of ipsv and cigarette smoking among women in union in png in the current study were relatively high irrespective of diverse demographic social and economic factors ipsv was still significantly associated with cigarette smoking among women in union in png the findings presented call the attention of policymakers and relevant authorities in png to an important association that needs to be addressed counseling awareness creation service provision and program design on ipsv are urgently required to minimize cigarette smoking and ipsv among women in union in png

introduction sexual violence is defined by the world health organization as any unwanted sexual act directed against a person regardless of the aggressors relationship with the victim and the context in which it occurs 1 the forms of sv may include sexual assault unwanted sexual advances sexual coercion or sexual abuse thus the term encompasses a wide variety of circumstances and configurations for example it includes rape within marriage and by strangers as well as abuse of minors and of persons who are mentally or physically incapacitated unwanted sexual advances or sexual harassment refusal to use protection against pregnancy or sexually transmitted diseases as well as many others are also included in their definition of sv the main reasons for the study of sv are the physical andor psychological consequences suffered by the victims other than the possible injuries produced by any violent experience unwanted pregnancy and the transmission of stds the appearance of phobias depressive and anxious symptomatology impoverished selfesteem sexual dysfunctions social difficulties and posttraumatic stress disorder are the most prominent consequences for victims of sv 2 for all these reasons sv is considered a social emergency that can have serious health consequences historically sv has been conceptualized as a type of violence carried out by a man against a woman based on a conception of power that to a large extent characterized the second feminist wave this perspective argues that men use violence against women as an extension of the patriarchal structure and as an expression of control and power over them 3 focusing on the intersection of class and gender systems of oppression 4 this theory received several criticisms one of the most notable was from black feminism which added the intersection of the racialethnic axis to take into account the particularities experienced by black women in the patriarchal and capitalist system since the traditional conception neglected such experiences 5 gradually axes of oppression were added whose intersection explained the particular experiences in terms of raceethnicity class gender age sexuality functional diversity religion etc specifically intersectionality as a branch of feminist theory is concerned with identifying how various systems of power operating at multiple levels combine and interact to confer disproportionate risk on populations with marginalized social identities 6 although stated in a very brief and simplified way as it is not the main focus of this paper we can see how the interest in the intersectional study of sv as opposed to the traditional feminist theory allows us to explain why some men might suffer victimization experiences even so only a small part of the existing research on intimate partner violence and sv to date is grounded in the theoretical framework and methods of intersectionality 7 so the collective of gay and bisexual men the subject of this study has been particularly neglected in relation to this most studies based on the feminist framework have neglected men rape and this maintains and reinforces patriarchal power relations and hegemonic masculinities 8 in terms of sexual orientation we could conclude that the study of sv still has a strong heterosexist bias 9 additional resistances can be identified that block the study of sv in this group first there exist a number of male rape myths and beliefs which are organized into three main themes denial myths blaming myths and trauma myths 10 the internalization of these beliefs would result in a decrease in interest in the subject by the scientific community and consequently a reduction in the number of studies addressing it second the reluctance on the part of researchers to address unwanted or nonconsensual sex in gbm as well as in any other lgtbiqa group could be related to an attempt to avoid reproducing heterosexist ideas that define sexual minorities as deviant criminal predatory pedophilic and rapist 11 in fact there is an intention on the part of the scientific community to reconceptualize samegender sexual relationships as healthy legitimate and nonessentially violent in order to debunk such myths 12 which although necessary inevitably obscures the violence that might occur within the collective third given the hiv epidemic there was a great interest and need to focus the study of men who have sex with men on the prevention of hiv transmission although this branch of study is interested in exploring sv 13 it tends to prioritize addressing the effects of hiv an incomplete part of the comprehensive study of sv in the collective in fact there is an overwhelming frequency in which certain variables appear in the quantitative literature related to the gbm collective especially putting the focus on hiv and stds 14 the study of these variables is indispensable but it is also necessary to expand the study of health and wellbeing among the gbm population to understand many other factors that can be crucial such as sv although interest in the quantitative and qualitative study of sexual violence in gbm has increased in recent decades it has been mostly in the context of intragender violence or domestic violence in samesex relationships 1516 in addition to prisonassociated sv 17 and child abuse 18 in fact to our knowledge there is no spanish study at present that addresses sexual violence in the gbm collective although there are a few that do discuss intragender violence 1920 there are however more international studies on sexual violence focused on the gbm population regardless of the bond between victim and perpetrator some of their results report a 352 prevalence of nonconsensual sex among men who have sex with men 21 540 prevalence of sexual assault 22 155 of physical sv sexual assault and stalking in the past 6 months 23 frequencies for sexual assault of 101 for cis gay men and 95 for cis bisexual men in the past year 24 39 lifetime contact sexual violence and 292 lifetime noncontact sexual violence for bisexual men and 177 and 333 for gay men 25 prevalence of sv reaching 3164 in gay men and 2944 in bisexual men 26 although all the studies mentioned above conclude that sv in the gbm population is drastically higher than in heterosexual cissexual men and similar to heterosexual cissexual women and also that trans people have a higher risk of victimization the figures differ greatly among them due to a lack of clear delimitation in the concept of sexual violence it has been noted that while some studies define it very narrowly and only include some of its most obvious manifestations others include a much wider range of situations 27 there are a number of factors that indicate that the figures on sv may underrepresent the reality of this group these factors are related to several barriers that affect gbm in relation to reporting experiences of sv first individuals who identify as male are particularly reluctant to admit psychological consequences that are inconsistent with male gender role expectations 28 resulting in poor communication of experiences such communication would actually be selective so they would need a higher level of distress to communicate such experiences 27 in this sense we should highlight the role of male socialization in understanding the differences in consequences and coping strategies between men and women when victimized 29 second gbm are so stigmatized by their sexual orientation that they may encounter additional difficulties in communicating their experiences of sv for fear of further discrediting themselves 30 it is also important to take into account the role played by how sexual relations and consent are conceptualized in this group since it is necessary for a sv situation to be labeled as such in order to communicate it in a relevant way in fact the most common method used by gbm to give consent is not to resist 31 this makes it difficult to differentiate a consensual situation from a violent one both for the perpetrator and the victim there are some perspectives that claim that there is a culture of silence in the collective 32 that accepts normalizes and consequently obscures sv although it seems that some people in the gbm collective accept all these situations and do not cause them discomfort some others are resisting such normalization 11 and they are having trouble labeling some experiences as sexual violence because they have them internalized there are a number of factors that would result in an intentional ambiguity in defining what is and what is not sv in sexual minorities such factors would include stereotypes like gay men always want to have sex gender norms regarding masculinity a particular vision of queerness that could in fact foreclose the role of power dynamics and the risk of social isolation when someone refuses sexualized social relations 33 the aim of this study is to make sv visible for gbm individuals in spain to do so the prevalence of victimization and the frequency in which certain specific violent situations occur as well as some of their main characteristics have been studied emphasis has been placed on the communication of experiences it is of interest to know to what extent victims communicate and to whom they turn in order to understand the low visibility of the problem and to propose preventive strategies and interventions it is not the purpose of this study to pathologize the sexuality of men who have sex with men nor to suggest that violent behaviors are the primary framework from which we can generalize all gbm sexual experiences instead it is intended to give voice to the discomfort experienced by some gbm individuals in order to promote a discourse that supports positive sexual experiences and the emotional wellbeing of gbm individuals materials and methods study design and data collection this is a crosssectional study aimed at obtaining quantitative information through a selfadministered questionnaire participation was anonymous and voluntary and aimed at the gbm population living in spain the final sample consisted of 550 respondents measurement tool the questionnaire was built using google forms v08 software the definition of sv from the who was used through which sv situations were extracted and transformed into items 1 thus the pilot version of the questionnaire consisted of these items it was administered for the first time in a small sample of gbm who had suffered some type of violence to ensure that there were no problems with the comprehension of the items and that the participants could give their opinions in general interviews were conducted with questions about the appropriateness of the items for the gbm collective in order to make them more sensitive to the reality of this particular group based on their recommendations the questionnaire was reconstructed in such a way that new situations of sexual violence and more response possibilities were added to define their characteristics as well as eliminating those questions that were labeled as uncomfortable or out of place it was also decided to divide the experiences into two separate blocks to ensure that the mildest situations were asked first and that the most sensitive ones were presented little by little the final version of the instrument was intended not only to collect data but also to serve as a tool for participants to share their perceptions of the experience at length if they so wished it can be seen as an attempt to provide a tool with which to express themselves given the invisibility and problems inherent in communicating the experiences of sv in this group the internal consistency of the questionnaire was α 087 for the total scale variables 231 sociodemographic information information on gender identity sexual orientation raceethnicity level of education to date and autonomous community of usual residence was collected questions on gender identity and sexual orientation were part of the exclusion criteria and sent some participants to the end of the questionnaire according to their answers the responses referring to the autonomous community of habitual residence covered all those autonomous communities and cities that are part of the spanish state to avoid bias the questions that formed part of the exclusion criteria were asked before explaining the goals of the study and the target population in this way we tried to reduce the probability that participants who did not meet the admission criteria could falsify their identity since once these variables were answered participants were directed to the end of the questionnaire and could not participate again from the same email address prevalence and frequency of sv experiences to study the prevalence and frequency of perceived sv participants were asked to what extent they have experienced a series of violent situations the information about the frequency offers us not only information about what proportion of the sample has suffered each situation but also informs us about the extent to which each participant has suffered those experiences these frequencies were recorded on a likert scale contrary to other studies we avoided asking about the exact number of times each situation occurred firstly it is difficult for participants to get the count of each situation right especially when dealing with potentially traumatic experiences or almost normalized experiences secondly because this study focuses on the victims perception a situation may have happened five times but for one person it may be labeled as sometimes and for another as many times the blocks of experiences have been differentiated as done by other studies to allow comparison into unwanted insinuation sexual coercion and sexual assault the situations that were part of unwanted insinuation were unwelcome sexually explicit comments and inappropriate exhibition of genitalia sexual coercion included excessive insistence to have sex verbal recrimination motivated by the refusal to have sex with the perpetrator blackmail and threats in order to convince the victim to have sex physical punishment motivated by the refusal to have sex with the perpetrator victim incapacitated to give consent or to resist and victim intentionally drugged by the perpetrator for sexual purposes sexual assault included unwanted touching with sexual intent attempted rape victim managed to escape the situation forced physically without penetration whether oral anal or vaginal and forced physically with penetration whether oral anal or vaginal items intentional and unwanted injuries during sex imagebased sexual violence the perpetrator shows or posts sexual images of the victim without consent and refusal to use protection or not using it without the victims consent did not correspond to any of the previous blocks to avoid ambiguity to the greatest extent possible the items have been written specifying that there must be a feeling of discomfort in this way an attempt has been made not to record those situations that were appropriate for the context for example without my consent and i did not want it and i think it was inappropriate if any participant answered never in all situations they were redirected to the end of the questionnaire because the rest of the questions were not applicable situational characteristics some information about the violent person has been examined in order to keep the questionnaire brief these characteristics have been recorded as well as all of the following for the overall situations of sv instead of asking for the characteristics of each of the situations separately for this reason it was reminded in these sections that in cases of having experienced several situations of violence or being protagonized by different perpetrators the participant should mark all the relevant answers regarding the age difference with the perpetrator exact numbers were again avoided with the same justification victims may have problems remembering all the exact ages and an age difference of five years for example may or may not be a clear age difference depending on the person and their relationship with the perpetrator the gender identity of the perpetrator and the bond with the victim at the time of the abuse were also explored it was asked if any of the violent situations had been group aggressions and if any of them had been carried out by the same person more than once information about the place where the violent situation occurred was also collected communication and social support participants were asked if they have shared their experiences and if so to whom they have shared them a general question was asked about the potential usefulness of support groups for gbm individuals who have suffered violence it was evaluated on a likert scale statistical analysis the statistical program stata version 142 was used for data analysis a univariate analysis has been conducted for the experiences of sv situational characteristics and communication and social support bivariate analysis is meant to uncover the differences between sociodemographic groups regarding sv prevalence and frequency the responses to each situation of sv were interpreted dichotomously for the prevalence study following the criterion of tolerance 0 that is any violent situation was considered to be present if the participant responded with any value other than 1 confidence of 95 was used for the elaboration of confidence intervals for the univariate analysis analysis of variance was carried out to determine the differences between groups regarding experiences of sv according to their sociodemographic characteristics gender identity sexual orientation age raceethnicity and educational level for the bivariate analysis statistical significance was interpreted with pvalue 005 from students t calculation bonferroni adjustment was calculated separately for the analysis of each group it should be noted that some category values do not have a large enough sample size to generalize the results situational characteristics and social support were examined from a descriptive approach ethics considerations the questionnaire construction and management considered the ethical aspects of the code of good practice of the autonomous university of barcelona and the recommendations of the european charter for researchers based on the fundamental principles of anonymity freedom honesty and responsibility the participants were aware of the objectives of the study and gave their consent to participate in it results sociodemographic characteristics table 1 shows the sociodemographic characteristics of the participants who were part of the final sample most of them were cis homosexual white young men with a high educational level prevalence and frequency of sv experiences table 2 provides a summary of the prevalence and frequency of occurrence of each of the vs items and blocks presented in this study the most prevalent situations for the gbm group in spain are unwanted insinuations especially consisting of explicit sexual comments that are inappropriate the figures on the denial of the use of protection are also relevant considering the great number of stds in this collective the prevalence of sexual assault is especially high with a 54306270 prevalence of situations of unwanted touching figures on rape prevalence are also alarming ranging from 1657 to 2340 results on frequency are coherent with those found in the prevalence analysis note the blocks unwanted insinuation sexual coercion and sexual aggression have been calculated from the average of the items that comprise them situational characteristics the results on the situation and characteristics of the perpetrator are presented below it is of interest to note that the perpetrator is a stranger to the victim in most cases and that their most usual characteristics are being a cis man older than the victim and online using gay dating apps 963 of the sample informs us to have experienced group violence and 2986 to have experienced violent situations with the same perpetrator more than once most participants were victimized when they were 1924 years old note the sum of the percentages for each variable is in some cases 100 because participants could choose more than one response option communication and social support finally the responses regarding communication and social support are reflected in table 4 the usefulness of the support groups for the participants was rated positively with a mean of 426 of all the participants of the study who have suffered any kind of violence most of them did not share all their experiences most of them trusted their friends to do so experiences of sv × sociodemographic characteristics the bivariate analysis that has been conducted regarding sv experiences vs sociodemographic characteristics is shown below with the symbols pvalue 005 pvalue 001 pvalue 0001 in terms of prevalence trans people report a higher prevalence than cis people in the situations of incapacitated and rape and in sexual assault bisexuals also reported a higher prevalence than homosexuals in situations forced without penetration the age variable had the greatest effect on the items referring to situations of sv with the youngest respondents showing a significantly higher prevalence this is the case for the items comments exhibition insistence blackmail and threats verbal recrimination rape and in the groupings unwanted insinuation and sexual coercion in addition people with no studies or only compulsory secondary education have reported significant differences showing a higher prevalence of sv in most cases compared to all other categories this is the case for the items chemical submission injury physical punishment and forced without penetration finally with respect to the raceethnicity categories differences were only found in the comparison between latinos and whites with latinos reporting a higher prevalence of sv such differences are found in the variables chemical submission and attempted rape note the sum of the percentages for each variable is in some cases 100 because participants could choose more than one response option regarding the frequency of occurrence the results are similar trans people reported higher frequencies in the item rape bisexual people in the items forced without penetration younger participants in the items comments exhibition insistence blackmail and threats verbal recrimination rape the groupings unwanted insinuation and sexual coercion people with no education or with compulsory secondary education in the items touching injuries and forced without penetration the groupings sexual coercion and sexual assault finally latinos reported a higher frequency of chemical submission discussion and limitations first it is necessary to review the characteristics of the sample to see how representative the results really are although it was intended to be representative of the spanish territory it is not representative of most sociodemographic issues so some categories are underrepresented the vast majority of participants were cissexual homosexual with a higher level of education white and young in this sense the sample of trans men is particularly small so the results should be interpreted with caution although many articles agree that this group receives more violence than cis people 35 the sample of people with special education and compulsory secondary educationno education is also insufficient as well as those of all raceethnicity categories except for white and latino men all of these difficulties were to be expected since first of all very large samples are required to do intersectional studies 36 and also the gbm population is very much in the minority so it is difficult to get participants and consequently to make it large and representative even so the considerable sample size of this study is considered a strength for the reliability of the results for the gbm population in spain although one of the objectives of the questionnaire was to ensure its brevity it would be much closer to reality to include nonexclusively categorical measures of sexual orientation and gender taking into account that from a constructivist perspective gender is constructed in each social interaction to the extent that heterosexist social conventions are repeated 37 it would be interesting to understand to what extent the tendency taken by this performance affects the directionality of the perpetrationvictimization rather than focusing exclusively on gender identity indeed in that sense the terms gay and lesbian beyond signifying only preferences in the object of desire could be wellrecognizable social identities perhaps authentic and proper genders 38 there is a need to advance the study of gender from a noncategorical queer perspective in order to understand the phenomena studied in all scientific disciplines in a comprehensive way specifically in the field of sv exploring beyond a binary definition of gender could help to make violence against nonheterosexual individuals more visible given the variability and multiplicity of definitions and interpretations of sv we cannot assure construct validity in this study although the items that form part of the questionnaire were elaborated on the basis of what the who defines as sv 1 and were modified under the evaluation of gbm individuals the figures on the prevalence of sv in the group are extremely high which is not surprising considering that a wide range of situations of greater or lesser severity have been examined and that this is a study on lifetime victimization however the numbers could have been magnified due to the method of data collection as most participants have been recruited by a gbm dating app and may be more likely to have experienced sv situations than those who do not use them comparison with other studies is not possible firstly because the instrument for exploring sv situations is different but also because some studies have only focused on childhood or adulthood experiences while others have only recorded situations that occurred during a period of time in addition to all these differences it is worth noting the different conceptions of the concept of sv or sexual assault 27 the only studies with which comparisons could be made report a 540 22 and 352 39 lifetime prevalence of sexual assault although the questionnaire they use is very different the definition of sexual aggression is slightly different and they are from different countries those figures are lower than the prevalence found in this study which is around 64 for sexual assault on the other hand the study on frequency is quite atypical in a work of these characteristics so there is no quantitative data with which to compare the results however it is consistent with the violent behaviors that have been labeled previously as normalized and that manifest themselves as unwanted sexual advances and touching which are precisely the variables that have shown the highest frequency averages as well as verbal recrimination 11 results show that bisexual men transgender men those with a low educational level and latinos are more at risk of experiencing sv this fact could be related to the concept of homonormativity which refers to the privileges that some lgtbiqa people have for conforming to heterosexual norms so that those cis homosexual men without disability with normative bodies gender expressions and affective relationships would get more social recognition so those deviant people would be more vulnerable to suffer violence 4041 still the sociodemographic characteristic that most significantly affects victimization is age in fact it is curious that as this is a lifetime victimization study it is the youngest people who report the most violence in a very significant way although it is not possible from this study to establish causal relationships it could be due to generational differences in the prevalence of sv probably due to the emergence of the internet and social networks or the existence of more nightlife spaces for gbm a greater ability to label violent situations correctly due to the influence of the fourth feminist wave 42 in younger people with movements such as metoo or a memory bias that would make it difficult for older people to remember violence in their youth especially for mild experiences of sv although the variable of victimization age to our knowledge has not been studied in sv within the collective it has been studied in studies of intragender violence the age variable is found to be the strongest and most consistent characteristic in relation to the victimization of any type of violence among gay male partners a fact that they attribute to the acquisition of internal and external resources with age that are protective against violent situations 43 however in our results it is much more frequent that the perpetrator is older than the victim considering that the majority of the sample in this study were young people more studies are needed in the field of sv on gbm to determine whether age could be a power resource for the perpetration of violence against younger people in relation to spaces the prevalence of sv in dating apps is particularly high in reference to this we should consider the manifestations of rape culture in such spaces particularly through grindr the geolocationbased social network most used by men who have sex with men it would manifest itself through violent comments and unsolicited nude photos and extend beyond online interactions in the form of sexual assault sexual coercion and imagebased sexual violence 44 this is consistent with articles that emphasize how grindr encourages its users to see each other as objects to be consumed and discarded at will 45 a fact that could be considered an ethical danger in that objectifying and instrumentalizing others for ones own sexual pleasure could result in avoidance and closure towards otherness 46 the effects that this whole scenario may have on the reproduction of vs is evident as it produces sexual encounters in which pleasure is centered on oneself and not on the interaction between the participants a fact that could hinder communication and the interpretation of consent signals the data from this study invites us to rethink the design structure and format of apps for encounters between men who have sex with men inasmuch as it is one of the spaces in which most situations of sv occur also noteworthy is the prevalence of sv in nightclubs and gay bars which could be explained by the effect that alcohol and other drugs have on the perpetration of violence by predisposed individuals 47 as well as on the vulnerability to victimization 48 a study of the expectations of the people who frequent these spaces could be of interest in order to investigate the relationship they may have with the perpetration of violent situations although several participants added in the other option spaces such as saunas chills cruising areas dark rooms etc they have not been addressed in this study because it would be too hasty to draw conclusions about sv from a quantitative point of view and could run the risk of stigmatizing these sexual practices these are situations that could be understood as violent in and of themselves which is why it is necessary to study them indepth from a qualitative framework in order to investigate how consent operates in these contexts 49 almost all perpetrators as reported by the victims are cis males older than the victim the bond with the perpetrator is one of the most interesting variables of the study as it shows that the vast majority of violence is perpetrated by strangers this implies that it does not make sense to study sv on gbm only in the area of intragender violence or intimate partner violence in homosexual relationships the figures are very similar to those found in another study 21 especially high for strangers casual partnersdates and acquaintances for future studies it would be interesting to include more types of bonds since the lgtbiqa group is very rich in forms of relationships and in this way a representation closer to reality would be achieved finally the fact that the vast majority of victims communicate their experiences to friends rather than to other links refers to the phenomenon of peers communication and is consistent with existing literature 16 in that sense victim support groups could be a useful tool to promote such communication it is important to note that all answers regarding situational characteristics and social support have been registered for all the situations of sv that the participants may have lived at once so this study is not capable of attributing this data to any specific situation of sv for example we cannot tell from these figures if most rapes in particular are carried out by strangers or by acquaintances those difficulties were accepted to ensure the questionnaires brevity and therefore to achieve the largest possible sample as this is a preliminary study it shows an overview of the problem and encourages other studies to further investigate the specific topics discussed above although it is inevitable that the study presents a series of limitations it is important to emphasize the importance of being a pioneer in the study of sv on gbm living in spain as well as its usefulness as a tool for communication and expression for the victims it is necessary to promote the study of sexual violence in this collective as it is for all the letters of the lgtbiqa group addressing this issue and consequently constructing prevention and intervention strategies focused on the particularities of this collective would have important positive health outcomes not only because it would improve physical wellbeing by preventing stds and the physical harm a violent situation may involve but because it would also have a positive impact on psychological wellbeing conclusions this paper reveals that sexual violence is common among gay and bisexual men findings show that prevalence figures depend on sociodemographic characteristics like gender identity sexual orientation raceethnicity and educational level prevalence would also be higher in certain situations and spaces some of the perpetrators and victims most usual characteristics have also been examined furthermore it has come to light that those who have been affected face challenges when it comes to sharing their experiences with others and that they mostly rely on their peers to do so epidemiological research and interventions should take into account the intersections between gender identity and sexual orientation to better tailor prevention and treatment in this collective given the invisibility and stigma associated with this issue this study highlights the usefulness that support groups could have in facilitating victims communication as a preliminary study this paper could be useful for further indepth research on the topics discussed above such as sociodemographic factors related to the risk of victimization or the role of external situational characteristics to specific situations of sexual violence it is necessary to promote the study of sexual violence in this group to understand the power dynamics that could underlie these situations data availability statement the data sets used and analyzed in the current study are available from the corresponding author on reasonable request institutional review board statement not applicable the protocol of the study was not evaluated by the ethics committee of our university because it did not include invasive procedures it did not include collection use or storage of biological samples from subjects nor did it include collection use or storage of genetic information from participants following the current spanish legislation approval from the ethics committee is mandatory only when a study protocol includes any of these procedures informed consent statement informed consent was obtained from all subjects involved in the study

sexual violence is an understudied issue in the population of gay and bisexual men although the existing articles to date demonstrate that it is a problem that merits public attention this study aims to approach the problem of invisibility around the matter as well as presenting a number of variables that have been usually overlooked in spanish research or have not been assessed at all lifetime sexual victimization sociodemographic characteristics situational characteristics and social support were examined among 550 gay and bisexual males living in spain using a selfadministrated questionnaire results analysis show that 9000 87189238 of participants reported at least one experience of unwanted insinuation 8727 84198994 reported at least one experience of sexual coercion 6400 59836802 reported at least one experience of sexual assault and specifically 1982 16572340 reported being raped during their lifetime significant differences have been found between some categories regarding gender identity sexual orientation age raceethnicity and educational level overall these results showcase sexual violence as a pervasive problem in the spanish gay and bisexual community

introduction more than a third of todays teenagers are overweight or obese with the prevalence of obesity slightly higher than that of overweight adolescents who are obese are at greater risk for obesity in adulthood which is associated with numerous health complications such as hypertension type 2 diabetes mellitus dyslipidemia and cardiovascular diseases additionally adolescents who are overweight or obese are more at risk for developing healthcompromising behaviors such as substance use and violent behavior there are also psychological consequences of obesity adolescent obesity has been associated with the development of body dissatisfaction which can put adolescents at risk for externalizing and internalizing problem behaviors and social and attention problems studies have also shown that body dissatisfaction may lead to eating pathology and is associated with poor perceived health body dissatisfaction is particularly worrisome for overweight and obese adolescents overweight and obese adolescents with body satisfaction are more likely to do something to control their weight whereas adolescents with body dissatisfaction are more likely to engage in unhealthy weight management behaviors and are at a risk for weight gain one study of adults found that body image partially mediates the relationship between obesity and psychological distress these findings illustrate potentially positive effects of fostering body satisfaction in adolescents who are overweight social engagement may affect adolescent body image for children and adolescents engaging with friends is a developmental advantage and a social resource increasing socioemotional maturity and fostering selfesteem and wellbeing friendships are also important in the development of body image and have been associated with body satisfaction among adolescents in general and with psychosocial health among adolescents with chronic conditions supportive friendships may be particularly protective for overweight adolescents bowker spencer and salvy found that for overweight adolescents positive friendship quality was negatively associated with emotionfocused coping and friendship conflict was a risk factor for internal blame besides improving overweight adolescents mental and social health peers have been shown to increase their physical activity and their motivation to exercise there has been relatively little research on the positive effects of peers on overweightobese adolescents body image most previous studies looked at teasing or social comparisons and fat talk where peer discussion of body weight and dieting may cause concern about ones own weight and body image less information exists on the role of social engagement in the association of weight status with body image having a supportive group of friends is an essential part of healthy adolescent development and for overweight adolescents could be a protective factor against body dissatisfaction the purpose of this study is to examine whether social engagement modifies the association between weight status and body image we hypothesize that overweightobesity is associated with body dissatisfaction overweightobese adolescents with more social engagement are less likely to be dissatisfied with their bodies than overweightobese adolescents with less social engagement because studies have shown that the influence of peers on other adolescent behaviors such as drinking is different for adolescent girls and boys we expect these relationships to vary by gender and therefore examine the relationships in separate models for boys and girls method sample the 20056 health behavior in schoolaged children survey is a nationally representative schoolbased study conducted every four years to measure adolescent health risk behaviors and the context in which these behaviors occur a threestage stratified clustered sampling with classes as the sampling units was used to select a sample of american students in grades 6 to 10 during the 20056 academic schoolyear black and hispanic students were oversampled to provide better population estimates for these minorities anonymous surveys were completed in the classrooms ethics approval was obtained from the eunice kennedy shriver national institute of child health and human development institutional review board the survey was completed by 87 of eligible students half of the 6 th graders who completed the questionnaire were not asked the questions on body image and were therefore excluded from the analysis as were respondents who did not provide all essential demographic information producing the analytic sample measures body imagebody image was assessed as a continuous variable created from the mean of five items from the body image subscale part of the body investment scale the bis was piloted in hungry and finland in 2005 and performed with good internal consistency the first subscale of the bis was constructed to measure body image feelings and attitudes and measured several aspects of body image evaluation attitudes and emotions this scale has been validated and used in other studies to assess body image in adolescents questions asked respondents how much they agreed or disagreed with five statements i am frustrated with my physical appearance i am satisfied with my appearance i hate my body i feel comfortable with my body and i feel anger toward my body suggest that the reliability of the 5item bis measure is essentially equivalent to that of the original 6item measure the scale ranged from 1 to 5 with higher scores indicating less body dissatisfaction weight statusweight status was a dichotomized measure of the students body mass index computed from selfreported height and weight according to the cdc 2000 growth chart overweightobese adolescents with bmi at the 85 th percentile or above were compared to adolescents with bmi below the 85 th percentile social engagementsocial engagement was a continuous scale from the mean of eight items this scale has been used in previous research investigating social isolation and quality of peer relationships three items asked whether it was easy to talk with a best friend friends of the same sex and friends of the opposite sex two items asked about the number of close male and female friends two items asked how many daysweek they usually spent time with friends immediately after school and how many eveningsweek they usually spent time with friends the last item asked how often they talk to friend on the phone or send them text messages or have contact through the internet the eight items were ztransformed standardized and averaged to provide the overall measure of social engagement sociodemographic characteristicsvariables included were age race ethnicity and socioeconomic status measured by the family affluence scale fas was constructed from questions about family wealth and categorized into tertiles a review indicated that the scale has good content and external validity statistical analysis all analyses were conducted using stata 9 to adjust for the clusterbased sampling design of hbsc weights were applied to provide nationally representative estimates the prevalence and means of the sample variables were calculated as were the bivariate associations between them multiple linear regressions separately by gender and controlling for age raceethnicity and socioeconomic status were conducted with an interaction term including weight status and social engagement when the interaction was not significant we concluded that the association between weight status and body image did not vary by social engagement and the interaction was removed from the model to examine the main effect of weight status on body image when the interaction was statistically significant we concluded that social engagement modified the association between weight status and body image and we then stratified the analyses by different levels of social engagement significance was set at the 95 confidence level results sample characteristics are presented in table 1 the mean age for both boys and girls was 144 years with no significant gender differences the largest demographic groups were white and moderate socioeconomic status the prevalence of overweight obesity was 339 for boys and 274 for girls while most respondents reported being satisfied with their bodies boys reported significantly more body satisfaction than girls girls reported more social engagement than boys bivariate analyses showed that adolescents overweightobese status was related to body dissatisfaction and less social engagement for both boys and girls wald tests were used to account for the design effects of our data overweightobese boys and girls had more body dissatisfaction and less social engagement than their normal underweight peers social engagement was however differentially associated with body image by gender for boys sociodemographic variables were significantly associated with body image black adolescent boys had more body satisfaction compared to white adolescent boys and boys of higher affluence reported more body satisfaction than boys of low affluence in subsequent multivariable linear regression models controlling for age raceethnicity and socioeconomic status the weight status by social engagement interaction was not significant therefore the interaction term was removed from the model to examine main effects final results show that overweightobese boys were more likely to have body dissatisfaction than normalunderweight boys boys with more social engagement were more likely to have body satisfaction than boys with less social engagement among girls sociodemographic variables including age and raceethnicity were significantly related to body image black girls with less social engagement were more likely to have body satisfaction than their white peers and black girls with more social engagement were more likely to have body satisfaction than their white peers age was significant in the model for girls with less social engagement for younger girls less social engagement was associated with body dissatisfaction in regression analyses controlling for sociodemographic variables social engagement moderated the relationship between weight status and body image because the interaction term was significant the data was stratified to examine the association of weight status with body image for girls with high social engagement and those with low social engagement overweightobese girls with high social engagement were more likely to have body satisfaction than overweightobese girls with low social engagement discussion this study examined the relationship between weight status and body image in a nationallyrepresentative sample of us adolescents as posited in our first hypothesis obesity was associated with body image dissatisfaction in boys and girls confirming previous findings although the prevalence of overweightobesity was higher in boys compared to girls adolescent girls reported significantly more body image dissatisfaction than boys social engagement moderated the relationship between weight status and body image for girls but not for boys thus partially supporting our second hypothesis however for boys social engagement was associated with more body satisfaction regardless of their weight status given the high prevalence of obesity more adolescents may be struggling with body dissatisfaction both obesity and body dissatisfaction are risk factors for low self esteem and depression and can lead to psychosocial and physical problems they may also lead to disordered eating behaviors which can increase the risk for weight gain the high percentage of adolescent boys and girls who were overweightobese in this nationally representative sample along with the consistent association between overweightobesity and body dissatisfaction across gender highlight the urgency to address the increasing prevalence of body dissatisfaction in adolescents much of the research examining peer influences on body image among adolescent boys and girls focuses on the messages peers impart rather than on a more comprehensive measure of social engagement however some studies have shown that low friendship quality may contribute to body dissatisfaction in adolescent girls so the peer group in general might have an important influence on body image the desire to conform to the specific norms of a peer group places pressure on adolescents to be thin this conflict between conforming to ideal norms of thin bodies and the reality of their actual body size may result in body dissatisfaction for boys and girls the positive association for boys and girls between social engagement and body satisfaction supports the idea that peers and social relationships are important for adolescent development despite the increasing prevalence of obesity society remains extremely disapproving towards overweight individuals as demonstrated by the high prevalence of institutional and interpersonal weightbased discrimination the stigma associated with obesity increases the probability that overweight individuals will internalize negative thoughts about themselves and develop body dissatisfaction even more distressing adults who had child or adolescent onset obesity have the most significant body image disturbances social engagement moderated the relationship between weight status and body image for girls but not for boys thus partially supporting our second hypothesis for boys social engagement was associated with body satisfaction regardless of their weight status to our knowledge no studies have investigated the association between peer groups and body image among boys but these findings suggest the need for further examining mechanisms linking social engagement to body satisfaction within this group for adolescent girls social engagement was a moderator of the relationship between weight status and body image overweightobese girls with less social engagement had more body dissatisfaction than overweightobese girls with more social engagement suggesting the importance of social engagement for adolescent girls especially if they do not meet the norms for weight status bowker spencer and salvy showed that supportive friendships were negatively associated with emotionfocused coping while friendship conflict was positively associated with internal blame among overweight but not normal underweight adolescents overweight adolescents are more likely to be socially isolated and on the periphery of social networks and overweight girls in particular may be more likely to experience peer exclusion which may reinforce overweightobese girls perceptions of body dissatisfaction based on the literature review and our conceptual framework we hypothesized that the major differences would be between adolescents with normativesocietyapproved weight status and those whose weight deviates from the normativeideal standards the weight status categories were dichotomized at the 85 th percentile but there could have been differences between the overweight and obese groups however both overweight and obese adolescents have been found to experience more teasing than average weight adolescents in addition prior to collapsing the underweight and normal weight categories we tested for significant differences in mean body image across these groups for boys and girls our results showed that there were no significant differences for either gender it is possible that body dissatisfaction works differently in underweight adolescents but our sample of underweight adolescents was insufficient to analyze separately future studies should look at this specific population this study has many strengths including the use of a large nationally representative sample that is socially and economically diverse the use of a previously tested valid and reliable measure of body image and the examination of associations that are central to adolescent development yet were seldom the focus of previous research one important limitation includes the crosssectional nature of the study which does not allow directional conclusions our proposed framework suggests that obesity leads to body dissatisfaction but a reverse direction might also be true eg body dissatisfaction may cause adolescents to indulge in excessive eating that could result in overweightobesity both pathways are plausible and can only be disentangled in future longitudinal studies additionally it is important to note that there may be a bias in who reports social engagement depression for example may cause an adolescent to report less social engagement and body dissatisfaction another limitation is that weight status was calculated from selfreported rather than actual height and weight studies however have shown that the bias in selfreported height and weight is minimal and certainly acceptable for analysis of group data in summary establishing friendships is an essential developmental task for adolescents and as this study showed social engagement can protect adolescents from having body image dissatisfaction our findings show that social engagement is protective against body dissatisfaction for all boys regardless of their weight status and especially protective for overweightobese girls therefore encouraging adolescents particularly overweightobese teenage girls to develop strong healthy relationships with peers may prevent them from having body dissatisfaction when faced with adolescent girls or boys regardless of their weight status who are dealing with body dissatisfaction physicians psychologists parents and teachers could inquire about their social engagement and possibly encourage them to establish more interaction with friends for example through involvement in clubs and team sports given the continuous rise in overweightobesity among adolescents the accompanying increase in the prevalence of body dissatisfaction and the numerous adverse health consequences that could develop from body dissatisfaction successful strategies that could prevent the development of negative body image are needed encouraging social engagement among adolescents may be one such strategy more research is needed however to examine potential racial differences in the proposed framework and to evaluate the relative importance of parental influence and social engagement in the association between adolescents weight status and body image research highlights • adolescents overweightobese status was related to body dissatisfaction • social engagement moderated the relationship for girls but not for boys • overweightobese girls with high social engagement had greater body satisfaction association between weight status and body image by social engagement in girls low social engagement is defined as and high social engagement as age raceethnicity and socioeconomic status were controlled in all analyses note low social engagement is defined as and high social engagement as age raceethnicity and socioeconomic status were controlled in all analyses body image author manuscript available in pmc 2013 march 1

this study examined whether the association between adolescent weight status and body image varies by social engagement a nationally representative sample of 6909 students in grades 6 to 10 completed the 2006 hbsc survey separate linear regressions for boys and girls controlling for age raceethnicity and socioeconomic status were conducted with an interaction term weight status x social engagement adolescents overweightobese status was related to body dissatisfaction social engagement moderated the relationship between weight status and body image for girls but not for boys overweightobese boys had more body dissatisfaction compared to their normalunderweight peers regardless of their social engagement however overweight obese girls with more social engagement were more likely to have body satisfaction compared to overweightobese girls with less social engagement encouraging adolescent girls to develop healthy relationships with peers may prevent them from developing body dissatisfaction

background the plight of orphans a and abandoned children is an increasing global problem that is particularly pervasive in southeast asia and subsaharan africa 1 improving the educational attainment of the 153 million orphans and other vulnerable children worldwide is a key goal for development policymakers and practitioners international declarations such as the millennium development goals and the education for all movement indicate that the educational attainment of vulnerable children has become a global priority most recently the 2011 political declaration on hivaids targeted increases in school attendance of orphans as an important and measureable indicator of progress 2 to understand which policies can improve educational attainment for oac decision makers must first understand the determinants of and barriers to these outcomes however there are mixed results regarding which factors including orphanhood itself are significantly associated with educational attainment previous research shows that the loss of a parent can lead to a series of developmental disadvantages resulting in poor education 3 4 5 6 7 such as lags in grade for age and school attendance relative to nonorphans 378 in contrast other studies find little negative impact of parental death on child education 9 10 11 and instead find that alternative factors such as wealth age or the childs relationship to the head of household are better predictors of education outcomes 12 importantly many of these studies are restricted to single country analyses rendering results arguably context specific additionally few studies examining the educational attainment of orphans move beyond outcomes such as school enrollment grade for age and attendance to disentangle what factors contribute to a childs learning 1314 other outcomes may provide more meaningful information a recent study showed that tests of cognitive development can be a useful measure in understanding oac learning and educational experience across settings in particular cognitive development was found to be positively associated with increases in exposure to formal education 15 one factor that may offer some insight into the development of oac is mental health previous research though not focused on orphans highlights the role of adverse childhood experiences in life outcomes 16 cumulative effects from multiple risk factors have been shown to be more predictive of compromised early cognitive development among vulnerable children than any one risk factor alone 17 in the research on orphans the role of psychosocial status on multiple outcomes has been studied though not specifically in relation to learning outcomes research on oac in low and middle income countries found that orphaned children are more susceptible than nonorphans to exposure to potentially traumatic events due to lack of adequate adult protection 18 19 20 21 a recent study found that oac anxiety and emotional difficulties increased with additional exposure to potentially traumatic events 22 another recent study found associations between orphan risk of psychosocial difficulties and subsequent risk of hiv infection 23 while there is a clear need for mental health interventions among oac few investigators have examined the role of mental health in predicting oacs cognitive development 24 25 26 to our knowledge no study has attempted to do a crosscountry analysis of community based oac to address these questions through these analyses we aim to understand better the linkages between emotional difficulties and a childs ability to participate in and gain from education in a context where children are particularly vulnerable to adverse events and subsequent emotional difficulties in this manuscript we employ withincountry and crosscountry analyses to examine associations between exposure to adverse childhood events the emotional difficulties that oac face and their cognitive development methods study description positive outcome for orphans is an ongoing longitudinal study following a cohort of children starting ages 6 to 12 who live in institutional or communitybased settings in 5 low income countries cambodia ethiopia kenya india and tanzania this analysis used 3 years of data from the communitybased sample to address the relationships stated above study sample the detailed sampling strategy and general characteristics of the sample have been reported elsewhere 2627 the following describes the elements of the sampling strategy applicable to this analysis the pofo study utilized a two stage random sampling methodology to identify a representative sample of 1480 orphaned and abandoned children living in communitybased settings in six sites across five low and middle income countries within each site geographic or administrative boundaries were used to define sampling areas 50 clusters were randomly selected at each site and up to five eligible children ages 612 years were selected from each cluster eligible children were defined as follows orphans were those children for whom one or both parents had died 1 and an abandoned child was one whose parents had left with no expectation of return eligible children were randomly selected from available lists or through a housetohouse census one child per household was selected to participate in the study for households with multiple ageeligible children the child whose name started with the earliest letter in the alphabet was selected to participate additionally each site enrolled 50 communitybased children who were not orphaned or abandoned at baseline as a comparison group data collection protocol as previously published 2226 the following describes the procedures of data collection relevant to this analysis children and each of their selfidentified primary caregivers were contacted and interviewed twice per year for up to 3 years baseline and annual follow up surveys collected data on numerous characteristics including the childs exposure to traumatic events symptoms of emotional and behavioral difficulties cognitive development and educational attainment additionally caregivers reported on household socioeconomic characteristics ethical approval was obtained from the duke university institutional review board and from local and national irbs in each participating country the primary measures utilized in this study include child selfreports of emotional difficulties tests assessing cognitive abilities and child and caregiver reports of exposure to potentially traumatic events all reported at baseline and at 12month 24month and 36month follow ups the measures used for trauma emotional difficulties and cognitive development were previously validated for use across cultures and fieldtested using pilot interviews study measures measuring cognitive development kaufman assessment battery for children and the california verbal learning test the kabcii is an individually administered test of intelligence and achievement that was developed with the intention of building in sensitivity to preschoolers minorities and exceptional populations 28 three nonverbal subtests from the second edition of the kaufman assessment battery for children hand movements triangles and pattern reasoning were assessed at annual child interviews in the pofo study the kabc was chosen because it is one of the most frequently used tests of learning ability internationally the three nonverbal subtests were chosen to be used across the five countries as they are less dependent on language differences the california verbal learning test is a test of verbal memory used by pofo researchers as an indicator of memory attention and motivation 15 pofo interviewers modified the memory list referred to here as the market list locally relevant lists were developed at each site that contained 15 items a child might see at their respective markets the test required children to encode and store information in order to repeat back what was read to them the market list was chosen based on observed variability of childrens engagement with the tests during pilot work in east africa suggesting that a tool that reflects motivation and attention would be an important addition to the learning tasks on the kabcii 15 previous analyses by pofo researchers validated these tests as measures of learning and performance for children living in lmic 15 the findings of this previous analysis provided support that across the five countries the subtests functioned as one would expect measures of learning to function that is raw scores increased with chronological age these tests were also strongly associated with years in school for age hence the kabc ii scores used here can be seen as an effective tool for measuring learning which also reflects experience in the learning environment 15 this analysis used the highest of the three kabc test standard scores for each child at each round as the primary outcome measure for cognitive development this measure represents the best the child was able to do across the three subtests when tested by the interviewer standard scores of the kabc ii range between 0 and 19 and each subtest has a mean of 10 and a standard deviation of 3 28 in this analysis scores were scaled to us age standards to enable comparison across children and these five settings the average number of items recalled in the first three repetitions on the market list was used as an ancillary measure of learning attention and motivation measuring psychosocial wellbeing and emotional difficulties the strengths and difficulties questionnaire the strengths and difficulties questionnaire is a behavioral screening tool designed for children ages 416 that measures psychosocial wellbeing across five dimensions emotional symptoms conduct problems hyperactivityinattention peer relationship problems and prosocial behavior each subscale has 5 items scored on a 3point likert scale the four difficulties subscales add up to a total difficulties score while the fifth subscale provides assessment of prosocial behavior pofo researchers chose the strengths and difficulties questionnaire for its brevity its psychometric properties and its frequent use in other international studies 22 the questionnaire can be completed in two versions either by parents teachers or caregiver report or for children ages 11 and older by selfreport 29 with scoring from 02 on each individual item the total difficulties scale ranges from 0 40 this analysis used the total difficulties score as a continuous variable rather than using a clinical cutoff which is not available across these sites the validity of the selfreported total difficulties scale has been assessed and confirmed in multiple contexts indicating that the scale itself is internally valid 1 in the pofo sample cronbachs alpha was 073 these analyses used the total difficulties score selfreported by the child as the primary measure of emotional difficulties limiting the sdq self report to ages 11 and older is in line with the recommendation of the sdq b measuring adverse childhood experiences the life events checklist this analysis used the life events checklist first created by the national center for posttraumatic stress disorder to aid in the diagnosis of post traumatic symptoms 30 this checklist which inquires about exposure to potentially traumatic events such as natural disasters witnessing someone being hurt or killed experiencing physical or sexual abuse or being forced to leave home is one of the most commonly used research instruments to evaluate exposure to trauma across countries and cultures 31 caregivers and children were independently asked at each interview whether the child had ever witnessed or experienced each of 21 types of events a child was counted as having experienced an event if either the caregiver or the child reported it as described previously four categories of events were excluded from this analysis 22 c a cumulative traumatic exposure variable was generated for this analysis which sums the total count of up to 17 different traumatic event categories reported through any given round additional covariates household wealth caregiver illiteracy and relationship to the child an asset checklist and other elements from the demographic and health surveys d of each site were used to derive a wealth index score for each participating household 32 33 34 35 36 wealth index scores are continuous standardized for comparability with wealth index scores in each countrys dhs and indicate greater affluence as the score increases caregiver illiteracy was assessed based on a literacy test administered at the time of each survey caregivers unable to read four short sentences in the local language were classified as illiterate the childs relationship to the caregiver and orphan status were included in the analysis analyses a linear regression model was estimated to describe the relationship between emotional difficulties and various explanatory variables including orphan status exposure to potentially traumatic events and household wealth additional linear regression models with the kabc topscore and market lists as dependent variables were used to estimate the association between emotional difficulties and cognitive development these models controlled for age gender orphan status wealth and caregiver illiteracy and the number of prior administrations of the kabc test to account for child learning over time models analyzed up to four time points for each child crosssectionally each model specification was run separately by site and jointly for all sites childlevel fixed effects models were estimated to describe the relationship between the sdq total difficulties score and cognitive outcomes while controlling for time invariant characteristics of children that may affect outcomes models were run jointly across all sites and controlled for age as the only other observed time varying characteristics expected to be associated with the childs cognitive development during the study period additional models run for sensitivity analysis evaluated whether the association between emotional difficulties and cognitive outcomes differed by caregiver type oac status or study site effect estimates for subgroups were calculated as linear combinations of sdq main effects and interactions with the respective indicator variables for each subgroup two additional fixed effects model analyzed the association of cognitive outcomes with the four sdq subscales and with caregiver reports of the sdq all models were estimated with robust standard errors to account for error correlations within sites and between multiple observations from each child childlevel fixed effects models accounted for clustering at the level of the child weights were constructed to account for differences in the number of children and their age and gender distributions across study sites and were used in all models attrition to evaluate the extent to which attrition may have biased our estimates bivariable logistic regression models of baseline characteristics analyzed whether children who left the study differed significantly from those who stayed results descriptive statistics table 1 shows descriptive statistics at baseline including proportion and frequency of oac status frequency of caregiver type and the mean and standard deviation of performance on the kabc ii child selfreported emotional difficulties mean count of exposures to types of potentially traumatic events and other characteristics single orphans constitute the largest group within the sample while the average topscore at baseline is similar across sites there is more variation by site on the average level of selfreported emotional difficulties with cambodia and hyderabad reporting the highest average scores the average selfreported total difficulties score was 102 for the entire sample at baseline on average children had experienced 17 types of potentially traumatic events in addition to their orphaning or abandonment nagaland and kenya had the lowest average levels of reported exposure to potentially traumatic events at baseline was negatively associated with higher levels of emotional difficulties in nagaland in two of the six sites kenya and tanzania exposure to potentially traumatic events was significantly and positively associated with higher levels of emotional difficulties there were mixed results for orphan status being a single orphan was associated with higher emotional difficulties relative to nonorphans in 2 sites and being a double orphan was associated with higher emotional difficulties in one site however orphaned and abandoned children in nagaland reported lower rates of emotional difficulties relative to comparison children while the wealth index exposure to potentially traumatic events gender and age were statistically significant when looking jointly across all sites no orphan status held significant associations with emotional difficulties in this specification predicting emotional difficulties predicting cognitive development tables 3 and4 show ordinary least squares and fixed effects regressions of emotional difficulties predicting cognitive development since exposure to potentially traumatic events was highly correlated with emotional difficulties exposure to trauma was not included in these models there was a significant negative association between emotional difficulties and the childs topscore on the kabc ii tests in five of six study sites there is no evidence that orphan status holds a significant relationship to the childs topscore wealth is positive and significant in cambodia and kenya caregiver illiteracy is associated with lower performance on the kabc ii tests with significant associations in kenya and tanzania female gender was associated with lower kabc ii scores in cambodia and kenya table 4 shows the results of a fixed effects model of the relationship between emotional difficulties and cognitive development thus controlling for all time invariant characteristics within one child since most covariates in previous models are considered time invariant age is the only additional covariate included in the model the relationship between emotional difficulties and cognitive development remains negative and significant in the fixed effects estimation in sensitivity analysis the relationship also holds for three out of the four subscales of the selfreported sdq as well as the caregiver reported sdq the negative and significant relationship also holds for most subgroups evaluated in the sensitivity analysis the relationship between emotional difficulties and the same models as in tables 3 and4 were estimated for the cvltt market list to test whether associations held across multiple measures of learning the correlation between the kabc ii topscore and the cvltt market list is 0373 indicating that while there is some shared variance the two indices still likely capture different aspects of the childs cognitive development the relationship between emotional difficulties and scores on the market list test was negative and significant in 3 of 6 sites for the ols model the relationship was also negative and significant across all sites in the fixed effects model with similar results for the sensitivity analysis as were found with the topscore measure results are presented in tables 5 and6 attrition and missing data attrition differed significantly across study sites and children living with parents were less likely to drop out results in tables 4 and6 suggest that the observed associations do not differ between children living with parents and nonparents thus it is unlikely that differential attrition between children residing with biological parents versus other children substantively biased our estimates further the direction of the observed associations was similar in most study sites there were no differences in rates of attrition across other relevant factors such as exposure to potentially traumatic events cognitive development socioeconomic status gender or the level of emotional difficulties using the child selfreport measure of the total difficulties scale resulted in a number of missing data points at baseline since children did not selfreport on the sdq until they were 11 years old to check whether missing data of this nature might change results crosssectional analysis was restricted to the 36month follow up were old enough to selfreport controlling for baseline characteristics with little change in results given that a the caregivers of nearly half of all participating children were not their biological parents b caregivers may significantly underreport the behavioral effects of traumatic events experienced by children 37 and c caregivers had been taking care of these children for variable amounts of time the child selfreported difficulties were considered more accurate than caregiver reports discussion this is the first crosscountry study to examine the relationship between orphans emotional difficulties and their learning moreover conducting such an analysis on a unique sample of vulnerable children who are susceptible to multiple instances of adversity including trauma provides evidence of the nature of this relationship within a context of heightened adversity and potentially higher risk of mental health difficulties this analysis showed that oac exposure to potentially traumatic events is an important predictor of emotional difficulties thus supporting previous literature that the number of adverse events matters for risk of mental health difficulties the most salient finding was a negative and significant relationship between a childs emotional difficulties and hisher cognitive development within and across five of six study sites rates of exposure to adverse childhood events among the orphaned and abandoned children in this study were high and exposure to adverse events in addition to male gender and lower household wealth was associated with significantly higher rates of emotional difficulties interestingly orphan status was only significantly associated with emotional difficulties in some sites and was not predictive of cognitive development although the negative and significant relationship between emotional difficulties and cognitive development held within each orphan subgroup these findings may suggest that when a child is more vulnerable to a number of adverse events it is the context in which a child loses a parent rather than the loss of a parent alone that better explains mental health outcomes children who are vulnerable from orphaning and have experienced other adversity are at heightened risk of increased emotional difficulties which is associated with lags in cognitive development these findings offer insights into the relationship between vulnerable childrens mental health and their ability to participate in and benefit from education in the context of multiple adversity the loss of a parent or orphan status does not show statistical significance in the hypothesized relationship between mental health and learning nevertheless the overall findings still underscore the importance of mental health intervention for children who are especially vulnerable it is likely that the effect of parental loss is further affected by the additional adverse events to which the child is even more vulnerable no trauma or potentially traumatic event happens in isolation although causality cannot be inferred from this analysis the results offer insight into the relationship between emotional difficulties and educational outcomes the fixed effects model controls for unobserved timeinvariant differences between children that may be correlated with emotional difficulties and may influence cognitive development consequently the results in table 4 give us an unbiased estimate of the relationship between a childs emotional difficulties and hisher cognitive development controlling for these differences the consistency of the association between these two factors across multiple contexts and measures and within different subgroups is striking this underscores the importance of providing trauma support and focusing on the psychosocial development of vulnerable children as a means to alleviate strains inhibiting a childs learning additionally the associations found between wealth and emotional difficulties may indicate that interventions aimed at easing households resource constraints could help alleviate emotional difficulties in some contexts one may hypothesize that in less stable resource poor settings children who were exposed to trauma may be less likely to recover from emotional difficulties interventions on both the child and family levels may work in tandem to improve education outcomes for orphans if policies and programs can improve economic and emotional stability for both children and families orphans may have a greater chance of pushing past the challenges of losing a parent and the additional traumas to which orphanhood exposes them while economic support does not treat mental health difficulties it may provide families with the resources needed to keep children in school which may aide their psychosocial development such support may improve a childs chances of overcoming the emotional challenges that are associated with lags in cognitive development we acknowledge several limitations childrens cognitive development is described by only two measures an aggregated score summarizing childrens performance on three nonverbal kabc ii subtests plus a measure verbal memory and attention based on the cvlt while ability is likely not to change over time the childs performance on the kabc ii tests is not only an indication of the childs ability but also a variety of other factors associated with motivation selfconfidence response to authority and the childs developed nonverbal skillset 1 we may interpret the association of test scores with the childs emotional difficulties to be related to changes in these additional factors while this measure may not singularly isolate the childs cognitive development knowledge of the critical role of emotional difficulties in the childs learning and subsequent academic attainment is an important insight for policies on global support for vulnerable children including but not limited to those vulnerable due to parental death further the available data do not offer adequate statistical power to describe the temporal association between the variables of interest and therefore cannot rule out possibilities of reverse causality it is possible that the observed relationships are circular and that even if higher emotional difficulties impede cognitive development lags in cognitive development in turn may heighten emotional difficulties with adversity psychosocial manifestations and cognitive delays spanning much of the life span of the children in this study the three year followup period does not offer sufficient withinchild variation to disentangle these effects regardless of the direction of causality if we know that children who are exposed to more trauma also report more emotional difficulties and perform lower on tests of cognitive ability interventions to provide emotional support for children living in adversity will help at least one or more of these difficulties even though we do not know whether emotional difficulties are driving lags in cognition or the other way around we still need to address the emotional difficulties specifically targeting potentially traumatic events finally the study findings may not be generalizable as there are many other groups of oac including street children institutionbased orphans and those that live in countries with widely different contexts than those in our sample these associations may differ in those samples the variability in the observed associations across the six study sites suggests that associations between trauma emotional difficulties and cognitive development and appropriate interventions are likely contextspecific nevertheless this analysis offers new insight into the relationship between psychosocial factors exposure to adverse childhood experiences resource constraints and the cognitive development of orphans in wide variety of contexts and diverse settings in southeast asia and subsaharan africa conclusions this study suggests that increased reports of exposure to potentially traumatic events among orphans and abandoned children are associated with higher emotional difficulties and increases in emotional difficulties are associated with lags in cognitive development hence exposure to trauma and emotional difficulties comprise important barriers to educational attainment for all such vulnerable children including orphans higher socioeconomic status and better educated caregivers may offer buffers to these difficulties since they are associated with fewer emotional difficulties and higher performance on tests of cognitive development interventions targeting both the psychosocial development of the child vis a vis their exposure to adverse childhood events and the socioeconomic status of the caregiver may work in tandem to improve educational outcomes for vulnerable children in a more holistic sense further family based interventions to stabilize socioeconomic conditions or increase caregiver education may help overcome psychosocial challenges that otherwise would present as barriers to the childs educational advancement most importantly psychosocial status may be an important actor in a childs ability to profit from and stay in school and one factor that influences this status is a childs exposure to traumatic and other adverse experiences these findings may provide a guide to developmental strategies for those working to improve education outcomes for children in less wealthy areas ethical approval ethical approval was provided by the duke medicine institutional review board the local review boards of savelives ethiopia and stand for vulnerable organization sharan and kilimanjaro christian medical centre and national regulatory agencies in all participating countries including the national ethics committee for health research the ministry of science and technology the indian council of medical research the kenya medical research institute and the national institute for medical research informed consent children under the age of 18 were asked for assent to participate in the study only after the guardian had first given permission for the child to participate and for the interviewer to speak with the child the project was explained to the child in an ageappropriate manner and the child was given the opportunity to ask questions about the project before assent was requested children who were not competent to give assent were not included in the study children who previously gave assent as minors were reconsented as adults when they reached age 18 endnotes a while the definition of orphan varies across cultures and settings unicef provides a commonly accepted definition for orphan as a child who has lost one or both parents b for more information see sdqinfoorg c hearing about a family member who has died had a brother or sister die seeing a dead body in town and having a painful or scary medical treatment were excluded from the trauma count variable almost all children had lost a family member hence the first event did not add to the variation in the count for the second event it was not clear whether the child witnessed the event themselves for the third event in some sites burials are opencasket so all kids had seen these events for the latter event event description was not specific enough it seemed that for some children this included blood draws or like events that were scary to the child but not comparable to the other categories d data was compiled from a variety of country specific dhs data sets see references for further information on data used e constants in linear regression models represent the estimated mean value for the reference group for whom the values of all variables in the model are zero competing interests the authors declare that they have no competing interests authors contributions me conceived of the analysis analyzed the dataset conducted the literature review and wrote the manuscript kw assisted with conceptualization of the analysis models and interpretation of the results and provided manuscript feedback jo assisted with conceptualization and implementation of the analysis data analysis interpretation of the results and provided manuscript feedback kod selected the measures of emotional difficulties and learning and assisted with study implementation and interpretation of the results all authors read and approved the final manuscript

background development policymakers and childcare service providers are committed to improving the educational opportunities of the 153 million orphans worldwide nevertheless the relationship between orphanhood and education outcomes is not well understood varying factors associated with differential educational attainment leave policymakers uncertain where to intervene this study examines the relationship between psychosocial wellbeing and cognitive development in a cohort of orphans and abandoned children oac relative to nonoac in five low and middle income countries lmics to understand better what factors are associated with success in learning for these children methods positive outcomes for orphans pofo is a longitudinal study following a cohort of single and double oac in institutional and communitybased settings in five lmics in southeast asia and subsaharan africa cambodia ethiopia india kenya and tanzania employing twostage random sampling survey methodology to identify representative samples of oac in six sites the pofo study aimed to better understand factors associated with child wellbeing using crosssectional and childlevel fixed effects regression analyses on 1480 community based oac and a comparison sample of nonoac this manuscript examines associations between emotional difficulties cognitive development and a variety of possible cofactors including potentially traumatic eventsthe most salient finding is that increases in emotional difficulties are associated with lags in cognitive development for two separate measures of learning within and across multiple study sites exposure to potentially traumatic events male gender and lower socioeconomic status are associated with more reported emotional difficultiesin some sites being female and having an illiterate caregiver is associated with lower performance on cognitive development tests in some sites while greater wealth is associated with higher performance there is no significant association between orphan status per se and cognitive development though the negative and significant association between higher emotional difficulties and lags in cognitive development hold across all orphan subgroups conclusions these findings suggest that interventions targeting psychosocial support for vulnerable children especially vis a vis traumatic experiences may ease strains inhibiting a childs learning family based interventions to stabilize socioeconomic conditions may help overcome psychosocial challenges that otherwise would present as barriers to the childs learning

introduction violence against adolescent girls and young women is a global phenomenon and has implications on their wellbeing according to the world health organization more than a third of women globally have experienced either physical or sexual violence or both from an intimate partner or nonpartner in their lifetime it has also been reported that about one in three everpartnered agyw aged 1524 years have experienced physical andor sexual violence by an intimate partner 1 in subsaharan africa about 37 percent of everpartnered women have experienced physical andor sexual violence 1 a report by the united nations childrens fund kenya county office indicated that in 2010 about 76 percent of agyw aged between 18 and 24 years had experienced sexual physical or emotional violence prior to age 18 years while about half of agyw aged 13 to 17 years had experienced sexual or physical violence in the 12 months preceding the study 2 exposure to violence has deleterious effects on agyws health outcomes including their mental sexual and reproductive as well as social and economic wellbeing it is one of the leading causes of death in this age group globally 3 4 5 6 kabiru and colleagues found that adolescent girls aged 1115 years who had experienced violence had lower expectations of achieving their aspirations compared to those who had not experienced violence 5 a study conducted in malawi and south africa showed that exposure to violence has an impact on school enrolment and performance 7 studies looking at risk factors for violence have found that womens economic status and norms that place womens status in society at a lower position have a significant association with violence experience 48 in their review of risk factors for agyws experience of violence in romantic relationships vezina and hebert also found that adolescent mothers and those who had dropped out of school were at a greater risk of experiencing dating violence having witnessed violence has been found to be a risk factor for violence experience 4910 vezina and hebert argue that having witnessed violence as a child may contribute to perceiving violence as an acceptable way of resolving conflict this is in line with the social learning theory which postulates that individuals model behavior based on what they observe from their environmentscontexts 11 living in urban informal settlements has been found to heighten risk of experiencing violence kabirumumah found that about one in three girls aged 1115 years in urban informal settlements of nairobi has experienced at least one form of genderbased violence urban informal settlements have been associated with high levels of poverty crime and violence poor health outcomesincluding hivaidsas well as poor access to basic services such as schools and health care facilities past studies have found strong association between violence experience and poverty at the household 912 and community levels 91314 a major characteristic of the urban informal settlements exposure to violence has been found to be associated with hiv acquisition 15 while hivpositive status is thought to provoke violence in some contexts 81617 in their review campbell et al argue that increased risk for hiv acquisition works through increased sexual risktaking behaviors forced sex with an infected partner and compromised negotiation on safe sex practices 18 agyw who have been exposed to violence may have low negotiation powers thus compromised safe sex practices in the slum context the risk of hiv and occurrence of interpersonal violence risk seem to be heightened while recent data are sparse a study conducted in 2007 showed that the hiv prevalence was higher at about 12 among slum residents compared to 5 and 6 among nonslum urban and rural residents respectively and this mirrored the national trend where the burden was higher among females 19 impersonal violence including violence against women is common slums compared to the general kenyan population 20 the hiv epidemic in subsaharan africa cannot be brought under control without reducing hiv acquisition among agyw the most rapidly expanding demographic group on the continent 8 the dreams partnership is an initiative aimed at reducing the incidence of hiv among agyw in 10 subsaharan african countries it supports a core package of interventions provided at scale targeting agyw their families wider communities including men who are the sexual partners of agyw 21 the core package includes interventions aimed at addressing hiv risk behaviors hiv transmission socioeconomic vulnerabilities and genderbased violence the interventions are aimed at empowering girls and young women to reduce their risk of hiv infection and include sasa and schoolbased hiv and violence prevention programs the core package interventions are described in detail elsewhere 21 nairobi kenya is among the 4 sites chosen for an independent impact evaluation 22 using enrolment interview data from agyw cohorts established for the impact evaluation this analysis aims to summarize the prevalence of experience of violence the severity of physical violence and to identify factors associated with experience of violence among agyw living in the korogocho and viwandani informal settlements of nairobi within the first year of dreams implementation we also sought to determine whether dreams is reaching those who experience violence by comparing those who were and were not invited to participate in dreams methods study design setting and sample the dreams impact evaluation design and data collection protocol have been described in detail elsewhere 22 briefly the design leverages the nairobi urban health and demographic surveillance system a longitudinal platform run by the african population and health research center in two informal settlements of korogocho and viwandani since 2002 23 both informal settlements are characterized by high levels of unemployment substandard housing and crowding limited access to education and other social services high levels of insecurity and inadequate water and sanitation infrastructure whereas korogocho is a more settled community with many long term residents the population in viwandani is more mobile and youthful 23 in spite of this known fact we took measures to reach as many sample participants as possible we used different interview tools for the age groups 1014 years and 1522 years as dreams had a different primary package for each age group but also some of the questions in the tool for the former group could not be asked to girls in the latter group as they were inappropriate given their age the tool for the 1014 years was adopted from the global early adolescent study tool and has been validated for this particular age group in our setting for the 1522 years the world health organization violence against women instrument 24 was included to measure exposure to violence in this paper we used round one data collected marchjuly 2017 on a randomly selected sample of agyw aged 1022 years for the 1014 yearolds a random list of 1017 girls was generated of these 333 were no longer eligible at the time of visit of the remaining 684 46 were absent for extended period of time 9 either refused or their parents refused their participation and 23 had their structures located but respondents whereabouts were unknown leaving 606 with successful interviews at enrolment we targeted a minimum sample of 1000 agyw aged 1522 years a random list of 2599 agyw was generated of these 695 were no longer eligible at the time of visit of the remaining 1904 6 had incomplete interviews 315 were absent from their residence for extended period of time 283 refused to participate either by self or their parentsguardians and 219 had their structures located but respondents whereabouts were unknown leaving 1081 with successful interviews our assessment of how those who participated compared to those who did not showed that there were no major differences by several sociodemographic characteristics indicating that there was unlikely to have been selection bias measures outcome variables among girls aged 1014 years experience of violence was measured using the questions listed in box 1 the questions were of two types 1 whether the girl has ever experienced and 2 whether the girl experienced in the last six months they were classified into psychological violence sexual violence and physical violence a girl was considered to have experienced violence if she gave any of the answers sometimes often for questions 14 or yes for question 5 or yes by both boy and girl yes by boy or yes by girl for questions 6 and 7 as these questions were not similar as those used for agyw aged 1522 years the data for this group were analyzed separately consequently the results for the two age categories are not immediately comparable among the agyw aged 1522 years experience of violence was measured using 15 questions on a binary scale of yes or no the questions read like has any male ever done any of the following things to you in the past 12 months the tool has shown good psychometric properties 24 25 26 27 28 29 the who classified these items into three dimensions of violence 24 psychological violence box 1 the items used to measure experience of violence among the early adolescent girls 1014 years old � questions 14 had the answer categories never sometimes often dont know refused question 5 had the answers no yes cant remember dont know refused to answer questions 6 and 7 had answer options of no yes by both boys and girls yes by boys yes by girl or girls cannot remember dont know refused sexual violence 12 touched you in a sexual way when you did not want them to 13 try to have sexual intercourse with you when you did not want to but did not succeed 14 physically forced you to have sexual intercourse even when you did not want to 15 forced you to perform sexual acts when you did not want to � the answer options were yes or no physical violence and sexual violence explanatory variables explanatory variables included selfreported invitation to participate in dreams slum of residence age at survey marital status whether the girl is currently in school educational level religion ethnicity recent employmentengagement in income generating activity ever had sex ever been pregnant ever given birth slept hungry at night in past 4 weeks selfassessed household economic situation and wealth index for ethnicity categories with low frequencies were grouped under other wealth index was constructed using principle component analysis with input as indicator variables on ownership of household and individual assetsitems household structure and on households water supply and sanitation 3031 the wealth index was split into three categories of poor medium and wealthy the variables ever been pregnant and ever given birth were excluded from the present analysis because of multicollinearity data on the gender of the teacher were not collected for the 1522 yearolds data were collected electronically using facetoface interviews by well trained and experienced field interviewers and supervisors who were also well conversant with the study area for the 1014 years cohort only selected female interviewers surveyed them to minimize potential response bias for the 1524 yearold cohort enumerators were both males and females with mean age 27 years and 24 years respectively the mix of gender among the interviewers catered for any respondent that may have preferred to be interviewed by a particular gender prior to the survey tools were translated into kiswahili only and were back translated to ensure the questions did not lose their meaning the tools were piloted and issues that arose were addressed analysis to estimate the prevalence of violence we obtained for each domain the proportion of agyw who reported to have experienced at least one of the acts of violence comprising that domain these proportions were summarized with respect to important demographic characteristics we also compared those who were and were not invited to participate in dreams to assess the severity of violence a womangirl was considered to have experienced moderate violence if she answered yes to one or more of questions 45 in box 2 a womangirl was considered to have experienced severe violence if she answered yes to one or more of questions 6 to 11 24 we note here that this could only be done for physical violence as who guidelines on violence classification as moderate or severe only exist for physical violence to our best knowledge 2425 however in another study 1 all acts of sexual violence were considered severe but it is not clear what items comprised sexual violence domain we return to this in the discussion section to investigate factors associated with violence we considered psychological and sexual violence outcomes as dichotomous that is not abused or abused physical violence was considered ordinal with three levels of none moderate and severe as described above ordinal regression analysis was used 32 for each of the three violence outcomes we evaluated three plausible link functions that is logit probit and complementary loglog based on the loglikelihood values and practical considerations the logit link was chosen thus all inferences presented in the next section were based on models with a logit link we adopted a threestep approach to the analyses first a model was run with one explanatory variable at a time next a model was fitted for explanatory variable adjusted for invitation to dreams site and age finally all explanatory variables significant at p�010 in the second step were included in a multivariable model explanatory variables were tested in the multivariable model using likelihood ratio test at p�005 significance level invitation to dreams site and age were retained in the multivariable model even if they were not significant as we wished to adjust for their effect data management and all analyses were performed using stata v14 computational details and model fit evaluation are presented in supporting information s1 text ethical considerations ethics approval was provided by the london school of hygiene tropical medicine and amref health africa written informed consent was obtained from each participant for legal minors assent was obtained from the minor before the guardian gave consent the participants were given copies of the consent documents and project information sheet the interviewer took them through the information sheet and consent form and gave them an opportunity to ask questions once they indicated to have understood about the project and agreed to participate they were requested to sign the certificate of consent incase the respondents were not able to write they had their thumb print on the consent form or put a mark on the soft copy of the consent and the field interviewer noted on the comments section that the respondent was unable to write results demographics of the adolescent girls and young women data were available on 606 and 1081 agyw the mean age for the 1014 year olds was 121 years and that of the 1522 year olds was 179 years of 606 girls aged 1014 years 53 were from korogocho and 47 were from viwandani five of the girls were not enrolled in school the majority were christians 10 were muslims they were of different ethnic origins including kikuyu luo kamba luhya somali and kisii about 5 had done chores or activities for which they got paid money over the past 6 months providing services among others of 1081 agyw aged 1522 years about half reported to have ever been invited to participate in dreams the majority had never been married were in school were christians had never engaged in an income generating activity had had sex and assessed their household economic situation as moderately poor the majority of agyw were from the kikuyu and kamba communities followed by luos and luhyas somalis and kisiis about nine in ten agyw reported to be knowing their hiv statuses prevalence among 1014 year olds table 1 shows for girls aged 1014 years the proportions that experienced violence in the past 6 months or ever experienced violence by demographic characteristics overall psychological violence was the most prevalent both within the past 6 months and life time followed by physical violence and sexual violence was generally less prevalent among those invited to dreams currently enrolled in school did not engage in chores or activities for payment during the past 6 months had never had sex or family had enough food s2 table shows that the proportions that experienced any form of violence in the past 6 months was 378 while in life time was 574 predictors of violence among 1014 yearolds s4 table summarizes predictors for violence among girls of ages 1014 years after adjusting for other factors the odds of experiencing any violence were greater among girls who engaged in chores or activities for payment in the past 6 months and among those whose family did not have enough food due to lack of money violence was lower among girls invited to dreams and among nonchristians prevalence of violence among the 1522 yearolds fig 1 shows the percentage of the 1522 yearold cohorts with a yes answer to each of the 15 violence questions listed in box 1 item 3 was the most experienced at 265 followed by item 1 then items 2 5 12 when you did not want them to and 13 at about 10 fig 2 shows that the prevalence of psychological violence among at the 1522 yearolds was 331 followed by physical violence and sexual violence in the past 12 months about 44 experienced at least one of the 15 acts of violence in the past 12 months further some of the agyw experienced more than one type of violence with 69 experiencing all three types of violence about 92 reported both physical and psychological 333 reported both psychological and sexual and 17 reported both physical and sexual violence tables 24 present the prevalence of the three violence domains by demographic characteristics they show that within each violence measure the prevalence of violence varied across the demographic characteristics with about 45 and 33 of those who respectively know and dont know own hiv status experiencing any form of violence severity of physical violence among 1522 yearolds of 1081 agyw aged 1522 years 92 experienced moderate physical violence and 138 experienced severe physical violence in the past year s4 table shows these proportions for several demographic characteristics in general severe physical violence was more prevalent than moderate physical violence levels across the levels of the demographic characteristics moderate violence was higher among agyw not invited to participate in dreams than those invited resided in korogocho compared to viwandani 1822 yearolds than 1517 yearolds previously or currently marriedliving with a partner compared to those who had never married or lived with a partner not in school ever had sex slept hungry and were poor severe physical violence was higher among korogocho residents compared to viwandani residents previously marriedliving with partner not currently in school with some secondary education or lower christians and other religious groups than muslims among luos and luhyas ever had sex slept hungry at night last 4 weeks assessed their household economic situation as not poor or were in the poor wealth quantile predictors of violence among 1522 yearolds tables 234show the logistic regression model results for psychological physical and sexual violence respectively from table 2 agyw who were previously marriedlived with partner or engaged in employmentincome generating activity last month or slept hungry at night during past 4 weeks had greater odds of experiencing psychological violence table 3 shows the odds of experiencing physical violence were lower among those who lived in viwandani slum relative to those living in korogocho and among muslims and the odds were greater among agyw who were previously married or lived with a partner or slept hungry at night during the past 4 weeks it can be seen from table 4 that the odds of sexual violence were lower among agyw aged 1822 years and among muslims sexual violence was higher among agyw who reported to have ever had sex or slept hungry at night during the past 4 weeks in summary sleeping hungry at night during past 4 weeks was found to be significantly associated with greater odds for all three forms of violence other factors held constant being a muslim was associated with lower levels of physical and sexual violence discussion this study provides data on the prevalence levels of and determinants for violence against agyw in slums settings of nairobi this is in line with and a response to a call by the who a decade ago urging researchers to incorporate violence against women components into hiv and aids prevention and adolescent health promotion programs 21 violence against agyw in korogocho and viwandani slums is common with about four in ten agyw aged 1014 years and 1522 years reporting to have experienced violence in the past six and 12 months respectively in both age categories psychological violence was the most experienced followed by physical violence and sexual violence these levels of violence are in line with previous studies that have shown that agyw in kenya are predisposed to physical psychological and sexual violence 233 in a study by mathur et al about two in ten agyw aged 1524 reported sexual violence by an intimate partner in the 12 months preceding the study more concerning however is our finding that at 1014 years about six in ten of the young girls had ever experienced violence our finding that having ever slept hungry in the last one month increased the odds of experiencing physical psychological or sexual violence is similar to findings from other studies conducted in subsaharan africa and elsewhere a study conducted in botswana found that women who were food insecure were more likely to experience sexual violence 34 food insufficiency has been linked to highrisk sexual behavior and sexual vulnerability among women 3536 the high levels of food insecurity reported within the nuhdss 23 are therefore likely to contribute to the high likelihood of agyw experiencing physical sexual and psychological violence food insecurity puts women at greater risk of violence through 1 path of stress by causing hunger and worry about having sufficient access to food which might act as a trigger to interpersonal violence 2 making it difficult to walk out of an abusive relationship due to dependence for food 3 engaging in transactional sex as a means of getting food and so on 37 marital status was associated with experiences of physical and psychological violence whereas being in a current marital union reduced the likelihood of experiencing psychological violence having been in a marital union previously increased the chances of experiencing both physical and psychological violence the finding here that the odds of psychological abuse among formerly married women were more than twice that for single women may point to abuse as a reason for termination of such relationships the 2014 kenya demographic and health survey shows that a greater proportion of women and men who were divorced separated or widowed reported to have ever experienced physical sexual and emotional violence compared with those who were in marital unions 38 other studies have also shown that the risk of violence increases considerably when women want to leave are trying to leave are in the process of leaving or have left a relationship 39 40 41 42 there seem to be some protective normscultures religion was found to be significantly associated with experiencing violence overall agyw who identified themselves as muslims had lower likelihood of experiencing all three forms of violence this finding is consistent with past research where being religious has been associated with lower likelihood of perpetrating violence 43 the modalities of most religions encourage peaceful coexistence at individual family and community levels and also are likely to provide support services for their congregants to resolve conflicts however religion may also increase the vulnerability of agyw as it discourages dissolution of marriages and thus it may encourage a victim to stay in an abusive marriagerelationship nevertheless it is not clear whether they are indeed protected or it is an issue of reporting bias a previous study found tolerant attitudes of muslim women towards violence which is a portrayal of the religious restrictions they have to abide by 44 and which could contribute to under reporting agyw who were in employment in the past one month were more likely to experience psychological violence the autonomy and independence that often comes with financial freedom has been identifiable as risk for abuse in other studies this finding reflects socialcultural attitudes towards womens employment and may be closely associated with the belief that men hold power in household allocation of resources and decisionmaking on household expenditures 45 this may imply that women who work may have little or no decisionmaking powers on how their income is utilized future studies focusing on this can provide valuable data findings from other studies in ssa 4647 suggest that women form a higher proportion of people working in the informal sector and that they experience exploitation work for long hours are underpaid and are engaged in other forms of work beyond their contractual agreement factors that are likely to contribute to psychological violence korogocho slum is characterized by higher levels of poverty low education attainment and violent crime these directly or indirectly have implications on the risk of physical violence amongst agyw which in viwandani is estimated to be lower by almost 50 the fact that the propensity of experiencing sexual violence among older agyw was lower by almost 40 may point to evidence from previous studies that has shown that while the perpetuators are often thought to be strangers a lot of this is by close family members or friends who take advantage of young agyw who are not empowered to resist or report such advances our finding that having had sexual intercourse increased the odds of experiencing sexual violence was expected and is in line with previous literature 48 sexual experience in this study includes sexual intercourse that agyw were forced to participate in including rape and this could explain the increased odds of sexual violence among those who had had sex however we did not distinguish between intimate partner and nonpartner sexual violence we found no significant association between dreams invitation and any domain of violence using these first round data this could be attributed to the fact that the first round of data collection took place when dreams intervention had just started given the staggered rollout of interventions we do not expect dreams to have had prevented violence at this early stage of the program second we have no baseline to measure change in violence over the course of that year in summary our study has found high prevalence of and have identified some protective and risk factors for violence among agyw in two nairobi slums the high prevalence among the younger age group in particular calls for urgent intervention as childhood exposure to violence has been reported to be a risk factor for violence in adulthood our findings can help the formulation and implementation of both national and subnational policies budgets and actions to reduce eliminate and mitigate the consequences of violence against women as data used in this paper are part of an independent impact evaluation the learnings from these results have not been used to influence dreams implementation however our finding of no difference in violence among those invited to the program and those not invited among agyw aged 1522 years raises a flag for us to pay attention to measurement details which if okay might point to the fact that since social change tends to take long to happen the implementation period might need to be longer we also note that violence seems to occur together with other forms of social vulnerability such as food insecurity which is very important in situations where single interventions might fail to lead to expected outcomes within dreams 21 promising interventions such as gender norms training schoolbased hiv and violence prevention programs and lessons and tools from sasa intervention in uganda 49 exist that need to be scaledup in rural south africa the intervention with microfinance for aids and gender equity combined a microfinance program with a gender and hiv education to reduce risk of gender based violence and hiv 15 other promising strategies to leverage also exist 50 this study has some limitations whereas all due care was taken to ensure that the tools captured the right information we cannot rule out the possibility of misreporting it has been shown in other studies that to avoid feeling embarrassed women tend to underreport physical and sexual violence such as rape as is often the case might be blamed on the victim 51 52 53 the slum population is generally unique with different social challenges compared to their rural and urban nonslum subpopulations therefore results drawn from this study may not accurately be generalizable to the entire population of agyw in kenya whenever data allow there is need to make comparisons across subpopulations and over time to be able to fully understand the dynamics and general trend of occurrence of violence and possibly link it to other health and social outcomes such hiv acquisition pregnancy outcomes and schooling outcomes among others another limitation is that there is no unified framework for classifying different violence domains into moderate or severe in the present study we have classified physical violence only into moderate or severe following who guidelines standard guidelines for such classifications need to be developed for the other violence domains as well to allow for studying on severity of violence in settings such as ours finally whereas this study has a unique sample given the age of the cohorts and the setting the use of two different tools could not allow us to immediately compare the two age groups conclusions physical psychological and sexual violence among agyw in the two nairobi slums is common the violence is intimately related to some of the social as well as cultural norms but importantly seem to be driven by the economic circumstances under which these girls find themselves in given the association between violence and hiv acquisition in young women addressing violence against women and girls is critical to curbing the hiv epidemic overall and interventions against this should be supported and promoted all relevant data are within the manuscript and its supporting information files supporting information

we sought to estimate the prevalence severity and identify predictors of violence among adolescent girls and young women agyw in informal settlement areas of nairobi kenya selected for dreams determined resilient empowered aidsfree mentored and safe investmentdata were collected from 1687 agyw aged 1014 years n 606 and 1522 years n 1081 randomly selected from a general population census in korogocho and viwandani in 2017 as part of an impact evaluation of the dreams partnership for 1014 yearolds we measured violence experienced either in the past 6 months or ever using a different set of questions from those used for 1522 yearolds among 1522 yearolds we measured prevalence of violence experienced in the past 12 months using world health organization who definitions for violence typologies predictors of violence were identified using multivariable logit modelsamong 606 girls aged 1014 years about 54 and 7 ever experienced psychological and sexual violence respectively about 33 16 and 5 experienced psychological physical and sexual violence in the past 6 months the 1014 year old girls who engaged in chores or activities for payment in the past 6 months or whose family did not have enough food due to lack of money were at a greater risk for violence invitation to dreams and being a non

introduction worldwide over a million people acquire a sexually transmitted infection daily every year there is an estimated 357 million new infections with one of the four stis globally chlamydia gonorrhoea syphilis or trichomoniasis 1 the united nations defines youths as those persons aged between 15 and 24 years 2 young persons are those in the transition period from the dependent phase of childhood to the interdependence of adulthood 3 sexually transmitted infections are common among young people with approximately 20 million new cases of stis being reported every year in the united states of which the majority occur among people aged between 15 and 24 years 4 young people are at high risk of getting an sti for the following reasons young womens bodies are biologically more prone to sexually transmitted diseases lack of access to healthcare confidentiality concerns and multiple sexual partners among others 4 the nigerian national demographic health survey in 2008 reported that 16 of young women and 6 of young men aged between 15 and 24 years had sexual debut before the age of 15 years a survey in nigeria on the prevalence and predictors of early sexual debut among adolescents reported that an average of 186 had sexual debut before their 15th birthday 166 in boys and 202 in open access girls 5 this is clearly one of the reasons for the high prevalence of stis among young people 6 sexually transmitted infections can lead to severe complications beyond the immediate impact of infections some stis such as herpes and syphilis can increase the risk of human immunodeficiency virus acquisition threefold or more gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and infertility in women 1 data on the incidence and prevalence of stis in nigeria are limited because of the underreporting of stis especially among young persons which is attributable to inadequate diagnostic facilities and limited access to treatment facilities asymptomatic episodes of the infections and the stigma associated with sti 7 young adults are also exposed to diverse sources of influence transecting different levels of causation 2 the knowledge of the nonhiv causes of stds is still lacking and the risky behaviour practiced by sexually active young adults is on the rise prevention of stis includes counselling behavioural interventions comprehensive sexuality education sti and hiv preand posttest counselling condom promotion and interventions targeted at key populations 1 the prevention of stis especially in the regions where they are endemic propelled mainly by heterosexual transmission includes vaccination and practice of the abc approach 8 literature on the knowledge and preventive practices of stis in lagos state is quite scanty if any at all especially in surulere local government area which is one of the highly sociable urban areas with numerous bars clubs lounges malls and pubs highly populated by young persons hence this study was conducted in surulere lga in lagos state to determine the knowledge of attitude towards and preventive practices adopted by young unmarried persons against stis materials and methods background information to the study area study population design sample size determination and selection of participants the study population consisted of young unmarried youths who must have spent at least 6 months in the selected communities in the lga the study was a communitybased descriptive crosssectional study the cochranes formula for descriptive study n z 2 pqd 2 was used with a standard normal deviation at 95 confidence interval a prevalence rate of 625 from a similar study carried out in enugu south east nigeria 12 and an error of precision at 5 the minimum sample size was 360 an additional 20 of this was added to allow for possible data loss hence 450 respondents were used for the study a multistage probability sampling technique was used to select the respondents from the study population in five stages stage 1 comprised the selection of five wards of the nine wards in surulere lga by simple random sampling using the ballot method in stage 2 20 of the total number of streets in each of the selected wards was selected through simple random sampling by ballot selection of houses was done via systematic sampling with the sampling interval being the total number of houses on the street divided by the number of required houses in stage 3 in stage 4 one household was selected from each of the selected houses while stage 5 consisted of the selection of one respondent from each household by simple random sampling using the ballot method study instrument and data collection a pretested intervieweradministered semistructured questionnaire adapted from the reviewed literature 1213141516 was used for data collection the questionnaire consisted of four sections section a consisted of questions on sociodemographic characteristics of the respondents while section b had questions on the knowledge of the respondents about stis section c had likertscale questions assessing attitudes of the respondents towards stis and section d comprised questions were asked to determine the preventive practices of the respondents against stis data analyses data analysis was performed using epiinfo 7222 results were represented in frequencies and percentages chisquare test was used to test for associations with the level of significance set at p ≤ 005 for the level of knowledge of each respondent about sti every correct answer attracted one point while every incorrect answer or nonresponse attracted a zero the scores were converted to percentages and graded as poor and good for attitude questions on likert scale the mean score was calculated scores below the mean were classified as poor while those above the mean were classified as good attitudes in assessing the preventive practices against stis every correct answer scored one point while an incorrect answer or nonresponse scored zero the total score for each respondent was converted to percentage and graded as poor preventive practices if 50 and good preventive practices if 50 open access ethical consideration ethical approval for this study was obtained from the health research and ethics committee of the lagos university teaching hospital written informed consent was obtained from each respondent with assurance of confidentiality of information and their right to withdraw from the study at any point in time the participants were informed that participation in the study was voluntary results sociodemographic characteristics of respondents a total of 425 out of 450 questionnaires administered which were adequately answered were analysed with a response rate of 944 the age range and mean age ± standard deviation of the respondents were 1524 and 199 ± 25 years respectively most of the respondents were christians of yoruba ethnicity and 640 had tertiarylevel education majority of the respondents were aware of sti and most of them got information about sti from the internet teachers and schools and electronic media knowledge of respondents about sexually transmitted infections viruses and bacteria were the most common known causes of stis among the respondents majority of the respondents knew that hiv or acquired immunodeficiency syndrome is a type of sti however a few believed that diarrhoea sickle cell disease tuberculosis and malaria were examples of stis majority of the respondents rightly knew that stis did not have any gender predilection as it can affect both men and women and 967 knew that stis were commonly transmitted by unprotected sexual intercourse more than half of the respondents also recognised blood transfusion as a means of sti transmission however less than half of the respondents identified mother to child route as a means of sti transmission more than half of the respondents knew that it is possible to be infected with no clinical symptoms pain on urination was the commonest sti symptom while open access infertility was the most known complication of sti identified by the respondents in addition most of the respondents knew that not all stis can be cured while majority of the respondents agreed that stis are preventable overall about threequarter of the respondents had good knowledge of stis attitude of respondents towards sexually transmitted infection prevention table 4 shows that almost all of the respondents were in favour of educating young people on sti in academic institutions while the majority agreed that people with stis should not be isolated a higher percentage of the respondents agreed with the idea of using condoms during sexual intercourse to prevent sti while 942 believed that screening for sti is good and majority of the respondents agreed that it was proper to contact the health personnel if one noticed sti symptoms a large number of respondents agreed that watching pornography can contribute to risky sexual practices that can lead to sti overall majority of the respondents had a positive attitude towards the prevention of stis age level of education attitude and preventive practices were all found to be statistically significantly associated with the knowledge of respondents about stis respondents preventive practices against sexually transmitted infections discussion sexually transmitted infections are among the worlds most common diseases with an annual incidence exceeded only by diarrhoeal diseases malaria and lower respiratory infections each day almost one million people acquire a new sti more than 340 million new cases of curable stis and even more new viral infections occur each year worldwide up to 80 of curable stis occur in developing countries of the world with adolescents and young adults having the highest rates of these diseases in developing countries like nigeria stis are among the leading causes of disability adjusted life years lost for women of reproductive age exceeded only by maternal causes and hiv 121718 in this study 450 young unmarried persons were assessed for knowledge of attitude towards and preventive practices of sti the mean age of the respondents was 199 ± 25 years and most had tertiary education which is in line with similar studies carried out in shone town ethiopia and malaysia where majority were undergraduates 1315 this study is however contrary carried out in southwest nigeria which reported a lower mean age 14 this difference is likely because of age difference in the study population most of the respondents had overall good knowledge of stis contrary to a study in adoekiti nigeria which reported only 69 of the respondents as having overall good knowledge of stis 14 this finding could be because of the fact that most of the respondents in this study were undergraduates compared to the adoekiti study which was carried out among secondary school students human immunodeficiency virus or aids gonorrhoea and syphilis were the major types of stis identified by respondents in this study which is in line with the finding of similar studies conducted within and outside nigeria 1215192021 majority of the respondents in this study knew that unprotected sexual intercourse was a major means of transmission of stis while less than half knew about transmission of stis via mother to child this finding is consistent with the reports of various other studies conducted within and outside the country 12131419 a statistically significant association was found between age and level of education with knowledge of respondents about stis which implies that as the respondents got older or attained a higher level of education their knowledge also increases for example respondents in the age group 2024 years and those in tertiary institutions had better knowledge of stis this finding is similar to that reported by a malaysian study where students in the age group of 2430 years were more likely to have good knowledge about stis compared to those aged 1723 years 15 which is slightly different from a study conducted in kwara state nigeria where age was not found to be statistically significant with knowledge but class do 22 with regard to attitude almost all respondents in this study were of the view that young people should be educated about sti in academic institutions this finding is comparable to that of an indian study 23 condom use during sexual intercourse to avoid stis was supported by most of the respondents in this study which is similar to the finding in the malaysian study 15 the majority of the respondents in this study agreed that multiple sexual partners played a major role in the transmission of stis while a high percentage of the participants opposed watching pornography similarly other studies in malaysia china and kampala reported that a higher percentage of the respondents knew that having multiple sexual partners was unsafe 152425 overall almost all respondents in this study had a positive attitude towards prevention of stis as was the case with that was conducted in shone town ethiopia13 this study found a statistically significant connection between knowledge and attitude of the respondents this implies that as the knowledge of the respondents on stis increases they show better attitudes towards its prevention about a quarter of the respondents in this study were sexually active during the time of this study this is in line with the finding in a study in ogbomoso nigeria and malaysia 515 more than half of the respondents in this study had sexual debut between the ages of 15 and 19 years this finding is similar to that of a study conducted in ikejiarakeji osun state southwestern nigeria which reported mean age at first sexual intercourse as 168 years 26 the study in ogbomoso nigeria found that mean age at sexual debut was 1580 years in girls and 1540 years in boys 5 early sexual debut has been reported to be associated with an increased risk of stis researches have shown that the probability of giving birth during the teen years is three times higher for those who had their sexual debut before the age of 16 compared to those who did not 5 this report has shown that about 20 of women in nigeria in 2013 were sexually active by the age of 15 years and the median age for first sex stood at 177 years for women and 206 years for men this declining age of first sexual intercourse has been proffered as one possible explanation for the increase in the number of stis 2728 some common misconceptions found among the respondents in this study about the prevention of stis were about 36 and 25 felt that contraceptive use and taking drugs before sex respectively are known protective measures against stis while alcohol intake before sexual intercourse was also regarded as a prevention method by about 18 of the respondents in a study conducted in china some of the respondents reported that taking antibiotics before or after sex taking a shower before or after sex or using a sex detergent wash before or after sex could prevent stis 24 about half of the respondents in this study had one regular partner and the majority used condoms and most of them used it always this finding is contrary to the report of a study among youths in nairobi where less than half of the respondents use condoms and in southern ethiopia where 290 use condoms and 119 respectively use it always 2930 these differences probably could be because of differences in the cultures and religious beliefs in the different study settings the study in malaysia reported that about twothird of the respondents had only one partner 15 these findings point to a higher rate of risky sexual behaviours among young unmarried people in the different study settings about half of the respondents in this study have been vaccinated against hepatitis b virus while almost all were not protected against human papilloma virus preexposure vaccination has been recommended as one of the most effective methods for preventing transmission of human papillomavirus hepatitis a virus and hepatitis b virus human papillomavirus vaccination is recommended routinely for boys and girls aged 11 or 12 years beginning at 9 years of age 31 overall about twothird of the respondents in this study had poor preventive practices against stis knowledge of respondents of stis was found to be statistically significant with the preventive practices of stis conclusion most of the respondents in this study were aware of and had good attitude towards the prevention of sti but gaps still exist in their knowledge of stis preventive practices of stis are very poor among the respondents therefore targeted education on behaviour change communication aimed at young unmarried persons in communities is highly recommended to improve their knowledge and thereby implementation of preventive practices against stis limitations this study had some limitations firstly our study participants were from only one lga out of the 20 in lagos state this study was conducted in a community and the results represent the views of the respondents in that community alone which might be different from others in other parts of the state the presence of recall bias in this study is also very likely therefore further research with a larger population with adequate power and sample sizes is recommended data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study competing interests the authors have declared that no competing interests exist disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors

background sexually transmitted infections stis are of public health importance as over 1 million stis are acquired daily worldwide onethird of the new cases of curable stis affect younger persons aged less than 25 years sexually transmitted infections can lead to severe complications beyond the immediate impact of infections as such aim this study assessed knowledge of attitude towards and preventive practices of sti among young unmarried persons in surulere local government area lga of lagos state nigeria

background the adverse experiences and profound structural changes related to the covid19 pandemic have resulted in severe psychosocial stress all over the globe there is a consensus that families have been particularly strained by the policies implemented to contain the virus eg due to limited access to family support services 1 and daycare facilities nurseries or schools 2 which resulted in additional childcare responsibilities for parents while often having to work from home while restriction measures have been gradually reduced or completely lifted the long course of the crisis and the accumulation of stress factors such as existential fears and worries loss and grief economic disadvantages negative personal and social changes in many life areas represent persistent stressors that can have adverse effects on eg mental health 3 accordingly studies have found an increase in depression and anxiety symptoms among parents since the beginning of the pandemic 45 with caregivers of young children at particular risk for these mental health issues 6 there is also evidence for an increase of parenting stress 7 8 9 which is closely related to the quality of parentchildinteraction 10 and both parental and child mental health 10 11 12 child mental health soon became a matter of concern in the early stages of covid19 national and international studies found significant increases of psychological problems in children and adolescents eg 1314 compared to prepandemic data however these studies largely focused on schoolaged children or merely included younger children without highlighting their specific situation hence comparable investigations of infants and young childrens mental health as well as their caregivers wellbeing are sparsepossibly due to this group being less directly affected by the structural restrictions implemented to contain the virus however parental psychosocial stress during the different waves of the pandemic is likely to have impacted very young children they depend almost exclusively on the physical and emotional care and protection of their parents in a phase of life characterized by rapid brain growth and development 1516 rendering them particularly vulnerable to stressful environmental influences 17 as evident during the pandemicwith severe possible implications for a healthy development 1819 one of the very few investigations with a specific focus on infants and toddlers is the coronababy study which surveys psychosocial stress factors such as parenting stress and parental and child mental health problems in families with 03 year olds in germany 20 first crosssectional results from a high incidence phase in 2021 showed that infants and toddlers showed an overall similar level of mental health problems at this point compared to prepandemic studies however a substantial number of the surveyed parents struggled with affective symptoms and reported limited emotional resources for childcare due to high levels of parenting stress because young childrens mental health is generally closely linked to the psychosocial wellbeing of their caregivers 1011 21 22 23 there could still have been delayed detrimental effects of parental stressors in later stages of the pandemic given that childrens mental health is the foundation for healthy development 24 it is of particular interest to understand the extent to which potentially harmful stressors were present in this population at different stages of the pandemic in order to provide appropriate support services following the very recent crisis we therefore investigated psychosocial stress factors namely perceived pandemic burden parenting stress and parent and child mental health outcomes in german families with children aged 03 years in a repetitive crosssectional study during three different phases of the covid19 pandemic in 202122 we aimed to answer the following research questions 1 how many families experienced psychosocial stress factors during phases of higher and lower covid19 incidence rates restriction measures during the coronababy study we expected a higher prevalence of perceived pandemic burden parenting stress parental anxiety and depression symptoms infant crying sleeping and feeding problems and toddlers emotional and behavioral problems among families in survey wave i due to high incidence rates and lockdown measures compared with families surveyed in wave ii during the summer with low incidence rates and restrictions followed by a rise in the number of psychosocially stressed families during the wave iii survey period with its renewed steep increase in infection rates which sociodemographic and pandemicrelated markers might contribute to the aforementioned psychosocial stress factors methods study design the measures all data were collected by standardized questionnaires via app participants were asked questions on general sociodemographic characteristics perceived pandemic burden parenting stress and parent and child mental health outcomes pandemic related restrictions and perceived pandemic burden overall ten questions were asked about specific restrictions and perceived burden related to the pandemic the perceived pandemic burden for parents and children was derived from the 5pointanswer from parenting stress to assess parenting stress we applied the parent domain of the german version of the parenting stress index high scores indicated limited parental resources for upbringing and care for the child the parent domain includes the following subscales health isolation role restriction parental competence attachment depression and spouse related stress answers were given on a 5point likert scale ranging from 1 strongly agree to 5 strongly disagree resulting in a possible score range of 28 to 140 the three cutoff categories for each subscale and the whole parent domain were not stressed stressed and strongly stressed internal consistency of the parent domain has been proven to be good and retest reliability after one year has been shown to be r 087 correlations with stress indicators and related constructs have resulted in the assumption of test validity 2526 parental depression and anxiety symptoms current parental depression and anxiety symptoms were assessed with the statetraitanxietydepression inventory 28 infants crying sleeping and feeding problems and toddlers emotional and behavioral problems for infants the two subscales crying whiningsleeping and feeding of the questionnaire for crying sleeping and feeding were applied parents answered 38 questions on behaviors in their infants answers were given on 4pointscales and mean values were calculated according to validated cutoff values the dichotomous outcome noticeable problems and no problems were calculated for the domains cryingwhiningsleeping and feeding the csf also comprises questions to identify excessive crying as defined by the wessel criterion 30 the validity of the questionnaire has been secured by the proof of high internal consistencies of the scales as well as by correlations with behavior diaries and clinical diagnoses 29 for toddlers the strengths and difficulties questionnaire was used to examine emotional and behavioral problems parents were asked to classify the individual characteristics to be not true somewhat true or certainly true for their child in four domains resulting in a score range of 040 points cutoff values indicated child behavior to be no problems borderline or noticeable problems internal consistency has been shown to range between α 073 and α 086 by means of comparison with other corresponding scales the validity of the instrument can be assumed 3233 statistical analyses the present crosssectional analysis is based on three survey waves of data collection wave i 1st of february to 7th of june 2021 wave ii 8th of june to 16th of october 2021 and wave iii 17th of october 2021 to 14th of march 2022 selection and comparison of time periods was based on covid19 incidences and corresponding measures to contain the pandemic wave i was characterized by high incidences and strict measures wave ii comprised the summer months with relatively low incidences the opportunity to get vaccinated for everyone and relaxations of measures wave iii was again characterized by very high incidences but had fewer restrictions for vaccinated or recovered people compared to earlier high incidence phases in bavaria germany statistical differences between the sociodemographic characteristics of the three survey wave samples were detected by using chi squared test for categorical and anova for continuous variables to answer the first research question we calculated chi squared tests and corresponding effect sizes to detect potential differences of the addressed psychosocial stress factors between the samples of the three individual survey waves to adjust for childrens age and sex logistic regression models were calculated with survey wave and childrens age and sex as independent variable and the respective psychosocial outcome as dependent variable in order to obtain clinically relevant answers the outcome variables were dichotomized as follows pandemic related restrictions changes and perceived pandemic burden were dichotomized into high very high versus low perceived restrictions respectively into stressful very stressful compared to less stressful parenting stress was classified into stressedstrongly stressed versus not stressed parental mental health problems were dichotomized into above average far above average versus average below average far below average and toddlers emotional and behavioral problems into borderline noticeable problems versus no problems in a second step we addressed the question which factors might have contributed to the surveyed psychosocial stress factors and included both sociodemographic factors and pandemicrelated factors as potential predictors to explore if these factors predicted parenting stress maternal depression and anxiety symptoms infants cryingwhiningsleeping problems and toddlers emotional and behavioral problems four multiple linear regression models over all three survey waves were calculated blockwise multiple linear regression models with binary sociodemographic variables as predictors in the first block and pandemic related variables in the second block were conducted the formation of the models resulted in the calculation of beta weights and their pvalues for corresponding predictor variables requirements for calculating the multiple linear regression models were met for the linear regression models independent variables were dichotomized as follows education status was dichotomized into high and low financial status was also dichotomized into high and low accordingly financial burden due to the pandemic was dichotomized chronic illness or disability of the child was defined as any chronic illness andor disability since submission of questionnaires was only possible when all items were completed we had only a few missing values because of obvious misreporting of parental age all described results were based on an alpha level of 5 a posthoc bonferroni correction was applied to control for multiple testing analyses were performed in ibm spss statistics version 280 for windows results sample characteristics in total we examined 2940 parentchild dyads 1004 of whom participated in wave i 938 in wave ii and 998 in wave iii overall 929 of the surveyed parents were mothers with a mean age of 335 years 66 fathers and 05 were grandparents and others children were on average 164 months old and were divided into infants with a mean age of 55 months and toddlers with a mean age of 263 months perceived pandemic burden and pandemicrelated restrictions almost two thirds of the parents perceived the pandemic as stressful or very stressful in wave i this proportion significantly decreased from wave i to wave ii and remained on a high level in wave iii the frequencies of perceived individual pandemicrelated restrictions can be seen in table 2 parenting stress and parental mental health parenting stress was present in 382 of the parents in wave i this proportion was slightly higher in wave ii and significantly higher in wave iii compared to wave i maternal anxiety and depression symptoms were similar in all three waves and ranged between 242 in wave i and 283 in wave iii in fathers these symptoms ranged between 143 and 284 child mental health in wave i 265 of the infants showed problems on the cryingwhiningsleeping subscale of the csf in wave iii this proportion was significantly higher in wave i 184 of the toddlers showed at least borderline emotional and behavioral problems in wave iii the proportion was 239 figure 1 shows the percentage of families with psychosocial stress factors in each survey wave influencing factors on parenting stress maternal symptoms of depression and anxiety infants cryingsleeping problems and toddlers emotional and behavior problems the blockwise fully adjusted linear regression model 7623 p 0001 showed familial conflicts to have the highest effect size on the outcome parenting stress for maternal symptoms of depression and anxiety 7376 p 0001 increased familial conflicts had the highest effect size for infants cryingsleeping problems the model 1079 p 0001 yielded having siblings to be a protective predictor with an effect size of β 0159 whereas increased familial conflicts was the risk factor with the highest effect size for toddlers emotional and behavioral problems the model 2397 p 0001 yielded increased familial conflicts to have the highest effect size discussion in a comparison of the three survey waves of the coronababy study including a total of 2940 parents with their children aged 03 years we crosssectionally investigated the number of families experiencing psychosocial stress factors in relation to higher and lower covid19 incidences and restrictions in bavaria southern germany our results show that psychosocial stress factors in families with infants and young children remained highly prevalent over the course of the pandemic while parental high pandemic burden mirrored incidence rates and respective restriction measures the number of caregivers experiencing noticeable parenting stress increased irrespective of pandemic events parental mental health problems were highly evident but remained more or less stable during the course of the pandemic similarly toddlers mental health problems were highly evident in later stages of the pandemic but did not increase significantly during the course of the study in contrast the number of infants with mental health problems significantly increased from one high incidence phase to another of several sociodemographic and pandemicrelated variables we found the increase of familial conflicts during the pandemic to have the strongest negative influence on parenting stress maternal infants and toddlers mental health looking at our results in detail we found a perceived high pandemic burden in up to 65 of our sample which appears to be a slightly higher rate than in a german comparison study including parents of children younger than 14 years 34 this result corroborates findings that parents of young children are particularly vulnerable to experiencing the pandemic as stressful partly as expected the number of families with a high pandemic burden roughly mirrored the restrictions during the individual survey waves with a prevalence peak during survey wave i a significant decrease in survey wave ii but only a slight renewed increase in survey wave iii these findings are in line with another study showing a peak of diseaserelated distress early during the virus outbreak and a decrease as time proceeded 35 a different picture emerged for parenting stress across the three survey waves from the beginning of the study with 382 of the families being affected parenting stress was highly pronounced compared to prepandemic data contrary to our initial assumption the number of families with elevated parenting stress significantly increased in wave ii despite lower covid19 incidences and fewer restrictions and only nonsignificantly rose to a peak in wave iii although the effect sizes were small overall more than half of the surveyed participants were affected by parenting stress while there are no studies that are fully comparable with regard to design survey periods and target group a longitudinal study on parenting stress found an increase with a longer duration of the pandemic in the year 2020 36 in addition a german longitudinal investigation of the general population found that psychological distress did not decrease between two high incidence phases in 2020 despite lesser restrictions during the second survey timepoint 37 as parenting stress did not decrease despite relaxation of measures to contain the virus it is likely to be a longerterm stress factor since it is closely related to parental 38 39 40 and child mental health problems 10 11 12 and negatively impacts the parentchildrelationship 3841 intervention efforts should aim at reducing parenting stress in families with young children in the aftermath of the pandemic turning to parental mental health we identified a peak of 283 of mothers and 284 of fathers with symptoms of depression and anxiety in survey wave iii the number of affected parents appeared to be higher compared to a prepandemic german study with approximately 20 of parents with children under the age of three experiencing affective symptoms 42 contrary to our assumptions the number of parents with affective symptoms remained high almost irrespective of pandemic events ie relaxation of measures this result is roughly in line with an austrian study on the general population showing a substantial persistence in mental health problems even 6 months after lifting of pandemicrelated restrictions 43 taking a look at childrens mental health the number of toddlers with borderline or noticeable emotional andor behavioral problems rose from 184 in wave i to a maximum of 239 in wave iii however these increases were not significant still while the number of toddlers with borderline and noticeable mental health problems almost exactly corresponded to the norm in survey wave i this appears to be no longer the case in later periods of the pandemic 3244 prevalence rates for infants cryingsleeping and feeding problems were already in the upper range compared to prepandemic data in survey wave i the number of infants with excessive crying or feeding problems did not change significantly in relation to different survey periods however the proportion of infants with cryingsleeping problems was significantly higher in survey wave iii than in survey wave i one of the vanishingly small number of studies targeting infant crying sleeping and feeding problems during the pandemic also used the csf and found combined cryingsleeping but not feeding problems to be significantly higher prevalent in infants born during the pandemic 45 while the small effect size in our study as well as differences in definition and operationalization of these problems have to be considered with as much as 355 of infants affected this rate is now higher than the ones found in prepandemic comparison studies 46 these findings suggest a staggered negative impact of pandemicrelated factors on young childrens mental health and policy makers should be made aware that the needs of infants and toddlers are as relevant as those of eg schoolaged children in the context of pandemic aftercare in a second step we explored possible influencing factors on parenting stress and mothers and child mental health problems for all four outcomes increased family conflicts had the highest predictive value with a medium to large effect on parenting stress a medium effect on maternal affective symptoms a small to medium effect on toddlers emotional and behavioral problems and a small effect on infant cryingsleeping problems this result highlights that also in the pandemic with its multiple external stressors the family microclimate is particularly relevant for parental and child wellbeing and should be one focus when counseling burdened families eg by providing conflict management strategies individually we found higher parental education to be predictive of higher parenting stress which is in line with earlier findings of the coronababy study and might be associated with higher educated parents worrying more about the pandemic survey wave and parental perceived pandemic burden also influenced parenting stress however all effect sizes were small mothers symptoms of depression and anxiety were more pronounced with increasing child age in contrast a metaanalysis on moderating factors for maternal depression and anxiety during covid19 did not find child age to be influential 47 as the found effect size in our sample of mothers was small this result might not be of high practical relevance higher pandemic burden was also predictive for maternal mental health again with a small effect size infant cryingsleeping problems were predicted by survey wave and parental pandemic burden whereas having a sibling was a protective factor the latter result could be explained by parents greater experience in handling cryingsleeping problems when having more than one child and has also been shown by another study on infant crying sleeping problems during the pandemic in germany 45 again corresponding effect sizes in our study were small toddlers emotional and behavioral problems were slightly more pronounced for children with a chronic disease or a disability which is line with earlier findings 4849 there are several possible underlying causes for the trajectories of the surveyed psychosocial stress factors first the decreasing number of parents perceiving a high pandemic burden over time might reflect the reduced visibility of covid19 with the gradual relaxation of measures but could additionally indicate the development of a habituation effect as a coping strategy second given the permanence of covid at the time of our survey the increase in parenting stress over the course of the pandemic as well as the constantly high number of parents with mental health issues might be explained by lack of prospects resulting in mental exhaustionthe so called pandemic fatigue 37 third with a longer duration of the pandemicand again irrespective of pandemic eventsthe number of young children with deteriorated mental health has increased to a worrying level while at the beginning of the study the numbers for both infants and toddlers still corresponded to the norm as both parenting stress 10 11 12 and parental mental health issues 21 22 23 are known to be related to child mental health problems the results corroborate the possibility of a staggered negative influence of high parental burden in this regard however these considerations remain theoretical as they cannot be answered on the basis of the data available in this study and will need to be addressed by future studies this study has strengths and limitations that have to be considered when interpreting the found results the coronababy study was the first and largest german investigation on psychosocial wellbeing during the pandemic specifically targeting families with children aged 03 years besides including a large number of participants parenting stress and parental and child mental health were assessed with validated standardized psychological questionnaires without notable missing values in addition the individual survey periods as well as the whole study duration of 13 months were considerably longer than of many other comparison studies enabling a broader perspective that goes beyond a momentary snapshot also we investigated later stages of the pandemic while a majority of the pandemicrelated research was conducted around the first outbreak of the virus we recruited a high number of financially welloff families with good education german background and mostly mothers these aspects have to be considered with regard to the generalizability of our study results another limitation might be that the coronababy study started a year after the initial outbreak of the virus and thus may not capture the most severe pandemicrelated stress experiences however a significant proportion of the surveyed sample exhibited psychosocial stress factors even if the crisis was no longer a new phenomenon and the number of burdened parents and infants even increased during the course of the study as the number of fathers in our sample was relatively small we cannot provide specific results for them future studies should aim to shed light on fathers mental health during and in the aftermath of the pandemic childrens mental health was assessed via parental report and we cannot rule out the probability that parents with higher stress levels perceive their childs behavior as more troublesome finally due to the crosssectional nature of our data we cannot draw causal conclusions with regard to the impact of the pandemic on the surveyed psychosocial stress factors however this study sheds light on trajectories of psychosocial stress in families with infants and toddlers in different stages of a global crisis and adds knowledge essential to provide adequate support for this vulnerable group conclusion taken together our results show that psychosocial stress factors in families with infants and toddlers remained highly pronounced or even increased with a longer course of the pandemic despite relaxation of restrictions and lower incidences although the pandemic might start to fade into the background in public perception the ongoing support needs of families with young children must not be allowed to fall out of focus because of their particularly high vulnerability and susceptibility to parental burden promoting infants mental health has to be a top priority for policy makers and health professionals in the aftermath of covid19 future investigations need to explore the underlying causes of the trajectories found and specifically examine the relationship between parental and child outcomes in a longitudinal design support measures should focus on promoting a positive microclimate in the family eg through conflict counselling by reducing parenting stress and by strengthening parental resources so that they can be fully available for the signals and needs of their young children • 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 abbreviations competing interests the authors declare that they have no competing 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background families with young children are particularly vulnerable for the stressors induced by the covid19 pandemic however studies on their psychosocial situation during the course of the crisis are still sparsein a comparison of three survey waves wave i and iii high covid19 incidences we crosssectionally investigated the proportion of families n total 2940 with children aged 03 years experiencing pandemic burden parenting stress and parental and child mental health problems in relation to covid19 incidences and restrictions in southern germany via validated questionnaires potential influencing factors were also exploredthe number of parents with a high pandemic burden decreased over the course of the pandemic with a peak of 653 in wave i significant changes except wave ii versus iii participants with high parenting stress significantly increased from 382 in wave i to 512 in wave iii the number of parents with symptoms of depression and anxiety remained constantly high with a maximum of 284 being affected infants with cryingsleeping problems increased significantly from 264 in wave i to 355 in wave iii toddlers emotional and behavioral problems showed a peak of 239 in wave iii no significant changes increased family conflicts were the strongest predictor for parenting stress ß 0355 maternal ß 0305 infants ß 0149 and toddlers ß 0216 mental health problems during the pandemic conclusions psychosocial stress factors in families with infants and toddlers remained highly pronounced and even partly increased irrespective of pandemic events the findings suggest a staggered negative impact of pandemicrelated factors on young childrens mental health promoting infants mental health as well as strengthening parental resources by reducing parenting stress should be a top healthcare priority in the aftermath of covid19the study was preregistered in osf osf io searc hq tksh5 page1

introduction spousal death has a wide range of health effects on older adults like mental social behavioral and biological issues 1 it is closely related to the risk of death in elderly 2 and increases the mortality of various diseases 3 in particular the mortality of old people increases in the first few months after a spouses death 4 5 6 the lifestyle changes caused by sd increase the incidence of almost all types of cancer 7 it is also a risk factor for stroke 8 and is related to the severity of cardiovascular disease 9 moreover widowed men have an increased risk of type ii diabetes 10 in 1980 a study demonstrated that in addition to medical technology and drugs a decrease in the proportion of sd was a reason for the decline in disabilities among older adults in the united states 11 although the emotional response of older adults after their spouses deaths may gradually decrease over time 12 their period of grief is several years long rather than temporary 1 13 14 15 and the sadness caused by a spouses death affects the occurrence of depression 16 similar to sorrow depressive symptoms continue to occur in elderly at a relatively high level 1718 the psychological social behavioral and physical conditions of the widowed are worse than those who are currently married or cohabiting this includes depression decreased social connections unhealthy lifestyles and poor cardiovascular health 1 another study also indicated that spouse loss increases the degree of depression and that it will last for several years 14 depression is a common mental illness among older adults 19 and a populationbased cohort study also showed that agestandardized depression prevalence in older adult was 68 20 old people with depression have a relatively high rate of disease comorbidity as well as increased mortality and risk of disability and suicide 21 22 23 older adults living independently from family or friends are particularly susceptible to depression 24 however social isolation is more likely to cause depression in this population compared with people who live alone 25 although family support can reduce the difference in depressive symptoms between old people who experienced sd and other older adults 26 the absence of children does not increase loneliness or depression in widowed elderly 27 in addition help from children and the sharing of living arrangements with them yield reduced depression symptoms and favorable selfrated health 28 this study explored the major effects of sd on older adults depression and whether in addition to sd the changes in lifestyle habits interpersonal relationships or living environments after a spouses death are influencing factors the results may provide health care strategies for the successful aging of older adults materials and methods study design and sampling the tlsa data source of this study is the institute of family planning which was the predecessor of the health promotion bureau of the ministry of health and welfare taiwan stratified threestage random sampling was adopted to select 4412 individuals from the registered population of taiwan who were older than 60 years at the end of 1988 of the selected individuals 710 completed the questionnaire before and after their spouses deaths a questionnaire survey was conducted by special investigators through interviews to collect baseline data for selected participants who could not respond to the questionnaire because of conditions such as unconsciousness severe illness or deafmutism family members or caregivers who understood their situations could answer for them questionnaire a total of six longitudinal surveys were conducted in 1989 1993 1996 1999 2003 and 2007 collected data included age sex ethnic group education level financial status smoking status alcohol consumption and selfrated heath status the simple version of the 10item center of epidemiological studies depression scale was used to measure depression and a score of ≥10 indicated depressive symptoms in the mobility investigation participants were asked if they had difficulty squatting raising both hands picking up objects with their fingers lifting an 11kg object walking up two to three floors or walking 200300 m with higher scores indicating poorer mobility in the survey on relative and friend support participants were asked if they believed that their rf were willing to listen to their worries whether their rf cared about them whether they were satisfied with the level of care expressed by their rf and whether their rf were hypercritical to what they did in addition the participants were asked whether their rf would ask for their opinions when making decisions or during discussions in terms of the quantification of support from rf a higher score indicated lower support regarding the questionnaire items reducedrank regression was first adopted to obtain the factor loadings for sd after which the scores for mobility and rf support were acquired therefore mobility and rf support scores were used to represent mobility and rf support in the later section of this study the dimensions measured in the questionnaire are shown in table 1 relative and friend support the rf were willing to listen to their worries the r rf cared about them satisfaction with caring from rf the rf were hypercritical to what they did statistical methods we conducted reduced rank regression to analyze the factor loading of mobility items and social support items higher rrr score in mobility means worse mobility function and higher rrr score in social support means higher level of social support the mcnemars chisquare test was conducted to determine whether each participant presented significant differences before and after sd and the effect of variable adjustment on sd was analyzed using multiple logistic regression sas 94 was employed with a significance level of 005 results factor loadings of mobility and rf support table 2 presents the calculation results for the factor loadings of mobility and rf support the factor loading for each mobility was positive and greater than 02 indicating a positive correlation between the degree of disability and depression it can be found that the factor loading of lower limb activity items were greater than 043 while the upper limb activity items were between 035042 this means that lower limb activity items have a higher impact on depression than upper limb activity items the factor loadings for the surveyed items of rf support were negative and greater than 02 implying a negative correlation between support level and depression it can be found that the absolute value of factor loading of care from significant others was greater than 05 while other items were between 027 to 04 this means that care from significant others have a higher impact on depression than other social support items participants characteristics table 3 presents the participant demographic variables and the descriptive statistics for sd time point and time since sd of the 710 participants 256 were men and 454 were women the participants were divided into six groups four education levels and four ethnic groups the majority of the participants were female educated at the primary level and fukinese the years 1989 1993 1996 1999 2003 and 2007 were used as the points of tangency for the time of sd occurrence as shown in table 3 the highest percentage of sd was between 1999 and 2003 this situation also reflects that participants will experience spouse death from the time they started participating in the study to a certain age time since sd was divided into five levels namely less than 3 months 36 months 612 months 1224 months and more than 24 months there were a total of 427 of participants where time since sd was more than 24 months pre and post spouse death table 4 presents data before and after sd according to participant sex no significant difference was observed in income satisfaction between men and women before and after sd a decline in the proportions of both men and women who smoked was observed however neither men nor women exhibited a significant difference in alcohol consumption before and after their spouses deaths in terms of selfrated health men did not exhibit a significant difference before and after sd whereas the proportion of women who believed that they had favorable health declined after sd in table 4 diff represents the result of subtracting the postsd score from the presd score men exhibited a significantly decreased degree of depression after sd whereas the womens degree of depression increased significantly a mobility score diff of 0 indicates improved mobility men exhibited reduced mobility after sd whereas the mobility of women improved neither men nor women exhibited a significant difference rf support scores after sd indicating no significant change in support from relatives and friends after sd effect of sd on depression table 5 presents the multinomial logistic regression analysis of the effect of sd on depression model 1 consists of the simple effect without any variable adjustment the mobility score was adjusted in model 2 selfrated health was adjusted in model 3 and the rf support score was adjusted in model 4 under the model 1 sd effect the proportion of depression among the participants after sd was 17 times that of before sd whereas the sd effects of models 2 3 and 4 resulted in a proportion of depression after sd 1517 times that of before sd and the increase was significant the odds ratios of the adjustment variables in models 14 were all significant indicating that worsened mobility declined selfrated health status and higher rf support were related to a higher proportion of depression after variable adjustment the sd effect on men remained significant and the ors of the adjustment variables were nonsignificant after the mobility score and favorable selfrated health status were adjusted the or of the sd effect on women became nonsignificant whereas the ors of the adjustment variables became statistically significant mobility selfrated health and rf social support are associated with depression in total subjects and in female but in male mobility selfrated health and rf social support are not significantly associated with depression in female the sd effect on depression disappeared after adjusting the mobility variable table 6 indicates that the proportion of postsd depression was 60 times 09 times 17 times and 13 times that of presd depression when time since sd was less than 6 months 612 months 1224 months and ≥24 months respectively the proportion of depression decreased rapidly after 6 months in the sexstratified analysis only men had a significantly higher proportion of postsd depression compared with presd depression in the 1224 months after sd whereas women exhibited a significantly higher proportion of post sd depression less than 6 months after sd the remaining variables yielded no significant changes regardless of gender the depression proportion is obviously high in six months after spouse death which declines after six months and without statistical difference for proportion after 24 months men suffered depression more than women in every period and in particular sd effect on depression in period 12 and 24 months after sd is statistically significant in men in the analysis of postsd living arrangements table 6 indicates that the proportion of depression among widowers and widows living alone and those living with family members was 23 times and 15 times that before sd a further sex stratification analysis revealed that men who live alone after sd exhibited more depression and men who lived with their families after sd exhibited significantly more severe depression compared with before sd in the stratified analysis of sd effect on depression in different living arrangements the results for female are similar to the trends for male but there is no statistically significant association under living alone or living with family members in terms of the stratified analysis of spouses health status table 6 indicates that a significantly large proportion of participants whose spouses had a favorable health status exhibited postsd depression however no significant difference was observed in the proportion of widowers and widows with postsd depression whose spouses were in poor health discussion our findings indicate that male sex spouses health and the period of 6 months after sd are risk factors for depression in elderly the maintenance of mobility positive selfrated health status and a shorter period of depression after a spouses death result in more favorable adaptability among women living with family members after sd can alleviate depression in older adults the strength of our study as a longitudinal study this study can provide clearer causal relationship between sd and depression tlsa is a national survey that has a representative sample of old people in taiwan this study used selfmatched to explore the effect of sd on depression in older adults smoking among men and women declined after sd whereas alcohol consumption among the participants exhibited no significant difference which was inconsistent with the finding of increased tobacco and alcohol abuse after sd in previous studies 29 30 31 32 the proportion of selfrated health decline after sd increased significantly among women this was consistent with the findings of previous studies indicating that widowed elderly have poorer selfrated health 3334 and that sd negatively affects health 35 men exhibited an obvious decline in mobility after sd whereas the mobility of women improved indicating a sex difference previous studies have demonstrated that womens mobility after sd is inferior to that of women whose spouses are still alive 3637 however another study revealed that widows in taiwan are more active in recreational activities compared with married women 38 the disparity between the present research results and the literature may be attributable to cultural differences although rf support did not differ significantly after sd depression and the degree of support from relatives and friends were positively correlated this may be explained by the increased care that participants received from older adults due to their depression however rf support had little influence on sd effects after variable adjustment indicating that such support cannot significantly alleviate depression according to attachment theory support from friends cannot compensate for the loss of someone to whom an individual had an attachment 39 and attachment problems are particularly prevalent among old people 40 these studies may explain why support from relatives and friends cannot effectively alleviate depression men exhibited a decline in depression after sd whereas women presented increased depression however after adjusting for mobility selfhealth rating and rf support the proportion of men who had depression after sd was greater than that of women indicating that sd had a significant effect on depression among men in other words adopting approaches to alleviate the effects of sd on depression is more difficult for men the proportion of women with depression after sd increased significantly however after adjusting for mobility and selfrated health the original effect of sd on depression was explained by the adjustment variables in addition the adjustment variables were significantly correlated with depression in other words the effects of sd on depression could be alleviated or reduced in women through more favorable mobility and a favorable perception of their own health a phenomenon not observed in men this result is consistent with the findings of previous studies which demonstrated that depressive symptoms caused by sd have a stronger effect on men whereas women have superior adaptability 41 42 43 moreover recreational physical activity has a preventive effect on depression in women 44 increased participation in recreational activities is beneficial for widows and changes in leisure activities after sd have a greater effect on health and disability compared with aging 45 these findings corroborate the aforementioned research results the proportion of depression was obvious within 6 months after sd however this trend gradually slowed after 6 months for women this increase was not significantly different after 6 months after 24 months both men and women exhibited no significant difference in depression before and after sd therefore the effect of sd can be alleviated over time a previous study demonstrated that older adults experience relatively high levels of depressive symptoms within 2 years after their spouses deaths 17 the proportion of depression among women remained high within 6 months after sd however this proportion decreased to presd levels after 1 year 18 these conclusions are consistent with our research results this study indicated that sd has a shorter effect on depression in women compared with men past research has also demonstrated that the amount of time after a spouses death affects morale and social engagement 46 the relatively short duration of depression among women after sd may cause them to have a more positive selfrated health status or participate in social engagement which may also explain why women have more favorable adaptability to depression caused by sd 4142 the proportion of depression increased after sd regardless of the participants living arrangements however depression in old people living alone after their spouses deaths exhibited a greater increase than those who live with family members although the aforementioned trend persisted after sex stratification depression among only men who lived with their families exhibited statistical significance therefore both living alone and living with family members significantly affects depression however previous research has demonstrated that living alone is not correlated with depression 25 after adjustment for demographic variables health status social support and financial status the effect of living alone on depression disappeared 47 although the same trend was observed in this study participants who lived alone still exhibited a relatively high proportion of depression older adults whose spouses were healthy exhibited significantly higher proportion of depression after sd a trend that was clearly observed in both men and women however older adults whose spouses had poor health exhibited no significant change in the proportion of depression after sd past studies have demonstrated that elderly who have lost their spouses are more likely to be depressed if they were not the primary caregiver of their sick spouses 48 and the accidental death of a spouse may increase the risk of depression 49 the aforementioned results can be used to illustrate the phenomena revealed in this study by conducting a longterm investigation of widowed elderly this study demonstrated that sd is a risk factor for depression among older adults in taiwan and men and women adapt differently to their spouses deaths womens shorter duration of depression after sd their ability to maintain their mobility and their more favorable selfrated health result in an increased willingness to participate in activities this enables them to have superior adaptability to the effects of sd older adults are at risk of depression within 6 months after sd relatives friends and social workers should increase their attention to and care of them during this period in terms of living arrangements encouraging elderly to live with family members or friends after sd can reduce the incidence of depression important scientific contributions and implications of this study are summarized firstly six months after spouse death is a highrisk period for depression families friends relatives or social workers have to pay more attention to widowhood elderly in six months secondly older men more vulnerable to depression than women after spouse loss in male life assistance instrumental and emotional supports are important practical issues after spouse loss third those who live alone after spouse death suffered more depression than those who live with their family members the living arrangement is very important to elderly which affects the rate of adjustment after spouse loss fourth the spouse was in good health before death which means the great psychological impact of this unexpected event frequent contact more care and support are needed for widowhood facing this unexpected event there are some limitations though we explore several important issues for spouse loss and depression firstly marital satisfaction marital relationship marital conflict and the length of time they were married were not collected in this study lacking these marital factors might limit us to elucidate their important roles in the rate of grief and grief adaptation secondly grief and major depressive disorder share similar symptoms such as intense sadness insomnia poor appetite weight loss etc this study uses the cesd10 depression scale without the grief scale measurement so it is difficult to distinguish grief and depression further studies may compare the differences of depression scale and grief scale in widowhood or perform singleitem analysis of intense sadness insomnia poor appetite or weight loss in widowhood to distinguish grief and depression according to our findings if the spouse was in good health before death hisher death will make the great psychological impact to the other people around these older adults should pay more attention to them we also found that living with families after sd can alleviate depression in elderly we suggested that these older adults who have experienced unexpected widowhood can take turns to live with their children or travel with good friends and receive care from families and friends conclusions our findings indicate that male sex spouses health and the period of 6 months after sd are risk factors for depression in older adults the maintenance of mobility positive selfrated health status and a shorter period of depression after a spouses death result in more favorable adaptability among women social workers or family members should focus on elderly people whose spouses died unexpectedly or within the last 6 months living with family members after sd can alleviate depression in elderly data availability statement the datasets generated during the current study are not publicly available but data are however available from the applicants upon reasonable request and with permission of the ministry of health and welfare in taiwan informed consent statement informed consent was obtained from all subjects involved in the study

in addition to increasing the mortality among older adults spousal death sd increases their risk of depression this study explored the factors affecting depression among widowed older adults to provide health care strategies for successful aging a total of 710 adults older than 60 years completed a questionnaire before and after their spouses deaths the survey data included age sex ethnic group education level financial station socioeconomic status sd including time point smoking status alcohol consumption selfrated health status center for epidemiologic studies depression scale score mobility and degree of support from relatives and friends the proportion of participants with depression after sd was 17 times that of before sd p 00001 worsened mobility odds ratio or 13 p 001 low selfrated health status or 05 p 001 and a high degree of support from relatives and friends or 15 p 001 had a significant positive correlation with depression after sd the proportion of depression that occurred within 6 months after sd was 60 times higher than that of depression before sd participants who lived alone after losing their spouses who were healthy before their deaths exhibited a significantly increased proportion of depression after their spouses deaths male sex spouses health and the period of 6 months after sd are risk factors for depression in older adults the maintenance of mobility positive selfrated health status and a shorter period of depression after a spouses death result in more favorable adaptability among women social workers or family members should focus on older adults whose spouses died unexpectedly or within the last 6 months living with family members after sd can alleviate depression in older adults

introduction there is an imperative to tackle avoidable differences in health this is now recognised in research design and reporting increasingly studies are investigating the application of an equity lens when reporting the effects of interventions in randomised trials this is important as it permits the assessment of generalisability of trial findings to wider or specific populations collecting relevant data on social deprivation status also enables evaluation to determine whether deprivation is a treatment effect modifier and importantly whether an intervention might contribute to health inequity furthermore from an ethical perspective principle 14 of the declaration of helsinki states populations which are underrepresented in medical research should be provided with appropriate access to participation in research accordingly there is an ethical imperative to ensure that this data is collected to ensure it is possible to evaluate how representative research is to the wider community to promote the collection and reporting of social deprivation data frameworks have been developed to explicitly consider equity and social stratification in research conduct and reporting one such framework is the progress framework it is acknowledged that participants in clinical trials are often not representative of the populations for which the interventions are intended we previously reported a bibliometric analysis of 402 trials recruiting people with msk disorders published between january 2019 to june 2020 5 this assessed the frequency of reporting indexes such as the index of multiple deprivation the usa social deprivation index and the new zealand index of deprivation in addition to measuresmarkers of deprivation we reported that trials rarely reported deprivation indexes only two trials reported deprivation indices when assessed by individual measures of deprivation 164 trials reported one or more measures the most reported individual measures of deprivation were employment status highest level of educational attainment and morbidity race ethnicity and annual income were infrequently reported communitybased deprivation indicators such as premature death quality of life crime location to amenities housing quality air quality and community status on road traffic accidents were not reported in any trial one trial presented subgroup results by deprivation measures a number of important research priority were presented firstly whilst there was wide diversity in deprivation measures reported there was no consensus on what should be measured or on how trialists selected which measures to use it is possible that poor understanding of the importance of collecting relevant indicators of deprivation influences poor reporting of these measures this has important implications for stratification and subgroup analyses to explore potential treatment effectmodification across people from different levels of deprivation the purpose of this study was therefore to begin to address these uncertainties by asking researchers their thoughts around the measurement and reporting of deprivation in studies recruiting people with msk disorders specifically we sought to understand • which indices and measures of deprivation do msk researchers know use and report • what factors affect the collection and reporting of deprivation indices and measures in msk research • is there an association between the knowledge collection and reporting of deprivation indices and measures and the characteristics of respondents ie country of origin academic background and clinical speciality methods an international online crosssectional survey was undertaken participants were recruited through two methods firstly we identified corresponding authors from 402 studies which formed the basis of our previous bibliometric analysis each corresponding author was emailed an invitation to complete the survey including a hyperlink to the survey secondly we advertised the survey in weekly tweets through twitter the tweets included the survey hyperlink consent was ensured through an opening page prior to the first survey question the online survey was delivered using google forms the survey is presented in supplementary file 1 potential participants were asked to read through an initial information page which detailed the surveys objectives and processes and explained how data would be stored and used following this they were asked to provide signed consent for those who did so the survey was released for completion the survey gathered information including • basic demographic information country of residence clinicalacademic position clinical background highest educational award method of research most associated with years since receiving highest education award years since most recent empirical study was published • knowledge of deprivation measures and indices which of these deprivation indices have you heard of collected in a research project reported in a research paperreport • barriers to reporting deprivation indices and measures why do you consider that deprivation data are rarely reported in msk research publications • facilitators to reporting deprivation indices and measures what do you feel could improve the reporting of deprivation data in msk research publications the survey was developed by the research team to identify factors which were hypothesised to be important in the updatereporting of social deprivation measures by msk researchers the proposed social deprivation measures presented to respondents were generated from the teams previous assessment of potential social deprivation measures reported in clinical trials the survey took approximately 20 minutes to complete it was piloted with five msk physiotherapists and researcher who had previously collaborated with the research team their assessment did not change the content or format of the survey but informed the anticipated duration of the survey their responses were not included in the reported results the survey link was posted on 20 th october 2020 and closed on 27 th november 2020 after three weeks of opening a reminder email was sent to all nonresponding corresponding authors from the first approach strategy to provide another opportunity to complete the survey weekly tweets were sent throughout the five weeks the survey was open data analysis descriptive statistics were used to summarise respondents characteristics and their responses results respondent characteristics in total 42 people responded to the survey respondent characteristics are presented in table 1 in summary the majority were based in the uk 12 from australia 7 from the netherlands and 5 from new zealand brazil and the united states of america nine respondents originated from other countries across europe asia and north america over half of respondents classified themselves as academics or researcher with 69 being educated to doctoral level fiftyfive percent considered clinical trials as their principal area of research with 55 from a physiotherapy background 17 orthopaedic surgery and 12 rheumatology awareness and usage of deprivation index and measures over half of respondents had not heard of the six deprivation measures presented in the survey the index of multiple deprivation was the most wellknown measure whereas the carstairs index was the least known seven respondents responded that they had reported data from the index of multiple deprivation two had reported data on the new zealand index of deprivation whilst one respondent had reported data on the townsend material deprivation score respondents identified other indices which were not originally proposed these included the index of community socioeducational advantage and socioeconomic indexes for areas by one respondent and items from the financial literacy core questionnaire by a second respondent table 2 summarises the results on the awareness and usage of deprivation measurements in msk research as this illustrates the most commonly reported measures of deprivation reported were employment education ethnicity and morbidity the least frequently reported measures included social factors including local amenities air quality and community status on road traffic accidents whilst a number of measures such as car ownership proportion of people living in poverty community statistics to premature death housing quality and crime were known to over 90 of respondents they were reported in research papers by less than five percent respondents identified additional measures not initially listed in the survey these included occupation and social capital income source use of food banks and health literacy such as the health literacy questionnaire barriers and facilitator for adoption of deprivation index and measures a summary of the barriers and facilitators for adoption of deprivation measures and indices are presented in table 3 the most common barriers to collecting these data were ranked as prioritising other measures of contextual factors which are perceived as more important uncertainty on what data should be collected fear of missing data due to participants not wishing to provide this information time and costs to collect this data and societal attitudes towards minority and diverse communities one participant felt that not understanding the relevance of these data was an important barrier twentysix percent of respondents believed that reporting deprivation was not important the most frequently reported facilitator to collecting deprivation measuresindices was if there was a consensus on the measures to be collected and reported seventynine percent of respondents felt that a greater awareness and understanding of the relationship between deprivation and msk health would improve the likelihood of collecting these data whilst 67 felt that mandating the use of reporting checklists that included measures of deprivation could facilitate the collection and reporting deprivation measures discussion the findings of this survey indicate that people who research msk conditions may largely have limited awareness of collecting and reporting measures of deprivation this may explain why these data are infrequently reported in academic papers whilst researchers are aware of individual measures which indicate deprivation these are not consistently reported to enable a full understanding of the characteristics of their patient cohorts factors such as believing deprivation data is a low priority uncertainties around what data should be collected and concerns that they and their participants may feel uncomfortable about providing such data which could appear intrusive are also acknowledged barriers increasing agreement on what measures or indexes should be collected increasing awareness of the importance and requirement for collection and a better understanding of the best ways to collect these data were considered key facilitators to addressing this shortcoming the results of this survey reflect the findings of our previous bibliometric analysis of 402 msk clinical trials the low reporting of measures of deprivation indices but higher reporting of individual measures particularly morbidity employment and education were reported however the survey indicates a far higher reporting of these measures than our bibliometric analysis for instance the bibliometric analysis reported the frequency of morbidity employment and educational status in 20 18 and 16 of studies compared to 43 60 and 60 in this survey this may reflect respondents being a selfselected sample of individuals more interested in deprivation measures than nonrespondents nonetheless the current findings suggest deprivation measures are not frequently collected and reported providing further evidence of this deficit in research conduct a third of respondents reported concerns that participants in msk trials may not feel comfortable about providing data on deprivation measures discomfort surrounding the social etiquette of collecting data on race and ethnicity within clinical encounters has been previously reported while baker et al suggested there is support to collect this data reservations about what the data will be used for and whether if appear discriminatory for both patients and healthcare professionals providing a full explanation of why the data is being collected may alleviate some of those concerns making this explanation directly related to improving care for the most disadvantaged to msk interventions could be a most effective strategy to change this perspective advocates for the collection and reporting of deprivation data argue this is critically important for two key reasons firstly reporting this data enables the reader to moreclearly understand the characteristics of study cohorts this may facilitate greater generalisability of findings to specific populations thereby aiding targeted research translation into practice for people with particular need for instance in msk practice a significantly higher prevalence of chronic pain is reported by black ethnic groups in the uk compared to other ethnic groups bangladeshi pakistani chinese and black groups in the uk are twice as likely to be living on low incomes compared to the white population which also highlights systemic inequality there is a higher prevalence of chronic pain in people living in deprived areas compared with those in least deprived areas and unemployed people with disability versus employed people these combined factors may result in multiple health disparities thus the reporting of deprivation measures is particularly pertinent in msk practice secondly collection of deprivation measures permits the analysis of trial findings by these potentially important factors poverty has been associated with increased symptom catastrophisation pain severity pain interference and disability in people with chronic pain greater deprivation is also associated with higher prescribing of slowrelease highdose opioids despite benefits being minimal in chronic pain accordingly deprivation may be a major confounding factor in msk research suggesting its role as an effectmodifier to outcome for example individuals with chronic pain and lower levels of education literacy and working memory may benefit more from cognitivebehavioural therapy than a pain psychoeducational approach by not collecting data to catagorise deprivation level it would remain unclear whether patients from different deprivation strata respond differently to specific interventions the consistent collection of such data would permit such important subgroup analyses to allow a better understand of whether such effects occur respondents identified several factors which may facilitate the collection and reporting of measures of deprivation in msk trials the key activity recommended was the increase in understanding of deprivation measures in msk symptoms why it is important that they are collected and determining what data should be collected and how this aligns with findings from stakeholder workshops to promote inclusive research inwhich a need for a set of information resources and training to support research teams was identified as a key priority area organisations such as the uk national institute for health research now request that trialists collect data on measures of social equity including geographical location age ethnicity socioeconomic status and access to health or social care but on the understanding that this will assess inclusion into trials rather than to categorisesubgroup analyses nonetheless this is an important step towards promoting deprivation measures as a standard element of data collection in msk research to take this work forward further study to gain greater representation through consensus group activities is required this would include engagement with trial stakeholders such as patient groups funders researchers and journal editors to gain consensus on what deprivation measures should be reported in the least intrusive way this would also include how to collect these data with different population how to talk about the measures with participants and the etiquette needed around proxy measures of deprivation such as income whilst this survey provides important findings to indicate how researchers may be supported to collect and report deprivation measures in msk research a number of important limitations should be considered firstly the cohort consisted of 42 respondents whilst they represent views from across the world this is a relatively small number of respondents in total furthermore this cohort may be consisted selfselecting as individuals volunteered to complete the survey and therefore we may only have gained the views of people interested in deprivation reporting and not those who may be least interested in collecting or reporting these data consequently there were insufficient data to explore the potential relationship between respondent demographic characteristics such as clinician versus academic positions country of origin educational or professional background and their responses to the use of deprivation indices and measures such an analysis may have provided granularity on potential explanatory variables to reporting conclusion there is low awareness and reporting of measures of deprivation in msk research this is partly due to researchers not viewing this as important contextual information and uncertainty regarding which specific data would best illuminate social deprivation differences there may be concerns that participants may not wish to report these data better promotion of why it is important may help to avoid issues of missing data activities are now warranted to improve reporting this includes work to gain consensus on what data should be collected and how this may be used to allow assessment of generalisability and effect modification from interventions to treat msk disorders figure and table legends a guideline for collecting information on social deprivation and reporting guideline can be useful 1 supplementary file 1 survey the collection and reporting of social deprivation measures in musculoskeletal research an international survey study version 20 dated 08 october 2020 section 1 respondent characteristics q11 where is your principal country of residence • freetext q12 what is your principal job role • academicresearcher • clinicians • clinical academic • other freetext q13 what is your highest educational award • bsc • ba q14 how many years has it been since you received your highest educational award • freetext years q15 what is the principal areas of research you are involved in • clinical trials • we would like to thank you for completing these questionnaires your contribution is much appreciated if you have any questions or queries about this form please contact email

the reporting of deprivation measures is typically poor in musculoskeletal msk research this survey explored msk researchers perspectives on the deprivation indices and measures that are or could be collected and reported in their studies and potential barriers and facilitators to collecting these data an online international survey was undertaken to determine knowledge use and reporting of deprivation indices and measures by msk researchers and the factors which influence this data were analysed using descriptive statistics 42 respondents from 16 countries completed the survey the index of multiple deprivation was the most wellknown measure 26 although only 17 had reported data from this index most commonly reported markers of deprivation were employment 60 education 60 and ethnicity 50 most common barriers to collecting these data included uncertainty on perceived importance of deprivation measures 79 what should be collected 71 and concerns on missing data and sensitivities from participants reluctant to provide this information 33 consensus on necessary measures to be collected and reported 88 and improved awareness of the relationship between deprivation and msk health 79 were considered key activities to improve deprivation recording in msk research to conclude there is poor awareness of the collection and reporting of deprivation measures in msk research greater understanding on the importance of these data in reducing inequalities in msk care is needed to facilitate improvement this would enable greater assessment of generalisability and to assess whether interventions have different effects in people from different socioeconomic groups

introduction resilience especially community resilience is a function of an ecosystems absolute ability to recover from various stresses and disturbances 1 particularly in relation to resisting shocks economic downturns climate change globalization and environmental disasters 23 the resilience of the community system therefore is not only a reflection of the pressure resistance adaptability and innovation of the rural system but also is one of the breakthrough points or at least a major turning point for current research into urban and rural development in china 45 the rural community results from the coupling between people and the natural environment 6 the internal structure and function of the rural community maintains a relatively balanced state depending on the resilience of the system and is reflected in economic ecological and social subsystems 7 the rural system is mainly composed of three subsystems ecological economic and social 8 among them the ecological subsystem resilience is mainly reflected in the stock of cultivated land the coverage of forest and the storage capabilities of hilly ponds 9 furthermore the economic subsystem resilience is generally measured using the per capita income of farmers and the yield of economic crops 10 whilst that of the social subsystem is based on the rural social network and is a reflection of the rural peopleland relationship 11 thus the social subsystem is significantly affected by the mobility of people especially from rural villages resilience theory which is at the core of the research reported in this paper was originally employed to study the antiinterference ability of ecosystems 12 13 14 15 in other words the maximum tolerance within which an ecosystem can maintain its stable state when facing change in the 1970s gunderson and holling introduced the resilience concept into social ecological systems holling stated that resilience is the ability of a system to resist interference and maintain its function and control and further stated that such a resilient system can effectively deal with the uncertainty that it could face in the future through the resilience of its management system 16 17 18 as a comprehensive reflection of social economic and ecological subsystems etc in time and space the rural community system has specific characteristics such as complexity ability to selforganize and diversity with an increasingly close relationship and increasingly apparent mutual influence between people and nature studying the response and adaptability of the system to external interference from the perspective of resilience has recently attracted the attention of sustainable development research 19 20 21 22 the prominent international academic organization resilience alliance led by holling used the theory of adaptive cycle to describe and analyze the dynamic mechanism of the social ecological system and put forward that such a system will successively go through four stages namely development protection release and update these development stages constitute an adaptive cycle based on certain rules 23 24 25 26 27 in the development phase the system has just formed and its resilience is gradually improved by continuously absorbing elements and establishing the connection between elements in the protection phase the system gradually developed with the potential for growth decreasing and resilience weakening in the release phase the system is affected by a large number of interference factors and becomes disordered at this time systems resilience is low interference factors have some ruinous capacity to destroy the system and are the sources of the update phase the system makes use of its resilience to obtain an opportunity of reorganization by learning and adapting to changes and then realizes reorganization then the system goes into the development stage again and goes back and forth or the system collapses due to the lack of enough resilience so as to exit the cycle 242527 in related research the largescale rapid outbreak of interference factors such as the sichuan earthquake in 2008 can serve to arouse the research interest of researchers and consequently the associated literature also appears in this stage 28 29 30 however in recent years for the rapid and accidental external shock events there has emerged an active interest in the adaptation and cultivation of the concept of resilience resilience research has shifted to the study of chronic and complex factors with more emphasis on active human agency using the bottomup communityled development model 143132 in terms of research content there are an increasing number of studies on the resilience of rural communities some scholars investigated the resilience of rural agriculture in the agricultural and nonagricultural processes and concluded that resilience is driven by internal and external agricultural processes 33 furthermore some scholars have formulated normative requirements and practical solutions of rural resilience development on the basis of known influencing factors of resilience and connected the theory to practice using the community resilience framework 3435 the rural policy conducts critical research and proposes normative requirements regarding the ability of digital technology to help rural development the provision of rural service solutions and the challenges of implementing localism 36 in terms of research methods scholars have used frameworks to assess the resilience of rural communities for example jurjonas and seekamp 37 proposed the rural coastal community resilience framework which include maintaining rural livelihoods creating job opportunities and addressing highly vulnerable populations in eastern north carolina wilson 18 built on a conceptual framework to assess community resilience in rural china and argued that chinese government policies need to be substantially realigned if the resilience of rural communities is to be improved research on resilience theory has moved on from discussions of concept connotation and construction of a theoretical framework to the establishment of a resilience evaluation system 38 however despite there being many frameworks for evaluating community resilience using qualitative analysis currently only a few frameworks use a quantitative approach in their research in addition in the context of urbanrural integration and rural revitalization proposed by china the existing community resilience evaluation framework has a relatively small scope of application and there is no research on the evaluation of the resilience of urban fringe villages furthermore the research on system resilience function evaluation is relatively deficient due to the complexity and diversity of social ecological systems 39 the aim of the research in this paper therefore is the measurement of the resilience regulating ability of rural communities close to the urban areas by constructing a new index system for the evaluation of socialecological system resilience thus developing a quantitative research approach which combines the visualization function of the geographical information system to reveal the resilience distribution characteristics of various subsystems on a village scale in order to provide a new research perspective for the development and revitalization of rural communities materials and methods study area zengcheng district is situated in the eastern part of guangzhou city which is located in central guangdong province to the south of china after zengcheng was annexed to guangzhou as a district in 2014 in order to comply with the urban division adjustment of guangzhou guangzhou municipal government produced the eastward development planning strategy and gradually transferred superior urbanization resources that accumulated over the years in zengcheng district as a core economic development area licheng subdistrict became a district with prominent ecological economic and social contradiction problems in this paper the remote sensing images of licheng subdistrict taken in 2014 and 2018 were processed and an analysis of the characteristics of changes in the size of the builtup area was carried out a comparison of the builtup area in 2014 and 2018 shows an obvious trend of expansion that is both typical and representative for these main reasons the 24 administrative villages in the licheng subdistrict of zengcheng district were chosen as the research object for this paper the rural community system which is located in the core urban development zo is an area of centralized exchange and interchange of urbanrural elements and present distinct interference landscape variation phenomenon on economic ecological and soc subsystems the massive influx of new urban resources effectively broke through interface of traditional rural communities and forced rural grassroot communities to tu from closure to openingup the resilience of rural communities therefore is faced w unprecedented challenges data source the research underpinning this paper takes all of the administrative villages the licheng subdistrict as evaluation units uses basic village data from the latest sta tics sourced from the town government of licheng subdistrict together with the 20 village data provided by the zengcheng urban and rural planning design and resea institute however due to the zengcheng gualv lake water conservation p ject the residents of the villages of luogang mingxing taiping guangming a xigualing were relocated which meant that these villages no longer had the attribute o the rural community system which is located in the core urban development zone is an area of centralized exchange and interchange of urbanrural elements and presents a distinct interference landscape variation phenomenon on economic ecological and social subsystems the massive influx of new urban resources effectively broke through the interface of traditional rural communities and forced rural grassroot communities to turn from closure to openingup the resilience of rural communities therefore is faced with unprecedented challenges data source the research underpinning this paper takes all of the administrative villages in the licheng subdistrict as evaluation units uses basic village data from the latest statistics sourced from the town government of licheng subdistrict together with the 2016 village data provided by the zengcheng urban and rural planning design and research institute however due to the zengcheng gualv lake water conservation project the residents of the villages of luogang mingxing taiping guangming and xigualing were relocated which meant that these villages no longer had the attribute of a traditional rural area therefore the basic data pertaining to these five villages were ignored leaving the remaining 19 administrative villages as the research object this research takes the economic subsystem resilience ecological subsystem resilience and social subsystem resilience as primary indexes and designates secondary indexes according to the attribute features of the subsystems to construct the rural community resilience function evaluation index system the characteristics of changes in geographical and human landscapes that the ecological economic and social subsystems show under the interference from urbanization are considered comprehensively for index selection and are quantified for the designation of secondary indexes through the three primary indexes and eight secondary indexes the resilience index system is constructed to analyze the resilience function of the rural community system for licheng subdistrict indexes that help strengthen the ecological environment economic income and social stability are positive indexes the higher in magnitude of a positive index value implies that the resilience is stronger on the contrary indexes that are bad for the development of the rural ecological social system are negative indexes the higher in magnitude negative index value implies that the resilience is weaker for the standardized processing of the original data this paper adopts the range method as expressed in equation y ij x ij x min x max x xj in equation y ij is the standardized value of the index in the year x xj is the original value of the index x max and x min are the maximum and minimum values of the index respectively the entropy weight method is used to determine the weight 4041 so as to effectively avoid any influence of the experts subjective judgment errors on the weight analysis and thus to make the evaluation result more objective the various calculations are as follows equation is used to calculate the proportion of index j in year i p ij y ij ∑ m i1 y ij equation is used to calculate the entropy of index i e j k m ∑ i1 p ij × ln p ij equations and are used to calculate the weight of each index based on the result from equation g j 1 e j w j g j m ∑ i1 e j equation is used to calculate the resilience function value for the subsystems of each administrative village z ij w j × y ij equation is used to calculate the total system resilience value for each administrative village s ij z ij z ij z ij the data for the administrative villages of licheng subdistrict after standardized processing are listed in table 3 using the entropy method as detailed in section 232 the weights for the various indexes were determined and used in the calculation of the resilience function measurement results which are listed in table 4 the visual resilience function values determined using the gis nature breaks method are shown in table 4 and figure 3 strength and spatial distribution characteristics of resilience of rural subsystems ecological subsystems for the resilience function values of the ecological subsystems for licheng subdistrict the strong value range is 0300104000 the relatively strong value range is 0200103000 the moderate value range is 0100102000 and the weak value range is 001000 the resilience function values of the ecological subsystems for most villages in licheng subdistrict fall into the moderate and weak value ranges there are 15 administrative village units in this range accounting for 789 of the total it can be seen in figure 4 that the ecological subsystems for licheng subdistrict lack resilience and the ecological environment is generally highly fragile the ecological environment is closely related to a good agricultural foundation the strong resilience value range of the ecological subsystems is centralized in the villages of qunai tangxia mutan and longjiao in the northern part of licheng subdistrict which is the main production area for large scale agricultural units enterprises farming cooperatives and production bases of the wider zengcheng district adopting completed ecological environment protection measures qunai village is the main cultivation base results rural system resilience strength and spatial distribution characteristics rural system resilience strength figure 3 is the rural community system overall resilience function values from which it can be seen that licheng subdistrict is in the value range 0146204647 a moderate resilience state according to the classification standard from relevant research 4243 resilience strength can be divided into four grades the strong value range is 0375105000 the relatively strong value range is 0250103750 the moderate value range is 0125102500 the weak value range is 0000001250 no village in licheng subdistrict has yet fallen into the weak value range however five villages fall into the strong range and five villages fall into the moderate range accounting for 3158 of the total ten villages fall into the relatively strong range accounting for 4737 of the total the highest proportion it can be found that most villages in licheng subdistrict have good adapting and learning abilities in addition to a good regulation ability rural system resilience spatial distribution characteristics the spatial distribution of the resilience strength of administrative villages in licheng subdistrict is characterized by dispersion in whole and aggregation in part this means that villages with different resilience levels are distributed dispersedly but villages that fall into the strong value range are aggregated in northern central areas and some eastern areas it can be seen that villages with strong resilience are characterized by linkage and sprawl which helps northern and central regions of licheng subdistrict absorb urban resources and promote rural revitalization strength and spatial distribution characteristics of resilience of rural subsystems ecological subsystems for the resilience function values of the ecological subsystems for licheng subdistrict the strong value range is 0300104000 the relatively strong value range is 0200103000 the moderate value range is 0100102000 and the weak value range is 001000 the resilience function values of the ecological subsystems for most villages in licheng subdistrict fall into the moderate and weak value ranges there are 15 administrative village units in this range accounting for 789 of the total it can be seen in figure 4 that the ecological subsystems for licheng subdistrict lack resilience and the ecological environment is generally highly fragile economic subsystems the function values of the economic subsystems for licheng subdistrict are in the range 00100200 implying a relatively strong overall resilience function with 8421 of the administrative villages reaching moderate or higher levels however the function values show a large span and the resilience function ranges of the economic subsystems differ significantly as can be seen in figure 5 for instance the strong economic resilience function value range is located in the central part of the subdistrict mainly including xiajie village and sanlian village whereas the relatively strong function value range is located in the northernmost part of the subdistrict the central area basically falls into the low resilience function value range and an aggregation block with xiajie village in the center is formed economic subsystems the function values of the economic subsystems for licheng subdistrict are in the range 00100200 implying a relatively strong overall resilience function with 8421 of the administrative villages reaching moderate or higher levels however the function values show a large span and the resilience function ranges of the economic subsystems differ significantly as can be seen in figure 5 for instance the strong economic resilience function value range is located in the central part of the subdistrict mainly including xiajie village and sanlian village whereas the relatively strong function value range is located in the northernmost part of the subdistrict the centrally distributed moderate function value range is located between the strong value range and relatively strong value range social subsystems the resilience values of the social subsystems for licheng subdistrict are obviously weak in the whole and are mostly centralized in the low value range of 0000000750 villages with the weakest social subsystem resilience values are in a zonal distribution and in a layered layout around villages with higher economic levels secondary indexes of social subsystems are obtained through quantitative processing and analysis of the situation of rural population loss talent introduction efforts and cultural heritage protection rural social resilience is based on the connection degree and social familiarity of population settlements 4445 since the 1990s after guangzhou entered into the stage of highspeed urbanization villages close to cities were brought to the urbanization system resulting in a strong economic pull factor that further attracted the labor force from less developed surrounding villages the frequent population flows in rural communities therefore increased the heterogeneity of these communities 4647 under such unstable conditions the stability of existing social relations in rural communities and the knowledge of rural subjectivity are especially comparing the villages of xiajie sanlian and liantang which are all in the strong economic resilience function value range it is found that the annual agricultural income of sanlian is more than rmb 20 million whilst xiajie and liantang have almost no agricultural income but the per capita income of farmers in these villages ranks top as most of their incomes come from rent and the ecological leisure tourism industry tourism matching industries such as farm tourism and native products are developed by relying on the unique ecological resources rural economic development no longer is based on a single agricultural production methodology but has evolved towards diversified production modes social subsystems the resilience values of the social subsystems for licheng subdistrict are obviously weak in the whole and are mostly centralized in the low value range of 0000000750 villages with the weakest social subsystem resilience values are in a zonal distribution and in a layered layout around villages with higher economic levels secondary indexes of social subsystems are obtained through quantitative processing and analysis of the situation of rural population loss talent introduction efforts and cultural heritage protection village and consciously adhere to its rules and regulations this continuously helps to promote rural social resilience discussion based on the calculation results above it can be concluded that rural communities in licheng subdistrict have a good overall resilience but the development of subsystems is extremely unbalanced and there are many problems that need to be solved villages close to the core urban development area have a relatively strong overall resilience good adapting and learning abilities that can generally meet the basic living demands of villagers the resilience of subsystems however is unbalanced although the resilience of economic subsystems is relatively strong the resilience of social and ecological subsystems differ significantly and the overall situation therefore is not optimistic this is especially the case concerning the resilience of the ecological subsystem which is apparently weakened against the longterm development of rural communities the diversified economic development modes provide an appreciation space for villages to attract the inflow of capital however a destructive impact has been made on the ecological environment due to the imperfect rural market mechanism which is not conducive to the stable development of the rural ecological social system currently rural communities in the subdistrict are in the phase of highspeed transformation of urbanrural elements in the process of urban sprawl traditional rural life dominated by farming culture with bloodtied relationships has been eroded by modern culture new planning design and construction achievements are separated from the original cultural landscape planning of traditional villages the conflict between traditional civilization and modern civilization is exactly a reflection of the rural community system resilience being subjected to strong interference the research carries out index quantification for such an interference degree measures it through the threshold range explores the strength of the overall resilience function of rural communities under the interference of urbanization through rural social resilience is based on the connection degree and social familiarity of population settlements 4445 since the 1990s after guangzhou entered into the stage of highspeed urbanization villages close to cities were brought to the urbanization system resulting in a strong economic pull factor that further attracted the labor force from less developed surrounding villages the frequent population flows in rural communities therefore increased the heterogeneity of these communities 4647 under such unstable conditions the stability of existing social relations in rural communities and the knowledge of rural subjectivity are especially critical for the promotion of system resilience for example in xiajie village which is in the strong social resilience value range there are many cultural heritage assets such as the xiajie ancient post road and huaiyin hall strengthening cultural awareness can contribute to the cohesion of communities in addition xiajie village attaches great importance to talent introduction aiming to protect traditional ancient villages and restore rural vitality the ancient village friendship association of xiajie village has assembled a team of professional planners who are proud of their native land and are actively participating in events to promote rural revitalization besides activities periodically held in xiajie village provide consultation services for migrant workers including health examinations and parentchild communication activities to enable migrants who live there to develop a sense of belonging to xiajie village and consciously adhere to its rules and regulations this continuously helps to promote rural social resilience discussion based on the calculation results above it can be concluded that rural communities in licheng subdistrict have a good overall resilience but the development of subsystems is extremely unbalanced and there are many problems that need to be solved villages close to the core urban development area have a relatively strong overall resilience good adapting and learning abilities that can generally meet the basic living demands of villagers the resilience of subsystems however is unbalanced although the resilience of economic subsystems is relatively strong the resilience of social and ecological subsystems differ significantly and the overall situation therefore is not optimistic this is especially the case concerning the resilience of the ecological subsystem which is apparently weakened against the longterm development of rural communities the diversified economic development modes provide an appreciation space for villages to attract the inflow of capital however a destructive impact has been made on the ecological environment due to the imperfect rural market mechanism which is not conducive to the stable development of the rural ecological social system currently rural communities in the subdistrict are in the phase of highspeed transformation of urbanrural elements in the process of urban sprawl traditional rural life dominated by farming culture with bloodtied relationships has been eroded by modern culture new planning design and construction achievements are separated from the original cultural landscape planning of traditional villages the conflict between traditional civilization and modern civilization is exactly a reflection of the rural community system resilience being subjected to strong interference the research carries out index quantification for such an interference degree measures it through the threshold range explores the strength of the overall resilience function of rural communities under the interference of urbanization through the combination of both qualitative and quantitative methods and provides strategies for strengthening community resilience according to the analysis results social relations in order to pursue employment opportunities and a good living environment most villagers flow to areas with higher economic levels and more comfortable ecological environments the rural population flow has the characteristic of selecting the nearest optimal location which is reflected in the layered decline of the resilience of the social subsystem forming a typical coreedge structure the optimization strategy for the resilience function of the social subsystem of rural areas can start from the cultivation of rural subjectivity 26 the arrival of the socalled global competition age served to interfere with the endogenous development of rural communities which were essentially squeezed by a more powerful foreign culture resulting in those rural communities losing the internal driving force of development and autonomy a prominent manifestation of this is the massive loss of villagers from several villages in licheng subdistrict and the inflow of a foreign population therefore it follows that strengthening the subjectivity of rural communities is especially important for managing nonacquaintance society relations with a long history the villages in licheng subdistrict were mostly built in the qing dynasty many ancestral halls are set up and the profound ancestral idea foundation is kept in these villages at the same time showing significant cultural potential for the whole subdistrict there is one historical and cultural site protected at the provincial level two sites are protected at the municipal level and 33 sites protected at the district level therefore in respect of the strategy of adjusting the resilience of the rural social subsystem the rich cultural resources can be used to cultivate the cultural identity of villagers reshape the human network of the social system and strengthen the regulating ability of social resilience for example licheng subdistrict has responded positively to the construction of the cultural line of the ancient post road carried out in the last two years professionals in planning local elites and the government have cooperated actively to carry out investigations and obtain on the spot evidence so as to arouse the villagers recognition of their own culture imperceptibly in addition social activities such as the post road activity also promote the regeneration of the rural social system conclusions the aim of the study was to assess the resilience regulating ability of rural communities by constructing a new index system for the evaluation of socialecological system the strong value range of rural system resilience is mainly distributed in the northern region and partially centralized in the central region due to the differences in the abilities of the economic social and ecological systems to cope with interference the resilience of each subsystem has different spatial distribution characteristics the ecological subsystem has an obvious polarization in resilience the northern region comprises many modern agricultural bases which have better soil and water conservation capacities therefore the ecological system in the northern region is less damaged through spot investigation it is found that chengfeng jinxing qingfeng and wuyi around xiajie are all urban villages agricultural production has seceded from the main local economic structure working outside and leasing houses for rent are the main means of livelihood of the villagers as the earliest core area that takes over the outflows of urban resources the central area of licheng subdistrict is undergoing increasingly severe urban sprawl that is causing a significant decrease in cultivated land which further causes a reduction of the ecoenvironmental quality in rural areas and directly affects the resilience of the local rural ecological system rebuilding a stable ecological pattern is critical for the current weak rural ecological subsystem resilience function the original ecological bases of most villages were gradually changed and original farming landscapes were devoured by industrial landscapes under the trend of urban sprawl the blurring of urban and rural landscape boundaries and the integration of rural spatial features are serious problems in the current rural development process restoring the rural landscape is the basis for a good system cycle to reshape the ecological pattern the coordination mechanism between urbanization and ecological environment should be established external tension focuses on strengthening population quality and legal norms technological innovation and industrial upgrading while internal tension depends on residents awareness of environmental protection the enhancement in the resilience function values of the rural economic subsystems for licheng subdistrict can be attributed to an influx of new activities during the process of urbanization these activities such as the rental of houses ecological leisure tourism and industrial development have created a favorable environment for structural and functional reorganization of the system so as to adapt the systems to the urbanization development mode loreau et al stated the importance of species richness of the system 48 the immigration of alien species can improve the adaptability of the ecological system to changes causing a fundamental reaction of the ecological system and in so doing changing its performance characteristics the accumulation of adaptability allows for improvements in system resilience 4950 rural economic development no longer is based on a single agricultural production methodology but has evolved towards diversified production modes this is consistent with the theoretical analysis on the mutual influence between biodiversity and resilience 51 in view of the high average economic system resilience of rural communities in licheng subdistrict villages need to use their own resources to find a breakthrough in the market change the role of passive recipients and take the initiative to use diversified urban resources to improve the creativity of the system the capital investment frenzy caused by urbanization has become an irresistible trend if the resilience of rural economic systems cannot actively filter and absorb the outflow of resources it will inevitably be swallowed up by market competition and fall victim to the capital cycle therefore when facing capital invasion the capital opportunity of the market can be utilized to enhance the resistance ability of the economic system and adapt to its competitive and changeable interference the sustainable development of rural areas cannot rely on a single industry the current technological developments have greatly reduced the manpower requirements for agricultural production and the redundant human resources need more employment opportunities to make a living the diversified economic development mode can not only solve the problem of a surplus of farmers but also reduce the centralized destruction of interference sources it is through the change of economy and ecology that has changed the original rural social relations in order to pursue employment opportunities and a good living environment most villagers flow to areas with higher economic levels and more comfortable ecological environments the rural population flow has the characteristic of selecting the nearest optimal location which is reflected in the layered decline of the resilience of the social subsystem forming a typical coreedge structure the optimization strategy for the resilience function of the social subsystem of rural areas can start from the cultivation of rural subjectivity 26 the arrival of the socalled global competition age served to interfere with the endogenous development of rural communities which were essentially squeezed by a more powerful foreign culture resulting in those rural communities losing the internal driving force of development and autonomy a prominent manifestation of this is the massive loss of villagers from several villages in licheng subdistrict and the inflow of a foreign population therefore it follows that strengthening the subjectivity of rural communities is especially important for managing nonacquaintance society relations with a long history the villages in licheng subdistrict were mostly built in the qing dynasty many ancestral halls are set up and the profound ancestral idea foundation is kept in these villages at the same time showing significant cultural potential for the whole subdistrict there is one historical and cultural site protected at the provincial level two sites are protected at the municipal level and 33 sites protected at the district level therefore in respect of the strategy of adjusting the resilience of the rural social subsystem the rich cultural resources can be used to cultivate the cultural identity of villagers reshape the human network of the social system and strengthen the regulating ability of social resilience for example licheng subdistrict has responded positively to the construction of the cultural line of the ancient post road carried out in the last two years professionals in planning local elites and the government have cooperated actively to carry out investigations and obtain on the spot evidence so as to arouse the villagers recognition of their own culture imperceptibly in addition social activities such as the post road activity also promote the regeneration of the rural social system conclusions the aim of the study was to assess the resilience regulating ability of rural communities by constructing a new index system for the evaluation of socialecological system resilience this approach contrasts with most other resilience evaluation frameworks that are based on qualitative analysis for example using nvivo to analyze data obtained through semistructured interviews 52 the quantitative approach using the new index essentially contributes to broadening the scope of resilience measurement research and appears to be especially beneficial in the analysis of rural areas that are close to urban areas we also analyzed the evolution mechanism and driving mechanism of rural communities from the perspective of protection and development strategy in the new dimension of resilience and explored a new perspective for rural rejuvenation in practice the main contributions of this paper are as follows rural systems close to urban areas have a stronger resilience strength its spatial distribution shows dispersion in whole and aggregation in part the resilience of most rural economic subsystems are higher while the ecological and social subsystems are generally weaker in addition we proposed some policy suggestions to promote the sustainable development of rural areas and realize rural revitalization the influences of multiple factors need to be considered for the establishment of the resilience index system which for the research area selected in this paper may have some limitations in the determination of the rural community resilience function values due to limited data more comprehensive data indexes such as the ratio of agricultural income and the ratio of secondary and tertiary industries can be considered in subsequent research in addition to the expansion of objective data onthespot tracking investigations can be enhanced to verify the accuracy of the results in practice the future planning should not only optimize the material space but also use a comprehensive perspective to analyze the rules of the rural social ecological system stimulate the driving mechanism of rural development and encourage more villages to move towards a new phase of growth and protection data availability statement not applicable

resilience of rural communities is becoming increasingly important to contemporary society in this study we used a quantitative method to measure the resilience regulating ability of rural communities close to urban areasin licheng subdistrict guangzhou city china the main results are as follows 1 rural systems close to urban areas display superior adapting and learning abilities and have a stronger overall resilience strength the spatial distribution of which is characterized by dispersion in whole and aggregation in part 2 the resilience of most rural economic subsystems can reach moderate or higher levels with apparent spatial agglomeration whilst the ecological subsystem resilience and social resilience are generally weaker the spatial distribution of the former shows a greater regional difference while the latter is in a layered layout 3 some strategies such as rebuilding a stable ecological pattern making use of urban resources and cultivating rural subjectivity are proposed on this basis in order to promote the sustainable development of rural areas and realize rural revitalization this work also gives suggestion for the creation of appropriate and effective resilience standards specifically targeted for rural communityaiming to achieve the delivery of local sustainability goals

introduction around one billion people worldwide are disabled ie experience moderate to severe functional limitations 1 the prevalence of disability is expected to further increase due to factors including demographic change and growing importance of noncommunicable diseases and injuries 12345 although for the society as a whole function ing must be a major effect comparative effectiveness research and surprisingly even disparities research and social epidemiology have rarely made use of comprehensive measures of functioning 6 switzerland as one of the richest countries of the world 7 provides a good example for studying the role of social inequalities in functioning if we find social inequalities of functioning in a country with a high expenditure on health care and social security 7 we would expect them to be even more pronounced in less wealthy countries several previous epidemiologic studies have shown social gradients of disability 8910111213141516 and chronic pain 17 these were however mostly confined to the elderly population 8910111213 comparative data on younger and middleaged populations are still lacking predictors have usually been comprised of measures of socioeconomic status 1213 with indicators of social integration being used less often 816 so far studies have assessed disability mainly by dichotomous outcome variables eg asking respondents whether or not they experienced a long lasting condition that substantially limits one or more basic physical activities 12 even if more complex scales were used information was often reduced to a binary outcome 113 in the case of switzerland several reports on social inequalities and health are available based on data from the swiss health survey 1997 a social gradient of disability was shown in persons aged 65 and older but younger respondents were not examined 18 information on impairments and activity limitations was combined and the outcome was again dichotomized a report based on the swiss health survey 2007 showed increasing problems in relation to activities of daily living with older age but did not account for ses 19 rather than viewing disability as a static attribute of an individual or population the whos international classification of functioning disability and health proposes a dynamic and multidimensional approach 20212223 disability can be conceptualized as a continuum of problems in functioning varying across life situations and environments 22 this concept of functioning encompasses the actual state of body functions and structures as well as activity and participation in a given environment in a recent study of british women aged 6483 dale and colleagues 24 found for instance that only restrictions in participation and limitations in complex activities were associated with increased risk of mortality in their fully adjusted models while impairment was not drawing on the icf framework we propose a theoretical model to guide our empirical analysis while controlling for demographics and health behaviours we hypothesize that the components of functioning are determined by ses and social integration that a p limitations are influenced by impairment and pain and that impairment a p limitations low ses and poor social integration exert a cumulative effect on perceived health 25 methods design we analyzed data from the swiss health survey 2007 26 obtained from the federal statistics office of switzerland the shs 2007 adopted the icf framework by including measures of functioning for population surveys developed by the united nations washington group on disability statistics 27 sample data collection the survey was based on a representative stratified random sample of all private swiss households with fixed line telephones household members aged 15 and above were randomly selected the survey was completed by 18760 persons corresponding to a participation rate of 66 people who did not speak german french or italian were asylum seekers had an extremely poor health status or lived in nursing homes were excluded 26 data were collected with computer assisted telephone interviews people aged 75 or above were interviewed facetoface 26 study variables functioning the shs 2007 included several measures of impairment pain and a p limitation with heterogeneous scales of questionnaire items therefore we dichotomized all respective information such that a value of 1 indicated the presence of problems and a value of 0 corresponded to none following the icf framework we then constructed 3 separate sum indices the impairment index comprised problems in the following areas vision hearing speaking body weight urinary continence defecation energy and drive sleep and heart rate the a p limitation index was based on problems in the following activities walking eating getting up from a bed or chair dressing toileting bathing preparing meals using a telephone doing the laundry financesaccounting public transport major household tasks and shopping the pain index used information on anatomical locations of pain including head chest stomach back hands and joints graphical and statistical tests showed that these indices shared a poisson distribution perceived health perceived health was measured by asking respondents how they would rate their health in general ses level of education income paid employment gender and migration background were used as indicators of ses education was categorised according to the international standard classification of education as the total number of years of formal education including school and vocational training 28 income was measured by net equivalent household income according to oecd criteria 29 participants were asked whether or not they were currently in paid employment information on migration background was gathered by determining whether at least one parent was of foreign origin social integration we constructed 2 sum indices for social network utilization and perceived social support individually the social network utilization index encompassed information on whether the following activities were performed at least weekly visits of family members phone calls with family members visits of friends phone calls with friends and participation in clubs or associations the perceived social support index comprised information on four items having someone to turn to having at least one supportive family member feeling lonely and missing someone to turn to in addition we considered whether respondents were married or not social class in order to test for an overall social gradient in disability we integrated information on income education and social integration and constructed a social class index with 4 groups we thus followed bourdieus concept of social class representing core dimensions of economic cultural and social capital 30 persons with income education and a combined social support and network index below average were assigned to the first group people with 2 out of 3 indicators below average were assigned to the second group respondents with one indicator below average were assigned to the third class and those with all indicators above average to the fourth group the 2 indices on social integration were combined to avoid overrepresentation of social capital the resulting distribution of social classes in the swiss general population had high face validity with most respondents being assigned to the middle classes and the lowest percentage to the highest class data analysis all computations were made with stata 11 with the exception of the missing value imputation which was performed with r the indices described above were checked using statas confirmatory factor analysis module confa 31 for each index the index solution was tested against the null hypothesis of a diagonal structure of the covariance matrix to test our hypotheses we calculated separate mixed effects regressions for the 4 outcomes of impairment pain a p limitation and perceived health the 26 swiss cantons were nested according to language regions five cantons are bilingual and in order to obtain a fully nested model were subdivided into smaller areas according to the dominant language random intercepts were introduced for the language region and canton to account for unobserved heterogeneity due to clustering of respondents by language region and canton we used poisson links to model pain impairment and activity limitation and an ordinal probit link to model perceived health assuming a latent metric variable underlying the ordinal scale distribution 32 in order to assess the models fit to the data we calculated pseudo r 2 values by comparing the log likelihood of the full model with that of an empty model 33 for the poisson type models we used the stata command xtmepoisson and for the ordinal probit model the command gllamm 34 we calculated 4 models for each outcome an overall model and 3 separate models for persons aged 1530 3054 and 55 and older the age cutoffs were chosen to allow comparability with other research particularly on elderly persons bonferroni correction was used to account for multiple testing ie empirical pvalues were multiplied by 4 to test for an overall social gradient in disability we used the models described above to predict the average number of impairments pain problems and a p limitations in the four groups of social class to correct for multiple testing 99 confidence intervals were used sampling weights provided by the federal statistics office were applied to the data the variables used for the construction of the social class index were treated as observed and all other variables were set to the class mean average marginal counts were computed using statas postestimation command margins 35 across all study variables less than 1 of values were missing corresponding to 2687 cases with one or more missing values proportions of missing values ranged from zero to 6 in order to avoid listwise exclusion of cases with some missing values all missing values were imputed using the multiple imputation procedure missforest 36 while we report results from the imputed data set the unimputed data set was used in a sensitivity analysis and the results compared no relevant differences in parameters were found all analyses were controlled for age in years and healthrelated behaviours we initially considered two economic macrolevel variables the gini coefficient and gross domestic product per canton since both variables failed to improve model fit we decided to exclude them from the analyses results the study population is described in table 1 more than two thirds of the swiss population experience at least one type of impairment or pain around 16 experience at least one a p limitation with growing proportions in older age groups results of the mixed effects regressions are presented in tables 2 and3 based on pseudo r 2 values the best overall model fit was obtained for the model explaining a p limitation followed by perceived health impairment and pain the regression models fitted the data better in the midlife and older age group than in the younger group impairment male gender paid employment higher education higher social support and social network utilization were all associated with a decreased number of reported impairments the number of pain problems was positively associated with the number of reported impairments no significant effects of income or migration background on impairment were observed overall results were consistent across age groups apart from social network utilization all effects of these variables on impairment were more pronounced in the midlife and older groups the effect of being married was confined to the midlife group pain the number of pain problems decreased with perceived social support but increased with the number of impairments being married was associated with a higher number of pain problems while being male reduced reported pain education and paid employment did not strongly influence the number of reported pain problems in the overall model income and migration background again did not reach statistical significance higher education however reduced the number of reported pain problems in the midlife group being in paid employment increased the reported number of pain problems in the younger group but decreased it in the older group perceived social support in turn exhibited a consistent strong inverse relationship with number of pain problems across all age groups a p limitation the number of a p limitations increased among persons who reported more problems in pain and impairment being in paid employment having higher education or higher income was associated with lower levels of a p limitation in the overall model migration background did not play a role stronger social network utilization was related to lower levels of a p limitation which was consistently observed across age groups stronger social support was associated with more a p limitation in the overall model which seems to be due to the older group pain impairment and ses variables displayed strong effects across all age groups in contrast to impairment and pain male gender was associated with less a p limitation perceived health a p limitation pain and impairment were the strongest negative predictors of perceived health while being in paid employment and perceiving high levels of social support were the strongest positive predictors in the overall model higher education and income as well as social network utilization further contributed to better perceived health being married and being male were associated with worse perceived health in the overall model these effects were particularly pronounced in the elder group migration background did not assert significant influence when it was adjusted for the other predictors overall social gradient of disability figure 2 shows the numbers of problems in impairment pain and a p limitation across 4 social class groups based on the above models the overall picture suggests a social gradient of disability in the swiss general population with higher social class being associated with less disability discussion in this crosssectional study of a representative sample of the swiss population we found that measures of ses and social integration were strongly associated with several dimensions of disability and perceived health socially deprived and isolated people were at higher risk of disability conversely the negative effects of impairments on pain of pain on impairments and of impairment and pain on activity and participation could be compensated by higher income better education and social integration to a large extent this finding was consistent across all age groups migration background did not play a significant role when it was adjusted for other measures of ses and social integration gender however was among the strongest predictors of disability and perceived health even when we adjusted for all other ses and social integration variables being male positively influenced impairment and pain but negatively affected a p limitation and perceived health when it was adjusted for the remaining disability components this finding suggests differential response behaviours of men and women potentially influenced by interactions of gender with other ses and social integration variables to our knowledge this is the first investigation that comprehensively explores potential social determinants of functioning and disability in a representative sample of young middleaged and older swiss residents of both sexes it also pioneers the application of the icf framework for disability research using a large national database most of our findings were in agreement with our a priori hypotheses thus supporting the icfs multidimensional approach towards disability our results are in line with studies from greece 8 and estonia 14 showing a social gradient of disability in the general population they also support findings from previous studies reporting a social gradient of disability in the elderly intercepts were 21519 for the threshold between very bad and the rest 2913 for very bad and bad vs the rest 2207 for very bad bad and fair vs the rest 1061 for all other categories vs very good oprobit ordinal probit note all models have been adjusted for age and and health behaviours doi101371journalpone0038782t003 91011121318 but draw on more complex outcomes in our study most associations have the same direction but differ in strength across the age groups these differences highlight the need for longitudinal studies in order to elucidate the evolution of disability patterns along the course of life the hypotheses on ses and social integration were tested simultaneously ie respective parameters were adjusted for each other consequently our study confirms the findings from nilsson 16 in middleaged danish men showing independent influence of financial assets and social support nonetheless social support might compound the influences of ses on functioning and disability we did however not examine respective interactions in our study several limitations need to be taken into account firstly our theoretical model assumes unidirectional effects however the crosssectional design did not allow the direction of reported effects to be tested secondly we did not elaborate on genderspecific associations nevertheless we observed genderspecific effects and gender is known to interact with socioeconomic variables a more detailed investigation would be desirable but was not the focus of this analysis thirdly the variables relating functional status did not allow the severity of problems to be gauged for instance for pain only the number of pain problems could be used without information on pain severity or duration fourthly we used 4 separate multiple mixed effects regression models and did not perform a test of an overall model eg based on structural equations 32 or conditional independence graphs 3738 further clarification of the structure of associations including potential moderation and mediation 39 is required from future research for example it may be the case that the influence of impairment on a p limitation is mediated or moderated by social position or gender finally switzerland is a high resource setting with high standards of health care and social welfare this makes it difficult to generalize our findings to lower resourced settings where we would expect social inequalities to be even more pronounced though typically data of good quality are not available from these settings these limitations are balanced by several strengths our results are derived from a representative sample of the swiss population stratified into three age groups and the application of a comprehensive set of variables measuring functioning furthermore we applied a theoreticallybased approach to linking socioeconomic and sociological factors with newly constructed sum indices of functioning and with perceived health robust statistical methods included confirmatory factor analysis of the indices mixed effects regression models to account for unobserved heterogeneity bonferroni correction to account for multiple testing and tests of the models fit to the data this study highlights consistent social inequalities in functioning and perceived health in a representative sample of the swiss population aged 15 or above higher levels of social integration and of ses were associated with better functioning in terms of impairment pain and limitations of a p and better perceived health our findings are challenging in view of the high living standard in switzerland indeed given the social gradients in disability observed in this setting they are likely to be even more pronounced elsewhere

many people worldwide live with a disability ie limitations in functioning the prevalence is expected to increase due to demographic change and the growing importance of noncommunicable disease and injury to date many epidemiological studies have used simple dichotomous measures of disability even though the whos international classification of functioning disability and health icf provides a multidimensional framework of functioning we aimed to examine associations of socioeconomic status ses and social integration in 3 core domains of functioning impairment pain limitations in activity and participation and perceived health we conducted a secondary analysis of representative crosssectional data of the swiss health survey 2007 including 10336 female and 8424 male swiss residents aged 15 or more guided by a theoretical icfbased model 4 mixed effects poisson regressions were fitted in order to explain functioning and perceived health by indicators of ses and social integration analyses were stratified by age groups 1530 3154 55 years in all age groups ses and social integration were significantly associated with functional and perceived health among the functional domains impairment and pain were closely related and both were associated with limitations in activity and participation ses social integration and functioning were related to perceived health we found pronounced social inequalities in functioning and perceived health supporting our theoretical model social factors play a significant role in the experience of health even in a wealthy country such as switzerland these findings await confirmation in other particularly lower resourced settings

although its meaning has changed the belief that women and men are held to different standards of sexual conduct remains pervasive in contemporary us society when reiss began researching the double standard over a halfcentury ago premarital sex and the stigma attached to women who engaged in it were primary concerns in the ensuing decades the sexual revolution largely destigmatized female premarital sex per se shifting double standard research to the gendered consequences of sexual permissiveness and casual sexual encounters today studies of gendered sexual scripts and the sexual double standard continue at a rapid pace both because empirical evidence of a double standard has been mixed and its implications for identity development and gender inequality remain profound an area that has received relatively little investigation is the sexual double standard in the context of adolescent development this omission is particularly striking given that most youth have reached sexual maturity by early adolescence and more than 30 begin engaging in sexual behaviors by 9 th grade although the wellstudied topic of sexual permissiveness is less relevant at this age peer evaluations of emergent sexual behaviors and perceived sexual precociousness are likely to have large and lasting impacts on adolescents adjustment moreover the emergence of sexual behavior in adolescence occurs in the context of increasing psychological investment in peer relations for companionship selfconcept and a sense of belonging thus the manner in which the peer ecology reacts to sexual debut is particularly important both for the adolescents who initiate sexual activity and for the development of attitudes and norms among those who do not in our study we draw on sexual script theory and longitudinal social network data to document sexual double standards in adolescence in the united states we take advantage of yearly longitudinal data from 921 youth to measure withinperson changes in adolescents friendships and sexual behavior from 6 th to 9 th grades such analyses help to elucidate the proposed mechanism underlying the double standard that peer responses to individual sexual behaviors differ by gender we also move beyond a unitary conception of sexual behavior by examining changes in peer acceptance following two sexual behaviors having sex and making out distinguishing these behaviors is theoretically important because light sexual activitiessuch as holding hands kissing and making outmay be consistent with female adolescents traditional sexual scripts and associated with increased peer acceptance alternatively male adolescents engaging in similar behaviors particularly if these behaviors do not lead to sex may be viewed as losing their independence and agency and see decreases in peer acceptance to our knowledge no study has yet tested this reverse double standard hypothesis for romantic noncoital behaviors sexual script theory and empirical research sexual scripts are socially constructed cognitive schema that define normative sexual behaviors and inform individual actions in sexual situations at the cultural level traditional sexual scripts are gendered prescriptions for appropriate sexual conduct which scholars commonly measure through qualitative and survey analyses studies in this vein generally find opposing sexual scripts by gender men and boys are believed to act on innate and strong sex drives to initiate heterosexual contacts for the purpose of sex and pursue multiple sexual partnerships in contrast women and girls are expected to desire romance over sex value monogamy and gatekeep male sexual advances within committed relationships a sexual double standard then arises because women and girls who violate traditional sexual scripts and have casual andor multiple sexual partnerships are socially derogated whereas men and boys performing similar behaviors are rewarded for achieving masculine ideals the existence of a sexual double standard has important implications for gendered sexual development in particular the sexual double standard likely socializes male and female adolescents to differing behavioral expectations and sexual risks empirical evidence demonstrates that young women who endorse the sexual double standard are less likely to have sex perceive greater barriers to condom use and are less likely to use condoms moreover the sexual double standard can lead girls and women to feel shame and guilt if they do engage in sexual behaviors in contrast young men who more strongly endorse the sexual double standard tend to have more sexual partners thus if peer ecology socializes male and female adolescents differently in reaction to their sexual behaviors and if adolescents incorporate these messages into their sexual schemas it might translate to future sexual beliefs and behaviors in adolescence and beyond recent research on sexual scripts and the double standard has focused on collegeaged populations and hook up culture the empirical evidence from these studies remains decidedly mixed qualitative studies generally find support for a strong double standard such that interviewed young adults report that men are likely to receive affirmations as players or studs for casual andor frequent sexual encounters whereas women are negatively labeled as sluts or hos for similar activities quantitative studies however have provided more equivocal results although some quantitative research continues to find evidence for the sexual double standard several experimental vignette designs and some attitudinal studies do not document a strong sexual double standard instead these latter studies find that young adults are negatively evaluated for permissive sex regardless of gender that is a weak double standard whereby the negative evaluations of young mens permissiveness are only somewhat less than the negative evaluations of young womens permissiveness or even a reverse double standard whereby young men are evaluated more harshly for their sexual behavior than are young women the differences between qualitative and quantitative double standard studies may arise from the level at which sexual scripts are measured qualitative studies may be identifying culturallevel scripts of genderappropriate sexual behavior whereas quantitative studies may be measuring interor intrapersonal scripts that are inconsistent with broader traditional beliefs alternatively apparent distinctions between culturaland individuallevel sexual scripts may be due to the gap between ideal beliefs and actual behaviors in social settings for example experimental evidence suggests that young adult men and women are more likely to detect social cues that confirm rather than disconfirm culturallevel sexual double standards thus survey and experimental research divorced from the social contexts in which sexual appraisals are actually made will underestimate traditional sexual scripts desire to apply a single sexual standard or hold sexually progressive views may not eliminate individuals applications of double standards in practice especially when sexual evaluations emerge in dynamic peer settings overcoming this methodological limitation requires data as close as possible to the social contexts in which evaluations of sexuality take place prior research on the sexual double standard suffers from two additional shortcomings first studies typically rely on convenience samples of undergraduates which provide important information about campus sexual cultures but do not illuminate gendered processes surrounding sexual debut which occurs prior to high school graduation for the majority of individuals in the united states furthermore it is estimated that only onefourth of adolescents have their first sexual experience outside a romantic relationship and the number of sexual partners in adolescence remains relatively low thus focusing on sexual permissiveness and casual sex as is typical of most collegebased and young adult studies does not generalize to adolescence norms and social reactions to sexual precocity rather than perceived promiscuity would be of more theoretical interest during adolescence this shift also places greater emphasis on early transitions from virgin to nonvirgin than number of sexual partners or frequency of sex second double standard research has predominantly focused on sexual intercourse behaviors such emphasis is warranted because these behaviors are clearly associated with traditional sexual scripts with female permissiveness and casual sex expected to be socially sanctioned through gossip and lowered peer acceptance in contrast similar male behaviors should generate social rewards and increased peer acceptance missing from this research however are behaviors consistent with traditional female sexual scripts but inconsistent with traditional male scripts female adolescents are expected to be desirable but not desiring meaning that dating and romantic noncoital behaviors should be socially rewarded through increased friendships and improved reputations these behaviors simultaneously demonstrate a girls othersex attractiveness and gatekeeping abilities for male adolescents light sexual and romantic behaviors that do not progress to sex could symbolize passivity and a sublimation of hegemonic masculinity to feminine control participation in noncoital romantic activities may then lower boys esteem in the eyes of peers because they are inconsistent with group expectations for competitive and aggressive masculinity this reverse double standard may be even more dramatic in adolescence when most couples are transient and peer groups are predominantly same gender indeed early romantic relationships may originate as means of garnering samegender acceptance or to fulfill group expectations understanding the consequences of both romantic and sexual behaviors in these peerdriven contexts should illuminate the contours of contemporary sexual double standards understanding a sexual double standard in adolescence is also of interest because early socialization to gendered sexual scripts likely has lasting impacts on future sexual attitudes and behavior peer influence and the importance of peer acceptance peak during early adolescence sustaining the social fishbowl in which sexual behaviors are monitored and defined moreover the gender segregation typical of child and early adolescent friendship networks adds to the policing and reinforcement of traditional sexual scripts not only does the gendersegregated world of teen peer culture increase the salience of gendered sexual scripts and make it difficult to maintain sexual secrets but gossip and evaluations of sexual conduct quickly diffuse through dense peer networks as a result female adolescents first experiences with sex not only may be less desired and satisfying than male adolescents first experiences but also may result in lower peer acceptance as prior friends seek to distance themselves from the sexual transgressor kreager and staff approached the adolescent sexual double standard through an innovative network lens using data from the national longitudinal study of adolescent health they tested associations between the number of selfreported sexual partners and peerreported friendship nominations they found evidence for a double standard in that the number of selfreported sexual partners was positively associated with peer acceptance for male adolescents and negatively associated for female adolescents furthermore they found that the associations varied by students socioeconomic status and by gender of the peers who nominated the student as a friend the double standard was more likely to occur for high ses females and low ses males the friendship benefits associated with male permissiveness and the friendship costs associated with female permissiveness were driven by females friendship nominations kreager and staff concluded that the double standard not only depends on the gender of sexual actors but also their sociodemographic characteristics and the gender of peer evaluators network approaches to the adolescent double standard although suggestive kreager and staffs study has several limitations its crosssectional design is a primary concern because the direction of the reported associations is uncertain in addition the associations could be spurious due to unobserved betweenperson heterogeneity for example lowesteem female adolescents may have low peer acceptance and seek approval through sexual relationships whereas highesteem male adolescents may have high peer acceptance and greater access to multiple sexual partners another study limitation lies in the aging add health data the sexual double standard is subject to cultural shifts and thus patterns observed in add healths twodecadesold data may not hold in more recent youth cohorts finally similar to other studies in this area kreager and staff narrowly focused on sexual permissiveness operationalized as number of selfreported sexual partnerships lyons giordano manning and longmore also approached the adolescent sexual double standard from a network perspective they did not find significant associations between sexual partnerships and selfperceived peer popularity interpreting these findings as some contradictory evidence regarding the basic notion that violating the sexual double standard is associated with heavy social costs however subsample interviews suggested that respondents did perceive and often contribute to a sexual double standard to resolve these apparently contradictory findings lyons et al asserted that sexually permissive female adolescents are able to maintain close friendships with peers who share similar behaviors or sexual attitudes even though the larger peer community evaluates such behaviors negatively the lyons et al study benefits from its mixedmethods design longitudinal assessment and more recent data collection however their sample was not schoolbased and therefore did not include peernominated status measures compared to selfreported popularity peer friendship nominations can provide more variability and they are less likely caused by psychological constructs like selfesteem and depression associating multiple sexual behaviors with a continuous and longitudinal measure of peer acceptance would advance prior tests of the adolescent double standard another advantage of analyzing the sexual double standard with longitudinal friendship network data is that researchers are able to distinguish changes in individuals selfperceived friendships from changes in their received friendships this distinction between selfand peerreported friendships is particularly advantageous for isolating social responses to individual behaviors or characteristics over time as link and phelan emphasize when reviewing stigma research a primary challenge to operationalizing the concept is that prior studies commonly take an individualistic focus and measure the perceptions of individuals and the consequences of such perceptions for the microlevel interactions missing from these approaches are the socially constructed consequences of nonnormative behavior for the stigmatized individual which link and phelan argue are typically social rejection and status loss measuring changes in an adolescents peerreported friendships after sex while controlling for his or her selfreported friendships then locates the source of potential status gains or losses in peer reactions rather than in the adolescents actions or attributes network data then allow us to more accurately measure social exclusion or acceptance processes and attend to goffmans call to view stigma as …a language of relationships not attributes… current study in our study we examine the withinperson association between peer acceptance and sexual behaviors in a longitudinal sample of male and female adolescents we derive two competing hypotheses for whether gender moderates the sexual behaviorpeer acceptance association from sexual script theory we propose that female adolescents peer acceptance will decrease following sex whereas male adolescents peer acceptance will increase the alternative hypothesis derived from several recent studies of young adults sexual attitudes and vignette evaluations asserts that peer acceptance of male and female adolescents will both decrease following sex from literature describing normative sexual scripts we generate another hypothesis for noncoital light sexual behavior asserting a reverse sexual double standard whereby female adolescents peer acceptance will increase and male adolescents peer acceptance will decrease following reports of making out following findings from kreager and staff we also test if the association among gender peer acceptance and sexual behaviors is moderated by students ses and the gender of peer nominators finally we conduct sensitivity analyses to test if sexual behaviors are associated with outofgrade friendships and if the associations between peer acceptance and sexual behaviors are moderated by adolescents dating status the former test is important for ruling out the possibility that sexually active youth replace their ingrade friends with older or outofschool friends whereas the latter test is important because sex may be less stigmatizing for female adolescents involved in a romantic relationship than for female adolescents who have sex outside a romantic relationship in sum our study represents a comprehensive analysis of the gendered social consequences associated with adolescent sexual activity method participants and procedure data came from a sample of adolescent participants in the promoting schoolcommunityuniversity partnerships to enhance resilience longitudinal study prosper is a largescale prevention effectiveness trial aimed at reducing adolescents substance use it follows two successive cohorts of 6 th grade students living in 28 rural communities in iowa and pennsylvania each community was selected because it had a public school district with 13005200 enrolled students and had at least 15 of students eligible for reducedcost lunches one of the pennsylvania schools did not agree to participate in the network portion of the study necessary for the current research resulting in 27 school districts available for analyses students completed confidential pencilandpaper questionnaires administered during school hours in the fall of 6 th grade and in the spring of 6 th 7 th 8 th and 9 th grades the inschool survey included friendship network items used to construct our dependent measures across the five waves participation rates ranged from 86 to 90 of enrolled students and eligible students completed on average 418 of 5 inschool surveys in addition to the inschool survey a random sample of 2267 participating families were invited to complete inhome written questionnaires for the focal adolescent mother and if present father adolescent inhome written questionnaires included selfreported sexual behaviors of the invited families 979 completed at least one inhome assessment and 914 of these families included an adolescent who also completed an inschool survey and comprise our analytic sample many invited families declined inhome surveys which may bring into question the generalizability of our results to the prosper population youth participating in the inhome interview were no different from other prosper youth with regard to freelunch receipt gender living with two biological parents and substance use initiation however they were less likely to be delinquent had higher grades and had higher peer acceptance than other prosper respondents table 1 displays descriptive statistics for all variables by wave and gender approximately 33 of girls and 34 of boys attritted from the sample by wave 5 measures peer acceptanceduring the prosper inschool survey all students nominated up to seven best or close friends in the same school grade and reported how many comparably close friends they had outside their grade or school friendship nominations were collected using an open name generator where students wrote the first and last names of each friend on the survey form which were then matched to student rosters names were matched 83 of the time we operationalized peer acceptance at each wave with the number of incoming friendship ties received from samegrade peers our primary dependent variable is thus a measure of sociometric likeability across all waves the average female respondent received 41 friendship nominations and the average male respondent received 33 nominations which was significantly different nominations ranged from 0 to 16 for females and 0 to 15 for males and the distributions were right skewed for both girls and boys the mean number of received friendship nominations peaked in 7 th grade we also created measures of samegender and crossgender peer acceptance because approximately 75 of the sample did not receive any crossgender nominations in any given wave we dichotomized the crossgender peer acceptance measure into no crossgender incoming ties and one or more crossgender incoming ties sexual behaviorswe measured students selfreported pastyear sex with the item during the past 12 months how many times have you had sex numerical responses were dichotomized into none and once or more for each wave as indicated in table 1 the prevalence of sex was extremely rare in the early waves approaching zero for both 6 th grade girls and boys but rose to 10 for both genders by 9 th grade the data therefore capture sexual onset for a minority of respondents to better identify students who transition from no sex to first sex we also created a first sex variable that is coded as 0 for all waves prior to selfreported sex and 1 for all waves after sex is reported one or more times there is a small chance that respondents who reported no sex at the first wave lost their virginity prior to the 6 th grade the nearzero prevalence of sex in the first two waves makes this possibility unlikely but data limitations mean that we cannot rule out the possibility by the 9 th grade 17 of girls and 12 of boys were classified as nonvirgins it is also possible that given the wording of the question respondents interpreted sex as heavy noncoital sexual behaviors other than intercourse throughout the text we therefore refer to this variable using the broader label of had sex rather than more specific labels of intercourse or coitus light sexual behavior was operationalized at each wave from the item during the past 12 months how many times have you made out responses were dichotomized into none and once or more although uncommon in the early waves a majority of the girls and over 40 of boys reported making out at least once by the 9 th grade as one would expect the overwhelming majority of adolescents who reported sex also reported making out and between 1025 of those who reported making out also reported sex at each wave control variableswe include several timevarying control variables that prior literature suggests are correlated with peer acceptance andor sexual behaviors and thus may make our hypothesized associations spurious these variables were measured in the inschool survey outdegree is the number of friendship nominations that respondents make at each survey wave for models predicting peer acceptance from samegender and othergender peers we include measures of samegender and crossgender outdegree and dichotomized the crossgender measure into no crossgender outgoing ties and one or more crossgender outgoing ties family relations at each wave is the grand mean of five subscales standardized to wave 4 means and standard deviations to provide a common metric assessing childparent affective quality joint activities parental monitoring inductive reasoning and family cohesion grades at each wave are operationalized from the question what grades do you generally get in school responses ranged from mostly lower than ds to mostly as religious attendance at each wave is derived from the question how often do you go to church or religious services responses ranged from never to more than once a week delinquency at each wave is operationalized through selfreports of 12 delinquent behaviors in the past 12 months a gradedresponse irt model was used to score this measure with item parameters coming from the middle wave of data collection irt differentially weights items according to their seriousness and provides scores that are approximately normally distributed drinking at each wave is derived from the item during the past month how many times have you had beer wine wine coolers or other liquor responses ranged from not at all to more than once a week school change indicates that a respondent changed schools between survey waves a transition likely associated with changing peer and sexual contexts finally we account for grade and age trends in our outcome with measures for wave and wave 2 a major advantage of the longitudinal network data in prosper is that it allows us to examine how withinperson changes in peer acceptance are associated with withinperson changes in making out and having engaged in sex in such analyses individuals are compared to themselves across measurement occasions thus these models statistically control for all timestable factors that might be related to both peer acceptance and sexual behavior for instance at least some of the effect of sexual behavior on peer acceptance may be driven by relatively stable betweenperson differences in attractiveness athleticism race or socioeconomic family background an added advantage of our withinperson analytical design is that it correctly specifies the temporal ordering of primary concepts the dependent measures friendship nominations are measured concurrent with survey administration and therefore chronologically follow the primary independent variables measuring sexual behavior occurring in the year prior to each survey wave this temporal specification reduces potential reverse causal ordering in fixed effects estimation mean values are calculated for each youth over time for each outcome and predictor variable these personspecific mean values are then subtracted from observed values at each time point withinperson deviations in outcomes are then regressed on withinperson deviations in predictors controlling for time formally the model appears as follows where i identifies each person t indicates wave y is one of the peer acceptance dependent variables x is a vector of timevarying independent variables β is a vector of estimated coefficients and ϵ are person and personwave error terms an additional advantage of fixedeffects models is that estimated coefficients remain unbiased if sample attrition is correlated with the individual error term ϵ i and in unbalanced panel designs we estimated these models with the xtreg fe command in stata this command yields coefficients that capture withinperson changes in peer acceptance as a function of changes in sexual activity and wave we added a small constant to the peer acceptance measure and then logged it to account for the right skew we estimate robust standard errors to correct for potentially heteroscedastic and dependent error terms and logistic models were estimated for binary outcomes in addition we used chained multiple imputation to impute missing data on our control variables the amount of missing data was relatively modest ranging from 0 for school change between waves 1 and 2 to 14 for religious attendance at wave 1 results overall sexual activity and peer acceptance we first examine if yearly changes in sex and making out are associated with changes in peer acceptance from grades 6 to 9 in the pooled sample table 2 presents estimates from a series of linear fixed effects models of peer acceptance in model 1 estimates for the total sample show that net of timevarying control variables year and timestable factors no statistically significant associations appear between having sex or making out and peer acceptance in the total sample that is averaging across females and males there is no evidence that having had sex or making out are associated with changes in incoming friendship nominations looking at other covariates in model 1 we also see little evidence that our individuallevel timevarying covariates predict changes in peer acceptance over the observed waves the significant positive coefficient for wave and significant negative coefficient for wave 2 suggest an inverted ushaped peer acceptance pattern over time consistent with the observed peak in peer acceptance in 7 th grade sexual activity and peer acceptance by gender null associations between the two sexual behaviors and peer acceptance in the pooled gender model may mask opposing patterns for females and males to test hypotheses 1a and 1b we thus split the sample by gender and estimate similarlyspecified models for females and males consistent with a strong double standard and in support of hypothesis 1a the coefficients for having sex are in opposite directions for female and male adolescents where females see an approximate 45 decline ie exp in peer acceptance in waves where they report having sex and males see an 88 increase ie exp in peer acceptance in waves where they report having sex moreover this gender difference is large in magnitude and is statistically significant a ztest of the equality of coefficients across independent samples demonstrates that the females coefficient for having sex is significantly smaller than the males coefficient the significant positive coefficient for having sex in model 1 for male adolescents also contradicts hypothesis 1b drawn from several studies of young adult sexual attitudes that both male and female adolescents are penalized for sexually permissive behaviors results from model 1 for females and males also show that net of reported sex females peer acceptance increases by approximately 25 ie exp in waves in which they report making out and males peer acceptance declines by about 29 ie exp in waves in which they report the same behavior as with having engaged in sex this gender difference is statistically significant we thus find support for hypothesis 2 that light sexual behavior is consistent with female sexual scripts and inconsistent with male sexual scripts the pattern of results suggests that participating in light sexual activity creates a sexual double standard opposite of that found for having had sex model 2 adds an outdegree covariate to model 1 which captures the number of outgoing friendship nominations sent by each adolescent respondent the coefficient for this variable is positive and significant meaning that adolescents who send more friendship nominations are also likely to receive more incoming friendship nominations from peers this result is not surprising and is consistent with ideas of social exchange more important for the current study was that including outdegree did little to affect the gendered associations between sexual behaviors and peer acceptance for example the reduction in females peer acceptance but increase in males peer acceptance following sex do not appear to be accounted for by changes in the number of adolescents outgoing friendship ties this finding suggests that the friendship consequences of having sex are not solely due to selfselection processes and have a solid basis in peer responses to the sexual behaviors themselves in unlisted analyses we also examined socioeconomic disadvantage as a potential moderator of sexual behavior and peer acceptance we created interactions between reducedcost lunch receipt at 6 th grade and our sexual behavior measures in model 2 for females and males because the freelunch variable did not vary over time it did not have a main effect in the fixedeffects model none of the interactions reached statistical significance suggesting that in contrast to hypothesis 3 the observed patterns did not vary by respondents level of disadvantage to help visualize the gendered patterns figure 1 plots predicted peer acceptance values over wave for hypothetical females and males who begin with similar sexual behaviors but then diverge from one another beginning at wave 3 we plotted predicted values for three hypothetical male and female adolescents a respondent who does not report having sex or making out at the observed waves reports making out at waves 3 through 5 but never reports having sex and reports making out and having sex at waves 3 through 5 note that we did not include a category for having sex without making out because this group never exceeded 5 of the sample at any wave as can be seen in figure 1a female adolescents who report making out without having sex beginning in the 7 th grade are expected to have approximately 05 more friendships by 9 th grade than are female adolescents reporting no sexual behaviors because the penalty for having sex is larger than the benefit of making out females who report both behaviors are expected to have approximately 05 fewer friendships by 9 th grade than are females who report neither behavior the opposite pattern is observed for male adolescents males who make out without having sex beginning in 7 th grade are expected to lose a little less than 05 friendships by 9 th grade compared to males without reported sexual behaviors male adolescents reporting both behaviors beginning in 7 th grade are expected to have about 04 more friendships by 9 th grade than are males who report neither behavior the sex measure reported in table 2 is operationalized as a timevarying covariate meaning that sex reported in waves following initiation are assumed to continue to influence the association between having sex and peer acceptance alternatively we can operationalize sex as the transition from virgin to nonvirgin this operationalization allows us to examine if changes in peer acceptance are primarily associated with the transition to first sex or with sex that continues to occur throughout the observed period model 1 table 3 replaces the timevarying sex variable with a variable capturing the transition to first sex for both female and male adolescents the coefficient for first sex varies little compared to the sex coefficients in model 1 table 2 the double standard appears to occur at both first sex and in time periods following sexual initiation it may also be that the association between having sex and peer acceptance is conditional on making out or vice versa in model 2 table 3 we examine potential moderation between sex and making out by comparing dummy indicators for personwaves where respondents report having sex and personwaves where respondents report making out without having sexto the reference category of personwaves where respondents do not report either behavior we combine waves where respondents report having sex without making out with waves where respondents report having sex and making out because of the low proportion of waves where sex was reported without making out for female adolescents waves in which they only make out without having sex are associated with significantly greater peer acceptance than waves where they did not make out or have sex for male adolescents we observe the opposite pattern such that waves where they make out without having sex result in significantly less peer acceptance compared to waves where they report neither sexual behavior although the coefficients for having sex are not significantly different than the reference category of not having sex or making out for both genders when the reference category is changed to making out these associations achieve statistical significance again the opposing patterns across gender are consistent with differential sexual scripts and a sexual double standard to this point we have predicted peer acceptance originating from all peers whether male or female in table 4 we disaggregate incoming friendship nominations by gender to examine if sexual behaviors result in greater changes in samegender versus crossgender friendships because the frequency of crossgender peers is low at our observed ages we dichotomize these into no crossgender nominations and one or more crossgender nominations which are then modeled with logistic fixedeffects regressions looking first at the samegender peer acceptance models we see strong similarities in estimated coefficients to model 2 of table 2 this result is not surprising because the majority of incoming nominations modeled in table 2 come from samegender peers more interesting are the crossgender models here we observe that similar to samegender nominations female adolescents who report having sex are significantly likely to lose male friends and female adolescents who report making out are significantly likely to gain male friends however for male adolescents coefficients from the models of samegender peer acceptance differ from those of othergender peer acceptance in particular males who report making out are likely to see significant declines in friendship nominations from other males but the coefficient for othergender peer acceptance is not statistically significant and close to zero any social penalty associated with boys making out appears to come solely from other male adolescents it is possible that sexuallyactive adolescents replace samegrade friendships with older or younger peer relationships this possibility may be particularly likely for female adolescents who are more likely than male adolescents to date older heterosexual partners we were able to gain leverage on this idea using items collected in prosper waves 4 and 5 during those interviews students were asked how many friends they had outside their schoolgrade ranging from 0 to 10 in unlisted analyses we used withinperson change analyses to predict this measure with the same model specification of table 2 model 2 for males and females we observed no significant associations between sexual behaviors and changes in female or male adolescents outofgrade friendships over the two waves we thus found no evidence supportive of hypothesis 4a that sexual activity coincided with increased outofgrade friendship ties it may also be that the association between sexual behaviors and peer acceptance is moderated by romantic involvement with the sexual partner female adolescents in particular may be at greater risk of stigmatization for engaging in sexual activities with a nonromantic partner unfortunately prosper did not begin collecting dating status items until wave 4 and nominated partners are not connected to reported sexual behaviors we were therefore unable to accurately test the romantic relationship moderation hypothesis however in unlisted analyses we did include past year dating status and interactions between this variable and our sexual behaviors in a withinperson change model of peer acceptance similar to table 2 model 2 for females and males dating had a significant positive association with peer acceptance but the interactions between dating and our sexual behaviors never approached significance so there was not support for hypothesis 4b discussion gender scripts perpetuating a sexual double standard remain a central concern among gender and sexual behavior scholars during adolescence a widespread sexual double standard promotes gender inequality suppresses female adolescents healthy sexual desires and motivates peers to stigmatize male and female adolescents perceived as gender nonconformists although the internalization and deployment of distinct and potentially harmful gender scripts occurs in childhood the application of differential gender expectations around sexuality begins in adolescence with the emergence of romantic and sexual strivings in our study we addressed a significant gap in our understanding of the sexual double standard with an adolescent grade cohort building on recent research in this area we operationalized peer acceptance using a network measure of received friendship nominations we then examined withinperson changes in peer acceptance following selfreported sexual behaviors to estimate the peer acceptance of the two sexual behaviors and look for potential gender differences in this association our approach extends prior research by focusing on sexual onset occurring in adolescence specifying the temporal ordering between sexual behaviors and gendered social responses from peers controlling for adolescents outgoing friendship nominations to better isolate the social reactions to sexual behaviors and accounting for timestable betweenperson differences that potentially create spurious associations between sexual behaviors and peer relations our results were consistent with sexual script theory and a strong sexual double standard female adolescents who reported having sex had significant decreases in samegrade friends whereas male adolescents who reported having sex had significant friendship increases these patterns suggest that females and males receive very different social feedback during a critical period of sexual development even sexually abstinent adolescents would observe the social costs associated with sex for female youth and the social benefits of sex for male youth for females abstinence in adolescence may be a strategy for maintaining social acceptance whereas for males precocious virginity loss may be a strategy for social success our analyses of light sexual behaviors add nuance to the traditional sexual double standard net of having sex female adolescents who reported making out saw significant increases in peer acceptance whereas male adolescents who reported the same behavior saw significant declines in peer acceptance we argue that this reverse double standard is consistent with gender scripts promoting romance for females and discouraging romance for males accordingly light sexual behaviors may serve as markers of sexual desirability and maturity for female adolescents but may signify dependence and submission for male adolescents moreover because making out almost always precedes sex female youth will tend to benefit more than will male youth early in romantic relationships this pattern would be consistent with giordano longmore and mannings mixedmethods study which found that early adolescent boys involved in romantic relationships tend to have less confidence and perceived relationship power than their girlfriends the authors argued that female adolescents have more experience than male adolescents with emotional and dyadic interactions resulting from their prior samegender peer relationships and they therefore adapt more easily to the new terrain of heterosexual romantic relationships our study adds to this narrative the idea that samegender peers provide crosspressures for sexual behaviors that affect romantic relationship dynamics that female adolescents appear to be rewarded more than their male peers for making out and that making out almost always precedes having sex likely contributes to female adolescents greater control over male adolescents early in romantic relationships in this view adolescent females will continue to receive social rewards prior to having sex but peer pressure and anticipated rewards contribute to adolescent males attempts to move relationships toward sex differential peer reinforcement thus helps to sustain female sexual gatekeeping in adolescent romantic relationships although we found that female adolescents reports of having sex and making out behaviors resulted in similar associations with being chosen as a friend by males and females the same was not true for males in particular making out was not associated with significant changes in male adolescents being chosen as a friend by female adolescents this finding suggests that for adolescent males the social costs of light sexual activity are primarily associated with responses from male peers an advantage of our analytical strategy was that we were able to predict changes in peerreported friendships net of changes in selfreported friendships in this way we come closer to measuring the gendered social reactions associated with adolescent sexual behaviors even though adolescents who reported more friendships were also more likely to receive more friendship nominations the gendered differences in the associations between sexual behaviors and peer acceptance remained significant when controlling for the former it is thus more valid to claim that sex creates a negative peer response for girls and a positive social response for male adolescents our distinguishing incoming and outgoing social ties therefore permits traction on the oftenelusive stigmatization process limitations and future research directions although our study represents a contribution to gender and double standard research it is not without limitations perhaps the most significant limitation concerns the unknown generalizability of results beyond prospers rural iowa and pennsylvania schools it may be that rural america holds more traditional sexual values and is more gendersegregated than nonrural settings supporting the former hypothesis the prevalence of sexual initiation by 9 th grade in our studys sample is less than half that found in recent nationally representative surveys this difference makes it essential that future researchers test if our results generalize to other regional and cultural contexts another study limitation pertains to the unknown social visibility of respondents reported sexual behaviors it is likely that adolescents attempt to manage if when and what their peers know about their sexual activities particularly given perceptions of the social consequences of such behaviors moreover sex only occurs in private settings so knowledge of its existence beyond the sexual actors themselves should only occur via selfdisclosure or gossip prosper did not ask respondents about their awareness of peer sexual behaviors so it remains unclear if changes in peer acceptance following selfreported sexual behaviors are the direct results of peer evaluations of those behaviors however recent research suggests that adolescents communicate openly and often with friends about sexual behaviors and risks and that this communication typically exceeds that with parents the likelihood that sexual information circulates in peer networks is heightened by our findings that at least one sexual partner benefit from such disclosures although our results are suggestive that sexual behaviors become public knowledge future research would benefit from asking adolescents their perceptions of the sexual behaviors of nominated peers another fruitful avenue for future research would be examining if a sexual partners social status conditions the association between sexual behaviors and peer acceptance for example a female adolescent who makes out with a low status male adolescent may drop in social status compared to a female who makes out with a high status male prosper did not collect dyadic data on sexual behavior so we were unable to connect selfreported sex with the respective partners characteristics longitudinal data of both friendship and sexual networks would be ideal for better understanding the sexstatus association longitudinal friendship and sexual data for a global network would also allow more sophisticated network analyses that estimate a wider set of network structural properties and are specifically designed to distinguish peer selection from peer influence processes it should also be noted that prospers friendship nomination data allow us to operationalize peer acceptance but not peerperceived popularity our study therefore focuses on the association between sexual behaviors and peer likeability rather than the association between sexual behaviors and peer reputation we are careful to confine our results to peer acceptance likeability or social preference but similar processes should occur with a peerperceived popularity outcome and we encourage future research to undertake such a study the survey limits our ability to understand social processes surrounding the sexual debut of sexual minority youth prosper did not ask respondents the gender of their sexual partners or their sexual orientation more broadly making it impossible to distinguish othersex and samesex sexual behaviors given the low prevalence of samesex intercourse during adolescence we assume that the observed patterns apply only to heterosexual relationships we thus urge future research using an oversample of sexual minority adolescents to evaluate peer responses to samesex sexual debut and public displays of affection finally future research should examine if the dynamics of sex and peer status vary from early adolescence to late adolescence and young adulthood prosper friendship nominations have only been coded for grades 69 providing limited variation to examine age as a potential moderator of the sexual double standard future research that includes friendships during late adolescence will be able to gain greater leverage on this issue which is particularly interesting because later adolescence coincides with a higher prevalence of sex and the prioritization of romantic and crossgender relationships over samegender friendships for both young women and men permissive and casual sex would also increase during this age range further complicating peer applications of traditional gender scripts additionally the association between precocious sexual behaviors and peer acceptance may vary in the shortterm versus the longterm for example allen schad oudekerk and chango recently found that making out was associated with increased peer status during early adolescence but that the correlation weakened over age moreover they also found that precocious sexual and minor delinquent behaviors were associated with longterm romantic relationship difficulties and increased substance use and criminal involvement examining such longterm consequences of sexual behaviors is beyond the scope of current project but should be the focus of a future study practice implications despite these limitations our findings have important implications for educators and prevention scientists who work with adolescents in school or other settings sexual health educators should recognize that the sexual double standard not only continues to exist but also shapes the structure of adolescents peer networks and individual adolescents friendship experiences sexuality education should include messages about mens and womens roles in romantic and sexual relationships as already recommended by siecuss comprehensive sexuality education curriculum beginning in preadolescence with coverage of gender roles in general and continuing in adolescence with discussions of gendered messages around perceptions and evaluations of peer dating and sexuality such lessons should include messages about gender equality but also should discourage boys from choosing to engage in sexual behaviors because they believe it is expected of them or would enhance their reputation in an age of social media sexual education should also emphasize the negative consequences of gossip and public dialogue that conform to the sexual double standard and stigmatize male and female adolescents for real or perceived deviations from traditional gender scripts in sum our results suggest that sexuality education should continue to consider gender dynamics within adolescent dating relationships given the differential reputation outcomes of sexual behavior and extend such education to cover gendered responses to sexuality within the broader milieu of adolescent peer society conclusion our study provides a significant contribution to sexual double standard research with longitudinal peer network nomination data we found evidence of a strong double standard during the period of sexual onset such that female adolescents tend to lose peer acceptance after reporting having engaged in sex and gain acceptance after reporting making out whereas male adolescents tend to gain acceptance after sex and lose acceptance after making out far from disappearing our results suggest that the sexual double standard and the gender scripts that underlie it remain alive and well during the developmental period when youth begin shaping their sexual identities and peer influence peaks predicted peer acceptance over waves by gender and sexual behavior first sex

a sexual double standard in adolescence has important implications for sexual development and gender inequality the present study uses longitudinal social network data n 914 1116 years of age to test if gender moderates associations between adolescents sexual behaviors and peer acceptance consistent with a traditional sexual double standard female adolescents who reported having sex had significant decreases in peer acceptance over time whereas male adolescents reporting the same behavior had significant increases in peer acceptance this pattern was observed net of respondents own perceived friendships further suggesting that the social responses to sex vary by gender of the sexual actor however findings for making out showed a reverse double standard such that female adolescents reporting this behavior had increases in peer acceptance and male adolescents reporting the same behavior had decreases in peer acceptance over time results thus suggest that peers enforce traditional sexual scripts for both heavy and light sexual behaviors during adolescence these findings have important implications for sexual health education encouraging educators to develop curricula that emphasize the gendered social construction of sexuality and to combat inequitable and stigmatizing peer responses to real or perceived deviations from traditional sexual scripts

in contemporary societies direct engagement in political action is crucial to disadvantaged peoples pursuit of social change taking part in mass movements such as the arab spring or occupy wall street signing an amnesty internationals petition or casting a vote in electoral events such as the recent eu referendum in britain are examples of actions that enable individuals to voice discontent challenge the status quo and improve their collective social and economic standing research in social psychology has shown that injustice appraisals and anger and a sense of efficacy are key factors in motivating individuals engagement in these direct forms of political participation however disadvantaged individuals may lack material and cultural resources to join political movements or engage collectively against relevant institutions they may have low confidence in their own abilities to influence the political decisionmaking process or doubt the systems willingness to respond to their needs as a result they may avoid engaging directly in political action thus the question remains if there are other channels through which disempowered individuals may express collective dissent from the status quo in this research i use the social banditry framework and propose that support for actors who disrupt the functioning of the system and who operate outside conventional societal and political structures of power and resistance is one such channel specifically i argue that support for such actors enables disadvantaged individuals to voice their discontent against an unjust system in a vicarious form a contemporary version of social banditry is the group of hackers calling itself anonymous anonymous challenge the states authority using trolling and other forms of misbehavior recently the group was named person of the year in the time magazine attempted to expose isis and intervened in the american presidential campaign despite their political and social relevance little is known about what motivates people to support this group the present research tests the social banditry framework to explain support for anonymous as a form of vicarious dissent direct participation in political action political participation may encompass institutional noninstitutional or even violent actions what these behaviors have in common is that they refer to a situation in which individuals directly engage in political action to influence and alter their political contexts according to van zomeren et als dual pathway model two complementary but independent factors contribute to explaining individuals decisions to engage directly in political action the first factor is injustice appraisal research has demonstrated that individuals subjective experience of disadvantage is a powerful predictor of actions aimed at confronting the disadvantage at the societal level perceiving the system as unfair increases the likelihood that individuals take part in protest importantly the perception of injustice elicits anger which mediates the linkage between injustice appraisal and engagement in protest the second factor is efficacy in order to take action individuals must feel able to achieve the desired change at the societal level individuals must perceive they can shape the political system and that the political system is responsive to their needs and demands a concept known as political efficacy research has demonstrated that stronger levels of political efficacy are associated with increased participation in different forms of political action such as voting or attending a rally current models of political action assume inaction and passivity when individuals are unable to cope successfully with an unjust disadvantage there is also some evidence that individuals are more likely to opt for violent forms of participation when they believe that their group cannot obtain change through collective efforts but how do individuals express collective dissent when they perceive an unjust system as irresponsive to their political needs here i contend that in such circumstances individuals may opt to convey their dissent vicariously rather than engaging directly in political action they may support actors who are otherwise outside the conventional realm of politics are often targeted as criminals by the state and whose behavior disrupt the systems functioning to test this contention in the present research i investigate support for the hacker group anonymous specifically i contend that support for this group represents an expression of inchoate anger and dissent when individuals do not feel they can express their political grievances by directly targeting institutions the system or the government social banditry as vicarious dissent if social and economic arrangements prevent subordinate groups from expressing dissent against oppression and injustice individuals must rely on alternative strategies for criticizing and resisting power for instance in traditional peasant societies the masses were devoid of political voice and had few means for pursuing or expressing a desire for social change in such a context individuals aspirations for social justice took the form of inchoate anger a desire for vengeance against the oppressive establishment groups like bandits rustlers and brigands often became the embodiment of such anger hobsbawm used the label social banditry to describe those outlaws who in peasant societies were labelled as criminals by the authorities but were supported and protected by local communities social bandits were sometimes regarded as heroes because their robberies and looting were construed as acts of defiance against the rich and powerful they disputed the social order by showing that the powerful and the oppressors could be challenged traditionally social bandits prospered in geographic areas that were hard to police such as mountains forests and deserts epitomized by figures such as robin hood or jesse james they were celebrated in local folklore as noble individuals who robbed the rich gave to the poor and used violence only for selfdefense and for righting wrongs their deeds enabled disadvantaged individuals who felt they had no access to other means to take part in a sort of vicarious protest against the oppressors sociological and historical research has long debated whether certain outlaws in specific contexts were in fact vicarious executor of the unarticulated rage of most of the rural poor or merely selfinterested criminals who preyed on and exploited peasants as well as landlords nonetheless regardless of its phenomenology social banditry has an important psychological function support for banditry may reflect disadvantaged individuals desire for more justice a vicarious expression of dissent such a psychological dimension has yet to be empirically investigated in this research i test the social banditry framework and investigate support for anonymous visàvis intentions to participate in direct forms of institutional and noninstitutional political action anonymous as social banditry anonymous is a network of hackers that emerged from the online board 4chan in 2006 originally anonymous was known for its outrageous pranks aimed at upsetting people and creating public amusement this behavior known as trolling includes spamming online forums disrupting access to web pages revealing peoples personal information and spreading disturbing content on the internet anonymous started to attract popular interest when it used these tactics to oppose scientologys attempts to limit freedom of expression on the internet since then anonymous has become an important global actor waging war against the us government isis and other actors and engaging in a series of operations against financial companies while the political meaning of such actions is more explicit compared to earlier hoaxes trolling has remained an important component of anonymous behavior anonymous shares important characteristics with the traditional concept of social banditry anonymous uses both legal and illegal tactics to attack its targets and challenge authorities although they do not have a coherent and unified political program as traditional bandits they operate in a space which is difficult to police and oversee the internet importantly anonymous is surrounded by the same ambiguity that characterized the concept of social banditry they may be perceived as robin hoodtype figures who take from the powerful to empower the disempowered or merely as trouble makers or even criminals their operations are conducted for personal enjoyment and amusement as well as punishing institutions and corporations social banditry individualism and anonymous social bandits were not revolutionaries and did not explicitly promote ideas about justice or collective change instead their actions sanctioned individuals desire for vengeance against the oppressors their ambitions to take the law into their own hands and the righting of individual wrongs here i propose that compared to direct engagement in political action vicarious dissent and support for social banditry reflect an affirmation of individualistic values individualism and collectivism are distinctive cultural values which place relatively stronger importance either on the individual or the harmony of the group respectively individualism emphasizes personal autonomy independence and selfinterest in contrast collectivism emphasizes interdependence groups common fate and harmonious relationships individualism and collectivism can be further divided along the vertical and horizontal dimensions depending on the importance of values of hierarchy or equality respectively the vertical dimension captures individuals acceptance of hierarchical relationships and differences in status among individuals whereas the horizontal dimension refers to the acceptance of egalitarianism the resulting fourfold typology encompasses horizontal individualism and collectivism vertical individualism and collectivism previous research has demonstrated such values may influence political decisions for instance using data from the 19901992 national election studies funk showed that stronger individualism was associated with lower propensity to engage in collective actions aimed at benefitting the community this is because people endorsing individualistic values may be less attuned to the societal interest and more attuned to selfinterest research has yet to investigate the role of individualistic and collectivistic values in the context of social banditry and anonymous according to the intracultural appropriation theory social actors challenging the established order seek legitimacy through cultural beliefs and values shared among the population to gain support justify their actions and achieve their goals for instance in the southern italian context travaglino abrams and randsley de moura showed that endorsement of masculine honor beliefs among youth was associated with a more positive view of mafiastyle groups this is due to mafias appropriation and strategic use of values of masculinity selfreliance and violence but which values are used by anonymous to obtain legitimacy the actions of anonymous are characterized by a strong tension between individualistic and collectivistic values prima facie anonymous seems to emphasizes collectivism for instance anonymous membership is subsumed under the umbrella of an overarching collective identity members all use the same sobriquet when they communicate with each other and they all wear the same guy fawkes mask when they interact with the public such measures protect members identity in case of illegal actions they also work as a check against potential temptations for selfaggrandizement and fame whereas anonymous is well known and influential its anonymous members are generally not however anonymous ethos places an even stronger emphasis on individualistic values it promotes personal privacy individual autonomy and unrestricted freedom of speech consistent with the broader hacker community ethos anonymous distrusts centralized authority and celebrates the tremendous power of the individual golumbia characterizes anonymous as libertarians a strongly individualistic form of political ideology importantly in line with the notion of social banditry anonymous operations resemble more closely acts of revenge against governments and corporations rather than a program aimed at improving the collective interest this research examines the role of individualistic and collectivistic values in predicting support for anonymous visàvis direct political engagement overview of the studies and hypotheses in this research i present two studies investigating attitudes toward anonymous visàvis engagement in direct forms of political action according to the social banditry framework people in an unfair context but with no political voice will feel anger against the system this should in turn boost support for actors who disrupt and challenge the system and thus who provide a vicarious voice for such anger this framework implies that stronger injustice appraisals and lower levels of political efficacy should predict stronger anger against the system anger should in turn predict more positive attitudes toward anonymous these studies compare attitudes toward anonymous to intentions to engage in noninstitutional and institutional forms of direct political action according to the dual pathways model injusticefueled anger and efficacy are two distinct paths that explain participation in political action therefore individuals should be more likely to express intentions to protest when they report higher levels of anger and stronger political efficacy finally stronger political efficacy should be a predictor of voting intentions because of the institutional and systemsupporting character of voting in addition study 2 tests the relationship between individualistic and collectivistic values and support for anonymous visàvis other forms of direct political engagement support for social banditry is a manifestation of individuals desire for personal vengeance against the system rather than a program for collective social change moreover anonymous promotes values of personal autonomy and individualism thus in line with the social banditry framework and icat i predict that endorsement of individualistic values will be linked to more positive attitudes toward anonymous in contrast participation in direct political action isby definitiona form of collective action aimed at promoting societal interest thus collectivistic values should predict intentions to engage in direct forms of political action such as protesting or voting because both support for anonymous and political action represent a desire for social change and justice both expressions of dissent should be predicted by horizontal values across studies i included measures of participants political orientation and subjective social status to control for their effects individuals political orientation may influence how they perceive inequality this in turn may affect individuals intentions to engage in direct forms of political action or their attitudes toward anonymous subjective social status refers to individuals perception of their position in the social hierarchy and may affect their confidence in political institutions thus it is important to control for this construct finally as previous research has shown that younger people are more likely to use the internet to engage in political action and because hacking is associated with a male stereotype analyses control for gender and age study 1 method participants and procedure three hundred and four british participants took part in the study the mean age was 3339 and the majority were english the remaining participants were from scotland wales and northern ireland participants were recruited using qualtrics via the online platform prolific academic to participate in a survey about social issues after completing the measures participants were debriefed in writing thanked and compensated for their time materials responses were measured on a 7point scale unless differently noted in the succeeding text for each construct the order of presentation of the items was randomized a mean score for each construct was computed by averaging the relevant items political efficacy political efficacy was measured using seven items from various scales the way people vote is the main thing that decides how things are run in this country it is only wishful thinking to believe that one can really influence what happens in society at large government officials dont care much about what people like me think it seems that whoever people vote for things go on pretty much the same i feel i am quite well represented in our political system how much influence do you think someone like you can have over national government decisions and to what extent do you feel that the basic rights of citizens are well protected by our political system items formed a reliable scale perceived justice of the system perception of living in a just system was measured using three items drawn from kay and josts system justification scale the items measured the perception that the uks economic and social arrangements are just and fair items used were in general i find british society to be fair most of the british policies serve the greater good and everyone has a fair shot at wealth and happiness in the uk anger participants perceived anger toward the political system was measured with three items participants read in general when i think about our political system i feel… and then indicated the extent they felt angry frustrated and outraged intentions to participate in noninstitutional political action intentions to engage in political action were measured with three items participants first read below are listed a series of activities people may take part in to express their voice andor dissent in society please indicate how likely you would be to take part in each of these activities in the future if the opportunity arises participants were then asked to indicate the likelihood to sign a petition attend a protest event and participate in a public demonstration voting intentions participants were asked how likely they were to vote in the next general elections attitudes toward results and discussion intercorrelations among variables means and standard deviations are presented in table 1 consistent with the social banditry framework an inspection of the bivariate correlations revealed a significant relationship between attitudes toward anonymous and political efficacy the perception of the fairness of the system and anger toward the system path analysis i tested the social banditry framework using a path model where the perceived fairness of the system and political efficacy predicted attitudes toward anonymous through anger against the political system in line with the dual pathways model paths were modelled from both political efficacy and anger to intentions to engage in noninstitutional and institutional political action residuals of voting intentions collective action intentions and attitudes toward anonymous were allowed to covary to capture systematic variation between the variables not accounted by the predictors gender age political orientation and sss were covariates in the model parameters were estimated using full information maximumlikelihood method given that there were few missing observations analyses were run in r using the lavaan package emulating mplus the model had a very good fit chisquare was nonsignificant χ 2 348 p 48 the other indices also indicated a wellfitting model agfi 998 cfi 100 srmr 001 rmsea 001 figure 1 summarizes the model perceived justice β 30 se 06 p 001 and political efficacy β 38 se 08 p 001 were negatively related to anger against the political system this is consistent with previous findings from tausch et al and suggests that perceiving the political system as unfair and irresponsive boosts anger against it anger in turn predicted attitudes toward anonymous β 22 se 05 p 001 there were no direct relationships between perceived justice and political efficacy and attitudes toward anonymous β ±08 se 09 p 24 in line with the dual pathway model intention to participate in noninstitutional political action was predicted by anger β 42 se 06 p 001 and political efficacy β 29 se 09 p 001 whereas the direct effect of perceived justice was nonsignificant β 07 se 06 p 30 finally voting intentions were significantly predicted by political efficacy β 16 se 11 p 027 and nonsignificantly by anger or perceived justice β ±012 se 07 p 86 suggesting that decisions to vote are not seen as an expression of protest in the british context the indirect effects of political efficacy and perceived justice via anger were tested using 5000 bootstraps as expected and consistent with the social bandit framework both the indirect effects of perceived justice β 07 se 02 95 ci 09 02 and political efficacy β 08 se 03 95 ci 17 04 on attitudes toward anonymous were significant in line with the dual pathway model there was a significant indirect effect of perceived justice on participation in noninstitutional political action β 12 se 03 95 ci 16 06 interestingly there was also a negative indirect effect of political efficacy on participation in noninstitutional political action via anger β 16 se 04 95 ci 29 12 1 study 2 method participants and procedure four hundred and ten participants from the usa were recruited using qualtrics and mturk the mean age was 3499 participants were from different states including california florida texas pennsylvania new york and illinois the other states represented in the sample each accounted for 5 of the sample data for this study was collected in december 2015 before the official start of the american presidential primaries materials the measures were the same as in study 1 except that a measure of horizontalvertical individualismcollectivism was included responses were measured on a 7point scale for each construct items sequences were randomized and a mean score was computed by averaging the relevant items political efficacy seven items as in study 1 were used to measure participants perceived ability to exert political power perceived justice of the system three items from kay and josts scale were used to measure individuals perceived justice of the system as in study 1 the items were adapted to the american context and formed a reliable scale individualismcollectivism participants orientation toward the individualismcollectivism and horizontalvertical dimensions was measured using a slightly adapted version of sivadas et als 14item scale the scale includes three items tapping hi three items tapping vi four items tapping hc and four items tapping vc anger perceived anger toward the political system was measured using the same three items used in study 1 intentions to participate in noninstitutional political action intentions to engage in political action were measured with the same three items as in study 1 voting intentions participants were asked how likely they were to vote on the next election day attitudes toward anonymous participants rated their perception of anonymous using the same nine items used in study 1 before completing the items participants were also shown an identical description and image political orientation one item measured participants political orientation would you consider yourself a liberal or a conservative subjective social status participants perception of their own social status was measured using the same graphic item used in study 1 results and discussion bivariate correlations showed a significant relationship between attitudes toward anonymous and political efficacy perceived justice and anger intercorrelations among variables means and standard deviations are shown in table 2 to check whether the scale used was able to distinguish the different cultural dimensions a factor analysis was performed on the 14 items measuring hi vi hc and vc using principal components as the method of extraction and varimax rotation a fourfactor solution emerged explaining 66 of the variance in line with sivadas et al items assessing each of the four constructs loaded on the expected factor except the item my happiness depends very much on the happiness of those around me which crossloaded on both hc and vc in addition the item children should feel honored if their parents receive a distinguished award whose expected factor was vc loaded more strongly on hc thus these two items were dropped a factor analysis on the remaining 12 items using principal components as the method of extraction and varimax rotation yielded a fourfactor solution explaining 73 of the variance all the items loaded strongly on the expected factor but not on the others the reliability of each of the threeitem subscale was satisfactory α 79 therefore the 12item version of the scale is used in the analyses below path analysis in line with the social banditry framework i tested a path model in which perceived justice and political efficacy predicted attitudes toward anonymous via anger against the political system following the dual pathway model distinct paths were modelled from both political efficacy and anger to intentions to engage in institutional and noninstitutional political action the horizontalvertical individualismcollectivism subscales were added as additional predictors of political participation voting intentions and attitudes toward anonymous as in study 1 residuals of political participation attitudes toward anonymous and voting intentions were allowed to covary gender age political orientation and sss were covariates in the model because there were few missing observations fiml was used to estimate parameters in the model analyses were run using r and the lavaan package emulating mplus the model had excellent fit and is summarized in figure 2 chisquare was nonsignificant χ 2 702 p 22 the other indices indicated a well fitting model agfi 997 cfi 100 srmr 011 rmsea 03 anger was predicted by political efficacy β 30 se 07 p 001 and perceived justice of the system β 29 se 06 p 001 in turn anger positively predicted attitudes toward anonymous β 16 se 05 p 002 perceived justice significantly predicted attitudes toward anonymous β 28 se 06 p 001 the path from political efficacy to attitudes toward anonymous was nonsignificant β 06 se 07 p 31 consistent with the dual pathways model intentions to engage in noninstitutional political action were predicted by anger β 36 se 05 p 001 and political efficacy β 29 se 07 p 001 the path from perceived justice was not significant β 04 se 06 p 55 voting intentions was predicted by political efficacy β 13 se 08 p 017 and unexpectedly anger β 18 se 05 p 001 there was no effect of perceived justice β 02 se 06 p 73 as expected hi was uniquely and positively associated with attitudes toward anonymous β 14 se 07 p 005 vi hc vc did not significantly predict attitudes toward anonymous βs 07 ps 14 this is consistent with icat and the hypothesis that support for anonymous reflect an expression of individualistic values in line with the idea that positive attitudes toward anonymous represent individuals aspiration toward more equality the horizontalbut not the verticaldimension predicted support for the group in contrast hc predicted intentions to participate in noninstitutional political action β 16 se 07 p 001 and voting intentions β 21 se 08 p 001 other dimensions of collectivism and hi and vi were not significantly related to either variable βs 08 ps 09 consonant with the fact that political participation and voting are activities driven by collective ideals general discussion this research investigated attitudes toward anonymous a group of hackers using different tactics to challenge and retaliate against governments and corporations i drew on the social banditry framework and proposed that support for anonymous represents a vicarious expression of dissent i hypothesized that weaker perceived political efficacy and stronger sense of injustice would be associated with more positive attitudes toward anonymous through anger against the political system across two samples and two different geographical contexts results supported this hypothesis study 1 used a path model to test predictors of attitudes toward anonymous visàvis intentions to engage directly in institutional and noninstitutional political action consistent with prior research stronger injusticefueled anger and stronger levels of political efficacy significantly predicted noninstitutional political action political efficacy was a significant predictor of voting intentions consonant with the idea that at least in the british context voting is a nonconfrontational form of political engagement in line with my theorising and the social banditry framework people who perceived weaker political efficacy and expressed lower justice appraisals expressed stronger support for anonymous through anger against the political system this pattern of results is consistent with the idea that social actors like anonymous may become a vehicle for individuals anger against an unjust system and convey dissent vicariously study 2 largely replicated these results in a different geographical context the us notably in study 2 anger was a significant predictor of individuals voting intention this is perhaps an indication of current party polarization and the resulting confrontational nature of voting in the american context in addition study 2 extended study 1 by examining the role of individualism and collectivism in the context of vicarious and direct political engagement based on the notion of social banditry and on evidence that anonymous emphasizes values of individualism and libertarianism i proposed that endorsing an individualistic orientation would be associated with more positive attitudes toward anonymous more specifically because support for anonymous conveys individuals aspirations for social equality i proposed that the horizontal dimension of individualism should be associated with support for the group results supported these hypotheses individuals who more strongly endorsed hi expressed more favorable attitudes toward anonymous this effect was independent of other constructs and cultural dimensions this indicates his distinct role in explaining attitudes toward anonymous in contrast those who more strongly endorsed hc had stronger intentions to engage in political action these findings are consonant with the social banditry framework and in particular hobsbawms observation that bandits are admired because their existence conveys a message of personal vengeance against the authority rather than a collective program for social change findings also provide support for icats central proposition that cultural values may bestow groups with legitimacy groups can then use this legitimacy to gain stronger social consensus accomplish their goals and objectives and obtain power and support future research should test the role of individualism in different political contexts and use different groups and forms of vicarious dissent efficacy anger and support for social banditry according to the dual pathway model injusticefueled anger and efficacy are independent pathways to political action evidence from this research is consistent with that assumption but only regarding direct participation in political of action across studies anger fully mediated the relationship between political efficacy and attitudes toward anonymous this result can be attributed to the fact that measures used in these studies tapped participants perception of the social and political system as a whole rather than participants sense of efficacy regarding specific issues or groups it is reasonable to expect that participants who perceive lower levels of political efficacy and are thus dissatisfied with the systems responsiveness to their political needs also express more anger toward the political system this is consistent with the idea that support for social banditry is a form of vicarious dissent whereby political grievances that cannot be otherwise voiced trigger anger against the political system which in turn promote support for bandits another interesting feature of this evidence is the relationship between political efficacy and noninstitutional political action political efficacy predicted intentions to engage in noninstitutional political action both directly and indirectly this suggests that anger may suppress the association between political efficacy and engagement in noninstitutional political action in turn this may explain why some authors have failed to find a relationship between political efficacy and participation in protest future research should further investigate the articulation between political efficacy anger and different forms of political engagement moreover this research demonstrates the key role of anger in predicting vicarious expressions of dissent recently tausch et al theorized that anger is a better predictor of direct engagement in rather than of support for other agents political actions for instance tausch et al showed that anger did not predict muslim students support for government policies aimed at supporting muslim communities in india somewhat inconsistent with this evidence results from these studies showed a positive relationship between anger and support for anonymous this may be due to the fact that groups such as anonymous represent a better vehicle for peoples anger compared to government policies this finding also supports the idea that different forms of anger have different implications for political action support for anonymous may be driven by feelings more akin to resentment due to the fact individuals perceive the political system as unjust and uncontrollable future research should better differentiate among different forms of anger visàvis support for anonymous limitations and future directions this paper has presented two studies investigating support for anonymous in the british and american contexts results support the social banditry framework and the dual pathway model and provide important new insights about the idea of vicarious dissent nonetheless this research is affected by some limitations first the measure of political efficacy used in this study does not allow to distinguish between internal and external political efficacy political efficacy is a complex concept with multiple dimensions future studies should include measures able to distinguish between internal and external as well as collective dimensions of political efficacy and investigate the specific role of each dimension in predicting vicarious dissent visàvis direct engagement in different forms of political action in similar a vein future research should better elucidate the role of grievances and injustice appraisals in predicting support for anonymous this research used items drawn from kay and josts system justification scale measuring the perception of the fairness of the system future research should test the effect of feelings of relative disadvantage and deprivation concerning more specific economic and social areas a key area for future research is the transition from vicarious to direct political expressions of political dissent there are circumstances in which anonymous supporters have taken the streets or joined forces with other more traditional social movements and protest groups it could be that support for groups such as anonymous ultimately provides an arena where new politicized social identities may emerge which may in turn promote individuals engagement in protest moreover some antiestablishment politicians such as nigel farage in the uk and donald trump in the us or parties such as the five star movement in italy may harness vicarious dissent to gain consensus indeed such actors often use the rhetoric of rebalancing power from large corporations and big government institutions and putting it back into the hands of the people these are important avenues for future research finally it is important to highlight that although crosssectional data allow testing of theoretically specified relationships among variables causal conclusions cannot be drawn from the data future research should use longitudinal and experimental designs to investigate support for anonymous or other forms of modern social banditry for example future research could manipulate perceived political efficacy and investigate its effect on anger and support for anonymous implications and conclusions this research is the first to investigate vicarious dissent and support for anonymous social psychological work has predominantly focused on engagement in direct forms of political action however disadvantaged and voiceless individuals can use different means for contesting their disadvantage support for social bandits and groups like anonymous might be one such means these groups may provide individuals with the opportunity to express dissent in a vicarious form this research introduces the novel social banditry framework to the social psychological study of political action theories of political action such as system justification or belief in a just world suggest that individuals may accept and justify existing social arrangements social identity theory contends that when individuals perceive intergroup boundaries as stable and legitimate they may avoid direct challenges to the status quo there is indeed plenty of evidence that in some circumstances individuals do justify the system moreover research indicates that perceiving the world as a just place or believing that intergroup boundaries as unchangeable dampen engagement in political action however it does not follow that when individuals are not directly engaged in political action they are supinely accepting their disadvantage even the most severe conditions of powerlessness can be accompanied by silent expressions of resistance to build a better understanding of power relations in society social psychology must make it a priority to investigate those expressions 1 study 1 also included a measure of contempt consistent with the idea that support for anonymous is an expression of anger against the system rather than contempt contempt did not significantly predict attitudes toward anonymous β 08 se 05 p 22 moreover contempt did not predict intentions to take part in noninstitutional political action β 06 se 05 p 41 however in line with previous work it was negatively and significantly associated to psychology 87 649664 doi 101037psychology 87 649664 doi 10 00223514875649 watts m w efficacy trust and commitment to the political process social science quarterly 54 623631 wong w h brown p a ebandits in global activism wikileaks anonymous and the politics of no one perspectives on politics11 10151033 doi 101017s1537592713002806 think of the ladder above as representing where people stand in society at the top of the ladder are the people who are best off those who have the most money most education and the best jobs at the bottom are the people who are worst offwho have the least money least education and the worst jobs or no job the higher up you are on this ladder the closer you are to people at the very top and the lower you are the closer you are to the bottom where would you put yourself on the ladder please select the number below which corresponds to the rung where you think you stand supplementary file sample information

the author thanks clare longhorn for helping preparing the measure for this study and discussing the manuscript with me my thanks also go to the participants at the culture and psychology conference sept 2016 university of kent and to libby drury for her comments and feedback on this work

introduction a historyofever catastrophic flooding occurred in zhengzhou city the capital of henan province and its around areas china on july 20 2021 affecting 150 counties which led to 302 deaths and 50 missing 1 in addition to the loss of lives and properties and physical injuries the natural disasters brought in a huge impact on the mental health of individuals who survived through the disaster when facing an unexpected disaster individuals are susceptible to a series of adverse physical emotional cognitive behavioral reactions these adverse responses are manifested by such as headache insomnia anxiety nervousness fear sadness depression anger irritability inattention memory loss and even life changes in beliefs and personality 2 posttraumatic stress disorders is a common mental health disorder that are associated with traumatic events for example approximately one third individuals had ptsd when they had motor cycle crashes or road traffic crash and this disorder could persist over time 34 a major earthquake disaster occurring in sichuan several years ago led to a high percentage of orphan survivors with ptsd 5 6 7 preventing chronic psychological injury in the early posttrauma period is needed to alleviate or prevent the occurrence of ptsd accumulating evidence suggest that social support plays an important role in the prevention of posttraumatic stress disorders social support may help alleviate jobrelated burnout in professional health workers 89 a negative correlation was observed between the severity of ptsd in individuals living in the disaster area and the overall perception of social support 10 similarly social support was reported to significantly reduce the severity of trauma symptom in patients suffering from rheumatoid arthritis and low back pain 11 several previous studies have shown that personality is associated with the severity of ptsd 1213 individuals with low neuroticism had relatively weaker ptsd than those with high neuroticism when they suffered the same trauma event 12 marked impulsivity aggression and a susceptibility to antisociality and substance abuse was observed in persons who had high negative emotionality and low constraintinhibition when they experienced traumatic events 13 the positive association between personality of neuroticism and ptsd is also validated whereas a negative correlation between extroversion and ptsd exists in the metaanalysis studies 1415 a higher incidence of negative emotions such as anxiety and depression frequently occur during the emergency of major public health issues the higher the degree of anxiety or depression is the greater the perception of stress natural disasters may add additional stress on persons particularly who are in the suffer increasing their anxiety and depression flooding has been shown to significantly increase depression 777 95 confidence interval 1514013 and anxiety in a previous study conducted in england 16 in china an intervention study showed that a systemic planned intervention including planned settlements intensive health service and environmental interventions could significantly reduce depression anxiety and floodingassociated ptsd 17 the flooding disaster recently occurring in henan province has led to the huge loss of lives and properties in the local area attention is worthy of being paid to the mental health of the residents living in the disasteraffected area keeping calm emotion and offering social support to the population are important in helping the individuals to walk out of the disasterinduced psychological injuries yao et al 8 has reported that professional health workers with different personality characteristics had significant performance and different outcomes when they faced jobrelated stress however it is yet to be determined how personality affects the mental health in the residents who experienced catastrophic flooding in henan china the purpose of this study was to analyze the associations between residents traumatic stress disorder social support mental health status and personality type after experiencing the natural disasters this study hypothesized that individuals with different personality had different psychological responses when they faced the natural flooding disaster which occurred in henan china material and methods methods impact of event scalerevised questionnaire to assess the psychological effect of the flooding disaster on the residents in henan province an impact of event scalerevised questionnaire was used to obtain the information on residents response to the traumatic stress this questionnaire in chinese version has a good reliability and validity in evaluating psychological stress in ptsd studies conducted in china 18 the questionnaire is consisted of 3 dimensions of intrusion avoidance and hyperarousal symptoms with a total of 22 items each item is scored using likert 04 grade method from 0 to 4 the total score for each individual is summed up of the score of each item which ranges 088 a higher score indicates that the stress is more severe according to the total score the stress disorder was classified into 023 2432 3336 and 37 the cronbachs α coefficient of the scale in this study was 0962 social support questionnaire the perceived social support scale questionnaire was used to measure the social support that the participants could obtain the psss is a scale measuring social support which is assessed based on the individuals selfunderstanding and selffeeling it measures the degree of social support from such as family friends and others 19 there are 12 items for selfassessment in the questionnaire and each item uses likert 7level scoring method the sum score of each item was calculated for each individual a higher sum score reflects that an individual feels more supports from the society the cronbachs α coefficient of the scale in this study was 0954 mental health status in this study a concise version of the depression anxiety stress scales questionnaire was used to evaluate the mental health status of the participants the questionnaire was compiled by lovibond and lovibond 20 which is composed of 21 items measuring the 3 negative emotional dimensions of depression anxiety and stress among them depression factors are related to pathological dysthymia low selfesteem and lowlevel positive emotions anxiety factors are related to the physical and subjective experience of anxiety arousal and stress factors are related to negative emotions such as stress worry and conflict the scale uses likert 03 grade scoring method scores were determined by summing the individual items and multiplying them by 2 a higher score indicates a stronger negative emotion experience the cronbachs α coefficient of the scale in this study was 0975 eysenck personality questionnairerevised the personality type was determined using the version of the eysenck personality questionnairerevised in chinese which is translated and revised by qian mingyi a professor of psychology at peking university which has been shown with good reliability and validity 21 two dimensions introversionextroversion and neuroticismemotional stability were used to assess the personality type the neuroticismstability scale was for emotional stability when facing negative affect such as depression and anxiety and the introversion and extroversion vector scale for the demand of external stimulation there are a total of 24 items each with a score of either 0 or 1 based on the score cut offs of 433 and 567 for the e and n dimensions respectively 4 personality types were defined stable introvert stable extravert unstable introvert and unstable extravert the cronbachs α coefficient of the epqe and epqn in this study was 0818 0874 statistical analysis all statistical analyses were performed using spss 180 software in this study the numerical variables showed an approximate normal distribution after normality test and m±sd were used to represent its average and standard deviation pearson correlation analysis was performed for the correlation between traumatic stress disorder social support depressionanxietystress and personality characteristics machine learning of generalized linear algorithm was performed using h2oai to analyze the importance of the factors in depressionanxietystress respectively in which the subjects were randomly divided into training and validation datasets the glm was fitted to estimate the set of parameters by maximizing the loglikelihood of the data for the best model the ternary interaction of traumatic stress disorder social support and emotional stability on depressionanxietystress were also examined the difference was considered statistically significant when a p 005 at the 2sided α level results commonmethod variation test the commonmethod variance of variables was first analyzed using harmans single factor method there were 14 factors with eigenvalues 1 and 2819 of the variance was explained by the first factor this result indicates that no severe commonmethod variance exists in this study based on the critical threshold of 40 distribution of traumatic stress disorder social support and depressionanxietystress in the participants table 1 shows the associations of the traumatic stress disorder social support and depressionanxietystress with several analyzed variables in the residents of henan province the individuals who live in the flooding areas had a significantly higher score of traumatic stress disorder than those who do not similarly significantly higher scores of traumatic stress disorder and depressionanxietystress were pronounced in male than female participants there was a significant association between marital status and the scores of traumatic stress disorder measured by iesr and stress measured by dass21 with a higher level in married vs single the differences were significant in the scores of traumatic stress disorder social support and depressionanxietystress among individuals with different personality types further pairwise comparisons showed that the score of traumatic stress disorder measured by iesr was the highest for the individuals with residents with unstable extravert personality followed by unstable introvert stable introvert and stable extravert personality those with stable extravert personality had the highest scores of social support followed by stable introvert unstable extrovert and unstable introvert the individuals with stable extravert personality had the lowest scores of depressionanxietystress followed by stable introvert unstable introvert and unstable extrovert personality to further assess the importance of these factors in depressionanxietystress the generalized linear model algorithm was performed using machine learning in h2o and the results are shown in the figure 1 among the risk factors of depressionanxietystress measured by dass21 the traumatic stress response measured by iesr ranked the first followed by epqn epqe gender age marital status social support and flooding counties the traumatic stress response epqn and age were positively associated with depressionanxietystress while epqe gender marital status social support and flooding counties were negatively associated with depressionanxietystress correlation between traumatic stress response social support neuroticism and depressionanxietystress neuroticism refers that an individual has low emotional stability and strong reaction when facing stress the emotional stability score was used in the neuroticismstability scale as the degree of neuroticism hereafter in the analyses pearson correlation analysis showed that traumatic stress response was significantly negatively correlated with social support while it was significantly positively correlated with depressionanxietystress and neuroticism respectively social support was negatively correlated with depressionanxietystress neuroticism was significantly positively correlated with depressionanxietystress extroversion was significantly positively associated with social support whereas it was significantly correlated with depressionanxietystress and neuroticism interaction of traumatic stress disorder social support and neuroticism in depressionanxietystress table 3 shows the results of the main effect of 3 variables and their interactions in model 1 gender age traumatic stress response social support neuroticism and extroversion were included it showed that 568 of the total variance of depressionanxietystress scores was explained by 6 variables traumatic stress response and neuroticism had a significantly positive association with depressionanxietystress while extroversion and women showed a significantly negative association no significant associations were found for social support and age with depressionanxietystress in the model 2 a 2way interaction term of traumatic stress disorder social support extroversion and neuroticism was added beyond the model 1 the main effects of gender traumatic stress disorder neuroticism and extroversion variables remained significant a significant interaction was observed between traumatic stress disorder with either social support or neuroticism or extroversion however there was no interaction between social support and either neuroticism or extro version and between neuroticism and extroversion in the model 3 a 3variable interaction term was added to the model 2 similarly the main effects of all variables except age and the interaction between traumatic stress disorder and either neuroticism or extroversion remained significant the 3variable interaction term of traumatic stress disorder social support and neuroticism but not traumatic stress disorder social support and extroversion was also significant explaining 14 variance of depressionanxietystress score traumatic stress disorder showed the largest positive main effect on depressionanxietystress to more directly visualize the interaction of traumatic stress disorder social support and neuroticism in depression a 3variable interaction diagram of depression was constructed based on the method described by dawson and richter figure 2 shows that as the traumatic stress response increases the depressionanxietystress of the affected residents gets worse residents with the same level of traumatic stress disorder high social support and low neuroticism had a lower depressionanxietystress score compared to those with low social support and high neuroticism compared with social support neuroticism has a more obvious effect on depressionanxietystress when experiencing high traumatic stress individuals with low neuroticism had a lower depressionanxietystress score than those with high neuroticism discussion this study demonstrated the effect of historyofever catastrophic flooding in henan province on depressionanxietystress in residents with different personality the residents who suffered flooding attack had a significant posttraumatic stress disorder compared to those who did not they had significantly higher depressionanxietystress than those who did not suffer the disaster the findings in this study are in consistent with previous report that natural disasters can lead to a severe impact on peoples psychology mainly manifested as depression stress anxiety and fear 5 a high prevalence of ptsd exists in many orphan survivors after a major earthquake disaster several years ago in sichuan 5 6 7 the risk of depression and anxiety significantly increase in residents who experienced flooding in uk 16 intensive health support could significantly reduce depression anxiety and floodingassociated ptsd 17 these findings suggest that psychological aids are needed to this population who suffered the disaster on time to resolve the ptsd the reason is that if these shortterm model 2 a 2way interaction term of traumatic stress disorder social support extroversion and neuroticism was added beyond the model 1 model 3 a 3variable interaction term was added to the model 2 psychological problems cannot be effectively resolved via all kinds of intervention programs on time longterm mental illnesses will be caused 5 there is a significant gender disparity in the traumatic stress disorder with a higher score in men than in women this finding seems inconsistent with some other studies which reported that women had higher lifetime prevalence of ptsd than men 22 one possibility may be due to the traditional belief that men should take more responsibilities in the family and society and they usually have greater psychological pressure a previous study performed in china also demonstrated that men were more susceptible to psychological problems such as depressionanxietystress after a natural disaster 5 a higher score of traumatic stress disorder and stress was also observed in married individuals compared to those singles in this study married individuals usually have more family responsibility there may have both kids parents and siblings to take care more economic burden on shoulders 23 and will always worry about the safety and situation of family members during emergencies in addition there is a positive correlation between the traumatic stress disorder and depressionanxietystress this finding is in agreement with the previous observation that the traumatic stress burden resulted in uncontrollable worries in individuals and stress could directly trigger negative emotions such as anxiety and depression 24 it has been reported that when facing emergency and stress individuals with different personalities take different actions and have different responses those with stable emotion could calmly challenge the stress and emergency situations displaying less fluctuations in their physiological response under stress and showing strong selfadjustment ability 25 emotional unstable individuals are more likely to be impulsive and anxious than those with stable emotion 26 while extrovert individuals usually have more social networks often participate in group activities and get more social supports from friends and relatives the individuals who are extroverted and stable emotion usually can keep calm in stress or emergency and can deal with various difficulties more rationally in contrast those with instable emotion may have anxiety and stressful feeling under these situations individuals with neuroticism or unstable emotion have higher ptsd compared to those with extrovert and stable emotion 15 it can be found that the interactions existing between traumatic stress disorder social support and neuroticism in depressionanxietystress when they faced the natural disaster when the individuals faced the floodingcaused damage and loss those with high social support and stable emotion had the best mental health status regardless of social support those with stable emotions had better mental health than those with unstable emotion particularly at high ptsd these findings suggest that emotion management and psychological aids may be an important measurement in prevention of ptsd and disasterrelated depressionanxietystress or mental health problems to a certain extent the amount of social support depends on social networks an individual owns personality usually can affect the plenty of social networks those with extrovert and stable emotion may have more social networks and may actively seek help from friends and relatives whereas those with introvert and unstable emotion may be shameful to seek help from others or may have difficulties in making friends thus when they faced the difficulties or the disasterinduced stress individuals with different personalities had different outcomes in mental health the findings in the interaction between traumatic stress disorder social support and personality in mental health are in agreement with the previous observations that extrovert individuals with stable emotion often adopt active coping styles to solve problem and seek help when they encounter difficulties and emergencies and they receive higher social support social support and friendship help play an important role in maintaining the mental health 27 similarly the prevalence of depression increased in the buildingcollapse survivors when they felt desperate with less social supports 28 another nightclub fire disaster study also showed a positive association between negative emotion personality and ptsd 29 thus social support to those who suffer natural disasters on time is an effective measurement to prevent ptsd and improve their mental health making them feel warm from society relatives and friends and fill their heart with full hope of live they are not alone interestingly in this study there is a significant interaction existing between traumatic stress disease social support and neuroticism but not between ptsd social support and extroversion in depressionanxietystress one possibility is the most likely when people face such a large scale natural disaster it is a challenge for everybody no matter how extrovert they are however the disastercausing stress may deteriorate the mental health problem for those neuroticism thus neuroticism individuals should be granted with high priority more social support to prevent mental problem in this study 2 scales of iesr and dass21 were applied to detect psychological disorder for ptsd and depressionanxietystress respectively both iesr and dass21 have been shown suitable for use in clinical and compensation setting to detect ptsd and major depression disorder in a motor vehicle crashes study demonstrating both scales with acceptable sensitivity and specificity in an injured individuals engaged in compensation 3 however 2 scales were applied in this study based on their applications initially designed iesr specifically for ptsd and dass21 for depressionanxietystress respectively the iesr has 3 subscale measurements intrusion avoidance and hyperarousal 30 this scale was used for traumatic stress disorder measurement after the flooding the dass21 assesses 3 dimensions depression anxiety and stress and this scale was used to measure the comprehensive depressionanxietystress interestingly there is a significant interaction existing between neuroticism social support and traumatic stress disorder suggesting that personality could modify the effect of ptsd and social support on depressionanxietystress in the residents living in the flooding area in henan china some limitations exist in this study first the crosssection study design was applied for the survey and it is a time point snapshot for all variables thus it could not be infered a causal relationship except the association which may be accompanied only a longitudinal or intervention study may help to address the causal inference secondly the participants voluntarily signed in to fill the online questionnaires the selection of subjects may have a bias eg women are far more than men in the number and the samples may not well represent the population moreover although 2 different psychological stress questionnaires were used and could not be clearly dissected each other however one of the strengths of this study is that the sample size is relatively large in addition this study was conducted immediately after the flooding and it may limit some recall bias and different intervention measurement effects in the survey conclusions in summary this study demonstrated the effect of traumatic stress disorder social support and personality on their interactions in the mental health of the residents in henan province where recently suffered a historyofever flooding it showed that personality modified the effect of traumatic stress disorder and social support on mental health individuals who have stable emotion had a better mental health compared to those who have unstable emotion even when they are at the same level of traumatic stress disorder these findings suggest that personality consideration may be helpful in improvement of mental health after the disaster when psychological aids and social support reach out however further followup studies are warranted to investigate the effect of different strategies or measurements on the prevention of posttraumatic stress disorder

to analyze the impact of the flood disasters social support and personality on the mental health of residents in henan province china providing fundamental knowledges for making measuring strategies to improve the psychological protection and antistress ability of the residents after the disaster material and methods a crosssection study was conducted via an online survey platform questionnaire star which included 572 residents in henan province which underwent the history of ever flood disaster on july 20 the questionnaires of impact of event scalerevised edition iesr perceived social support scale psss the depression anxiety stress scales dass21 and the scales of eysenck personality questionnairerevised epqr version in chinese were also administered to each participant generalized linear regression model was performed results the residents who live in the flooding areas are male and married had a significantly higher posttraumatic stress disorder ptsd score than their counterparts the scores of depressionanxietystress in the residents with stable emotion were significantly lower than those with unstable emotion p 0001 machine learning showed that ptsd ranked the top risk factor followed by neuroticism for depressionanxietystress after disaster the ptsd was negatively correlated with social support p 001 while it was positively correlated with depressionanxietystress and emotional stability p 001 there was a statistically significant interaction between ptsd social support and neuroticism on depressionanxietystress p 0001 with an independent effect of 14 on depressionanxietystress emotional stability showed the largest association with depressionanxietystress conclusions residents living in the catastrophic flooding areas had significant posttraumatic mental health issues and the severity of mental problems was differently affected by posttraumatic stress disorder and social support in individuals with different personalities introvert and ptsd were the major risk factors for depressionanxietystress after the disaster

introduction after initiating a couple of decades ago the percentage of transnational marriages reached the highest percentage at 307 in 2005 although there has been a decrease it is still at about 10 of the total number of marriages in south korea where the current intervention study was conducted 1 recently international marriage had increased in particular korean males who have difficulties in finding their spouses domestically tend to marry foreign females mostly from southeast asia including vietnam cambodia and uzbekistan as developing countries 2 korea traditionally had homogeneous culture and race 3 compared to other countries such as usa canada and australia ethnic diversity in south korea has not existed long enough to accommodate other cultures easily 4 thus there might be difficulties in accepting other culture among korean multicultural families whose family members have different nationalities a study of korean mothersinlaw showed that only 11 of them accepted their foreign daughtersinlaws culture 5 taking into account trends of international marriage in korea 2 multicultural families in the current study refers to as families with korean husbands and foreign spouses and mothersinlaw in multicultural families meant korean mothers on the husbands side different from usa australia and european countries the married couple a korean husband and a foreign wife are more likely to live in together with the korean males parents multicultural families with korean males and foreign females are five times more likely to live with mothersinlaw at 75 than domestic families at 141 67 similarly in the south asian cultural context if a mother becomes a widow she is likely to cohabit with their married son 8 as korean culture is different from southeast asian culture 9 mothersinlaw of foreign female partners in multicultural families tend to take the role of introducing korean culture and courtesies including table manners 7 specifically although both korea and vietnam one of the most common countries foreign daughtersinlaw are from have a confucian background there are differences in language cuisine and culture including uncertainty avoidance and longterm orientation 10 for example koreans seem to be rigid and intolerant of unwonted or unexpected behaviours or opinions on the other hand vietnamese tend to be more laidback and flexible towards rules 11 as seen in the previous literature 12 the elderly mothersinlaw experienced stress due to a burden of supporting their sons family and the differences in culture from vietnamese daughtersinlaw meanwhile mothersinlaw might have psychological stress due to communication difficulties at more than 30 and cultural differences at slightly under 15 13 moreover they might be concerned that their foreign daughtersinlaw could be running away from their sons and the couples grandchildren be left behind and afraid of blame from their son or others for conflicts with their daughtersinlaw 14 thus mothersinlaw of multicultural families may be perceived as three times more stressful than others 7 exposure to negative stress and failure of coping strategies can lead to depression loss of meaning of life demotivation and impairment of quality of life 15 compared to 20 of older adults who generally experience depression 16 mothersinlaw reported depression up to at 84 including 75 with a high level of depression 56 accordingly they perceive their qol impaired 14 according to lazarus 15 stressed out individuals tend to perform cognitive appraisal consciously or unconsciously in order to minimise physical andor mental harm by stress if an individual perceives stress as a threat or realises their absence of stress coping strategies the level of stress can be more negatively appraised than the actual stress level a negative appraisal can lead to physiological changes such as an increase of blood pressure and heart rate acceleration and can interfere with adaptation to stress repeated negative selfassessment can even cause physical illness anxiety depression impaired qol and social dysfunction on the other hand a resilient response to stress can lead to flexible coping strategies in various situations 1718 resilient cognitive appraisal can improve understanding of actions and emotions under stressful situations acceptability of others acceptance of diversity amicable relationships with others belief and acceptance of life and optimism for the future 19 20 21 furthermore it can lead to decreases of cholesterol anxiety stress depression and increases of belief and acceptance of life and satisfaction 22 23 24 25 resilience programs help in building psychological flexibility and relaxation 22 and in enhancing the individuals inner strength so as to adapt to stressors 26 in most of the previous literature resilience programs aimed at promoting resilience to negative stress for children 27 college students 2024 employees 22 and patients 2526 a resilience program for oncologyhaematology nurses in the previous study found to be ineffective for improving their stress management and qol in the shortterm and longterm points of view 28 however a resilience program for farmers showed significant effects on their qol 29 although resilience is manifested throughout the individuals whole life including older adult life and is capable of being learned 30 there is scant literature about subjects in old age particularly in south korea in addition there is a need for developing interventions for cultural adaptation stress depression and qol in korean mothersinlaw of multicultural families which have been rarely developed and applied while foreign daughtersinlaw could be wellsupported by programs or activities from multicultural family centres improving resilience of mothersinlaw who have been accustomed to rigid homogenous culture would be helpful for accepting the foreign culture and different lifestyle of their daughtersinlaw in the globalised era therefore considering the need from the previous literature this study aimed to develop and implement the cultural adaptation promotion resilience program for mothersinlaw in multicultural families and to verify its effects on resilience acculturation stress depression and qol among mothersinlaw in multicultural families comparing with the control group methods study design a nonequivalent control group preposttest design was adopted for evaluating effects of the cultural adaptation promotion resilience program for mothersinlaw in multicultural families both groups completed preand posttest questionnaires but the intervention group participated in the caprp after completion of the study the control group was provided an alternative program only one threehour session as needed the study design is presented in fig 1 study subjects participants were recruited from multicultural family support centres in the metropolitan city a a list of nine multicultural centres in the metropolitan city a was found and two centres accepted to participate in the study after the first author either phoned or visited the centres to explain the studys process the intervention group was randomly chosen from either c or d centres by picking out one piece of paper from an opaque box twentyfour participants from the c centre who consented and were enrolled to the study considered to be in the intervention group while 25 from the d centre to be in the control group inclusion criteria were participants who were 1 korean mothersinlaw living with her foreign daughterinlaw more than six months 2 providing consent to participate in this study 3 without mental or cognitive impairment 4 able to understand and answer questions in korean and 5 without any hearing impairment the sample size of the study was calculated in consultation with a health statistician based on the previous studies 31 32 33 the g � power 312 program was used for calculation at the two independent group ttest at a power of 080 a twotailed significant level of 05 and the effect size of 080 based on the previous research in resilience programs for families of patients with chronic schizophrenia 33 for family caregivers of the elderly with dementia 31 and for traumaexposed refugees 34 a sample size of 21 participants in each group was required taking into account a dropout rate of 10 a total of 50 eligible participants were invited in the intervention group and the control group among 25 invitees in each group 21 participants in the intervention group enrolled for the program after three dropped out due to no show at the first day of the program of the 25 invitees 22 participants in the control group agreed to take part in this study at the followup 21 participants from each group completed the entire study after one in the control group dropped out instruments the questionnaires of the study consisted of sociodemographic characteristics 5 resilience 35 acculturation stress 36 depression 37 and qol 38 appropriate permissions from developers of each instrument were received sociodemographic characteristics the sociodemographic characteristics of participants in this study included age marital status education level and religion their perceived economic level health state and satisfaction of family support was answered on a fivepoint likert scale information of whether they have any disease was also asked as well as disability due to disease on a threepoint likert scale questions about their daughtersinlaw included the country which their daughtersinlaw were from duration of living with them perceived daughtersinlaws korean level on a fivepoint likert scale satisfaction with the relationships with daughtersinlaw on a fivepoint likert scale and ethnocentrism asking if their daughtersinlaw should fully adapt korean culture regardless of their original culture on a threepoint likert scale resilience the resilience scale14 developed by wagnild young 35 was used for assessing resilience of mothersinlaw in multicultural families this instrument consisted of 14 items which can be divided into two dimensionspersonal competence and acceptance of self and life each item is scored on a sevenpoint likert scale ranging from 1 to 7 a range of the total score is between 14 and 98 higher scores indicating higher resilience subcategories can be referred to as very low low moderately low moderately high high very high the cronbachs α was 93 when developed and 91 for the current study acculturation stress acculturation stress of mothersinlaw in multicultural families was measured with a scale developed by chung park 36 this instrument includes 11 items which can be divided into three domainsperception of prejudice and discrimination cultural conflicts discomfort with daily life each item is scored on a fivepoint likert scale ranging from strongly disagree to strongly agree a range of the total score is between 5 and 55 higher scores indicating higher acculturation stress the cronbachs α was 86 when developed and 94 for the current study depression depression of mothersinlaw in multicultural families was measured by the 30item geriatric depression scale short formkorean version which kee 37 standardised and modified for korean older adults this instrument consists of 10 positive items and five negative items which are answered by yes scored 0 or no scored 1 a range of the total score is between 0 and 15 higher scores indicating higher depression the cronbachs α was 88 when developed and 79 for the current study quality of life the korean version of who quality of life scale abbreviated version by min et al 38 was used to measure qol of mothersinlaw in multicultural families this instrument contains 24 items which can be grouped into physical health psychological social relationship and environmental domains as well as two additional items about general qol and general health perception each item is answered by a fivepoint likert scale from 1 to 5 the range of the total score is between 26 and 130 higher scores indicating higher qol min et al 38 reported cronbachs α as 89 and the value of cronbachs α was 94 for the current study the cultural adaptation promotion resilience program preparation for conducting the program the caprp program was developed by the first author for mothersinlaw in multicultural families in this study and provided by the first author and an assistant researcher after appropriate training for preparing for implementation of the program the first author had completed several programs of art counselling psychology positive psychology resilience coaching narratives motivation counselling and built experiences in developing and conducting a strengthfocused resilience promotion program for older women in addition the first author tried to expand her expertise through attending various conferences and workshops related to psychology two assistant researchers were prepared for data collection by the first author for consistency development process and implementation of the program goals components contents activities and the number of sessions of the program were formulated after relevant literature review 30313940 professionals majored in geriatric nursing psychiatric nursing and psychiatry as well as doctors of positive psychology and resilience in older adults amended strategies then approved validity previous literature revealed that major stressors of mothersinlaw in multicultural families were differences in culture and lifestyle from their foreign daughtersinlaw and that they have somatic symptoms severe depression impaired qol enhanced by passive and negative coping strategies the final goals of the program thus are improvement in cultural adaptation resilience a decrease of cultural adaptation stress a decrease of depression and an increase of qol based on the seven components of resilience a goal for each session was selfopening causal analysis impulse control emotion regulation empathy sense of optimism and utilisation of strengths the contents and other details of the program are presented on table 1 the caprp in this study was implemented twice per week for four weeks 60 minutes per session for a total of seven sessions the program was provided to 21 participants in the intervention group by the first author of the present study with the help of a pretrained assistant an education room in the multicultural centres was selected considering the participants might be vulnerable so that the participants was able to feel comfortable and free to share their thoughts the venue was equipped with internet and a beam projector used for presenting various examples of multiculturalism data collection process data were collected from january 04 2016 to march 04 2016 by two trained research assistants to avoid researcher bias on the first day of the program three of the enrolled participants in the intervention group were noshows and 21 participants completed the baseline questionnaires and took part in the program in the control group 22 participants attended to answer the baseline questionnaires one participant in the control group dropped out at the followup a total of 42 participants were included in and completed the study a week after completion of the program both participants in the intervention group and the control group were asked to answer followup questionnaires ethical considerations an ethics approval from the institutional review board of the related university was obtained two research assistants explained the purposes of this study its procedure voluntary participation confidentiality and privacy then the written informed consent was obtained from all participants incentives for participation were provided with the equivalent of transport fares data analysis the collected data were analysed using the spsswin 230 program the homogeneity of the two groups was analysed with descriptive statistics chisquare test fishers exact test and ttest the effects of the program were examined by ttest after a normality test of the dependent variable and the effect size of the caprp was calculated and presented with cohens d 95 results participant characteristics and homogeneity table 2 presents the homogeneity of general characteristics for two groups which were not significantly different age range of the participants in this study was from 62 to 79 years old with the mean age of 6848±409 in the intervention group and 7010±506 in the control group among the participants 476 of the intervention group and 619 of the control group were satisfied with the relationship with their daughterinlaw a majority of participants in both groups905 of the intervention group and 809 of the control groupresponded that their daughtersinlaw should follow the korean culture looking at table 3 there were no significant differences in scores of baseline questionnaires about resilience acculturation stress depression and qol between the two groups effects of the caprp the intervention group showed a significant decrease in acculturation stress and depression while resilience and qol significantly increased compared to the control group table 4 presents differences in resilience stress and qol of the intervention group and the control group discussion the current study assessed the effects of the sevensession caprp on mothersinlaw in multicultural families the main findings of the current study showed that the caprp was effective on improving their resilience and qol whereas acculturation stress and depression was diminished it was difficult to compare the results of this study to the previous research because of the scarce research regarding resilience programs for older females including mothersinlaw conversion scores were used in the discussion due to differences of instruments in the previous literature the participants in the current study scored resilience as 44 this was similar to the study conducted by kim na 41 the subjects in this study were community dwellers with schizophrenia who have judgement and perception of reality and reported with the mean score 43 on the other hand patients with neurofibromatosis 25 patients with breast cancer 26 and indonesian elders who experienced tsunami 19 were more likely to score higher at 49 52 and 61 respectively than participants in the current study the subjects in the studies by vranceanu et al 25 and loprinzi et al 26 were capable of utilising information about their illness whereas the subjects in the study by kim na 41 showed a difficulty in perception under a stressful situation seemingly the participants in this study had lower resilience than those in previous studies because they lacked perception of and information about multiculturalism in a single culture society in addition not only had they difficulties in daily communication but also insufficient support and coping resources the 5point converted score of acculturation stress was 29 among mothersinlaw in multicultural families in this study this score was similar to the score 28 of chinese international students in south korea 42 while it was slightly lower than the score 31 of female marriage migrants 43 the experiences of the participants in the current study were close to those in the previous studies the chinese international students expressed such difficulties as feeling alone being sick and not knowing what to do 42 the marriage migrants showed emotional restraint due to a different cultural point of view 43 it can be assumed that they might be more stressed out than the international students or the mothersinlaw requiring multiple roles as a wife a daughterinlaw and a mother as well as acculturation as a result of the caprp the 5point converted score of acculturation stress decreased by 23 among the mothersinlaw in multicultural families who used to restrain their emotions in a patriarchal society participating in the program they learned how to express their emotions in a positive way throughout the activities such as drawing a person that everybody knows drawing a mandala and tearing a piece of paper it was considered that the time when they appreciated each others drawings might help them understand various points of view park park 42 applied cognitive art therapy including drawing and making a story board to the chinese international students who had difficulties in verbal communication resulting in a decrease by 24 of acculturation stress yang lee 43 applied collage group art therapy to the migrant women to help them in recognising their emotions and finding their strengths resulting in a decrease by 20 of acculturation stress the programs in these previous studies were similar to that in the current study where participants who had difficulties in verbal expression learned to convey their emotions by drawing activities and spontaneously understood others without blame the 15point converted score of depression was 53 showing a decrease to 30 after the caprp among mothersinlaw in multicultural families in this study this score was higher than older adults living at home who scored 18 44 on the contrary the score in the current study was lower than patients with neurofibromatosis scoring 84 and 76 after the program 25 and with older adults from older citizens public centres scoring 97 and 90 after the related program 45 compared to previous studies the change in depression in the current study was substantial it might be due to the fact that the caprp enhanced selfperception with causal analysis and acceptability of different cultures provided enough time for sharing their experiences with the others who were placed in a similar situation vranceanu et al 25 included a problembased approach for understanding the illness in part of their program however the program mainly contained emotional coping strategies such as meditation and imagination lee park 45 included in their program notions causes and 11 coping strategies for stress depression and somatisation the program ran for five weeks for an hour each week which might be insufficient for getting acquainted with the information after the caprp the 5point converted score of qol increased from 29 to 37 among the mothersinlaw in multicultural families the results of the current study were similar to those of a study comparing a positive psychotherapy program with a cognitive behaviour therapy program among depressed older adults 46 the participants in this study showed a 30 level of qol at baseline in both groups the character strengthsbased positive psychotherapy improved qol to 36 while the cognitive behaviour therapy only increased qol to 31 46 similar to the previous studies 2346 the program in this study applied coping strategies such as developing optimism building positive relationships and recognising strengths after identifying negative emotions under stressful circumstances in addition to this feature the program also attempted to change circumstantial factors by exposing the participants to positive experiences or positive emotions right after negative experiences prior to dealing with the culture of their daughterinlaw as a result of these efforts the caprp was effective in improving participants resilience and qol despite the relatively short research period and the participants lower level of demographic characteristics than that of previous studies there are several limitations to the present study as follows firstly the mothersinlaw in multicultural families who participated in the current study were unable to take part in this study for a longer period because they had to spend much time with house chores and rearing their grandchildren it is suggested to examine the longterm effectiveness of the program in the future studies secondly comparison with previous studies was limited because there were no previous resilience programs for mothersinlaw in multicultural families further studies applying the caprp program with larger sample sizes would be recommended to examine effects of the intervention thirdly the control group did not receive any treatment so it can be recommended to compare the caprp program with other treatments or regular programs for the seniors in addition the effect of a program may decrease over time 47 thus a regular cognitive behaviour training program would be suggested for enhancing or maintaining their resilience fourthly we only included mothersinlaw in the program and did not include much information about daughtersinlaws characteristics such as age children in the current marriage and ruralurban residence before immigration to korea it is recommended to develop an integrated program for promoting cultural adaptation of both mothers and daughtersinlaw in multicultural families together taking into account daughtersinlaws individual characteristics lastly the nationalities of the daughtersinlaw of the intervention group were vietnam at 90 whereas those of them of the control group were at 69 due to random allocation considering the results of the present study a cautious interpretation is needed future studies on effects of the program for different mothersinlaw who have daughtersinlaw from various countries would be recommended in spite of these limitations the current study has a few strengths to our knowledge this caprp is the first program for cultural adaptation of older females that is mothersinlaw previous programs for the elderly were mostly focusing on their depressive symptoms 32 recently a leisure program 48 or a mourning program using art therapy was applied 49 on the other hand the caprp could enhance participants psychological strength comprehensively based on the lazarus compared to other programs dealing with only limited aspects considering that the communication problem was one of the most important issues for them the program contained sessions for improving communication skills it also helped to build on their empathy with their daughtersinlaw from different culture by watching videos about multicultural families particularly about foreign female migrants and writing cards to their daughtersinlaw based on a thorough literature review of previous domestic and international studies the components of resilience among mothersinlaw in multicultural families were identified as selfopening causal analysis impulse control emotion regulation empathy sense of optimism and utilising of strengths this finding can be applied when developing resiliencerelated education programs for those with similar characteristics additionally the caprp was effective for decreasing stress and depression as well as increasing qol thus it can be utilised for intervening in situations of stress depression and qol of the older members of the community given the fact that the numbers of the older population and migrants are expected to continuously increase until 2040 50 the program mostly adopted visual aids as educational materials in order to minimise the limitation of literacy compared to the previous resilience promotion programs for people without cognitive impairment and illiteracy further the caprp could be applied to older females in other countries whose culture might be as rigid as korea to help them become accustomed to different heritage values or lifestyle the program may also be applied to where there is a huge generation gap in any society all relevant data are within the manuscript writing review editing sanghwa lee donghee kim kyoungrim kang

mothersinlaw in multicultural families tend to experience psychological burden this study aimed to verify the effects of the cultural adaptation promotion resilience program caprp on resilience acculturation stress depression and quality of life among mothersinlaw in multicultural families fortytwo participants from multicultural family support centres in the metropolitan city a were assigned to either the intervention group or the control group the caprp was performed for 60 minutes twice a week for four weeks the intervention group showed a significant decrease in the acculturation stress p 002 and depression p 006 while resilience p 001 and quality of life p 001 significantly increased compared to the control group the intervention group reported significant improvements in resilience acculturation stress depression and quality of life in comparison with the control group the results indicated that the caprp developed based on positive cognitive appraisal was an efficient nursing intervention for mothersinlaw in multicultural families

background a clinical study is an investigation that uses human subjects to contribute to knowledge that can be applied to benefit society clinical studies typically evaluate an intervention that is applied to study subjects the intervention might be a drug vaccine or therapeutic or surgical procedure 1 clinical studies are indispensable for the progress of medicine especially for the discovery of new pharmaceuticals 2 however the use of human subjects in these studies as a unit of analysis introduces certain challenges 3 in the past study participants have suffered from the experiments that they were subjected to one example is the experiments that were performed on prisoners during world war ii 4 which generated a series of tragedies that are still remembered today those experiments violated the ethical rules that are currently applied to clinical studies 56 past violations have contributed to the development of mechanisms to protect human subjects 7 the scientific community was made aware of these violations and various regulations have been elaborated to protect human rights and the integrity and dignity of individuals participating in biomedical research 8 however the unethical studies of the past have left a strong impression and are still referenced in developing countries in brazil the general perception is that the risks to study subjects are greater than the benefits and the term human guinea pig is commonly used to describe clinical study participants 9 the basic principles of bioethics 10 may be violated in clinical studies on human subjects in such developing countries as brazil and may be a source of bias within the study 11 the characteristics of study populations from these countries such as poverty illiteracy lack of education and lack of availabilityaccess to health care may create inherent bias in addition several authors warn that populations in developing countries require special protection due to these factors 12 these study subjects may not understand the study process or may participate in clinical studies because they do not have access to medical care other authors have noted that these study participants are more susceptible to coercion and may more easily become volunteers in clinical studies 13 fortunately it is clear that there has been increased emphasis on bioethics in brazil in relationship to clinical studies of human subjects the clinical study regulation was created under resolution 19696 of the national health council of the health ministry as a result the ethical evaluation process that a clinical study must pass is sufficiently rigorous and is in accordance with national laws 14 in addition to the bioethics evaluation performed by the ethics in research committee of the study institution international studies must also receive consent from the national commission of ethics in research of the national health council and the national sanitary monitoring agency 5 all subjects receive an informed consent statement this document explains in accessible language the research details to ensure that that the subject understands the procedures risks discomforts benefits and rights involved and makes an autonomous decision 1516 despite the rigor of these interventions the idea persists that study subjects in brazil participate in clinical studies for the wrong reasons 9 the objective of the present study is to identify the specific motivators that inspire brazilian volunteers to participate in clinical studies and to describe the demographic profile of these study subjects in addition we will evaluate whether the motivations are in accordance with established ethical and legal principles methods rationale for the choice of methodology a multimethods study 17 with qualitative and quantitative phases was used qualitative methods were used to identify the motivations for study participation focusing on interviewees perception and behaviors 18 quantitative analyzes were used to compare the motivators for research participation between groups and the variables that are associated with this motivation recruitment of the participants a convenience sample was used three clinical research centers that conduct phase i and phase iii studies provided the records of subject participants one center was in são paulo another was in campinas and the third was in goiania in brazil there are few phase i studies therefore we considered bioequivalence studies which use healthy volunteers to compare the bioavailability of a generic medicine to a reference medicine to be phase i studies the participants were selected from 10 lists with a total of 500 volunteers each and were contacted by telephone for a personal interview in the federal university of são paulo these lists were composed of volunteers who participated in previous studies when they left permission to be contacted for future studies they included the names of participants of studies conducted by the centers for the two years previously the participation rate was 89 in total 90 participants were contacted and 80 agreed to participate the 10 refusals to participate included 4 men and 6 women from the 3 centers procedure for translating the data the interviews were conducted in portuguese being recorded and later on transcribed and analyzed the final result was translated into english by aje a site of experts from the scientific community with expertise in the two languages the quotes were back translated in order to ensure the fidelity of the interviewees statements sample size the sample was composed of 80 volunteers who had participated in at least one phase i or phase iii clinical study the sample size was limited by the qualitative indepth interview furthermore this pilot study was not intended to be representative of the entire population of study participants rather this study was designed to identify the main motivations that lead to clinical study participation and whether these motivators differ by research phase to share knowledge about the study the ki introduced the theme of the research noting the peculiarities of the participants 19 a total of ten kis were interviewed three were principle investigators from the study centers two were clinical study center coordinators one was a representative of the brazilian society of clinical study professionals one was a representative of the brazilian association of clinical study representative organizations one was a regional director of clinical operations of the pharmaceutical industry and two were doctors responsible for conducting the studies in public and private reference hospitals the interviews with the kis were unstructured conversational interviews 2021 they were recorded transcribed analyzed and provided information that could be used to develop interview questions for the clinical study subjects and to aid in understanding the discussions of the interviewed individuals 19 these interviews allowed for comparative analysis of the motivations for participation in research studies according to subjects and kis data collection instrument the categories that emerged from the discussion with the kis were used to describe the study subject volunteer profile and topics in the survey script this survey script included sociodemographic data type of clinical study the involved pathology and location the number of times that the volunteer participated in clinical studies the motivation for participation information concerning the ics compensation received for participation and recruiting vehicles socioeconomic class was measured using the abep scale which takes into consideration the education level of the head of the household and ownership of assets 22 this scale was used to sort participants into standardized subgroups labeled from a to e where a was the highest economic strata mean family income at the elevel of the abep index is very low whereas a dlevel family enjoys a mfi value roughly 15 times the elevel mfi the clevel mfi is roughly 23 times the elevel value alevel and blevel is approximately 27 times and 9 times the elevel mfi value respectively the anonymous interviews were semistructured indepth conversations that were recorded with the consent of the respondent the interviews were approximately 40 minutes in duration and the participants were compensated r 2000 upon completion of the interview analysis of the results qualitative analysis of the interviews after transcription the interviews were submitted for content analysis as proposed by taylor and bogdan 23 and bardin 24 in accordance with the following steps initial reading the initial reading allowed for the formation of general impressions preparation of the material the material was prepared by separating and categorizing the responses according to topic this material gave rise to independent archives for each script item age gender education level motivation for participation study type number of times the individual participated in clinical studies method of recruitment compensation for participation understanding of the ics and socioeconomic class each item included 80 responses that correspond to each sample constituent with this information the categories were constructed treatment of the results the frequencies were calculated allowing for interpretation in the present study the triangulation technique was used 19 each interview was coded by more than one researcher to ensure the consistency of interpretations and increase the reliability of the categories excerpts from the interviews with kis and study subjects appear in italics in the results statistical analysis hypothesis tests were conducted for each of the script variables to compare the characteristics and motivations of phase i and phase iii study subjects after codifying the answers from the qualitative phase each theme was analyzed to generate up to 5 response categories these variables were tested for the homogeneity of the distribution of responses across categories the students ttest was used to evaluate average age study phase and research motivation the pearsons chisquare test or the fishers exact test was used for the categorical variables a significance level of 5 was adopted and stata version 11 software was used to perform the analyses ethics the protocol was reviewed and approved by the universidade federal de são paulo research ethics committee with provisions for participants to participate anonymously to decline to participate to leave questions unanswered and that they could interrupt their participation at any time according to the declaration of helsinki no one of the researchers occupy dual role results there was a predominance of women among the respondents table 1 shows that the majority completed high school or college were less than 50 years of age were in either socioeconomic class b or c and had participated in only one clinical study analysis of the interview motivation to participate content analysis of the interviews identified motivating factors for participation in clinical studies figure 1 lists the main motivation for participation categories that emerged from the discussions with the kis and study subjects both groups identified the therapeutic option and financial compensation as key motivators suggesting that the kis understood the motivations of the volunteers therapeutic option key informants opinion of the kis versus the study subjects according to the kis the therapeutic option to have access to a new treatment and the hope that this new drug can produce an improvement is a motivator to engage in clinical studies for potential experimental treatments the discussions with the kis in the following transcripts reveal the opinions of these professionals the group of patients because they already have the illness is always searching for something better a new treatment they submit themselves to the collateral effects of the medication to try a new medication ie for cancer others opt to participate in the study because they do not have another therapeutic option these cases are more common in oncology and rare illnesses with few conventional treatment options study subjects motivation for participating in a clinical study according to study participants according to study subjects the therapeutic option is a strong motivator to enroll in a clinical study the potential benefit of a new medication was the most cited motivator however it is worth noting that this motivator is restricted to those volunteers with some type of pathology the following excerpt is from an interview with a study participant motivation it was for the benefit itself because it was a problem that i have i thought lets do it financial compensation key informants according to the kis financial compensation influences a volunteers decision to participate in a clinical study especially among healthy volunteers although the brazilian legislation only allows for compensation for time spent in the study this remuneration is often attractive to a portion of the participants i believe that the healthy volunteers in phase i studies and in some other situations are motivated by a financial compensation although in accordance with resolution 196 we cannot pay a study subject in brazil but in some way this compensation is the greatest motivation to participate in the study there is a camouflaged payment compensation for the workloss day but many times it is much higher that the workday compensation study subjects healthy volunteers identified compensation as the principal motivation for participation in a study the majority of volunteers did not want to reveal the amount that they received for participating in these studies it is not the first time that i have participated they pay well and i have confidence in the place and it is good because they do several examinations and i a find out about how my health is access to healthcare key informants according to kis many study subjects enter clinical studies because they believe that they will have improved access to health care and better quality of care the subjects believe that they will be better able to check up on their health and will be able to avoid the time that they would spend in the public health sector moreover the ability to call a study physician at any time is attractive to these patients in general the people who participate of clinical studies participate in research projects because they receive excellent attention and a healthcare option that is frequently better than the healthcare medical plans the patient feels truly taken care of this is very difficult for me to assume but it is what happens the easiness in the attendance the patients undergo examinations they are taken care of with a special attention by the doctor the kis mentioned access to healthcare as one of the main reasons for engaging in a clinical trial however the clinical trial participants did not evaluate it the same way they acknowledge access to healthcare as a benefit but secondarily to other reasons that they consider more important for participating in a clinical trial such as financial advantage or therapeutic option altruism key informants the kis believed that a small portion of the study subjects altruistically engage in these studies to improve the lives of others i believe that there is an emotional component to this condition that emerges for example a father that volunteers for an aids vaccine because he lost a child to the disease study subjects some of the respondents mentioned the possibility of helping other people as a motivator for participating but always as secondary motivation it was to improve my knee and also to help in the study first because i have arthritis and my healthcare plan was very bad and second because i am helping the researcher and who knows maybe humanity other motivations key informants the kis also commented that the possibility for volunteers to make friends with people of a similar age and health status might lead them to participate experiences they talked and they started to meet outside of the clinic the possibility of receiving the test medication for the entire illness period even after completing the study was another motivation that was mentioned by the kis study subjects few study subjects cited motivations other than a new therapeutic option and financial compensation however some added additional motivators such as the recommendation of their personal physician to participate in the study i wanted to try another treatment the ones that i had tried had no effect that was when my doctor said that there might be a good opportunity for me to participate in a study for a new arthritis medication informed consent statement all the interviewed subjects declared that they had read and understood the ics they also reported that when they were unsure that there was a professional available to help them however when asked if they could remember the principal points of the ics a number of participants did not remember any of the content among those that remembered some parts of the ics none mentioned the potential risks of the study in which they participated that i could quit whenever i wanted to and that i could speak with a doctor at any time i could stop when i wanted to that i would take laboratory medicine with a name that i cant remember i had to do the exercises correctly i gone through the entire interview i did all the examinations but i do not remember what was written i enrolled with the desire to resolve this health problem results of the statistical analysis table 2 shows that participants in different types of studies have different motivations to participate for example 947 of respondents that were motivated by financial compensation were phase i study subjects conversely 100 of the respondents who were searching for a therapeutic option were phase iii study subjects other motivations such as altruism and access to the healthcare were mentioned but were not the main motivators only 4 of participants alleged that these were the principal motivators the average age of participants was significantly different depending on the phase of the clinical study those that participated in phase i studies were younger than participants in phase iii studies the average age varied by study purpose the bioequivalence and medication studies had the youngest average ages in this case all were phase i study subjects most of the volunteers from both phases belonged to class c however the proportion of class d and e subjects varied according to study phase only 25 of participants from phase i clinical studies belonged to the classes d and e none of the respondents belonged to class a no statistically significant differences in the proportions of men to women when stratifying for study purpose or research phase in addition there were no differences in social class or education level when stratified by motivation for entering the study discussion developing nations are participating in multicenter clinical studies at increasing rates this participation is due to the reduced operational costs ease of recruiting study subjects ability to conduct research and regulatory capacity of these countries 26 according to several authors this shift is primarily due to economic considerations 2027 suggesting that volunteers for clinical studies in developing countries are guinea pigs 9 therefore there should be heightened concern for the ethical requirements to conduct a clinical study in these areas 21 further innovation in the pharmaceutical field requires these countries to be able to conduct clinical studies ethically it is essential for international studies to be conducted in brazil to advance the body of knowledge 2 despite advances in legislation and in professional development in this field brazil is far from being considered a major research center the idea that brazilian research participants are guinea pigs is not justified brazil conducts only 18 of total global clinical studies in contrast the united states performs the majority of clinical studies 543 of global clinical studies are conducted in the us 25 these numbers demonstrate that brazil is still not an important clinical research center despite having characteristics that would be conducive for performing studies therefore it is inappropriate to accuse brazil of being the supplier of guinea pigs for clinical studies 9 however this finding should not decrease the focus on ethical concerns for clinical studies these advances must be made rationally and should avoid unfounded critiques and prejudices of emerging countries altruism should be the main reason for a subjects decision to participate in a research study 28 ideally the volunteer is capable of making decisions based on the information provided about the proposed study and understands the purpose risks benefits alternatives and requirements of the study after receiving this information the volunteer is able to decide to participate free from coercion or improper influences 28 however there is concern that the benefits may interfere with the study subjects evaluation of the risks 21 the results of the present study although preliminary show that health and financial benefits are the primary motivators for respondents to become study subjects individuals from higher socioeconomic classes were more likely to cite altruism as a secondary motivator after economic advantage or therapeutic option the same motivations were also identified by the kis although several authors insist that these motivators are more common in developing countries 21 studies demonstrate that they are found in study subjects throughout the world 2930 in a review by stunkel and grady 29 12 of 13 studies showed that financial motivation was the main reason to participate in studies one volunteer from these studies comments nobody is robin hood to make the good for the society in the studies where the participants affirmed that compensation was the main motivator no participants refused payment 31 in a study of the motivations for healthy subjects to participate in research vrhovac et al 32 found that almost 80 reported compensation as the primary motivator however in that study 206 of the volunteers denied that the money was the principal reason and identified humanitarian motivations and the desire to contribute to society the key informants for the present study also mentioned altruism however it was only mentioned in exceptional situations alternatively there are study subjects that believe that compensation should be commensurate with the risks of the study and that compensation should be increased for invasive procedures such as drawing blood 33 almeida et al 34 found that volunteers with low education and low socioeconomic status were more likely to cite financial motivations to participate in a clinical study in this study we did not find this association there was no difference in education level between phase i and phase iii participants however participants in a higher socioeconomic class were more likely to participate in phase i studies these findings are in agreement with those of kass et al 30 who found that caucasians with a higher education level were more likely to be motivated by financial benefits these findings are in contrast to the beliefs of some authors who say that compensation attracts lowincome volunteers resulting in a disproportionate number of poor people participating in clinical studies 35 gelderen 36 found that the youngest volunteers were the most likely to mention money as the primary motivator to participate which is a finding that was reproduced in our study this result is not surprising as younger people might not be as financially established and may be looking for ways to earn money moreover phase i participants are required to be healthy which is a criterion that is more common among younger adults included studies of menopause and temporomandibular pain anova among phase iii participants the principal motivation for participation in clinical studies was to search for a new treatment a motivator that was also mentioned by the kis grecco and diniz 37 have noted that clinical study volunteers in developing countries see participation in clinical studies as an opportunity to receive better healthcare easier access to more expensive laboratory examinations and novel drugs according to grecco and diniz these motivations constitute a conflict of interests it is worth noting that brazilians have universal access to the unified healthcare system which is funded by the federal government 38 however access to this system does not limit the interest in clinical studies perhaps due to the quality of the services or the degree of individualized attention cabral et al 1 have noted that in the research environment the physicianpatient relationship is inverted classically the physician satisfies the needs and interests of the patient however in a clinical study the patient satisfies the interests of the study and thus the researcher lackey 27 adds that the researcher for the advancement of the study must treat these subjects as scientific objects submitted to the laws of cause and effect the study subjects may not understand this distinction and may continue to participate in the study expecting a cure when in reality the medicine may not have any effect canvin and jacob 39 observed a group of volunteers for a study of epilepsy and noted that these volunteers were happy to help others only when they could also help themselves the authors called this behavior weak altruism and mccann et al 40 have called this behavior conditional altruism according to these authors the desire to help others or to contribute to the body of knowledge does not lead a volunteer to participate in a study unless that volunteer perceives that his participation in the study may benefit him personally the informed consent statement which is required under resolution 19696 is provided for the volunteer to inform him about the study including the associated risks and the responsibilities of those involved the ics is indispensable to the ethical conduct of the research according to a number of authors volunteers do not always pay enough attention to the ics this oversight may occur because the volunteer trusts the doctor and does not take into consideration the role of the doctor as a researcher that is the doctor is not necessarily focused on meeting the patients global health needs 27 additionally the patient may overestimate the benefit for himself and lose the ability to weigh the disadvantages of the study 41 finally the volunteer may not understand the ics because of a low educational level 42 in the present study most volunteers had a good education and all declared that they understood the ics however when they were questioned about the study details they only remembered the possibility of speaking with a doctor and the possibility of leaving the study none of the subjects mentioned the disadvantages of the study such as the risks or potential adverse reactions to the medicine these findings may indicate that the volunteers did not adequately understand the ics it is worth noting that a portion of the respondents did not remember that some items of ics may be limited to the time that they participated in the study the more comfortable situations associated with the study were remembered while the situations associated with risks were not mentioned however the date of last participation in a clinical trial was not questioned which may constitute a limitation in analysis of the data conclusion in the present study study volunteers were motivated by some type of personal benefit from participating in a study which is a finding has been observed in clinical study participants in other countries according to several authors this finding is accentuated in emerging countries such as brazil due to the limitations of the health care systems even despite the universal access provided by the sus altruism was not a common motivator and when it was mentioned it was never the primary reason some have called type of motivation this conditional altruism the ics was understood by all participants however the degree of understanding may have been limited none of the subjects remembered the text referring to the potential harms of the procedure or medicine the authors hypothesize that this behavior results because the individuals participate out of selfinterest rather than altruism study limitations this study was a preliminary study with a qualitativequantitative approach the study sampled 80 participants and was not representative of the total population of clinical study participants another limitation is the fact that those who refused to participate in the research were not surveyed study strengths this study demonstrates that personal benefit is the primary motivation for volunteers to participate in clinical research however we argue that this motivation seems to be universal and is not limited to developing countries moreover the theory that financial compensation disproportionately attracts poor volunteers has not been supported furthermore the fact that study participants are primarily motivated by personal benefit does not suggest that they do not evaluate the risks of participation for further consideration if we consider altruism to be the only ethically acceptable motivation for study participation must we evaluate whether the principle of autonomy has been disrespected competing interests the authors declare that they have no competing interests authors contributions san conceived the study and participated in its design and coordination and wrote the final version of the manuscript gbi collected data and zms performed the statistical analysis and interpreted the data obtained all authors read and approved the final manuscript

background in the past clinical study participants have suffered from the experiments that they were subjected to study subjects may not understand the study process or may participate in clinical studies because they do not have access to medical care the objectives of the present study were 1 to analyze the motives that might cause a volunteer to participate as a study subject 2 to identify the socialdemographic profile of this study subjects and 3 to determine whether the motives to volunteer as a study subject are in accordance with the established legal and ethical principles for research in brazil methods mixedmethods research was used a qualitativequantitative approach a sample of 80 volunteers underwent a semistructured interview which was based on a survey script that was elaborated from discussions with key informants the sample was randomly selected from a database of clinical study volunteers that was provided by brazilian clinical study centers the interviews were recorded and transcribed descriptive statistics were used for content analysis including contingency tables with hypothesis testingthe motivations for clinical study participation were linked to types of benefit the most frequently encountered motivations were financial gain and therapeutic alternative altruism was not a common motivator and when altruism was present it was observed as a secondary motivator all participants reported that they understood the informed consent statement ics however only two parts of the form were remembered by all of the volunteers the section on being able to leave the study at any point and the section that stated that there would be some responsible professional at their disposal for the entirety of the studythe present study shows that study participants are primarily motivated by personal benefit when volunteering to participate in clinical studies whether these study participants had an integral understanding of the ics is not clear

this research also presents evidence that the complexity of local adaptation arises from the political economic social cultural and institutional factors and processes that interplay within the households and communities sometimes these same factors and processes work against effective local adaptation at both household and community level however engle claims that adaptive capacity of a nation or community that is affected by climate variability is influenced by the institutions management and governance the findings presented in this thesis illustrate that at household level women are not given a chance to contribute to household resilience to climate variability because of cultural values that suggest that women are subordinates and that therefore only men have the authority to actively participate in such developmental activities the motivation of this research is based on the extent and intensity of floods in flood prone areas and the growing scholarly and personal interest to understand the context and dynamics of vulnerability to floods and local adaptation the main objective was to understand the impact of floods on sustainable development specifically how communities living in flood prone areas perceive their vulnerability to floods and how they are coping with the floods in situ this chapter presents the research questions that this thesis sought to answer it also presents the methodology that was used to collect data and finally the thesis layout with brief description of what is presented in the different chapters list of tables background of the study in january 2015 malawi experienced fatal floods which affected 15 districts out of the 28 districts and a state of emergency was declared by the president of the republic of malawi on january 13 th 2015 during that time 1102364 people were affected by the floods 104 people were reported dead 645 people injured 172 people were reported missing and 336053 people were displaced with 225 displacement sites in nsanje where the research was conducted out of a population of 238103 74250 people were displaced in 22 displacement sites representing 28 of the total population in the district of which 31 people died and 153 people were reported missing a section of nsanje district has been experiencing floods for over a decade and was declared a flood prone area the same time therefore firstly this research seeks to understand how the communities that live in the flood prone areas perceive their vulnerability to floods and how some of them have been coping with the floods since 1952 just over 6 decades this study is important because it contributes to knowledge on understanding the changes in the extent and intensity of the floods in flood prone areas and the corresponding adaptive measures that have been implemented over the years in 2012 communities living in flood prone areas of nsanje district experienced devastating floods that resulted in loss of property and damage to infrastructure furthermore following a flood in 2009 a declaration was made that ta nyachikadza one of my research sites was no longer habitable because it is surrounded by a marsh and due to the geographical position of the area it was prone to extreme flooding in the same year some villages in traditional authority mlolo under group village kadyamba were also declared uninhabitable due to the severe flash floods that were experienced in the areas the government of malawi through officials from the department of disaster management affairs advised the communities living in these areas who are mainly communities to move to upland areas which are not prone to flooding the first meeting was held in 2010 then in 2012 and the last one in 2015 where dodma officials strongly advised communities living in flood prone areas to relocate upland so that they should reduce the impact of floods on their lives however the communities have refused to relocate and have insisted on living in the flood prone areas even after the 2015 floods the majority of the communities moved back to the flood prone areas currently there is no data that explicitly explains the factors that motivate communities to live in flood prone areas however there have been claims from various individuals through the media that suggest that the communities continue living in flood prone areas because they are used to receiving handouts and humanitarian relief support and services during floods this research therefore secondly seeks to understand the factors that motivate communities to continue living in the flood prone areas despite the previous experience and exposure to devastating floods for over a decade there have been climate change adaptation programs in nsanje district according to nsanje district development plan targeting communities that live in flood prone areas to help them minimise the risk and vulnerability to floods over the years as evident by the 2009 2012 and 2015 floods there has been a noteworthy increase in the number of households that cannot cope with the floods recently there has been an increase in the number of communities that have become more vulnerable to floods over years and struggling to cope with the floods without external support however there has been no research that sought to understand and explain why these communities are failing to be resilient to the floods despite all the investments made through climate change adaptation programs this research furthermore explores some of the challenges that these people face which have exacerbated their vulnerability to floods vulnerability and adaptation to climate change variability until 2006 only 6 districts were affected by climate variability including floods in malawi with no reported deaths after close to a decade malawi had become more vulnerable and exposed to floods that affected a larger population according to mcsweeney et al malawi experienced a 09 degrees celsius increase in the mean annual temperature between 1960 and 2006 which reflects an average rate of 021 degrees celsius increase per decade furthermore mcsweeney et al predict an increase of rainfall up to 19 by 2090 using their rainfall model however the authors did not explicitly predict the extent of the impact on communities living in flood prone areas the extent of their vulnerability and how complicated local adaptation would become it is clear that some groups of people and some regions would be more vulnerable than others although there have been various uncertainties in climate variation there is need to come up with adaptation strategies that go beyond the activities that these people are currently implementing to cope with climate variation scholars reveal the need to prepare and plan for the unknown extent of risks to reduce vulnerability and be able to cope with the extreme weather events however with the recent global disasters as a result of extreme weather events it is clear that there is need to understand the realities within the vulnerable communities in terms of their perceptions power dynamics and local adaptation to be able to have adequate data to facilitate informed debates in climate variability vulnerability and adaptation discourses the intergovernmental panel on climate change ipcc has stressed that global temperatures are increasing hence very likely that there would be huge negative impacts on the climate environment and the various ecosystems in addition the united nations framework convention on climate change unfccc indicate that developing countries will suffer more because they are more vulnerable to climate variability due to inadequate capacity in terms of finances and expertise to deal with the negative impacts of climate variability within the affected communities people are affected differently depending on various factors including social class gender age geographical position culture and group the studies furthermore emphasise that even though an area would be affected by the same effects of climate variability the poorest of the poor would be affected more because of lack of alternative sources of livelihood and cash orphans women people living with disability and people living with human immunodeficiency virus acquired immunodeficiency syndrome would be heavily affected due to various differences in factors contributing to vulnerability adaptation measures are also different and they depend partly on culture geographical positions local and institutional changes and power goldman and riosmena 2013obrien and wolf 2010 the differences in various factors that contribute to vulnerability and hence influence local adaptive capacity have demanded more research in various parts of the world to better understand the context of vulnerability and the dynamics of local adaptation to climate variability trawöger emphasises that there is a need to deeply understand the local perspectives of climate variability in order to deliver climate change adaptation projects and programs that would enhance community resilience effectively and efficiently the global perspective of climate change and the associated risk should not be generalised but rather should be case specific in order to design appropriate approaches to adaptation to climate variability there are gaps in the vulnerability literature in terms of understanding climate change impacts on natural systems and social economic trajectories including adaptation which necessitates the need for more case studies to understand these relationships and interactions in addition harrison and chiroro stress the need to understand the contexts that shape vulnerability and how communities differ within themselves to better develop adaptation and resilience projects that foster sustainable development this thesis therefore seeks to fill the identified gaps and contribute to literature in sub saharan africa odi and cdkn reveal that many countries in the region including malawi do not invest in long term climate change adaptation strategies hence exacerbating the vulnerability to floods in the long term in addition lack of appropriate climate information in most developing countries to enable the flood victims to plan accordingly has been argued to be one of the factors that has exacerbated vulnerability to floods investing in long term climate change adaptation plans requires more financial and technical resources which currently most developing countries do not have the unfccc strongly recommends that developed countries should commit themselves to helping developing countries to cope with the extreme weather events even though the reality suggests that little is done towards implementing that in other contexts stasavage and moyo cite an example of how the international monetary fund imposed a cash budget system in uganda and zambia as a means to decrease the deficit on the budgets of the countries these two countries were directed to spend only on what they have as cash to reduce overspending by the government which results in recurring government deficit contrary to the direction there was evidence that the politicians and national employees managing the funds did not agree with the system since they had their own way of implementing the national activities these examples of how donors impose how governments in the global south should manage the donor funds intrinsically reveal power dynamics in bilateral aid and donor conditions where the developing countries receive aid but have to implement the programs the way the donors want bryan et al stress that climate variability will mainly affect communities living in africa because agriculture is their main source of income a better understanding of communitys perception of climate change adaptation strategies and decisionmaking processes are critical to inform policies that focus on promoting successful adaptation strategies this thesis emphasises that missing the underlying causes and differences in the extent of vulnerability has led to the generalisation of adaptation strategies that are not applicable in some areas for example adaptation projects in malawi focus on sustainable and climate smart agriculture even in flood prone areas which is purely a shortterm strategy and not effective to prevent damage and harm from floods hunger famine and permanent migration are factors that usually threaten poor households whilst economic losses affect mainly those who have valuable assets at local level it is argued that different people are affected differently by climate variability even though adaptation strategies are designed to address vulnerability equally amongst the affected communities ribot stresses that there is a need hence to study different cases separately to deeply understand the underlying causes of vulnerability to floods at local level and how the communities that are affected by the floods cope with the floods in order to inform policies and guide development practitioners on what is feasible and to whom with evidence this thesis explores therefore is important because it provides evidence of how vulnerability to floods is created differentiated and exacerbated in nsanje districts and how the affected communities are responding to the floods dilling et al reveal that vulnerability is dynamic and complex such that there is no definite longterm strategy to reduce vulnerability due to unstable ecosystems culture social interactions and landscape with time furthermore the authors suggest that short term adaptation is possible although they doubt the likelihood of longterm resilience using fixed climate change adaptation policies and strategies long term resilience can only be determined by the way the people who are affected by climate variability frame their vulnerability to the floods over time and therefore take appropriate actions accordingly to address their vulnerability to floods this thesis provides evidence that vulnerability to floods is dynamic and differentiated therefore communities respond to the floods based on the way they have been affected by the floods in other words the extent and intensity of floods determines how the communities respond to floods therefore suggesting that adaptation strategies are also dynamic fixed long term strategies that are targeted towards addressing climate variations must therefore be considered with caution because there are cases where they may not be applicable fixed climate related decisions that are made at different stages may affect vulnerability either positively or negatively in the long term this thesis explores the factors and processes that affect the smallholder farmers that live in flood prone areas as they cope with the floods these factors and processes include power dynamics within the sociocultural environment and the interaction between political and economic factors within flood prone areas problem statement currently there is no data that explicitly explains the factors that motivate people to live in flood prone areas however there have been claims from various individuals through the media that suggest that people continue living in flood prone areas because they are used to receiving handouts and humanitarian relief support and services during floods floods have negatively affected the sustainability of the overall development of the district despite huge investment to deal with effects of floods in nsanje district the continued trend of floods continues posing a threat to the overall development of the district a lot of research has been conducted in the area of floods however in malawi floods and sustainable development while considering nsanje district has not been studied conclusively it is against this backdrop that this study would like to establish the impact of floods on sustainable development objectives of the study main objective the overall aim of the research was to understand the impact of floods on sustainable development and how communities living in flood prone areas perceive their vulnerability to floods and climate variability to investigate the power dynamics at household and community level and to explore the complexities associated with local adaptation programs in the flood prone areas specific objectives • to find out how do communities living in flood prone areas perceive their vulnerability to floods • to find out what motivates communities to stay in flood prone areas • to investigate factors that have caused the communities living in flood prone areas to continue being vulnerable to floods • to find out if flood management strategies mainstream sustainable development approaches in its implementation research questions • how do communities living in flood prone areas perceive their vulnerability to floods • why are communities motivated to stay in flood prone areas • what are the factors that have caused the communities living in flood prone areas to continue being vulnerable to floods • how does flood management strategies mainstream sustainable development approaches in its implementation significance of the study the research findings would give guidelines to the malawi government in the formulation of appropriate laws and policies that would seal the loopholes that create hindrances on sustainable development to the academicians this study may contribute to the literature of floods and sustainable development within the country which already exists in addition the study may also stimulate further research on the area of floods and sustainable development in particular in malawi and other countries structure of the paper the study has been organized into five chapters chapter 1 introduction chapter one gives a general introduction and background to the topic of study it also presents the problem of the study research objectives and research questions finally it presents significance of the study and chapter summary chapter 2 literature review chapter two deals with the review of literature pertaining to the research study it presents theories and concepts that are related to the study it also presents previous work related to the study and conceptual framework of the study chapter 3 research methodology chapter three gives description of the research process and the methods adopted for collecting and analyzing data chapter 4 research findings and discussion this chapter presents results from the research questionnaires which are analyzed using spss and presented in tables and figures mainly it contains demographic results of the participants and the main results on the effects of employee participation on the organization performance chapter 5 conclusions and recommendations chapter five summarizes the findings conclusions and relevant recommendations are presented chapter summary this chapter has presented the general overview of this study it has also presented the background of the study problem statement research objectives and the significance of the study in addition the chapter has presented the overall and specific questions the significance of the study and finally it has presented the structure of the study chapter two literature review introduction this chapter presents a review of literature on the impact of floods on sustainable development particularly paying attention to floods and unpacking the concept of vulnerability furthermore literature is reviewed in order to understand the different factors that contribute towards vulnerability to climate variability in general followed by various case studies that describe vulnerability in context local adaptation and the barriers and limits to local adaptation finally the main debates in the literature are summarized and ways in which this research fits into the wider academic discourse on impact of floods on sustainable development vulnerability and local adaptation this thesis recognizes that vulnerability in flood prone areas is created and exacerbated by several factors including social environmental cultural technological economic political and historical factors in addition the thesis acknowledges that a transformational change in the way adaptation initiatives are designed is important in order to incorporate all these factors which would help to reduce vulnerability and enhance the local adaptive capacity theoretical literature malawi like many southern african countries is experiencing increasing climate change and variability which results into poor crop yields andor even total crop failure due to drought and floods being an agrobased economy with more than 85 of the population relying on rainfed agriculture for their livelihood and survival the level of vulnerability has increased with the increasing extremes of drought flooding and erratic rainfall patterns for example in 2012 it was indicated that floods had caused an annual loss of up to 12 of maize in the southern part of malawi and drought destroyed 46 of the maize crop a study by msowoya et al predicts that there will be a 14 decrease in maize production by midcentury and 33 at the end of the century in lilongwe district which is the largest maize growing district maize is malawis staple food that is grown during the rainy season rain fed agriculture will decrease food production and hence there is a need to invest in various farming technologies that are climate compatible for example irrigation farming growing new varieties of maize crop diversification and natural moisture conservation strategies malawi being one of the poorest countries with limited resources to implement the proposed technologies it is very likely that smallholder farmers will struggle to be resilient to climate variability malawi and many countries in southern africa have adopted conservation agriculture to adapt to droughts and erratic rainfall even though other studies reveal that there is need to adjust conservation agriculture depending on agroecological system floods have led to displacement of communities loss of life and assets and have contributed to reduction of community resilience in southern africa including malawi 2015odi and cdkn undp according to magis community resilience refers to the existence development and engagement of community resources by community members to thrive in an environment characterised by change uncertainty shocks and unpredictability community resilience and community adaptation to various climatic shocks differ according to the communities priorities this suggests that farming communities would have different adaptation strategies to fishing communities furthermore their work suggests that communities with different socioeconomic status and perhaps culture values and community myths will have different coping and adaptation strategies this thesis also examines how communities who live in the flood prone areas cope and adapt to the floods by exploring existing opportunities within the flood prone areas that enhance their livelihoods this thesis also addresses the existing gap in literature on how communities are coping and adapting to the rapid unprecedented and complex environmental changes in flooding areas of urban lagos nigeria it was revealed that women in low income households are more vulnerable than men and women in the middle and high social classes in nepal women were more affected by the earthquakes than men among farming households in flood prone areas women are also more vulnerable than men bee indicate that understanding the gender dimensions of vulnerability helps researchers and practitioners to understand further the context of vulnerability and thus lead to more appropriate adaptation initiatives cutter advocates for more and explicit research and publications on how women and children are affected by the social and environmental injustice and particularly gender in vulnerability and climate adaptation within and among the vulnerable communities in addition understanding gender roles would enhance the effective implementation of adaptation programs that would like to empower the most vulnerable groups in iran a study on the capacities of women in disaster management systems reveals that women play an important role in managing household chores and family livelihood including taking care of children and cooking during and after disasters participation of women during implementation of adaptation programs is important because it empowers them within their socialcultural and economic context to avoid misunderstandings that distract effective adaptation gender relations social power relations and knowledge processes influence womens perception of environmental changes and determines how they respond to environmental and social risks this suggests that women in particular should be given attention in adaptation programs because of their important role at household level how they are heavily affected by disasters there is a need to understand the roles of women in context to find a means of empowering them and equipping them to be able to deal with disasters reyes and lu indicate that women provide food keep up hope for the family take care of the sick or injured members of the family therefore womens roles before during and after disasters exceeds those of men furthermore women from low income groups and single parents are more heavily burdened than other women during floods and other crises male farmers usually migrate in search of better livelihood leaving women with children at home where the women become responsible for household and agriculture activities female farmers have limited access to agriculture extension and training programs whilst the male farmers are well exposed and actively participate in the agriculture extension programs as household heads this presents an example of how inequalities in exposure access to resources vulnerability opportunities and capabilities are usually gendered and political in nature hence different groups of people are affected differently and adaptation measures should thus reflect this social differentiation as it shapes adaptive capacity in flood prone areas the capability to evacuate during a disaster is highly gendered as it is highly determined by the cultural constraints in female mobility and lack of physical skills and strength in addition to various gender roles these findings indicate that masculine strength is often greater than that of women meaning that they can lack the capacity to escape floods on time furthermore neumayer and plümper indicate that when floods occur the number of women who die is more than the number of men and that floods reduce the life expectancy of women in flood prone areas although there is great variation from situation to situation past research has indicated that women within flood prone areas have less capacity to cope with the disasters due to a combination of demographic emotional and social factors that characterise them these studies suggest that gender disparities should not be overlooked in vulnerability and adaptation studies furthermore they suggest that understanding vulnerability using a gender lens is critical to understanding what factors exacerbate vulnerability amongst women living in the flood prone areas and also how adaption programs can be designed and implemented to purposefully address the gendered vulnerability violence against women has been shown to increase in disasterstricken communities even though in most cases these incidences are not recorded investigated or shared exacerbating vulnerability of women in these areas this suggests that in some cultures women are often disadvantaged in terms of exposure to new skills and are oppressed in terms of gaining appropriate knowledge and skills that might empower them in a study involving fish farmers in northern thailand lebel and lebel reveal that financial stability plays a significant role in the interactions between attitudes analysis and emotions in making climate change decisions that are risky this suggests that financial stability ensures right and effective adaptation measures regardless of gender race and class in pakistan high education status in women reduces health related sicknesses and underutilisation of health facilities in flood prone areas emphasising the role of women in promoting good health in flood prone areas hence reducing their vulnerability to the effects of flooding the extent and context within which the women are disadvantaged need to be unpacked to help guide policy makers and development practitioners who are working on adaptation programs in order that these programs have a meaningful impact on the lives of the most vulnerable the distinctive role of women in flood prone areas and the gendered dimension of vulnerability to floods including emotions and attitude towards vulnerability to floods illustrates the complexity of vulnerability and therefore how important it is to facilitate effective adaptation in flood prone areas this thesis therefore explores the ways in which gender affects vulnerability and local adaptation in flood prone areas to illustrate the need for effective transformation in understanding vulnerability and addressing adaptation issues which are differentiated based on local power dynamics and politics around gender culture class attitude perceptions and partly emotions adaptation to climate variability including floods globally it has been recognised that developing nations are more vulnerable to the effects of climate variability because they do not have adequate expertise and finances amongst other things to deal with for example floods droughts dry spells strong winds and earthquakes as a result a plea was made in 1992 to developed nations to assist developing nations through financial and technical support including humanitarian aid in times of disasters to ease the burden of managing disasters through the global conventions on climate change such as the unfccc the world conference on disaster risk reduction amongst others global and national policy on climate change and disaster risk reduction have been formulated these climate change and disaster related policies were formulated to guide implementation of adaptation programs at international regional and local level and to guide policy formulation at those same levels the national adaptations programs of action and national climate change policies for participating countries were formulated after the kyoto protocol in 1997 during the kyoto protocol some developed countries committed to reduce the production of greenhouse gases in order to reduce global warming and the associated effects of global warming the countries that ratified the kyoto protocol in 1998 were encouraged to develop the national adaptations programs of action highlighting the major climate change effects that the particular countries experience in addition the napas were to indicate how best the countries were going to deal with the climate change effects in targeted areas following a thorough risk assessment at national level however due to climate variability the intensity of extreme weather events became so severe such that other disaster related institutions were established in order to help to manage such disasters in 2005 parties that signed the disaster framework formed national disaster management policies with guidance from the hyogo framework for action 2005 2015 in order to reduce vulnerability to disasters and make certain that vulnerable populations are protected by their states during the convention it was evident that developing countries were struggling to cope with the disasters due to inadequate financial and technical capacity as a result developing countries were advised to conduct disaster risk assessments at national level to specifically identify disaster prone areas to relocate vulnerable communities to safer areas in 2015 the sendai framework for disaster risk reduction 2015 to 2030 was formulated and adopted by interested countries the framework highlights areas that needed to be adjusted following a thorough assessment and evaluation on the hyogo framework of vogel notes the significance of the programme in bringing interdisciplinary experts to tackle vulnerability to global environmental changes and suggest that it is a good way of enhancing effective adaptation to environmental changes the interdisciplinary aspect of vulnerability also suggests that there are several ways of coping and adapting to climate variability including floods the human dimension in dealing with climate change effects has enhanced the development of climate change adaptation policies that mitigate climate change effects in a way that enhances livelihoods of vulnerable populations the interdisciplinary approach also has resulted in development of disaster related policies that integrate the management of disasters with disaster risk reduction strategies and mitigation measures that focus on the most vulnerable populations at both international national and local level in addition there have been risk assessments to find out means of reducing vulnerability of populations at risk and provide support to enable them to adapt to the environmental changes to become resilient in the long term adaptation to climate variability including floods has been romanticised obrien and selboe argue that adaptation has been presented as a problem that can be solved by technical expertise and yet the realities indicate that adaptation is a complex process that is linked to identities of the affected people politics power values beliefs and world perceptions on adaptation the authors furthermore illustrate that the realities suggest that technical expertise alone can never solve adaptation challenges but rather a combination of personal political and social change depending on the spatial locations and how all these factors interplay as presented earlier on several studies indicate that local adaptation is necessary to reduce vulnerability to floods shackleton et al emphasise that research on barriers to adaptation needs to start asking why these barriers emerge how they work together to shape adaptation processes who they affect most and what is needed to overcome them this research therefore unpacks how various factors interplay in the flood prone areas and also explores the barriers and limitations to effective adaptation that emerge in the flood prone areas at national level after the development of the napas various programs have been designed and are currently funded by international organisations both government and nongovernmental organisations companies and other civil society organisations there are several structures through formal and informal institutions through which development aid humanitarian aid and other forms of support are directed to vulnerable communities however debates continue on how effective these national and local institutions are to develop and implement the climate change adaptation programs that will reduce vulnerability of the communities and empower them to be able to effectively cope with and adapt to the effects of extreme weather events a study conducted in south africa reveals that the local institutions despite having such an important role in climate change adaptation do not have adequate skills in resource and project management they also lack network skills that would help them to partner with other organisations in order to work as a team this study emphasises the need for additional skills that go beyond managing the flood itself to partnerships in order to effectively adapt to climate variability this thesis explores other factors that help communities to adapt to floods and make climate related decisions beyond the flood management knowledge manuelnavarrete and pelling emphasises that the politics of transformational change in different spatial locations needs to be explored in order to understand the power dynamics and decisionmaking processes in various places several case studies conducted in vulnerable communities suggest that community adaptation programs prioritise short term challenges whilst indirectly ignoring the sustainability of such interventions communitybased adaptation has been defined by reid et al as a communityled process which is based on the priorities of the communities their knowledge needs and capacity communities are not homogenous hence there is a need to examine how projects impact various groups in these communities for example women youth elderly the poor orphans people living with disabilities and many others blaikie amongst other scholars illustrates how community based natural resource management as a concept and theory in forest management yields different results in different countries and how the implementation and success is differentiated based on particular political power dynamics and socioeconomic relationships within the different settings in addition it is evident that success of the program is based on the agendas of the organisations who initiate and implement it there is a clear generalisation on the definition of resilience by international donors rather than the actual definition of what resilience means to the differentiated affected communities this implies that some interventions are imposed on the affected communities based on the priorities of those who see the needs and problems from outside the communities there is also a need to understand the perspectives of those whom these adaptation programs are designed to benefit and whether or not the targeted social group benefit from such projects it is important therefore to unpack critical elements of local and community adaptation based on actual community problems and proposed interventions using political ecology theory to understand how communitybased adaptation can reduce vulnerability to climate variability in a sustainable manner that will enhance local resilience to climate variability households in nigeria for example communities cope with floods by selling their assets borrowing loans to diversify their livelihood migrating to other places where they can work to get money to sustain their livelihoods utilising support from social networks and following new farming methods and technologies critically assessing the coping mechanisms selling assets to cope with disasters seems a very good strategy in the short term whilst it creates vulnerability to the households in the long term in addition relocating to other places during flooding also does not offer long term solution this thesis therefore explores the most reliable adaptation strategies that the smallholder farmers have being relying on over the years in order to understand how adaptation practices have changed over time and how the smallholder farmers themselves have transformed over the years due to climate variability dodman and mitlin reveal the need for development practitioners to contextually understand and incorporate political structures culture power and gender dynamics in their development plans to adequately and effectively address issues that are affecting climate vulnerable communities understanding vulnerable communities is vital because meaningful adaptation has to be designed in context in order to help the communities that are affected by climate variability this suggests that there will also be sustainability of the projects after the project implementation period is over furthermore it is important to understand the extent of losses level of vulnerability and flood coping strategies in developing countries as it will shape the future of specific strategic and effective adaptation strategies the lack of this understanding will result in unsustainable interventions that will be costly and not accepted within the communities that such interventions are meant to assist this thesis therefore unpacks the context of vulnerability how it is differentiated and various ways in which the affected communities monitor the floods and cope with floods flood monitoring and politics in flood prone areas flood management consists of various assessments including hazard vulnerability exposure risk early warning system damage and risk mitigation planning rahman and di suggest that there is a relationship between several factors that determine vulnerability and adaptive capacity of vulnerable communities however the study does not explicitly indicate how these factors interact to create vulnerability instead it focuses on major factors that exacerbate vulnerability to floods and not adaptive capacity issues including flood monitoring firstly authors suggest that tropical countries have high flood risk and low financial and institutional capacity to afford groundbased monitoring of rainfall and river discharge hence are more vulnerable to floods most developing countries use remote sensing which is sometimes not adequate enough to provide timely early warning information that led to timely evacuation and planning in most cases remote sensing provides information in changes in the soil moisture content over time and is usually used to determine and predict flash floods however remote sensing technology is not affordable to all countries some countries in particular developing countries have inadequate capacity to obtain updated remote sensing technology and space technology therefore flood management in developing countries will remain a challenge raju et al indicate that remote sensing technology has advanced and is providing all the relevant information that would enhance effective planning for flood management the soil moisture levels that are depicted over time predict the changes in soil moisture thereby predicting flash floods and floods in flood prone areas it is clear that flood management requires a huge investment in order to obtain effective early warning information that will reduce the effect of disasters including floods in flood prone areas however where this research took place communities use their local knowledge to monitor floods in addition the meteorology department does not have adequate finances to procure advance weather monitoring equipment this thesis therefore informs flood monitoring research on how floods are monitored locally and how the current flooding trends require a change even in ways in which floods are monitored at local level in order to cope with the floods effectively remote sensing is an option for most developing countries however it depends on the willingness of the ruling governments to prioritise spending on the flood management in the national agenda affordability of the technology in this case is subject to various factors including but not limited to national earnings and taxes which suggests that flood management is also political in ghana for example the government authorities do not actively stop people from settling informally in flood prone areas even though the authorities do not invest in flood mitigation measures in those areas the governments priority is to win votes from people who live in the flood prone areas this is the political nature of ruling governments where the focus is to remain in power regardless of their obligation to make certain that people are safe during the floods this also suggests that the ruling government benefits more from allowing people to live in flood prone areas because it gets more votes from the people who live there without being responsible for disaster risk infrastructure this is a political strategy which is socially unjust to people who live in the flood prone areas although political and economic dimensions of governmental decisionmaking may differ drastically from context to context these findings indicate how governments in some developing countries prioritise their agenda to win more votes during elections these findings also suggest that there is a lack of proper discussions between the government and communities that are affected by floods the people who are affected by the floods are not given an opportunity to negotiate for government led services to reduce their vulnerability to floods as indicated earlier on vulnerability to disasters is also socially constructed and influenced by political relations and other socioeconomic factors the lack of dialogue and poor government priorities in developing countries exacerbate vulnerability of those people who live in flood prone areas this thesis reveals how political decisions and public disaster policies interplay together with other social and economic factors in the flood prone areas in order to understand the complexity of monitoring the floods and local adaptation in those areas this thesis acknowledges the differences and complexity in governance institutions at different levels government community and household level some adaptation initiatives are delivered through government departments and established nongovernmental and civil society organisations whilst other local adaptation practices are implemented by communities themselves through their particular norms beliefs and culture therefore further studies including this research in different socioeconomic political cultural and geographic settings will facilitate substantiated debates on vulnerability and local adaptation under various institutional arrangements in context barriers and limitations to effective adaptation to climate variability the adverse effects of natural hazards on people do not only lie within the hazard itself but derive from the position of these individuals within social economic and political relations methmann and oels indicate the main factors that put vulnerability and local adaptation in context this thesis unpacks these social economic and political factors in context in order to understand the dynamics of vulnerability and how the various factors affect local adaptation islam et al 2014bjones and boyd 2011urwin and jordan 2008 stress that unpacking how and why each of those underlying factors affect vulnerable communities would inform climate related policies reduce vulnerability to climate variability and promote successful implementation of adaptation programs at local level in addition various scholars emphasise that understanding the complexities of vulnerability and local adaptation in context would promote transformational adaptation which is context specific and would effectively address adaptation challenges thereby reducing vulnerability to the negative effects of climate variability in some developing countries climate change and other national policies are poorly mainstreamed during implementation of projects and programs lack of comprehensive policies at national level results in many policies that become difficult to be mainstreamed some of the most important issues that need to be addressed by such policies are neglected such as the flow of money and other livelihood benefits who is affected more why they are more vulnerable than others who is responsible to benefit from the implementation of such policies under what agreed criteria and justification for purposeful exclusion malawi has many policies that conflict with each other for example the agriculture policy promotes farming close to water sources for irrigation purposes whilst the water policy indicates that farmers should not farm close to water sources to avoid water pollution and environmental degradation around the water bodies the inconsistency in the policies has brought confusion amongst the public and those that facilitate the implementation of development projects the lack of clarity on such policies also affects the implementation of adaptation projects and in some cases also exacerbated exposure to floods due to soil erosion and degradation near the river banks according to pasquini et al there are various factors that affect the mainstreaming of climate change issues some of which include lack of knowledge and understanding of climate change issues and lack of political will by those in authority at both constituency and local government level in southern africa globally the focus and priorities set by ruling parties determine the major support from the national budget and other resource allocation the national budgetary allocation towards a particular theme is where more funds at national level are allocated to the theme of interest at a particular point in time this mainly depends on the priorities of the current presidents andor ministers although some governments have more decentralized power structures than others this also suggests that in some cases environmental issues are not given a priority by most politicians because most politicians focus on issues that will give impact or results in the short term so as to win peoples favour and votes many environmental projects will usually yield benefits in the long term for example planting a tree will take a number of years before benefits are realised due to this they are not given a priority amongst ruling governments as well as the majority of people who have crucial needs that need immediate interventions interministerial coordination supported by the highest levels of government is more relevant to the success of mainstreaming and integrating climate change issues into the national development priorities ibid this also suggests that if interministerial coordination is supported district and local coordination will also be improved since these local institutions generate from the line ministries therefore this argument indicates that proper coordination is relevant to enhance effective implementation of adaptation projects at local level and programs at national level kosamu states that there are inadequate human and financial resources to support climate change adaptation programs in most developing countries not many people have the adequate skills qualifications and experience in climate change adaptation programs hence lack effective delivery of significant contributions and outputs in climate change programs this is in relation to cases where practically modern science and technology methods and mechanisms are being applied as opposed to the local indigenous coping strategies in malawi there is also little or no interaction and collaboration between climate change stakeholders such as ngos civil society organisations and the government as evident during disaster needs assessment and response which results in lack of collective commitment in implementing climate change adaptation programs furthermore the post disaster assessment reveals that collaboration in disaster related issues will enhance adaptive capacity in the flood prone areas by ensuring that vulnerable communities are prepared for disasters however the ability of the community or household to be able to cope with the floods or other disasters is complex and requires a multisectoral approach that empowers communities to be resilient to the floods in the long term understanding the political and social barriers that have worked against successful adaptation to climate variability is vital to assist the government and other development actors to determine distribution of costs and benefits in society for example global climate change effects that were addressed intrinsically exacerbated social injustice through the distribution of benefits and burdens between those who create the environmental problems and those who are burdened with the consequences of the environmental changes in addition the social policies made create intergenerational injustice that will continuously disadvantage those who suffer more and who are not capable of dealing with the environmental changes the intergenerational injustice unfair and injustice distribution of climate variability burdens and the misrepresentation of vulnerability to climate variability has been noted in the case of developing countries as they continue to suffer consequences of extreme weather events that they did not create whilst the rich continuously pollute the environment and claim that carbon trading is a solution to the problem in such international policies lie the realities of social equity role of power responsibility and rights which reveal that poor communities will continuously become more vulnerable to climate change effects whilst the richer communities will continuously contribute to global environmental changes however maguire and lewis indicate that there are attempts made to address such injustices even though it is still not clear how they could be explicitly tackled this section therefore illustrate how dynamic and complex vulnerability issues are and how dealing with them is challenging at all levels solutions to climate related problems therefore should not be very technical because there can never be a single way of addressing the challenges but rather a combination of technical social economic political and cultural strategies the unclear ways of addressing such global injustice suggest that these inequalities will continuously be reflected in many adaptation programs hence creating a challenge in meeting the global regional national and local adaptation plans whilst exacerbating vulnerability to climate variability the author indicates that global justice does not exist and the social injustice that has been passed on from generations the burdens of climate change will have to be shared with future generations inevitably and hence a need to plan for future adaptations to reduce vulnerability this argument presents a case that there is need to understand the vulnerability context now to plan better for future adaptation in some cases vulnerability is transgenerational and communities who are vulnerable now will continuously be vulnerable to climate variability hence empowering them to adapt to climate variability is vital these arguments both demand the need to understand and invest in climate change adaptation immediately to lessen the impact of climate variability in the future environmental injustice has partly exacerbated vulnerability in communities that have limited capacity and influence to deal with the negative effects of environmental changes in the case of east boston massachussets a flood prone area it was revealed that the communities experiencing the floods had no influence and knowledge on adaptation plans but rather all the decisions were made by institutions and people in authority this reflects some of the reasons that have caused failure in climate change adaptation programs in various communities and countries and also reflects on how vulnerable communities will remain vulnerable to climate change effects however sen advocates that the vulnerable should be given a platform to be heard the realities suggest that the governments and those that have the power focus on political interests therefore dialogue over social injustice does not realistically solve the problem power dynamics is therefore indeed one of the issues that needs to be addressed strategically at all levels to reduce issues of vulnerability to climate variability blaikie and brookfield stress that environmental problems are complex and hence require a deep understanding of the social and political setting in which the particular environment is surrounded this led them to develop political ecology theories that seek to understand the dynamics and complexity of environmental problems in their specific social and political contexts neumann acknowledges that the phenomena under investigation can be very complex and interdisciplinary hence political ecology is important because it involves a multiscale analysis that includes political economic analysis historical analysis ethnography discourse analysis and ecological field studies in a recent study middleton et al use a political ecology lens to understand the relationship between migration vulnerability resilience and social justice that is associated with flooding in an environmental social and policy context in southeast asia the authors focus on ways in which floods play a role in the livelihoods of the migrants in southeast asia in contrast to flood related policies that refer to floods as a sole driver of migration this thesis focuses on environmental migration as an alternative adaptation strategy against floods by smallholder farmers that live in flood prone areas the discrepancy on perceived vulnerability to floods between the public and people affected by the floods and temporary migration during the flooding season has been investigated in the thesis conceptual framework political ecology theories this thesis presents an understanding of how vulnerability is framed based on selfperceptions that are differentiated based on locations personal experience age and gender amongst other factors this thesis also reveals the need for transformation in the way adaptation strategies and policies are perceived designed and implemented to incorporate important aspects of culture gender and power dynamics at household and community level that form the basis of effective local adaptation to floods this thesis also makes reference to other scholars that have done similar work adopting political ecology theories and ideas focusing on vulnerability to climate variability and the dynamics of local adaptation in addition the thesis builds on research conducted by scholars who have focused specifically on social transformation as an adaptive strategy that has potential to reduce vulnerability to climate variability these authors stress the need to understand the politics and how decisions are made within the vulnerable spatial locations such as flood prone areas and areas that are prone to war and other socioecological disturbances the authors also emphasise the need to reduce vulnerability to climate variability through supporting appropriate sustainable livelihoods options that also enhance the adaptive capacity of the vulnerable communities this thesis thus builds on the understanding that vulnerability to climate change is created by the interaction of social and natural systems and that adaptation initiatives should incorporate cultural political and social factors to reduce peoples vulnerability to climate variability this research addresses the gap in knowledge and understanding of how the historical cultural social economic environmental changes power dynamics and political factors have exacerbated vulnerability of smallholder farmers living in flood prone areas using nsanje district as a case study pelling suggests that vulnerability for individuals and social groups has three components exposure resilience and resistance these components are simultaneously the products of political and socioeconomic structures and the capacity of individual actors and social institutions to adapt to hazard stress the focus of this thesis is to understand the extent to which smallholder farmers are exposed to floods and the opportunities that lie within the flood prone areas that have shaped their livelihood options and survival during and after the floods this study is important because it illustrates how climate related decisions are made by community members in the flood prone areas and how the discrepancy between public perceptions and selfperceived vulnerability has resulted into inappropriate policy options that do not reflect the extent context and intensity of vulnerability to floods this thesis further seeks to understand why the smallholder farmers that live in flood prone areas are not able to cope with the floods in a way that their livelihood is not affected despite huge investments over us 50 million in climate change adaptation initiatives by the government of malawi and development partners including the world bank global environment facility world food program food and agriculture organisation european union and various united nations departments this thesis explored how these smallholder farmers understand local adaptation projects what it means for them and what is involved in addition to understand and learn from them the factors that would assist the smallholder farmers to be able to cope with the floods recover after the floods and become resilient to the floods in the long term pelling stresses that understanding the economic environmental political technical institutional social and cultural transformations is vital to reduce complex vulnerabilities to climate variability this thesis therefore provides a case study of how these multiple factors interplay in the flood prone areas to create exacerbate and reduce vulnerability to floods the local adaptive capacity framework figure 1 the local adaptive capacity framework accessed at the local adaptive capacity framework is similar to the adaptive capacity wheel in that it acknowledges the relevance of resources in forms of assets assets are very important to enable the households and communities to cope with floods in addition it acknowledges that information and knowledge facilitates learning and room for autonomous change which facilitates innovation in which the households and communities deal with the dynamic and complex effects of floodsall the frameworks therefore indicates that communities need to be empowered economically socially and politically in order to effectively adapt to climate variability the frameworks also illustrate that communities and households need a multidisciplinary approach in order to deal with the effects of climate change policy makers therefore need to understand the dynamic and complex nature of communities in order to effectively design and implement adaption programs that will reduce vulnerability to climate variability whilst enhancing the adaptive capacity of the households and communities the local adaptive capacity framework just like other adaptive capacity frameworks that measure and assess communities vulnerability and adaptation is important because it also helps researchers to understand what influences communities to adapt to floods in ethiopia uganda and mozambique the framework was introduced to measure how development interventions impact on adaptive capacity at the local level and it is mostly used by international nongovernmental organisations and other partners in development usually these assessments are done on formal institutions that govern communities and households formal institutions enable access to various resources within the communities including land and water and are partly held responsible for failure in adaptation however it is important to understand the systems in which the context or arguments can be made based on the social political and ecological factors for example in nsanje district in malawi an irrigation scheme rehabilitated after participatory consultation has benefited one community and has exacerbated flooding problem in another community this presents a situation that needs to be considered when coming up with some of the adaptation and resilience projects as they might be harmful to other communities exacerbating their vulnerability whilst economically empowering other communities perhaps this also suggests that there can never be a perfect adaptation option between the government and people who are affected with the floods and among different communities in the flood prone areas in some cases social injustice is inevitable when designing climate change adaptation programs because vulnerability is complex and linked to other areas geographically addressing vulnerability issues in one area might therefore unintentionally affect other people in other spatial locations this thesis explores the dilemma that exists in the flood prone areas the associated political and economic issues how decisions are made who is consulted who benefits and the basic understanding of environmental and social management of risks and plans that are involved chapter summary this chapter has presented an exploration on the impact of floods on sustainable development who is affected why they are affected and how adaptation can be designed in order to reduce vulnerability to floods based on the review it is clear that vulnerability is multifaceted and is generated by multiple factors including biophysical socioeconomic political cultural beliefs and norms and other factors that are specific to a particular setting chapter three research methodology introduction this chapter describes the research methodology under which this research was undertaken importantly this chapter describes the data that was collected a mixed method approach was used to collect data relevant for this research this is where both quantitative and qualitative data is collected to understand various research topics in context i used a household survey key informant interviews focus group discussions and participant observations to collect data for this research the chapter provides details of the type of data that was collected how it was collected why it was collected that way and how it was analysed in response to the research questions study limitations are also highlighted to indicate the jurisdictions and boundaries within which this research was conducted and within which its findings apply research design in this research i used a case study design to explain describe and explore selfperceived vulnerability to floods and local adaptation in nsanje district in malawi under an interpretivist epistemology at both household and community level interpretivist epistemology is an understanding that there are several realities depending on the context through which the reality is constructed and that the reality can never be objectively determined and perceived hudson and ozanne define ontology as the nature of reality that is characterised and influenced by several factors within a particular setting and context epistemology on the other hand has been defined as the way in which the reality is captured by a researcher within the particular settings that forms a reality it is a relationship that exists between the researcher and the situation on the ground that form a reality the interpretivist epistemology approach helped me as a researcher to understand how the communities living in flood prone areas perceive their vulnerability to floods the social realities obtained enabled me to also understand how the communities have been able to cope with the floods for several decades and why they have refused to relocate to safer areas that are not prone to flooding in my research it was important to understand the motivations significances explanations and other subjective experiences that are applicable and make sense to the smallholder farmers that live in the flood prone areas this research therefore needed to adopt the interpretivist approach it did and acknowledge that these findings are true to the communities living in the flood prone areas without any preconceived beliefs and ideas that could have shaped the findings population of the study the research areas for the study were sampled out of the whole community that live in the flood prone area through a community mapping exercise the community mapping exercise enabled me to identify areas that experience severe flooding to determine the study sites to focus on furthermore data collection involved a series of key informant interviews focus group discussions and a household survey where a unique sampling process for each method was undertaken as will be discussed later on in the chapter firstly i will provide details of the community mapping exercise community mapping i conducted a community mapping exercise at the district council office with the help of the district civil protection committee members including the district disaster risk management officer the environmental district officer the district environmental health officer the district social welfare officer and area civil protection committee representatives the area civil protection committee representatives are based in the flood prone areas and more knowledgeable on the maps and environmental changes that have occurred due to the floods the aim was to identify with reference to the district maps areas of high vulnerability in relation to exposure to floods and droughts from their experience of flood response this exercise was done during the first planning meeting to enable me to allocate resources accordingly and also to inquire how the areas where accessible on the maps 46 group village headmen under traditional authorities mlolo mbenje ndamera and nyachikadza were identified by united nations disaster assessment coordination team as being at risk of floods because of their location however even though all the areas are affected by the floods the magnitude of the impact is not the same according to dodma and it was also indicated by the dcpc members a combination of community representatives and district officials working in disaster prone areas was essential because there was a discussion on which areas where worse off and better off also adaptation activities that are being implemented in the areas to reduce vulnerability to floods during this mapping exercise the places where the people who are affected by the floods migrate temporarily during the floods were indicated this exercise helped me to strategically identify participants for key informant interviews to understand the interdependence between the smallholder farmers living in the flood prone areas and those living in upland areas based on the community mapping the dcpc also indicated nongovernmental organisations that are working in the areas to reduce the vulnerability to floods from the community mapping it was shown that there were several climate change adaptation initiatives in ta mlolo that included irrigation farming whilst there was none in ta nyachikadza according to the ddp the areas that are under ta nyachikadza were declared uninhabitable due to the severity in exposure to floods the area is surrounded by a marsh hence with the frequent flood experiences smallholder farmers were advised to relocate to upland areas through dodma officials to which they have refused the dcpc members were able to indicate some areas that have been complying by adopting new conservation agriculture and climate change related activities more than other areas this according to the committee enables them to identify new areas that need interventions in terms of coping with the adverse weather effects in addition it enables them to monitor progress and identify gaps in their approaches this exercise was beneficial to me because it enabled me as a researcher to have an idea of the places i was going to conduct my research and also clarified and deepened my understanding on some of the community behaviours that i noted whilst collecting data the community mapping exercise was also done to explore and relate what communities in flood prone areas do to reduce their vulnerability how they become innovative and what decisions they make in relation to reducing their vulnerability this was done to be able to compare what is documented in district documents such as the socioeconomic profiles and development plans with what i would find in the field since 46 group village headmen and their people were affected by the floods i had to determine the actual research sites which also determined who would be eligible to participate in the research at district level the areas are divided into traditional areas which are then sub divided into group villages and then villages in other words a group village comprises of several villages a traditional area comprises of several group villages and a district comprises of several traditional areas sampling procedure a purposive sampling was used to determine which individuals and households were to participate in the research according to palinkas et al palys and suri purposive sampling is a sampling technique whereby the sample is chosen based on a certain criteria determined by the researchers interest in order to obtain applicable data in relation to significance meaningful understanding and depth of the researched matter out of the 46 group village headmen 10 group village headmen were identified as being severely hit by the floods based on the flood assessments and extent of exposure to floods i then narrowed my research to focus on communities living in these 10 group village headmen based on the guidance and prior knowledge obtained from the dcpc members the same applied for nsanje district as described in the previous section however not every community living in the 10 group village headmen participated in the survey neither did all the communities along the shire river in traditional authority kunthembwe participate in the research i had to determine the actual sample size for the research according to the different methods that were undertaken sample size in terms of sample size this research involved 227 households during the household survey and 12 focus group discussions with communities in addition 57 key informant interviews were conducted i acknowledge that the sample size varies with the type of research and size of population so there can never be a specific and fixed size the household survey was conducted before the 2015 floods whilst the focus group discussions and key informant interviews were conducted after the floods the floods came earlier than expected but only after the sampling processes identified those to take part in key informant interviews and focus group discussions i reviewed literature for sample sizes for various research as per academic researchers experience and expertise there has been debate on the sample size that should be considered adequate for qualitative research depending on the type of study whilst charmaz indicated that 25 is the right size green and thorogood suggested that a sample size of 20 should be adequate ritchie et al suggested that a sample size close to 50 should be adequate because with such a bigger sample one is certain that all the information that was expected to be captured will have been captured in addition to this they claim that it is very likely that no new concept will have been missed from all the 50 research participants sandelowski suggested that if the sample size for research is relatively big and complex the research presents a new and richly textured understanding of experience based on this understanding i am confident that the data for this research that has been collected using mixed methods through household survey key informant interviews focus group discussions and participant observation has adequately answered my research questions data collection baxter and jack indicated that a case study is an approach that helps a researcher to explore a phenomenon within its context using a variety of data sources in order to understand the cases thoroughly data was collected through both quantitative methods namely a household survey and qualitative methods namely key informant interviews focus group discussions and participant observations i used multiple sources of data collection so that i should also increase credibility of my research also referred to as methodological triangulation in social science research methodological triangulation is a way in which multiple data collection methods are combined when collecting the same type of data at different places and at different times in order to increase the strength of the information that is being collected in social science research in this research people living in three communities participated two communities in nsanje the comparative study was very important because it helped me to deepen my understanding of the different cases and be able to relate compare and contrast critically understanding how communities perceived their vulnerability to floods and how they cope with the environmental changes in different contexts also deepened my understanding and application of political ecology theories however in each community based on the communities definition of wealth status the households were grouped according to their socioeconomic status there were three groups based on whether the households were very poor had average income or were relatively rich using participatory wealth ranking which is described in the next section under household sampling quantitative data quantitative data for this research was collected through a household survey using a semistructured questionnaire ie household survey however the questionnaire also contained a section where qualitative data was collected this method was used to determine how communities perceive their vulnerability to floods how they rank their risks in the flood prone areas and what they are doing to cope with the floods this method was also used to explore livelihood options and community behaviours that needed to be deeply understood through participant observation focus group discussion and key informant interviews household survey a total of 227 households were involved in the household survey with the help of research assistants whose positionality is described under the research assistant section research assistants spent 45 minutes to 1 hour with each household a total of 52 farming households participated in each of the 4 traditional authorities in nsanje district traditional authority mlolo mbenje nyachikadza and ndamera in traditional authority kunthembwe only 19 households participated in the survey the sample size was smaller than the other traditional authorities in nsanje because firstly the affected area was relatively smaller than the one in nsanje district secondly the survey was conducted to understand how the communities living in this different catchment of the shire river basin middle shire perceive their vulnerability to floods and how they adapt this area is also prone to floods the communities have never experienced severe floods before january 2015 communities in traditional authority kunthembwe experience droughts and had started practicing irrigation agriculture in 2013 usually there has been excessive run off from this area that contributed to flash floods in nsanje however in january 2019 communities lost all their farm land due to the rainfall which according to the data i collected in nsanje had contributed to the change in the soil structure therefore i decided to also conduct a household survey to understand how communities perceive their vulnerability to floods and learn from them of initiatives they are taking to mitigate the effects and manage the flood risk for sustainability in addition i also wanted to find out how they perceive environmental degradation flooding and agriculture specifically the household survey was used to collect information on how households understand the incidents of floods and droughts what causes them and what the associated effects are the survey was also used to obtain information on how households identify risks and the associated security issues in terms of their perception this enabled me to understand the motivation and willingness to participate in activities that reduce their vulnerability i only referred to activities that are specifically designed by the government and partners in development to increase household resilience to floods and droughts households were also asked to weigh the risks which they identified in relation to the issues they face and rank each risk on a scale that ranges from very mild to extremely severe furthermore the individuals were asked how as a household they come up with decisions that reduce their vulnerability to floods and droughts the assumptions they make and who they involve and consult there was a sampling process that was used to determine who was to take part in the survey as described in the next section household sampling process the list of households periodically affected during the floods in the targeted areas was collected at the office of disaster management affairs under the nsanje district commissioners office in nsanje i also followed the same procedures in blantyre district the list was then verified at respective traditional authorities through the area civil protection committees the list was verified to make sure that it was up to date since there are some familieshouseholds that relocate to other areas for various reasons including but not limited to marriage and job opportunities in addition i also wanted to be certain that the people that were indicated on the list indeed live in the various villages as sometimes the lists are altered for political reasons for distribution of campaign and other materials the other times the lists are combined strategically to facilitate implementation of donor projects and other requirements during relief distribution the list is based on number of households that form a particular village in order to facilitate the distribution of developing projects and humanitarian aid a household comprises of individuals that feed from the same pot and consider themselves to be a family i used stratified random sampling to identify research participants in all the three groups the stratification was important so that i should collect comprehensive data from all the social classes to understand how the households perceive their vulnerability and local adaptation the variation in perception and local adaptation strategies was also important to understand how the social inequalities and social injustice play a role in perceived vulnerability and local adaptive capacity to the floods droughts and extreme weather events in addition the inclusion of all social groups ensured inclusiveness of research participants and eliminated social biases that naturally exist in rural communities within each group 17 households were selected at random in order to do this all households in each of the three groups was allocated a number which was written on a small piece of paper the pieces of paper with numbers on them were rolled and placed in a small basket some members of the community including the chief and area and village committee members then picked the small pieces of paper only those households whose numbers were picked were eligible to be interviewed and were interviewed after obtaining their consent out of the selected 17 households per group survey participants alternated between males and females to balance the gender of the research participants to get an equal number of males and females however there were 109 males and 118 females who contributed to the households there were more female research participants because there were more female headed households in the poorest of the poor groups than male headed households out of the 227 households 70 households were poor based on the participatory wealth ranking exercise from which 40 were female headed data entry and analysis i used the statistical package for social sciences package for data entry and simple analyses mainly frequencies mean mode and simple correlations i designed the data entry template and together with a data entry clerk entered all the quantitative data that was collected during the household survey continuous data was summarized using measures of central tendency such as means mode median and range categorical data was summarized using frequency counts and proportions inferential statistics was also used sparingly especially when applying correlation analyses the findings that were drawn from the sampled research participants were used to interpret certain actions and describe relationships that exist between different factors and processes in the flood prone areas using nvivo i grouped the responses from open ended questions to identify themes that were critical during the research to enhance my understanding of how smallholder farmers perceive their vulnerability to floods and how they are coping i also used nvivo to identify themes from the qualitative data that was collected through key informant interviews and focus group discussions the full details on qualitative data and analysis is given in the next section qualitative data qualitative case study methodology enables researchers to study complicated phenomenon within their context using descriptive data guiding questions were used to guide the fgd and kii the aim was to collect similar information but at different levels to enhance triangulation of the data the focus in this case was on collective community perception to floods droughts and extreme weather events and local adaptation in addition i wanted to explore community responses to floods and droughts and the social networks that help communities to be resilient to floods and droughts as part of adaptation strategies the aim was to be able to differentiate the responses between households and communities and also to triangulate and deeply understand some of the information that was collected during household interviews and participant observation for example to deeply understand why temporary migration as opposed to permanent migration is relevant in the flood prone areas in some cases some of the information collected during the focus group discussion was even more deeply understood during interviews with key informants more especially information on historical contexts of the floods environmental refugees interdependence between communities living in flood prone areas and those living uplands social networks and transfer of knowledge and information between communities in relation to adaptation to floods key informant interviews i personally conducted 57 kii with selected small participant and key stakeholders at the district level using a question guide kii took approximately 1 hour and 30 minutes at the community level i interviewed 1 traditional authority 2 village headmen 2 members of the civil protection committee and 5 smallholder farmers living in nearby communities not affected by the floods themselves but have the interdependence relationship with the flood victims for the key stakeholders i interviewed 1 district commissioner 1 disaster management affairs officer 1 environmental officer 1 member of the district civil protect committee 1 district agriculture development officer and 2 officers working in relief agencies international nongovernmental organisation with a focus on climate change i also interviewed a total of 23 participant who had been experiencing the floods for over a decade and have lived in the flood prone areas since birth all these participants were identified strategically through the sampling process in terms of gender there were more males than females and partly it was because the males held the strategic positions that i targeted in addition even at community level influential people that were identified and those holding positions in civil protection meetings were men key informant sampling a snowballing process was used to come up with key informants that participated in the interviews based on professional expertise and community knowledge on vulnerability to floods and local adaption at district level the list of key stakeholders was strategically identified based on the positions that the individuals held the positions had an implication on the significant role they played in disaster related issues including the floods i also used my personal professional knowledge through my previous role as a civil servant in the area to identify some of the key people that were interviewed at professional level at the research sites the first people to be contacted were the chiefs and civil protection committee members who gave me names of participants who could provide the information that i was looking for the selection of the communities was made based on the communities experiences and understanding of the floods and local adaptation in the community since the wealth and social classes played a major role in the research these people directed me accordingly so i had a balance of views from different social classes in my research sites through the process communities living in neighboring villages to the research sites were also identified as playing a major role in local adaptation to floods it was indicated that the communities in the neighboring villages have extensive social networks with the flood victims and provide shelter to the flood victims during the floods information collected at the district council also indicated that there is an interdependent relationship between the affected households and those from neighbouring villages therefore i included key informants from the neighbouring villages to the research sites to have a deeper understanding of how these different groups of participants relate and how they depend on each other in addition i wanted to understand if over the years they also have made deliberate changes in their livelihood and adaptation initiatives due to noticeable environmental changes i also wanted to investigate if there are any long term strategies that are in place in terms of the support they offer to the flood victims in addition to the temporal short term strategies additional information to deepen my understanding was collected through focus group discussions with selected communities focus group discussions a series of 12 focused group discussions were conducted with smallholder farmers living in the flood prone areas three focus group discussions were conducted in each of the four study areas using guiding questions the discussions took approximately 1 hour the aim was to determine how the communities collectively perceived their vulnerability to floods and how they were adapting to floods locally at community level the first group comprised of men only the second group comprised of women only and the last group comprised of youth the gender groups of male and females were separated in order to give women room to discuss the vulnerability issues freely due to the patrilineal tradition in most cases women do not raise their concerns in the presence of men and are not comfortable to disagree with mens point of view the youth groups however comprised of young men and women because due to the nature of their age less than 35 years old in most cases young women are able to talk freely even in the presence of young men unlike the older generation the focus group discussions were conducted with 9 participants in 1 womenonly focus group discussion in nsanje and 11 participants in the remaining 11 focus group discussions only participants that were randomly selected through a list that was collected at the district council and verified at the ta participated in the focus group discussion sampling process for the fgds a mixture of participnts in different social classes were identified through purposive sampling the fgds enabled me as a researcher to understand some community approaches and concepts that might have been missed out during the household survey and key informant interviews but were relevant to understanding participants selfperceived vulnerability to floods and local adaptations using the political ecology theoretical framework in addition i also observed some of the behaviours in the flood prone areas to have an understanding of the study areas and context in which they were applicable participant observation participant observation refers to studying households within a community whilst living with them with the aim of understanding the meaning behind their actions the participant observations lasted two weeks in each community in order to deepen my understanding in terms of their livelihoods their perception towards vulnerability to floods and droughts and how they make livelihood decisions furthermore it enabled me to understand how participants see their world and how they construct their reality which then enabled me to understand the findings and discuss in context data entry and analysis for all the qualitative data i firstly gathered the data based on the different methodology using mostly nvivo 11 i entered all the data that i collected based on the themes that i had identified ie selfperceived vulnerability vulnerability and risk crop production and postharvest handling and local adaptation for the responses under the themes i provided different codes and colours to distinguish the different responses under subthemes and also to enable me to isolate the responses for analysis based on the various responses in different codes i then grouped similar responses to create other emerging themes from the findings which were the novel contributions of my research data analysis strategy data analysis for this thesis was led by the research questions that formed the basis of the research in addition literature review on differentiated vulnerability and local adaptation in various spatial locations in developing countries partly influenced the way the results and discussion chapters were shaped firstly it was based on how the communities who live in flood prone areas frame their vulnerability to floods the data under this theme was further grouped and interpreted based on various factors that influenced the differentiation in the responses on how communities perceived their vulnerability to floods thereby also influencing how they frame their vulnerability to floods as it is presented in chapter 5 this analysis adds more knowledge on differentiated vulnerability mainly illustrating that selfperceived vulnerability is also differentiated therefore selfperceptions at all levels should be incorporated in climate related decisions policies and programs in order to design programs that would adequately reduce vulnerability to climate variability secondly the data was analysed to explore the various factors that motivated the communities to continue living in the flood prone areas despite the evidence that the areas are exposed to floods hence their livelihood is at risk this analysis that is presented in chapter 6 further illustrates that in some cases communities also benefit from living in flood prone areas therefore disaster related policy makers should be aware of such benefits and formulate disaster related policies that support the positive attributes rather than only focusing on the negative aspects unisdr focus on the safety of the communities that live in disaster prone areas and suggests that relocation to safer areas is the best solution however in some spatial locations promoting best livelihood options within the flood prone areas reduces further vulnerability to climate variability and is the preferred solution by the communities that are affected by the disasters limitations of the study although there was much effort to make certain that all study limitations were taken into considerations there are a few limitations that need to be highlighted firstly the research being crosssectional in nature there are chances that the information collected and explained represent the perceptions of the communities during the particular research period and may not be true for the other times this research therefore does not depict changes in communitys perception over a period of time and cannot guarantee that there can never be any changes in due course this study therefore is limited in terms of continuity and following up of participants to deepen the understanding of the continuous effect of climate variability in perceived vulnerability and behaviour change in addressing the floods droughts and dry spells secondly there was a gap during the data collecting period due to floods in some research sites as a result some areas became impassable hence we could not visit some of the farms and areas that are extremely exposed to flooding to have an idea of what it means to be farming and living in areas that are extremely exposed to flooding however the data that i collected provides evidence that vulnerability to floods is subjective and that selfperceived vulnerability is influenced by various factor and processes that interplay within the flood prone areas in addition my study illustrates that local adaptation is complex and that communities cope with floods differently my study provides an overview of how smallholder perceive their vulnerability to flood and how they are coping with the floods however i acknowledge that the extent and context of vulnerability and also the dynamics of local adapting in my study might be different in other areas thirdly i acknowledge that this thesis is based on my understanding of political ecology and that therefore the study findings might reflect different arguments from studies that would be conducted using different approaches in addition the context within which the issues of gender culture vulnerability and local adaptation are discussed in this thesis are subjective to the context of vulnerability to floods and local adaptation in flood prone areas in malawi therefore i acknowledge that there are other cases that would reflect these issues differently the findings from this research however adequately reflects that vulnerability in flood prone areas is exacerbated by floods and other factors that interplay within the areas it is important therefore to integrate such factors during design and implementation of adaptation programs that aim at reducing vulnerability in flood prone areas fourthly i would like to acknowledge that this research has limitations in the way male and female research participants emotions are being discussed because i did not focus much on the emotions but rather the actual responses between the two groups of people during and after flooding which are related to emotions in addition the issues of false consciousness in relation to some behaviours that are gender related myths and beliefs in the case studies can be debatable chapter summary this methodology chapter has provided detailed information on how the data for the research was collected and the analytical processes that were undertaken it has described how the quantitative and partly qualitative data was collected through household surveys and how most of the qualitative data was collected through key informant interviews focus group discussions and participant observations furthermore the chapter details how spss and nvivo were used to aid analysis of the data that was collected finally the chapter presented the study limitations which provide an indication of the context within which the study was conducted and therefore the context within which findings are valid chapter four research findings and discussion introduction this chapter presents wider publics perceptions of the vulnerability of the smallholder farmers who live in flood prone areas it also presents findings and discussion on how communities living in flood prone areas in nsanje frame their vulnerability to floods based on their own perceptions this selfperceived vulnerability to floods is differentiated based on geographical location and position personal experience frequency of the floods age gender and emotions the chapter also presents the factors that have contributed to some communities being more vulnerable to the floods than others including low socioeconomic status lack of social networks and inability to cope with the floods combestfriedman et al emphasise that households that live in flood prone areas are aware of the increase of rainfall and changes in the intensity of floods hence these people are aware of the associated risks the important debate however is whether households in the flood prone areas are able to cope with the floods and will be resilient to the floods in the long term demski et al explored the extent to which personal exposure to floods influences how the affected people perceive their vulnerability to floods and therefore engage in climate change adaptation and mitigation initiatives their findings indicate that statistically those that experience floods have high risk perceptions and are likely to be involved in adaptive actions in some cases however demski et al found that there was no difference in perceived vulnerability to floods between those that are affected by the floods and the public it is important to unpack the extent to which perceived vulnerability to floods is similar between communities that are affected by the floods and those that are not affected within a particular context in order to critically explore the similarities and differences that exist the fact that in some cases personal exposure does not influence perceived vulnerability to floods suggests that in those instances communities can continue living their normal lives without taking appropriate actions to adapt to the environmental changes they experience this chapter therefore seeks to illustrate and understand how communities perceive their vulnerability to floods and to critically examine the factors and processes that influence the perceived vulnerability to floods in order to understand the link between selfperceived vulnerability and local adaption to floods in context communities in nsanje emphasised that floods are part of their lives and livelihoods the smallholder farmers have been experiencing floods for over six decades during which they have on occasions had to relocate in the flooding season it is important to note however that the discrepancy in the number of years that communities have been experiencing the floods is due to lack of specific secondary data in the district council and national documents the period in the documents is estimated to be just over two decades when the communities in research sites indicate that it is over six decades this in itself highlights the importance of conducting the research in the selected research sites and to some extent contributes to the discrepancy in perceived vulnerability to floods this chapter illustrates through qualitative data and quantitative data that there is a need to understand and contextualise selfperceived vulnerability to floods and sustainability the responses from the communities elucidate the realities of vulnerability to floods and point out to the factors that can assist the government of malawi in the design and implementation of climate change adaptation strategies that reduce vulnerability to floods for people that are affected in various locations in addition the insights shared in the districtlevel interviews reveals that most of the time the media does not report on the most important topics that form the livelihood of the communities living on the flood prone areas from the data it is evident that it is vital to understand the complexity of the lives of the people living in the flood prone areas to successfully address climate change vulnerability and adaptation challenges at policy program and project level public discourse towards communities that live in flood prone areas interviews with key stakeholders including government officials journalists officials working in related organisations and some communities living in upland communities indicated that the communities living in flood prone areas are stubborn and enjoy receiving humanitarian aid and support during the floods communities that live in flood prone areas are stubborn they deliberately refuse to relocate to upland areas because they know that the government will always support them during floods in addition the government officials who work at the district council indicated that we have told them to move upland several times but they do not move we do not know how they want us to tell them information was officially sent in 2020 and we remind them every now again they are very stubborn it is evident therefore that little is known about the processes and factors that influence the communities to continue living in the flood prone areas which influences public perception towards the vulnerability of communities that live in flood prone areas this often results in misconception and inappropriate adaptation strategies which do not incorporate the realities of vulnerability in the flood prone areas some officials working for nongovernmental organisations and civil society organisations working in the area and others who visited nsanje to support the people affected with the floods indicated that they have been supporting the affected people for over 5 years but that despite this support that the people are becoming more vulnerable to the floods rather than better able to cope with them i remember the first time i came to support the people affected with the floods here there were only a few people who were affected and many areas that have been affected now were not affected then that time some of the people who were affected then have been affected again now they were told to relocate that time but they never relocated i personally cannot understand why they choose to suffer during floods when they could be in safer places in addition another official indicated that our organisation has been on the governments side advising communities to relocate to safer areas they have refused to relocate i believe it is because they know that during the floods the government humanitarian organisations and other wellwishers would always send relief items to support them they are so dependent on the humanitarian aid i wish they could love their lives more and relocate another key informant also indicated that to some extent i think organisations and the people themselves have contributed towards their continuous stay in the flood prone areas as a humanitarian worker i get busy when such incidents happen these people in their situation have created work opportunities for us without them we could be jobless the other part of us feels they should indeed move whilst the other part of us is glad that we have work to do it is a complicated situation it is evident that communities living in the flood prone areas are not given an opportunity to express themselves in order to be understood how they perceive their own vulnerability to floods and even why they communities are motivated to live in the flood prone areas the lack of knowledge on the communities perspectives has created a general misconception of the livelihood of these communities one participant indicated that it is unfortunate that some people out there think we love and enjoy receiving handouts in form of humanitarian aid and support i wish we could be given an opportunity to tell them how humiliating it is to be in camps where there is no personal freedom and the support we get is not enough for our families these words accentuate the point that there is a meaningful gap in knowledge of perceptions towards vulnerability between the communities living in flood prone areas and the policy makers and also key stakeholders that are implementing disaster risk reduction and climate change adaptation programs the results from the household survey indicate that all the smallholder farmers that participated in the research would like to be supported in a way that they become independent rather than being dependent on humanitarian aid the proposed strategies included being supported with farming inputs and tents to put up temporary structures whilst they work towards settling down after the floods whilst policy makers are determined to move the communities from the flood prone areas communities themselves indicate that they are comfortable in the flood prone areas based on reasons that are valid to them the misunderstanding between these parties creates questions on who these policies are designed for if the ones that are affected by the policies have a different perception the next section presents how communities living in flood prone areas perceive their own vulnerability to floods in addition it highlights how their perception to floods is differentiated and what factors influence the different perceptions communities frame vulnerability to floods as part of their livelihood which is contrary to how the public presents it as a fatal risk that requires permanent relocation to upland areas that are safe selfperceived vulnerability to floods according to communities who live in flood prone areas their perspective of the floods is influenced by the location where they live their personal interaction with the floods age the timing and severity of the floods loss of life emotions and gender the next sections expand on these factors to present an understanding of how they influence selfperceived vulnerability to floods in the flood prone areas selfperceived vulnerability to floods by location some communities derived their selfperceived vulnerability based on the location where they live which they referred to at different scales from the district level to village level communities in nsanje are more vulnerable to floods usually the floods just sweep off the top soils our homes are intact and not all our crops are destroyed unlike the smallholder farmers in nsanje we hear they lose their crops and even homes are destroyed according to the household survey all the respondents in nsanje were aware that communities in nsanje are more vulnerable to floods than them for various reasons during focus group discussions some of the indicators of vulnerability that were mentioned included the extent of damage caused by the floods in nsanje as well as the way they are exposed due to the location lower shire valley a traditional chief in kunthembwe explained that we are lucky that we are upland our friends from the lower shire valley are in big trouble all the water from upland ends there i hear they benefit from the fertile soils after the floods but they lose everything we are less vulnerable than the communities in nsanje in nsanje during household survey key informant interviews and focus group discussions communities said that they are aware of their vulnerability to floods due to their geographical position a lady from ta mlolo who is also a civil protection committee member explained that we are more vulnerable to floods because our friends in the upper shire catchments have cut down trees hence contributing to soil erosion and which makes water not to sink into the ground but run over the top soils during the rainy season as a result we are always the victims during the rainy seasons apart from the geographical position in nsanje these communities attribute their vulnerability to floods due to environmental degradation that has been caused and exacerbated by the smallholder farmers living in the upper catchment of the shire river in addition a male participant who is 75 years old and living in ta nyachikadza in nsanje district indicated that they have become more vulnerable because of the changes in the rainfall patterns and amount we have always lived close to the marshy areas all our lives and it is only recently due to changes in the way the rain is falling nowadays and the times in which the rainfall starts and end also the amounts of the rainfall that we have been experiencing the disastrous floods frequently a combination of geographical position rainfall patterns and environmental degradation in the upper shire river catchment has been indicated as causing communities in nsanje to be more vulnerable to floods than in other disticts settling in flood prone areas changes in land use and deforestation are some of the factors that have caused global vulnerability to floods these authors indicate that extreme hydrological events are also a natural phenomenon that will continue to occur regardless of all the underlying factors and suggesting that it is necessary to understand the extreme hydrological events and live with them over a decade the data that i collected in addition to other national documents that i reviewed indicate that although hydrological extremes occur naturally changes in land use and deforestation in upper areas have exacerbated vulnerability to communities living in flood prone areas clearly this indicates that vulnerability is more complicated with several factors that exacerbate it different locations are affected differently by floods based on various factors in 2000 it was indicated that the fight against floods and droughts by all the stakeholders in the mediterranean region had not been successful there are various reasons that have resulted to the communities not being able to cope with the floods and droughts in various places the need to further understand the context in which communities are failing to cope with the floods and droughts helps to scrutinise the challenges and therefore often offers appropriate strategies that are strategically targeted to deal with the underlying challenges kundzewicz stress that higher and more intense precipitation is being observed around the globe and that some places are more exposed to such precipitation than others hence create a difference in the levels of vulnerability this is still the case in many parts of the world where vulnerability varies depending on the extent of exposure to the rainfall and the effects adaptation strategies that aim at reducing the effects of floods should not adopt a onesizefitsall approach the approach should instead be on specific and appropriate measures that are applicable to the region country district area and village in question the more that communities are exposed to floods the more they struggle to cope with them in bangladesh people who live in areas that are not heavily affected by floods and live in better socioeconomic conditions are likely to cope with the floods better than people who are more vulnerable to the floods and are worse off in terms of their socioeconomic conditions in the philippines households are aware that there have been an increase in rainfall rainfall variability an increase in the intensity and frequency of storm events however in terms of perceived risk to floods their results indicate that spatial location and resource dependency are the factors that determine their perceived risk to floods whilst the social economic conditions do not have any influence nevertheless social economic conditions are factors that characterise households and communities and therefore very critical in adaptive capacity however the extent to which selfperceived vulnerability and social economic conditions influences perceived risk to floods needs to be unpacked in context in order to provide contextual evidence of the claims to some extent individuals make decisions on their vulnerability and how to cope with their vulnerability partly based on the available resources for example in my study area the poorest of the poor indicated that they are more vulnerable to floods because they do not have an alternative source of livelihood neither do they have valuable assets that they can sell during or after a disaster to help themselves the rich however people whose economic status is high based on their local indicators indicated that they are exposed to the floods but are not very vulnerable they explained that they have valuable assets which they rent out and sell during and after a disaster for their survival hence their livelihood is not hugely affected however combestfriedman et al concluded that spatial location is the most significant factor that determines how households perceived their flood risk to household assets but not perceived risk to their households the spatial location determines how these households will be affected in terms of losses and damages to their household assets such as blankets cups pots and furniture this scenario suggests that the people that are affected by the floods are not concerned about their lives being in danger and their livelihood but rather the assets they own which could be swept away or damaged by the floods this could be another factor that motivates the households to continue living in the flood prone areas my results on the contrary suggest that spatial location only partly influences how smallholder farmers perceive their risk and vulnerability to both household assets and livelihood therefore indicating the dynamics and complexity of selfperceived vulnerability as will be discussed in the following sections another man who before the january 2019 floods was categorised as a middle class farmer indicated that floods have been part of us for a very long time however with the recent experience of floods in january 2015 we feel helpless floods are now posing a real threat all our assets have been destroyed including our farm land previously we were rejoicing when floods came because we could get fertile soils that enhanced our agricultural production during the january 2019 floods our soils have changed and we do not know what to grow this is a big blow to us the results indicate that with the increase in the intensity and severity of floods over time the smallholder farmers have realised that the floods put both their household assets and livelihood at risk and that they are more vulnerable to floods the results further suggests that perception can change over time depending on the extent of risk and severity of the floods that determine the extent to which the smallholder farmers become vulnerable to floods in this case the findings indicate that floods damaged the farm lands in 2019 unlike the previous years where only household assets were damaged these findings also suggest that the extent and type of damage varies depending on the geographical positions where communities that are in low lying areas suffer more and differently than those in upper areas the variation in how vulnerability is framed suggests that vulnerability to climate variability is heterogeneous and dynamic and therefore that adaptation plans and strategies must acknowledge and respond to that if they are to enhance sustainable local adaptation in a dynamic environment the comparison in the case studies clearly indicates another aspect of vulnerability whereby communities are exposed to floods due to heavy rainfall environmental degradation and excessive runoff in other parts of the country contributing to wider literature the study context illustrates how complex vulnerability issues are and that there are various levels of exposure that need to be explored in various locations to understand vulnerability levels this understanding is needed further in order to design effective local adaptation strategies that are more relevant and suitable to the affected areas and affected communities in addition to this personal experience based on age and exposure to extreme floods was observed as another aspect that influences vulnerability to floods as discussed next selfperceived vulnerability based on personal experience of interactions with floods the findings illustrate the way that communities have personally experienced floods in terms of the actual suffering and number of times they have experienced severe floods have also contributed to the way communities perceive their vulnerability the previous section described vulnerability at a wider community level based on spatial location whilst this section describes individual experiences and those at the household level we have been experiencing floods for over two decades we have survived the worst floods we are exposed and more vulnerable to floods floods have become part of us we prepare for the floods experience the floods and over the years we have come up with strategies that will reduce the negative impacts of floods key informant 9 who has lived in traditional authority all his life and is over 75 years old indicated that floods are not a new phenomenon and that they have been experiencing disastrous floods several times in his life time in another key informant interview an elderly man said floods are indeed an issue of concern however it is important to note that we do not experience floods every year over the years the january 2019 floods have been the worst there are some years when we experience normal rains and we do not move floods are just one of those occurrences that happen once in a while so we are not too scared of them we live a normal life the participant emphasised that the personal experience through interaction with floods over the years has created an opportunity for them to get used to the floods and learn to live with them the communities stressed that floods are not an extraordinary problem but rather a problem that is location specific and has been incorporated in their social environment this statement suggests that personally some smallholder farmers have accepted the floods as part of their lives and though admitting that they are affected sometimes it has ceased to be a major concern that they would worry about every year this aspect of how communities frame their vulnerability based on their personal experience to floods is important because it illustrates the type of attitude the people have towards the floods therefore suggesting preferred form of intervention that should be advocated for personal experience of floods influences the way the affected people perceive their personal vulnerability and risk to floods in addition to their perceptions to climate change and the way they respond to floods however demski et al also highlight that there are some cases in the united kingdom whereby some individuals who have never experienced a disaster before can perceive the vulnerability to disasters similarly to those that have experienced disasters these findings therefore suggests that there is need to understand ways in which personal experience affect peoples perception towards floods and that such claims should not be generalised but rather should be contextualised my research suggests that personal experience with the floods is significant in determining how the communities perceive their vulnerability to floods and that it is different from the public that does not experience floods during household interviews focus group discussions and key informant interviews the communities were able to distinguish their selfperceived vulnerability to floods based on the different times and circumstances when they had experienced the floods the extent of damage that was caused by the floods and the intensity of their vulnerability in all those times in addition this thesis overall suggests that apart from the actual flooding experience there are several other endogenous and exogenous factors that have influenced the communities selfperceived vulnerability to floods as evidenced by another study in chile lara et al emphasise that spatial locations timing of the floods gender and environmental degradation in the upland areas influence how smallholder farmers perceive their vulnerability to floods in context whilst some factors and processes are relevant in some areas these may be different in other areas hence the different factors that are being mentioned by different scholars to be influencing perceived vulnerability the nsanje case presents evidence of where location and personal experience influence selfperceived vulnerability to floods as will be discussed next in tas nyachikadza and ndamera the communities have been experiencing flood for over 2 decades similar to ta mlolo however to them as indicated in the quotes floods have always been a part of their lives and they were used to them until the 2015 floods which were different due to their timing and extreme nature the disastrous floods came during the middle of the night an old man indicated that we have experienced floods for a very long time and in all those times we were able to relocate to neighbouring villages with our belongings in good time the only difference is that this time the floods came unexpectedly and at night the whole area was flooded in less than 10 minutes hence we could not think we struggled to save our lives and lost all that we had our household items farm produce and boats it is as if we have lost our livelihood we have no idea of where to start from now the inability to prepare for the floods and relocate prior to the floods has changed the way in which some communities perceived their vulnerability to floods this emphasises that selfperceived vulnerability to a risk is not constant it changes over time based on the extent of personal exposure the ability to prepare for the floods and relocate before the areas are flooded and associated damage to personal assets whilst some smallholder farmers indicated that floods are part of their normal lives some of the key informant interviewees indicated that they are more vulnerable now and helpless after the january 2015 floods similar findings are reported in a study in lagos city nigeria by adelekan and asiyanbi their findings illustrate that each city is affected by climate variability differently even though they are all in the same country implying that context of vulnerability and therefore adaptation needs and resources cannot be generalised and should never be uniform but rather each case should be treated differently based on adaptation needs and personal interaction with the floods this thesis emphasises the extent of severity of floods in different locations and therefore that vulnerability to floods differs based on geographical settings it also emphasises that the ability to cope with the floods and climate variability differs amongst different individuals based on their personal circumstances the factors that cause vulnerability in the different settings can never be the same the geographical boundary can go beyond citiesdistricts to as small as village level as found in this thesis it is evident that in nsanje district regardless of location and type of hazard individual experience with the flooding situation is crucial in vulnerability and local adaptation studies as it builds selfperception to vulnerability and over time helps those that are affected with the floods to find ways of coping however it was also evident that people are used to the situation where they are able to monitor the floods and have enough time to relocate in the event where they were not able to adequately prepare for the floods they lost all their assets and some people lost their lives this situation suggests that communities are used to certain ways in which flooding events occur and how they prepare for the floods in the event where there is a slight change in occurrence mainly the middle class communities and poor communities are disturbed and become more vulnerable unlike the perceived rich communities within the same locations over time however this research would suggest that the affected people would similarly find a way of coping with the new form of threat on the other hand people who are not able to cope with the extreme floods mainly the poorest of the poor and the elderly would be deterred from continuous exposure to a risk and choose to relocate as will be discussed in detail later on in the chapter during a focus group discussion with the chiefs and other influential communities that live in flood prone areas it was clear that the some communities who are mainly old would prefer to relocate to safer areas due to lack of strength and capacity to escape during the floods for some of us we started relocating about 10 years ago previously the floods did not come with much force hence we could still be in our homes during the flooding season with time we started relocating during floods with all our belongings now the flooding style has changed floods are coming with no notice at all this is dangerous for some of us who are growing old now and we do not have enough energy to run or change strategies relocation is better for us in addition older communities indicated the same whilst the younger generation who were still productive and have experienced floods in various dimensions were still willing to continue taking the risk indicating that the risk is more valuable that relocating to other places where their livelihood would be neglected in malawi kakota et al emphasise that the groups of people who are more vulnerable to climate change include the elderly because they are usually so poor with limited alternative source of livelihood and cash to sustain themselves during and after a disaster in relation to my study therefore the more vulnerable a particular group is to the floods in terms of age and inadequate capacity to cope with the floods the more they are willing to relocate to upland areas permanently due to the hassles the vulnerable groups experienced during the extreme weather events the selfperceived vulnerability goes beyond the individual experiences with the floods in relation to how they suffer personally and how as individuals they are able to cope with the floods over time and with age to the frequency of the floods in the area selfperceived vulnerability based on frequency and severity of floods and causing damage and loss of assets during all the focus group discussions in nsanje it was indicated that there are differences in the timings of the disastrous floods that led to relocation in nsanje district during focus group discussions communities that were relatively rich indicated that they do not perceive floods as a great risk to their lives and livelihood because of the variation in their occurrence whilst also indicating that there are other factors that influence their selfperceived vulnerability smallholder farmers indicated that floods that cause displacement and damage to household assets and houses do not occur annually yes we are vulnerable to floods however the vulnerability to floods is not something we think about every year there are some years that go by without experiencing floods that is why we remember that it is a problem during the years that we are displaced in addition another participant indicated that floods are sometimes a problem however we do not consider it a major threat because it does not happen every year if we were displaced every year i think the way we think about our vulnerability to floods would have been different in traditional mlolo however one of the chiefs said that to be honest it is during the recent years that we have now started considering floods as a threat to our livelihood we experienced disastrously floods that led to displacement in 2012 barely 3 years later we have also been displaced it is now becoming an inconvenience to us and hence we need to seriously think of a permanent solution to avoid being displaced and losing all our assets the responses from the different areas in nsanje suggest that apart from spatial locations the frequency of floods also influence selfperceived vulnerability to floods this is very important because it also influences how farmers respond to the issues of floods and the attitude towards the urgency of some of the adaptation strategies that are advocated by the government and other stakeholders during the january 2015 floods all the smallholder farmers in traditional authority mlolo indicated that they had become more vulnerable to floods than in the previous years because the soil structure had changed due to huge soil deposits in addition some communities whose soil structure had not changed indicated that they are more vulnerable to floods but because their houses farm products households items and livestock were washed away this year 2015 we have lost everything we have nowhere to stay our houses household items and livestock were washed away previously we had time to rescue our household items including farm products and livestock our houses would contain the water to a certain level during the floods but would dry off after a couple of days this year there is nothing left after the floods we have become more affected with the floods than in the previous years the communities living in traditional authority mlolo and nyachikadza are used to the floods as they have been extremely exposed to the disastrous floods over a long time during flash floods traditional authority mlolo is the first to be affected then traditional authority nyachikadza due to the geographical position of these places however their perception to floods changes when floods bring unexpected results including changes in soil structure and washing away of farmland which leaves communities with no land suitable for farming the results hereby suggest that some communities do not perceive their vulnerability to floods as a serious threat to them if their agricultural land is still suitable for farming this therefore indicates that selfperceived vulnerability also depends on the significance and attached value to what has been affected in this case the farm land provides an area for farming which forms the major part of the communitys livelihood in the areas that are heavily affected by floods mostly in traditional authority mlolo and traditional authority nyachikadza houses are strategically built with mud and poles to avoid huge losses during floods the strategic adaptation brings another aspect of selfperceived vulnerability to floods that should be accounted for in adaptation strategies in the situation where these smallholder farmers are requested to relocate to reduce vulnerability to floods they have temporary houses built with mud and poles that are easily replaced the damage of houses in the case therefore is not a significant loss to them where as it is significant to the government of malawi that is responsible for infrastructure including roads and bridges these findings raise questions about who would actually benefit from the proposed relocation the people who are affected by the floods or the government itself in terms of reduced pressure to offer support to the communities that are affected with the floods during and after the floods during the key informant interviews all the government officials that were interviewed lamented about the pressure that the government has during floods and after the floods due to inadequate funds it is evident that with limited funding the best option for the government would be for the communities that live in flood prone areas to relocate however this is contrary to what was evident during the research because many people would prefer to migrate only temporarily during the floods rather than migrating permanently in addition to this the results illustrate that the adverse effects of floods on the people goes beyond the hazard itself to the interaction of social and economic factors within the system methmann and oels illustrate that that there are several factors and processes within a system that exacerbate vulnerability to climate variability including social economic and political factors in my case studies it was revealed that specifically issues of gender influence how communities perceive their vulnerability to floods as discussed next selfperceived vulnerability to floods according to loss of life and gender apart from losing agricultural land loss of life during the floods also determines how smallholder farmers perceive their vulnerability to floods in flood prone areas a participant in traditional authority mlolo during the focus group discussion a woman indicated that i have never experienced floods to this extent my 3 children were carried away with the floods i was helpless for the first time i have realised that floods are dangerous and it is indeed dangerous to live in flood prone areas communities realise that living in the flood prone areas is dangerous after losing their loved ones this statement suggests that previously the danger of living in the flood prone areas was not considered seriously until the smallholder farmers witnessed loss of lives in an indepth interview with a man from ta mlolo who had lost a wife and 2 children he indicated that i was deeply affected with the loss of lives of my family members my wife and 2 children however life must go on so i will continue farming there and live there because it is gods will that i have now lost my family members this statement further suggests that for some communities it is not just the vulnerability to floods that is associated with the death but rather powers that they have no control over in this case he mentioned god the statement illustrates that perception to floods is influenced by not only what is lost but also the extent to which as human beings they have control over a situation and the extent to which they are able to cope with the emotions of losing household assets family members and their farmland the acknowledgement of the situation where communities realise that they have no control over nature poses an interesting debate in the prevention of disasters since in this case they have a choice to either cope with the situation or do nothing about it and face the realities of environmental changes some women were afraid to go back to the flood prone areas to avoid the trauma in ta ndamera during a women focus group discussion all the women agreed to what another woman said that i have now realised that floods are dangerous and that living in the flood prone area is not ideal with the way we suffered to get to a safer place this time i strongly agree now to the idea of relocating floods are dangerous they kill and taking chances is as if we are mentally disturbed this suggests that emotions also play an important role in determining how smallholder farmers perceive their vulnerability to floods in the case of the communities living in nsanje if it were not for the disastrous floods that caused death all the communities would have still considered floods as part of their livelihood and not as a threat during interviews and discussions women showed and illustrated that they were heavily affected when they lost their family members during the floods whilst men showed that they were dealing with their emotions in a way that was presented as another trauma as part of life this might be taken to indicate that women can be more emotional in times of bereavement hence need more psychosocial and moral support where bereavement and trauma is involved in the flood prone areas after the floods during focus group discussions and participant observation some women cried when they were explaining what they went through during the floods some women indicated that they were failing to sleep because of the memory of the flooding event whilst none of the men i interacted with indicated that they had reached that extent nsanje is a patrilineal society were the men are culturally perceived as being responsible to take care of the wife and children the women relocate and stay at their husbands land and are culturally expected to be submissive to their husbands the discrepancy in the findings on dealing with emotions will no doubt be influenced by culture and the responsibilities either part has to play in the society and also the fact that some men cannot openly admit that they are heavily affected emotionally in this setting all the women indicated that they were struggling emotionally with the loss of their beloved ones more than the men since they had to continue managing the homes whilst the men were out most of the time socialising with their friends and drinking beer sometimes a study conducted by lebel and lebel suggest that emotions are important in climate related decision making therefore they should be explored in order to understand certain behaviour within a particular environment in northern thailand women were perceived to be emotional and therefore struggled to make informed decisions when they were in an emotional state unlike men however lebel and lebel revealed that regardless of gender emotions played a role in different decision making scenarios this thesis illustrates that emotions are subjective and therefore should not be generalised based on gender but rather to an extent within which an individual has been affected by an incidence and the realities that surround them in flood prone areas and evacuation centres despite being emotional women play a major role in making certain that children and men are fed and all their household demands are met during floods all the women have the responsibility to cook for their household members fetch water for their household and do all their household chores we force ourselves to be strong because there is no one who can help us some men usually go to see friends in nearby villages whilst for us we have to be with the children and do all the chores this reinforces the point that all women are not irrational but rather many are responsible and know when to do what is expected of them even during a crisis for example even after experiencing loss of family members during the floods and some struggling with their emotions they were able to comfort their children who were also traumatised during participant observation in the field the women who suffered loss would cry when their children are out to play but remained emotionally strong in the presence of other family members after the floods the affected households evacuated to designated evacuation sites where tents were assembled for shelter during that time many men could not be found in tents during the day i was told that they were going out to chat and drink with friends during the day every day whilst socialising with others was perceived as a way to deal with their emotions women never had that opportunity due to their household responsibilities women had to stay around the camps to cook for their families including their husbands and to take care of their children amongst other chores women therefore experience tough situations and had to fulfil all the husbands and societys expectations in the home regardless of their experiences bee indicates that understanding the gendered dimension of vulnerability is relevant to design appropriate local adaptation programs that meet the needs of the communities that experience the disasters in this case understanding gender roles and responsibility before during and after the floods is critical to providing specific targeted and adequate psychosocial and emotional support to the vulnerable communities as well as guiding policy makers on the type of support that is needed and to whom rather than generalising support to the affected people reyes and lu highlights that women keep up hope for the family care for the sick and provide home in the family afriyie et al madhuri illustrate that different groups of people and genders are affected differently during floods women are emotionally stressed during and after the floods hence there is need to provide more psychosocial support to women who are bound to the evacuation sites with limited opportunity to visit friends and family members as per this thesis the sections on various factors that influence selfperceived vulnerability to floods partly explain why many communities have been living in the flood prone areas despite the associated risks according to the household survey and key informant interviews and focus group discussions communities indicated that they grow various crops and are involved in some smallscale businesses these activities are part of their livelihood in the flood prone areas that is more valuable to them and worth the risk of living in the flood prone areas in addition the frequency of the floods is such that the flooding problem does not occur annually hence giving the communities confidence to continue living in the flood prone areas subsequent chapters in the thesis discuss how communities realised that there is need for more sophisticated early warning system to prepare them during flooding and are willing to cooperate with scientists hydrogeologists and other professionals that can assist them in the design and implementation of an effective early warning system officials working in government meanwhile need to understand how the affected communities are coping with the floods identify gaps and challenges and be able to fill the gaps to achieve sustainable and effective adaptation to floods and other extreme weather events instead of insisting that the communities should relocate to safer areas this research suggests that there is need to understand the complexities of vulnerability adaptation and resilience inclusive and comprehensive vulnerability assessments and adaptation planning design and implementation is necessary to effectively adapt to the floods and other extreme weather events in ta nyachikadza and some parts of ta mlolo and ta ndamera the government stopped providing services to the communities because they were designated disaster prone areas and therefore not suitable for human settlement however during floods the government helps in evacuating the communities that are affected by the floods and offer humanitarian aid and support such as food cooking oil legumes buckets plates blankets clothes and other essential items the government in this case is still responsible and concerned about the safety of the people from the disasters this case study presents a need for governments to consider other factors that either shape or reduce the vulnerability to floods in the flood prone areas however during elections these areas are allocated voter registration sites and polling stations within the flood prone areas more details on this will be presented in the next chapter as i will be discussing on the absence and presence of the government in the flood prone areas motivations to live in flood prone areas this section focuses on factors that motivate communities to continue living in flood prone areas the factors include communitys livelihood through farming their social networks within their original homes and their attachment to the flood prone areas political ecology studies suggest that emotions are tied to a particular landscape ancestral values culture memory and dignity hence many people prefer living in their original homes places of birth and where their families are rooted from work in ghana addo and danso indicate that communities that live in flood prone areas are not willing to relocate because of a variety of reasons including low incomes and thus inability to pay rent in the new areas not willing to lose land and social networks they have built over the years and fear of losing their source of livelihood my findings as presented in this chapter indicate that these and several other factors motivate people to live in their original homes and thus to live with floods using the case study of communities living in flood prone areas the results exemplify that these factors are variously political socioeconomic and personal in nature in the previous chapter it was important to understand selfperceived vulnerability because it enabled me to understand the factors that motivate communities to live in the flood prone areas regardless of the flood risk and of the malawian governments request that they relocate to safer areas currently the government officials including the media and other stakeholders do not understand why the communities insist on living in flood prone areas despite all the associated risks this chapter presents that the factors and processes that motivate communities to live in the flood prone areas are complex in nature floods in some cases are not perceived as a main problem in the areas due to their seasonality communities also have local knowledge on the flood management hence are confident to face the floods during the flooding season other factors are political social cultural and economic in nature which are experienced personally but based in the wider community hence indicating that relocating to safer place is not easy for all communities living in the flood prone areas nevertheless there is widespread misunderstanding of motivations to live in the flood prone areas with the wider public perceiving the reluctance to move to safer areas as strategic so that the communities benefit more from relief items and other forms of humanitarian aid addo and danso highlight that communities in ghana prefer to live in the flood prone areas because they are not willing to lose their land they have low income to pay rent and they do not lose their livelihood furthermore dallman et al found that in california people prefer to live in their original homes because of emotional ties with their ancestral values culture dignity and landscape in a study of political ecology of emotions dallman et al stress that even changing the physical environment within the original home is likely to destroy some cultural and sacred places where peoples emotions are attached it is clear therefore that emotions play a role in the decision to live in the flood prone areas however the emotions can be attached to different things for example sacred places ancestral bonds culture and tradition floods not perceived as the main problem in flood prone areas the interaction between the changing environment socioeconomic culture and livelihood amongst other factors and processes in the flood prone areas has shaped the way communities weigh the problems they experience in their daily lives according to the household survey 833 of the communities living in flood prone areas indicated that they perceived hunger as their main household problem when responding to an open ended question asking communities what they perceive as their main problem apart from the areas being exposed to flooding it is often also affected by droughts which affect crop production this clearly indicates that even though these communities are exposed and vulnerable to floods the floods are not the major concern in their lives during fgds and kiis communities indicated that they perceive hunger as the main problem hunger has been a major problem in our lives for over a decade i remember those days we used to have enough food for the whole year nowadays our harvest is not adequate to last the whole year for most of us that live in the areas that experience floods we are better off because we grow fruits vegetables and even maize in the marshy areas hence making us to have enough food throughout the year and for some households most part of the year in another interview another participant said that i would never relocate upland because i know for sure that i would not be able to have enough food for my whole family most of the people in the upland areas rent part of our fields we help them to be food secure if they come to us for help it means our land is good for agriculture hence we are better off here the communities that live in flood prone areas are afraid of hunger more than the floods therefore living in flood prone areas is an advantage for them other studies also reveal that a source of livelihood is one of the reasons that communities that live in flood prone areas would not be willing to move and relocate upland however fewer studies have been conducted in rural areas where communities are living in flood prone area this chapter exemplifies that in rural areas too communities value their livelihood through farming and fishing and through their sources of income from leasing their farmlands this reveals an important aspect of livelihood decisionmaking that is decisions are made based on what is actually lost during the floods and what is not lost this chapter therefore illustrates that relocating the communities would not be an appropriate solution as many communities would not be able to sustain their livelihood upland and would not have the capacity to resettle in the new areas a man who lost everything during the floods explained that for most of us we would struggle to settle in new areas because we have lost everything it will be difficult to obtain a farm and acquire new assets in the new areas that will require a huge sum of money that we not have in addition we would not be able to buy food and bags of fertilizer that will be needed in our farms currently we do not apply fertilizer in our fields and we never buy maize this quote suggests that only communities that have other assets in the form of capital and money can afford to relocate whilst those who have nothing would suffer more if they were to relocate this also suggest that vulnerability would increase in the new areas hence it is appropriate for communities who do not have any form of asset to remain in the flood prone areas these findings are similar to a study that was conducted in thailand by tahira and kawasaki which suggested that regardless of the damage that the floods might pose the poor communities have inadequate capacity to recover hence relocating them would worsen their situation tahira and kawasaki argue that the poor communities would struggle to establish a new livelihood in new places that they would be requested to relocate to due to inadequate adaptive capacity relocating to new areas requires capital land and other assets that would help the communities to establish themselves in the new areas in the absence of these these communities would suffer therefore they suggest that the focus should be on improving the early warning system dykes and offering some form of compensation for the lost earnings my study states that communities are motivated to live in the flood prone areas because they are able to address food security issues which is the main perceived challenge to them in addition the communities clearly illustrate that they have devised ways of coping with the floods which also forms part of their motivation local knowledge and water level monitoring communities indicated that they have experienced floods for a very long time and that over time they have devised mechanism of monitoring water levels in rivers that cause flooding in the area communities explained that over the years they had come up with ways of monitoring the water levels in the rivers that flood as part of an early warning system apart from the 2015 floods the chiefs the elderly even some of the youth always observe the water levels in rivers that flood during the rainy season we place some poles other people place sticks a few metres from the river bank as a monitoring tool when the water in the river is too much the river will swell and usually water will reach the poles placed on the river banks we move the poles whenever the water reaches them up to a certain point which then we pack our things and move upland temporarily using that system we know when it is going to flood and even before then we have time to move our assets upland as we prepare for the floods that is why we have never suffered any death during floods in a key informant interview with an old man in the village he indicated that we are able to know when we are going to experience a calamity through our visit to mbona we have a sacred place in ta ngabu one of the areas in nsanje refer to case study description in chapter 2 where we go and offer sacrifices to mbona and consult him on several matters happening in our communities for us older people depending on the visit based on experience we are able to know that we are going to experience floods this is for old people like me many young ones do not take time to observe these things communities have designed their own ways of understanding the extreme weather events ranging from beliefs and myths of the mbona to innovative ways of flood monitoring using sticks based on these experiences communities have been able to evacuate from the flood prone areas in good times before the whole area is flooded in addition they have been having time to save their belongings from being swept away however as it has been explained in the earlier text all the strategies were not utilised because the floods came in the middle of the night and the communities were trapped in the floods local knowledge has also been used in various parts of malawi to predict disasters such as floods and droughts however recently communities say that both the local knowledge and climate information from the meteorological department has not been adequate as a tool for weather forecast at the local level there are no weather stations and some of the equipment in the weather station is outdated hence the unreliable weather forecasts during focus group discussions communities explained to me that we have lost trust with the climate information from the meteorology department in 2010 they told us that we are going to experience floods some people moved their belongings upland but instead we experienced droughts that year our elders said we would experience drought and they were right another woman said i remember hearing that we are going to experience floods during the day and we experienced the floods during the night a car from the district commissioner went around shouting that we should move because we would be experiencing floods as usual none of us moved because we could not believe them from what happened i would suggest we use both our local knowledge and even the information from the meteorology department if we had moved some of us could have been better off by now shaffer indicates that a mixture of indigenous knowledge and other scientific knowledge coupled with new technology is important and useful in helping communities to adapt to climate variability in their original homes the realities of climate change effects is that they have become more complex and in some cases difficult to predict using the traditional means of monitoring the river flow the material presented in this chapter indicate that people who live in flood prone areas are motivated to live there because they monitor the floods locally and can therefore anticipate and deal with them however during the flooding event in 2019 their local knowledge on flood and local early warning system did not work effectively this clearly illustrates that the early warning system needs to be integrated with modern ways of flood monitoring to enhance effective and appropriate flood preparation that would reduce loss to property and lives there has been an effort from the department of climate change and meteorology department of disaster management affairs and the local government through the district council to disseminate climate information to those who live in flood prone areas for their safety during floods the people are told to move upland to safer places to avoid being swept off by the floods this had reduced vulnerability of the communities to floods in the flood prone areas since most of the times they were able to move upland before the floods occur and were able to save their belongings during the 2019 floods however the results indicated that flood occurrence is unpredictable and complex for the existing local indigenous and scientific monitoring hence there is a need for a more comprehensive and sophisticated way of monitoring the floods that goes beyond recording amount of rainfall over a period the traditional way of monitoring water levels with a stick in the flood prone area needs to be combined with reliable climate information from weather stations that have automated and more sophisticated weather monitoring equipment in the long term the results show that there is need for a comprehensive and more reliable early warning system from the service providers to build trust between the climate information service providers and those that need to utilise the information my study corroborates another study that was conducted in the philippines which indicates that communities do not trust the early warning system because the messages are not clear and do not provide convincing information to make people move upland this study shows that forced evacuation is necessary where people do not follow official evacuation advice and do not follow government warning my research however suggests that insisting that communities should evacuate is totally impractical due to the affected peoples livelihood attachment to the area and other factors that are important but are ignored in the policy some of which are political and costly in nature as will be discussed in the next section social and cultural factors in living with floods during the household survey almost 80 of the communities indicated that they have a good social network with people living in upland areas during floods our friends and relatives that live upland accommodate us in their homes we keep our belongings there too and wait till our home is dry and we come back during droughts we offer them some piece of land where they can grow crops another participant added that there are some people who let out some of the houses during floods based on the agreements some charge in cash or number of bags of maize the charge is very subjective and usually depends on the type of relationship that the people have another community member living in upland area indicated that we have a good relationship with communities that live in flood prone areas during droughts many of us farm in the flood prone areas even in a normal year we grow winter crops including maize in the flood prone areas we benefit from each other the social networks and the relationships between the communities living in the flood prone areas and communities living in the upland communities suggest that land in flood prone areas is an asset in itself this illustration presents a novel contribution in framing vulnerability to floods based on selfperceived vulnerability communities living in the flood prone areas perceive their land in flood prone areas as an asset that supports their livelihood adding to the discussion earlier on that floods do not occur every year the results suggests that communities are less vulnerable to climate variability in the flood prone areas communities are therefore better off living in the flood prone areas than in upland areas due to droughts and limited space in some cases some communities that live in the flood prone areas are not happy that they are given names during floods during floods the communities that live upland mock us and give us various names that are associated with being displaced by floods even though during droughts we do not give them names associated with droughts another old man who has relocated 5 times indicated that we are called refugees in the same country as if we do not have our own homes this humiliation during floods has taught us that one is respected in their own land hence we shall never settle in any mans land apart from our original land climate migration is another aspect of resettlement that have been discussed by various scholars as providing a degrading status for the relocated communities hence indicating how complex and dynamic the relocation process is as part of local adaptation more details will be presented in the next chapter where i will be discussing the complexity of local adaptation and relocation however the public has different perception towards the communities living in the flood prone areas contrary to what was indicated by the communities adaptation to floods the results from the household survey reveal that 40 of the households mentioned that they were able to cope with the floods without external support indicating that they are able to survive on their own and recover after floods without any form of support from the government or humanitarian organisations the other 60 of the farming households that participated in the research indicated that they cannot cope with the floods on their own without external support in terms of cash shelter and food during the floods and about 5 months after the floods communities are used to the way they live in the flood prone areas the social cultural political and livelihood interactions lead to local identities and convey a history of where they come from how their ancestors have been surviving the floods and a unique livelihood which they are proud of they are referred to locally as anthu akumadzi meaning people who come from a place that is surrounded by water this chapter therefore examines the opportunities that exist in flood prone areas that enable the communities and household to cope with the floods this is important for adaptation studies and projects as it suggests that policy makers and project designers and should seek to support already existing strategies and practices this would represent a less costly approach which would thus be particularly relevant for lowincome countries the role of assets in adapting to floods the farming households indicated that they have various assets that are useful in various ways during floods the findings show that the valuable assets for the farming households in the flood prone areas are farmland livestock operational radio operational mobile phone and a functional bicycle a valuable asset according to the research participants is an asset that communities identified as very important to their livelihood in the flood prone areas the household survey revealed that over 40 of the farming households who are able to cope with the floods own a combination of assets including farmland livestock operational radios operational mobile phones and functional bicycle these same households are able to cope without external support therefore suggesting that in the flood prone areas land livestock bicycles radios and mobile phones are critical assets that support communities to be able to cope with the floods without seeking support from other people or institutions each asset will be discussed below in relation to the role it plays in facilitating adaptation in the flood prone areas farmland is one of the critical assets owned by those living in the flood prone areas a middleclass participant in ta nyachikadza explained that we depend on the land that was passed on to us from our ancestors some of us have 4 acres many people have bigger pieces of land that is even not cultivated because of inadequate capacity to do so in another interview a very innovative participant in ta mlolo articulated that we have huge pieces of land that even the government can utilise for agriculture to make the nation food secure we feed malawi there are several trucks that collect maize during high peak of sales imagine if we were to grow maize on all the farmland that is available malawi would be food secure another smallholder farmer living in a village next to villages that flood claimed that communities living in the areas that flood is better off because they have huge farmlands which they grow crops and even some land is left idle that case is very rare uplands because of population pressure the land is not adequate for us and unfertile too resulting in low yields that is why we go to rent farmland in the flood prone areas so that we should be food secure another participant relayed that farmland is also a source of income for most of us communities living upland rent the farms from us during droughts and even during the normal rainy season that way we are able to have money to buy soap paying school fees buy clothes sugar relish for example beef and eggs without the land we have as an asset most of us would have been in trouble no food no extra cash whilst much emphasis is put on the economic losses of agricultural land and products in relation to levels of vulnerability and coping strategies in the flood prone areas of anambra state in nigeria my study indicates that there is also an economic gain in the flood prone areas as well as economic losses the land that is accessed and passed on from communitys ancestors has created a form of security that enables them to sustain their livelihoods in times of droughts and minimal flooding participant explained that after the floods we grow maize and sweet potatoes and they grow very well as a result we usually harvest enough to feed ourselves we might lose our crops during the floods but we are able to grow crops again using the moisture after the floods that way we do not suffer too much we grow enough to even sell to communities that live in areas that do not flood they still depend on us this suggest that these communities remain food secure after growing and harvesting their crops even some are able to have surplus for sale which enables them to have money to meet their daily needs as per the quotes in the key informant interviews in some ways floods enhance the communities livelihood in the flood prone areas it is crucial to understand the role of farmland in the flood prone areas it reveals how the government and other development partners can learn from the existing strategies to develop strategies that ensure that the farmland in the flood prone areas is protected and that as part of recovery from floods agricultural inputs should be included as part of the recovery support communities clearly indicate that they are trying on their own to support themselves to cope with the floods they also expressed that they would like the government to support the existing strategies to promote sustainable livelihoods rather than neglecting the relevance of their livelihood communities living in the flood prone areas have been perceived as stubborn victims seeking sympathy from their governments and humanitarian organisations crop production the communities indicated that they grow various crops depending on the place and type of season these farmers indicated that their main reliable crops are maize rice and cotton we usually grow rice in the flood plains because it is usually wet with more moisture which is not suitable for other crops such as maize we also have vegetable gardens near river banks where we grow different types of leafy vegetables tomatoes onions cucumbers carrots and sugarcanes amongst other crops another participant shared that …the soils we have here are also good for various fruits including mangoes pawpaw pears and bananas amongst the popular ones according to the household survey maize is one of the main staple food and is grown by approximately 95 of the farming households maize is grown twice in the year during the normal rainy season and during winter through irrigation during droughts maize is still grown through irrigation in addition these farmers have been introduced to new farming methods that reserve moisture known as conservation farming in order to enhance crop production in the face of droughts and floods this type of farming is being led by the government through the ministry of agriculture and food security conservation agriculture is the type of farming that is encouraged in areas that have been highly affected by environmental degradation and soil erosion and other types of farming that have resulted in loss of soil nutrients and soil cover conservation agriculture aims to enhance agricultural production in areas that experience droughts and dry spells interventions such as ca and climate smart agriculture programmes are implemented across the whole of malawi by the ministry of agriculture government of malawi without meeting specific and localised agricultural demands in some of the areas in nsanje district about 80 of the targeted farming households revealed that agricultural production had reduced since the change of the old agricultural practices to ca whilst the other 20 of the farmers presented that they had noted an increase in the agricultural production in addition during fgd 1 in ta ndamera chiefs and some civil protection committee members indicated that ca is not suitable in the flood prone areas due to the nature of the soils and existing soil moisture levels the findings on ca clearly indicate that national programs need to be tested at regional local and even at a smaller scale in this case village level in order to identify implementation challenges that need specific attention the major highlight in this example is that such programs are not tested in the areas where it needs to be implemented before the actual implementation starts in order to check suitability and practicality of the intervention there have been several criticisms of this type of farming as to whether indeed it increase the yields for farmers and reduces the workload for famers during weeding as it is claimed in the nsanje case 40 of communities in the household survey suggested that conducting soil sample analysis would be appropriate to determine the type of soil that has accumulated over time through the flash floods to guide extension workers and farmers on the type of crops that would be suitable to be grown which farming methods would be appropriate and the conditions that would be favourable to enhance crop productivity a group village chief indicated that during the january 2019 floods our farmlands have been affected badly the soils have changed and the maize is no longer growing we even tried potatoes but they still have not grown we do not know what to do now the government and other organisations should do research and then advise us on what we should grow we have been affected so much and we have run out of ideas the current change of soil structure in some flood prone areas in ta mlolo suggests that there is need for more agricultural research to identify suitable farming methods and appropriate crops to be grown this also implies that the floods and unstable climate pattern will require more robust agricultural research to enhance agricultural productivity currently in these flood prone areas the change in soil structure due to floods in some areas and ineffectiveness of ca in other areas will exacerbate vulnerability of these smallholder farmers to floods and other effects of climate variability in addition my results indicate that the farmers who practice ca adopted it because they were advised by the agriculture extension workers to do so and that it was recommended by the government due to loss of soil nutrients and soil erosion this is in line with wall who suggests that successful adoption of ca depends on how well the farmers are aware of it and the problem they are facing in terms of low agricultural production in this study the farmers also indicated that they changed their ways of farming because they were having less yields and due to climate variability they were experiencing droughts and lost most of their crops however for some farmers that have not experienced the benefits of ca they indicated that they are hopeless because either way there is a reduction in the crop yield and they said that they are waiting upon the government through the ministry of agriculture to facilitate further research and come up with appropriate farming recommendations other farmers indicated that they are conducting various farming techniques on a trial and error basis and hope that one day they will discover for themselves what will work for them this in a way indicates that some communities are being innovative by trying what they think can work for their agricultural land even though it is a long and frustrating process as the climate is changing with projected increase in rainfall intensity and drought events it is becoming clear that new farming methods and types of suitable crops will be needed this therefore suggests the need for new studies on soil structures and textures in flooding sites to be able to provide adequate technical support to the communities this also offers an opportunity for joint experimentation of agricultural research institutes and communities whereby new approaches to farming would be identified to enhance food security in the face of climate change these farmers through extension workers have been introduced to irrigation farming drought tolerant crops and other transferable skills relating to agriculture during floods after their crops are swept away they usually grow sweet potatoes during drought and dry spells they grow drought tolerant crops mainly millet and sorghum in terms of farming agriculture extension workers play a major role in the type of farming these farmers are involved in according to the farmers the extension workers are government representatives hence are respected however it was observed that some communities followed what the extension workers taught them despite not understanding why they had to change the type of farming around 75 of the respondents when asked why it was important to follow new methods of farming indicated that they had to follow what authorities say this has various implications on the sustainability of the activities the lack of ownership of interventions in communities results in abandoning of the strategies when the projects end and there is no one leading the interventions some factors that have been attributed to as enhancing adaptation and development projects in sub saharan africa are ownership shared responsibility transparency and community involvement therefore in cases when these factors are lacking sustainability of project interventions is expected to be low ca interventions in malawi are supported by international organisations such as the food and agriculture organisation through the ministry of agriculture the findings that about 75 of the smallholder farmers implement ca activities because they are told to do so by agriculture extension workers suggests that if fao changes focus and reduces support on ca and if the ministry changes its focus on another type of farming or intervention it is very likely that ca will no longer be practiced by some farmers this then reveals that there is inadequate and inappropriate training to the farmers to make them understand why they are doing what they do when introducing the interventions to ensure sustainability of the seemingly best agricultural practices the results also illustrate that the farmers are not motivated to own the interventions and sustain them without the help of agriculture extension workers there is lack of proper technical communication between the communities and agriculture extension workers which presents a lack of understanding on the new farming methods and technologies in farmers at the beginning of the interventions to ensure ownership and sustainability of beneficial interventions after the funding period is over this raises concern on how sustainable some adaptation strategies are and how they will reduce vulnerability to climate variability in the long term in areas where more people are poor the adoption of ca and obviously some new technologies will be different and in other cases slower than anticipated in the flood prone areas the findings illustrate that ca is not beneficial to all the smallholder farmers even though it is highly encouraged by the ministry of agriculture the changes in the soil structure due to the fatal flash floods reveal that whilst other areas are benefiting from the fertile soils communities in gvh kadyampa in ta mlolo have been negatively affected by the same flash floods it is therefore evident that vulnerability contexts are different unequally distributed and shaped by the way several physical and social factors interact therefore adaptation strategies ought to incorporate the vulnerability context and address the specific challenges in this case the soil needs to be tested to identify the new type of soil that has been created due to the flash floods and therefore present the type of crops that can be suitable based on the soil characteristics and the physical environment postharvest handling in relation to postharvest handling all the research participants indicated that they currently store their maize in sacks designated for storing maize these sacks are the regular bags for maize that are not treated and none of the research participants were aware of any new forms of storing maize during conferences i interacted with another doctoral student working in a nearby community who indicated that the agriculture research institute in malawi is planning to introduce the new forms of storing technologies to the smallholder farmers such as treated empty sacks of maize and metal silos these new storage technologies that will be introduced will be an entirely new concept for the farmers which as shown in my study has the potential of taking a long time to be accepted and established in addition to that some of the farmers do not produce enough for long term storage this suggests that whilst communities are still struggling with how best they can produce more in some cases the government is focusing on how to store the produce according to the household survey about 98 of the communities indicated that they do not suffer produce losses after harvesting although this is possible during flooding and outbreaks of pests however it is important to note that i am not suggesting that the new storage technologies are not relevant in the areas but rather that adaptation priorities need to be identified and understood the discrepancies in the need and intervention by various programs indicate that there is inadequate dialogue between the communities that are affected by the floods and the service providers and donors older research participants indicated that they used to store their maize in chikwa which was a traditional form of silo the chikwa was handled with some cultural beliefs only women and younger children were allowed to take maize from the silos because they were regarded as clean and not mischievous men and older children were not allowed because it was believed that if someone was mischievous in conduct the produce would decrease during that time the maize would never go bad the whole time it was stored over the years these traditional beliefs have been lost to new concepts of storage and all farmers have been advised to change according to the agricultural extension workers there was fear that the maize would be getting damaged by weevils and other pests hence the introduction of the new sack bags whilst for some farmers they indicated that the chikwas used to be too big hence it was not necessary to use them with the amount of produce they harvested whilst agricultural extension workers indicate that they discouraged use of chikwas because of weevils that attack the stored produce over 90 of the farmers did not relate the change of storage due to that this indicates that communication is a challenge between the extension workers and the smallholder farmers where the extension workers struggle to effectively pass on the technical and scientific explanation to the communities hence some communities do not know or understand why some changes are necessary even for a change in new farming technologies most of the communities indicated that they heard from agricultural extension workers that they needed to change and they complied without understanding the reason behind it the communication gap in this case could contribute to the slow adoption rate of adaptation strategies that might reduce vulnerability of the communities by enhancing their livelihood during an indepth interview with an extension worker he indicated that it is true that sometimes they do not fully explain these scientific and technical issues to communities because they have huge pressure on their work and time is limited in addition he indicated that for some communities they are not interested to know so due to a lack of adequate extension workers in the areas they do not explain these things this could be one of the reasons contributing to the death of projects after the development partners leave the area because there is no adequate ownership and understanding of the concepts within the local community apart from the farmland crop production and postharvest handling issues i also examined the role of radios mobile phones and bicycles as valuable assets that complement the livelihood of the communities in the flood prone areas the role of livestock in adapting to floods livestock also play an important role in the flood prone areas livestock is used as a source of prestige exchange for shelter in the upland areas during flooding and a source of income during seasons of crisis in our community owing livestock is a sign that someone is rich even though someone might not have cash readily available the cash is tied to the livestock so we say those people are rich those who have a variety of livestock such as cattle goats sheep pigs guinea fowl ducks chickens and doves are considered very rich the others who only have chickens guinea fowl ducks and small livestock might not be considered very rich but are considered to be better off those who have no livestock at all are considered poor in this community an indication of wealth is subjective to the communities and district during one of the wealth ranking studies i conducted in chiradzulu in 2008 when i was working as a consultant communities indicated that owing small livestock such as chickens guinea fowls and doves was not a sign of being rich being rich was associated with bigger livestock such as cattle goats pigs and sheep in this community the people who had chickens guinea fowls and doves were considered to be poor because they were mostly beneficiaries of a livelihood project that target the ultrapoor it is important to note that for the purpose of the livelihood of the communities living in the flood prone areas the distinction between being rich better off and poor is very important as it determines the adaptation strategies and survival during flooding during the january 2015 floods poor smallholder farmers and those who had lost everything including money lamented that those who had money livestock or produce were rescued first by private boat owners who demanded payment instantaneously leaving behind those who did not have any form of payment that was demanded by the boat owners communities in traditional authority mlolo indicated that during the floods some people with private boats come to our rescue they usually come with two boats one to collect people and the other to collect a form of payment usually bags of maize rice and livestock including chickens and goats those who do not have livestock or agricultural products are left behind a relatively rich smallholder farmer explained that i gave the boat owners 2 goats and 3 chickens as a form of payment for me and my 5 children the payment is subjective and it depends on how one negotiates the payment it is subjective fgd 10 ta mlolo june 2022 another participant who belonged in the group that was perceived to be worse off in terms of economic status and therefore more vulnerable to floods lamented that during the january 2019 floods some of us who did not have money were left behind i regretted to have been so poor the boat owners refused to be merciful to me and just take me without any form of payment they requested payment and said repeatedly that they were focussing only on those who had any form of payment we ended up climbing the trees because there was no hope for us but we could not give up another participant in the same group further lamented that that we had to climb trees until the government intervened we were rescued by helicopters because everything was swept off including our houses and everything was under water kii 40 ta mlolo may 2022 the poor suffer more in the flood prone areas due to inadequate agricultural products and livestock that they could use to cope with the floods survival in the flood prone areas without government intervention thus depends on the type of assets a household has the poorest of the poor the elderly orphans and those that could not afford to pay had to wait for the government arranged boats and helicopter these are mostly the group that also survived the floods in trees whilst waiting to be evacuated by the government during focus group discussions the communities indicated that the communities lost their boats and did not know where the men with private boats came from they emphasised that if they were from neighbouring villages most of them would have negotiated to make the payments after the floods hence they could have been rescued without upfront payment communities who are perceived to be better off have two homes one in the flood prone areas and another in the upland areas their livestock and produce is kept in both places unlike those that cannot afford to have another home in the upland area during floods those that have one home in the flood prone areas lose everything whilst those that have two homes have part of the livestock and produce in the upland areas hence they sell part of that to recover after the floods as indicated earlier on the social networks are strengthened due to interdependency within the smallholder farmers in the event where the communities in flood prone areas are destitute the communities in upland areas do not keep them for free hence they have to live in evacuation camps until their land is dry communities offer livestock as payment for temporary shelter in the upland areas during the floods during the floods we either sell our livestock to get money that we use to pay for our rent in the upland areas or we give the tenants the livestock as a form of payment it depends on the agreement sometimes the form of payment for rent in the areas that do not flood is both agricultural products such as bags of maize or rice and the livestock another participant indicated that the payment is subjective for example in a month one can pay 2 bags of maize and 2 chickens if the landlord wants the maize and the chickens sometimes one can pay k20 00000 it depends on the agreements and how close you are with the one offering the place the results suggest that those who have livestock are more likely to survive without external support during the floods since they can afford to negotiate the payment for temporary shelter in this case clearly suggesting that those with neither livestock nor surplus agricultural products cannot cope without external support this further suggests that in times when the floods are unexpected and situations where the early warning system is ineffective all the communities would not cope with the floods without external support since they would lose all their agricultural products and livestock this clearly illustrates that the adaptation strategies that are implemented in flood prone areas such as irrigation farming and ca would only help communities to be food secure but do not adequately empower the communities to acquire assets that would enhance their adaptive capacity to cope with the floods during and after the floods supporting the poor in the flood prone areas is not based on their needs hence does not meet the different demands of the poor in the various locations a livelihood vulnerability study in bangladesh indicates that the poor are more vulnerable to floods and depend on social networks and local authorities because they do have any asset that would enable them to cope with the floods there is need for the state to invest in various sectors including health water and infrastructure in the flood prone areas there is no timely rescue plan at district level to make certain that those who are poor and the vulnerable groups are preidentified to facilitate the evacuation process timely evacuation from the flood prone areas during floods to established evacuation camps or to other relations and social networks is important to reduce vulnerability to floods that can be fatal if evacuation is delayed it is clear that regardless of the efforts to stop the smallholder farmers from living in the flood prone areas by the government not providing all the necessary amenities in the areas including boreholes and schools these areas are still habitable and will continue to be habitable it is clear that communities that are relatively poor will need adequate support from the government and other development partners to be able to cope with the floods and evacuate before the floods threated lives in the next section i will discuss the role of social networks in the flood prone areas as communities cope with the floods the role of institutions and organisations in adapting to floods according to hodgson institutions are defined as systems of established and embedded social rules that structure social interactions institutions are there to support local adaptation at both the household community and district level hence enhancing local adaption to floods and droughts in addition churches schools households communities government department civil society organisations nongovernmental organisations have also supported the communities and households to cope with the floods household and community dynamics and adapting to floods only 10 out of the 227 households indicated that the responsibility to provide for the home lies between both the male head and the spouse in this case they both participate in income generating activities and sometimes they share responsibilities where the womans responsibilities are less than the mans responsibilities the men usually make more money than the women so they are responsible to address more needs in the home whilst for women it is usually supplementing what the men provide in the home in this case also it can be implied that men are still held responsible for the management of the home where the man is alive and responsible and women only supplement what the men provide and when the men are not there the household head is expected to meet the household need by virtue of their role as the head figure 8 shows who the responsibility for decision making for everything falls at household level amongst participants in the study revealing that this mostly falls on men the participants indicated that even in climate related decisions men make the decision and women do not participate in the adaptation decisions in the home this situation is another example of exclusion at household level where women do not take part in decision making even though they are also affected with the decisions that are made during indepth interviews with communities who had leadership positions and during focus group discussions all the communities living in flood prone areas indicated that they consider floods as the main problem even though hunger is also amongst the challenges they experience the contradiction in response could be explained by difference in community and household priorities the results reveal that households focus more on individual and personal problems whilst in a group the farmers will mention problems which affect them as a group at the community level it was also apparent that during indepth interviews with some chiefs and members of the village committees floods and droughts were mentioned as major problems affecting the communities as community heads in this case this indicates that chiefs and community leaders consider community problems more and are concerned with them personally unlike communities at household level whose concern is mainly on their households welfare and livelihood these findings illustrate that household members could be interested to participate in activities be it adaptation strategies or development activities that firstly addresses their household needs otherwise they will always focus on how to deal with their personal household problems first this is an issue that demands attention when designing adaptation programs because reducing household vulnerability to floods and droughts require more collective strategies than individualism siegel and alwang also indicate that for poor rural households the ways of coping with either droughts or floods are usually not economically sustainable they are short term thereby increasing household vulnerability to the climate variability they are trying to cope with the farmers during my interviews indicated that when they are pressed with a need they first of all consider doing piece work as a source of income which will help them to address the current household need if that fails then they resolve into selling household assets such as livestock bicycles radios phones and other agricultural products including the maize they store to take them to the next harvesting season now this in itself is not sustainable and can cause problems because like in the case of the farmers i interviewed the price of the bags of maize they sell and whatever asset they sell when they are desperate for money is usually less than the amount they will need to replace it this in itself exacerbates their poverty and vulnerability during drought and floods this strategy of selling assets for payment of services leaves the communities worse off because they never invest in other assets but instead they spend the proceeds on consumables and perishables this clearly illustrates that there is not any adaptation intervention that empowers the poorest of the poor economically to enable them to address their daytoday problems whilst also empowering them to be able to help themselves when disaster strikes in addition this suggests that because these poorest of the poor communities isolate themselves they are likely to continue being more vulnerable when a disaster strikes there are no deliberate efforts designed to encourage such communities to take part in community activities and also belong to certain social networks that would enable them to learn other transferable skills and empower themselves the findings suggest that a deliberate social group at village level that would support the vulnerable groups at all times can be explored as a necessary aspect within the local adaptation strategy the role of chiefs in adaptation to floods community leaders and chiefs are approached when there is a community crisis or need unlike with a crisis at the household level where the head of that particular household is turned to out of the 227 households survey 68 indicated that it is the village headmen who are approached when there is a disaster in the community including floods and droughts according to fieldwork discussions the majority of the communities indicated that community leaders provide security and communities short and long term solutions during a crisis including a disaster such as flooding the participant who indicated that they consulted no one during a crisis further indicated that we feel left out in the community we are not regarded as part of the community when it comes to making decisions our voices would not be heard at all however during floods we are rescued together with other affected people and during social cash transfers that are meant for the poor we are also considered sometimes our chief is still responsible for us this group according to the communities themselves included the most vulnerable households the poorest of the poor the aged and farmers who do not usually have social networks within and outside their living environment this also verifies that there are various social groups within the affected communities that are left out in community activities because of their socioeconomic status and social group identification however 10 out of the 30 households that indicated not to consult anyone when a disaster strike indicated that they do so as a result of personal preference twenty households indicated that they feel that they are not welcome in other social groups that they are stigmatised and hence withdraw themselves from such social groups apart from chiefs there are church leaders teachers and the police play a significant role during flooding barriers and limitations to local adaptation it is clear that gender and culture play a very important role in the lives of the smallholder farmers living in the flood prone areas in this chapter i will discuss how misconception of power dynamics and gender issues at both household and community level by policy makers governments the affected communities themselves and various institutions that support adaptation to climate variability exacerbates vulnerability and limits adaptation in the flood prone areas in addition this chapter illustrates that there are also some factors beyond the factors that are mentioned in the local adaptation frameworks 2010 engle 2011gupta et al 2010 that need to be adopted in order to comprehensively assess the adaptive capacity of households communities and institutions the factors that are highlighted in this chapter illustrate the factors that affect local adaptation in nsanje and in malawi therefore can be similar to other areas that have similar characteristics however this thesis is clear that vulnerability is differentiated with some groups of people being more vulnerable than others the adaptation strategies therefore should be different to suit and address the different levels of vulnerability and groups of people finally this thesis illustrates that some of the challenges to local adaptation are dynamic and more complicated hence present themselves beyond the categorised barriers and limits their manifestation therefore require more transformation in the way adaptation issues are strategised in order to effectively reduce vulnerability to climate variability gender imbalance gender plays a hugely important role in creating vulnerability and has an opportunity to enhancing adaptive capacity amongst those living in flood prone areas in terms of gender roles the men are the head of the family and hence the decision maker in most households women are not given a chance to share their views during focus group discussions one woman indicated that even if there are rare cases when the men would listen to the womens view their views are never considered and the men still do what they have decided according to the discussions and indepth interviews it was revealed that it is the men that make overall decisions in the home for various reasons during a focus group discussion with male chiefs and community leaders the men explained that we are men and household heads so we are supposed to make all the important decisions in the home in actual fact we are supposed to make all the decisions in the household men are considered to be the head of the household therefore they feel they are supposed to make decisions in the home the attitude of being a man and hence needing to make decisions in the home has contradictory consequences in the positive it gives the men the responsibility to make certain that the households are surviving in terms of availability of food and other household necessities for any man to be considered responsible these aspects could then mean that whilst the women are focusing on managing the home and farming the men would focus on providing for the home and farming however the majority of women in the farming household and during focus group discussion indicated that this concept of men making decision in the household has led to women being passive we are regarded as voiceless powerless and not knowledgeable in our homes we cannot participate in any decision making if we speak up we are considered rude and stubborn hence we just have to agree to everything that a man says in addition one male farmer said a woman is always a woman a man who bows down to what a woman says is considered to be a coward in our society where would they get the knowledge from they know nothing most of the men during the men focus group discussions also indicated the same which then implies that women are powerless and voiceless during the focus group discussions with both men and women women were respectful of the men and even chose not to argue with them accordingly when they were raising issues that were oppressive the women only felt able to make unpleasant facial expressions and only made comments about it after i assured them that the issues that we were discussing were meant for studies and i would not expose them to community leaders and other people in their community this idea reflects women are oppressed in their environments there are many cases of injustice and unfair decisions that are made to the disadvantage of women and yet the women themselves are voiceless this is one of the issues that is critical to enhance participatory decisionmaking at household level that would then lead to households being resilient to their own problems in this case strategic womens groups that would support and empower women and empowering women through education can partly inspire women to take part in meaningful discussions at household level however there are also challenges with this approach as will be discussed in the next section which suggests that transformation is required in order to reduce vulnerability to floods at all levels household power and capacity to cope during a focus group discussion with women only women articulated that if only these men were very supportive we could have gone so far in terms of adaptation it is difficult to effectively adapt to the floods and climate variability because the men pull us down at household level which also exacerbates household poverty that is why we are failing to develop another woman indicated that many of us here are not happily married our husbands have other girlfriends and they spend most of their time and money there as women we struggle on our own to provide for the home food for us and the kids we do small businesses and when we are coping and making profits these men come and take the money from us they say they have better plans with the money only to go and drink and go to other women and thats how we live another woman said that men are very powerful here sometimes if you dont comply they actually beat you up so to avoid being beaten we surrender the money and we struggle again it is evident hereby that issues of gender and power dynamics at household level offer an opportunity of abuse for those that are weaker in the society abuse of power at household level and women not being given an opportunity to participate in household decision making reveals that unless adaptation strategies are deliberately inclusive of these specific gender issues women will not benefit from adaptation interventions inclusive adaptation and deliberate strategies that incorporate women and encourage participation of women at both household and community level would eventually encourage women to actively take part in adaptation strategies that would eventually enhance household resilience to floods and other effects of climate variability dealing with attitude and breaking abusive and nonconstructive cultural norms is necessary in flood prone areas to enhance the effective design of adaptation programmes as codjoe and issah allude to in a culture and adaptation study in communities in ghana local cultural context is very important in the design of effective adaptation options the authors found out that adoption and participation in adaptation strategies was mainly due to cultural norms in different communities hence suggesting that culture is a component that should be incorporated in the design and implementation of local adaption strategies there are also cases where women themselves have low selfesteem which also puts them at risk of being abused we all need a man at some point and we are respected when at least people know we are married regardless of what the man does many women agreed to this point and it has a reflection on how women feel they are so vulnerable and can never do anything on their own to make their lives better this aspect of gender and power dynamics at household level has a negative impact on household adaptation hence exacerbates vulnerability of the household level in addition it is the women that are more stressed and under pressure because they work so hard to make ends meet whilst some men take advantage of them the findings reveal that adaptation strategies are not comprehensive in addressing these issues that negatively affect adaptation at the household level in addition this suggests that women cannot be protected and empowered when they are living with abusive men they fail to negotiate with their men to come up with collective solutions that will enhance resilience to floods and droughts in the household adaptation strategies do not address all aspects of household power dynamics therefore most women do not take part in climate related and livelihood decision at the household level climate related decisions at the household level are not done in a respectful and mutual understanding manner therefore fail to collectively address climate related challenges every individual in a household needs to be able to understand how they can reduce their vulnerability to floods and enhance local adaptation at household level to be resilient to climate variability failure to which household vulnerability to floods and poverty levels will be exacerbated my understanding in these findings is that if women are given much support adaptation initiatives would be fruitful as they are practically home managers and responsible for household needs and events even though commonly men are considered to be the head hence heading everything in the household women need to be supported and empowered to be able to negotiate with men to overcome obstructive traditions chapter five suumary conclusion recommendation introduction this final chapter summarizes the overall findings and contributions of the thesis focusing on how the research questions have been answered in relation to selfperceived vulnerability to floods and local adaptation the chapter presents significant findings on how complex vulnerability and adaptation issues are including how they are generated and exacerbated in the contexts of the everyday lives of smallholder farmers living in the flood prone areas in addition the chapter highlights the disadvantages of permanent relocation process as a means of reducing vulnerability to floods in the flood prone areas versus the benefits of temporary migration as a commonly practised adaptation in the flood prone areas the chapter then presents some of the implications for local national and global adaptation to climate change plans and strategies and suggests that the generic adaptation strategies are exacerbating vulnerability to climate variability there is a need to contextualise vulnerability understand how it is created how the affected people perceive the vulnerability and how they are adapting to the environmental changes in order to meaningfully contribute towards reducing their vulnerability by enhancing their adaptive capacity in situ discussion of the findings environmental migration has been framed differently by various institutions based on their agendas ransancooper et al highlight the different terms and situations that define environmental migrants as adaptive agents security threats victims and political subjects furthermore they highlight that the different frames have an implication of the how the policies that are formulated and thereby revealing power relations in the way adaptation projects are designed the review of these various frames indicates how external actors and institutions perceive environmental migrants from particular viewpoints whilst limited information and studies have been conducted to understand how the environmental migrants themselves perceive their vulnerability it is evident that some groups of people in various regions of the world are more vulnerable to climate variability than other developing countries suffer the effects of climate change more than the developed countries because they do not have the financial and technical capacity to cope with the floods my research illustrates the contexts that shape and define the vulnerability to floods and climate variability in the flood prone areas and contributes to other scholarship on how the social economic political cultural and natural factors interplay in various contexts to either exacerbate or reduce the vulnerability bryan et al indicate that smallholder farmers will be vulnerable to climate variability more because they rely on agricultural products which will be directly affected by the extreme weather events in another perspective dilling et al reveal that vulnerability is dynamic and complex with various factors interplaying at the local level to shape and define vulnerability the need therefore to understand the underlying causes of vulnerability and local adaptation in context is relevant to inform climate change policies and shape the design of climate change adaptation programs that seek to reduce vulnerability and enhance adaptive capacity of those that are heavily affected my research demonstrates that there is a discrepancy in the understanding of vulnerability to floods and local adaptation between the communities who experience the floods and the government of malawi through the department of disaster management affairs firstly this research contributes towards framing vulnerability based on the perception of the different groups of people that are vulnerable to climate variability and have experienced environmental changes throughout their everyday lives the communities living in the flood prone areas perceive floods as part of their livelihood the communities have experienced floods for over 5 decades and have been implementing adaptive strategies to help them cope with the floods during this time temporary migration is one of the effective adaptive strategies that the communities living in the flood prone areas implement during floods this is contrary to how the government and the general public perceive environmental migration as an adaptation strategy they suggest that permanent relocation is the best solution that would effectively address vulnerability to floods ransancooper et al presents a clear understanding of perceived vulnerability by various actors including international organisations politicians governments and scholars that suggest that affected communities are helpless contrary to such understanding communities living in flood prone areas engaged with in this thesis are aware that the environment is changing and have designed adaptive strategies that have enabled them to cope with the floods in a way that is beneficial to them the communities spoken to during the study indicated that temporary migration during severe floods is normal for them and forms part of their livelihood they are aware that they have to move during the flooding season and many smallholder farmers have set aside plans that facilitate the temporary migration social networks and interdependence between the communities living in the flood prone areas and those that live in the upland areas have made temporary migration during floods easier for the communities living in the flood prone arear the communities living in the upland areas also relocate to flood prone areas during droughts thus benefitting from agriculture through moisture in the flood prone areas the strong relationship between these communities through social networks and interdependence clearly indicates that the smallholder farmers living in flood prone areas are not victims neither are they security threats to neighbouring communities and country mozambique as suggested by some governments however it is evident that these communities are partially adaptive agents and have become political subjects over time due to external power dynamics these smallholder farmers are affected by both international and national disaster policies that present them as victims severely exposed to floods and therefore they are helpless in their environment the smallholder farmers in the case studies illustrated that permanent relocation to upland area would exacerbate their vulnerability to climate variability and that their livelihood is better managed and sustained in the flood prone areas the communities indicated that they possess valuable assets such as agricultural land livestock bicycles radios and mobile phones that sustain their livelihood in the flood prone areas secondly communities exemplified that climate change adaptation strategies and policies in some areas will exacerbate vulnerability to climate variability and create new vulnerabilities that the affected communities will eventually fail to cope with it is important to realise that the adverse effects on climate change can never be isolated from the political social economic and cultural factors that interplay in the communities therefore suggesting that the same factors interact to reduce the impact of the disasters this thesis presents a unique and important social relation revealing interdependence between the communities living in the flood prone areas and those that live in upland areas the farming households in upland areas migrate temporary to the flood prone areas during droughts for farming purposes whilst the farming households in the flood prone areas migrate upland temporarily for shelter during floods this in itself is a novel way of understanding how different communities affected by different climate hazard depend on each other as part of adapting to the hazard the power of social relations and interdependence is usually undermined in adaptation programmes and policies selling of assets has been well articulated as an adaptation strategy but this thesis presents evidence of a more sustainable way of utilising the land in flood prone areas through letting out part of the farm land to communities that are affected by drought adger explains that communities that are vulnerable to climate variability will find strategies within their localities within which they can use to adapt to climate variability land is an important and reliable asset for the communities living in flood prone areas because apart from yielding crops and produce from it it is also a reliable source of income the motivation to live in the flood prone areas mainly comes due to the possession of land which is used for agriculture and hiring out to communities that live in the upland areas during drought the seasonality of floods considering that they do not occur every year presents a benefit to the communities because the upland communities are affected more with droughts than they are with floods overall in cases where floods do not occur every year temporarily migration is an attractive adaptation strategy because the communities still have access to their farmland and possess it permanently which then enables them to rent it out during droughts as an alternative source of income in addition to agriculture thirdly this research presents evidence that the complexity of local adaptation arises from the political economic social cultural and institutional factors and processes that interplay within the households and communities sometimes these same factors and processes work against effective local adaptation at both household and community level however engle claims that adaptive capacity of a nation or community that is affected by climate variability is influenced by the institutions management and governance the findings presented in this thesis illustrate that at household level women are not given a chance to contribute to household resilience to climate variability because of cultural values that suggest that women are subordinates and that therefore only men have the authority to actively participate in such developmental activities for fear that women will become empowered and hence would be rude and forget their household roles men do not allow women to participate in activities that would empower them thereby retarding household reliance to floods most importantly both women and men are oppressed at household and community level even though due to culture the oppressed accept the oppression as normal behaviour some cultural values work against efforts to make households resilient to floods thereby revealing that the need to address cultural values that households and communities hold to be able to address some fears and myths that work against effective adaptation to climate variability including floods the need to understand gender issues and social groups should not be undermined as these shape the adaptive capacity of the households and communities this study therefore exemplifies the dynamic and complexity of gender roles and expectation within the flood prone areas and women mostly are taken advantage of due to misconception of power and understanding of respect in addition politicians at all levels exacerbate the vulnerability of these communities to floods it is evident using a malawi case that politicians are not primarily interested in investing in disaster risk infrastructure but rather votes in contrasting evidence obradovich and zimmerman found that across sub saharan countries with evidence from malawi and south africa the voters are not interested with climate change policies and that they do not support the implementation of such policies this evidence suggest that voters are interested in other things that constitute their welfare therefore politicians respond to those issues to be able to win votes in the case of malawi however as illustrated in this thesis politicians are actively involved in organising help in the moment when communities are affected by the floods even though they do not invest in longer term and more permanent disaster risk infrastructure during voting period the polling stations are positioned in the flood prone areas for voters to vote even though the government stopped providing for amenities in those areas after indicating that those areas are prone to floods and therefore not suitable for occupation this research highlights a political aspect of vulnerability and local adaptation where politicians are influential but looking for the votes and how the voters themselves are vulnerable to climate variability they are not influential but have the voting power fourthly it is evident that an effective early warning system is desirable to reduce vulnerability to floods in the flood prone areas a combination of indigenous knowledge hydrogeology and sophisticated weather readings is essential to build an effective reliable meaningful and trusted early warning system flood management in developing countries remains a challenge due to economic financial and technical challenges due to the intensity of the flash floods in malawi in 2015 the indigenous early warning system there was not able to provide timely warnings to the communities of the flash floods in addition the way in which earth and rock movements persisted before the floods came and communities failed to realise that floods were coming explains how sophisticated the early warning system needs to be raju et al explains the role of advanced remote sensing technology in predicting flash floods through depicting soil moisture content over time this thesis suggest that a combination of advanced remote sensing hydrogeological measurements and indigenous knowledge on the early warning systems needs to be encouraged in order to deal with the complex floods that are more becoming fatal than in previous years fifthly in terms of adaptive capacity with reference to the adaptive capacity wheel the thesis illustrates that at both household and community level leadership resources and room for autonomous change are very crucial in enhancing the adaptive capacity of the communities it is evident however that processes in fair governance variety and learning capacity are not adequately present in the areas communities and households only achieve half of the adaptive capacity wheel but are partly striving in the flood prone areas this entails that communities are not homogenous in nature hence factors and processes that enhance their adaptive capacity will vary with reference to the local adaptive capacity framework however the thesis provides evidence that the institutions are resource tight not powerful enough to make decisions and provide sustainable solutions in the flood prone areas also that entitlements are not clearly visible in many deserving smallholder farmers however at the household level the asset base innovation knowledge and information and flexible and forwardthinking decision making was evident in households that are able to cope with the floods the findings in relation to adaptive capacity illustrate that household adaptive capacity is critical in flood prone areas and that community and structural responses to climate change are not reliable an increase in the number of households that are able to cope with the floods on their own without financial support from the government and humanitarian organisation will enhance the adaptive capacity within the flood prone areas whilst community work is not totally discouraged this research provides evidence that understanding households adaptive capacity portrays a true reflection of vulnerability and adaptation challenges and provides foundation opportunities on how best climate change interventions can be designed areas for further research this thesis presents findings from research that took place at one moment in time significantly either side of a major flood event there is need for other similar studies in the same areas with the same communities in order to find out if there will be significant changes in terms of how these communities will be coping with the floods over time such studies would be important in order to highlight if there will be any changes in terms of the adaptive capacity and vulnerability context over a variety of time scales there is need for research that would seek to find out to what extent women empowerment projects as an adaptation strategy would enhance the household adaptive capacity finally i would recommend research that will examine understand and explore the relationship between the state politicians and voters in the disaster prone areas in order to explore opportunities and challenges that exist between these three groups of stakeholders that are also critical in reducing vulnerability to the effects of climate variability at village and community level chapter summary this study provides evidence that floods have become more severe and fatal in some places to which communities are having to deal with in the effort to reduce vulnerability to climate variability unisdr suggests that communities that live in flood prone areas should relocate to safe areas to reduce vulnerability to climate variability the malawi government declared some areas in malawi flood prone areas and requested those that live in the areas to relocate to safer areas there has been resistance by the affected communities to relocate upland

a section of nsanje district has been experiencing floods for over a decade and was declared a flood prone area the same time gom 2006 therefore firstly this research seeks to understand how the communities that live in the flood prone areas perceive their vulnerability to floods and how some of them have been coping with the floods since 1952 just over 6 decades the overall aim of the research was to understand the impact of floods on sustainable development and how communities living in flood prone areas perceive their vulnerability to floods and climate variability to investigate the power dynamics at household and community level and to explore the complexities associated with local adaptation programs in the flood prone areas this research contributes towards framing vulnerability based on the perception of the different groups of people that are vulnerable to climate variability and have experienced environmental changes throughout their everyday lives the communities living in the flood prone areas perceive floods as part of their livelihood the communities have experienced floods for over 5 decades and have been implementing adaptive strategies to help them cope with the floods during this time temporary migration is one of the effective adaptive strategies that the communities living in the flood prone areas implement during floods

description and table s1 all of the datasets we consider describe the facetoface proximity relations of the monitored subjects with a temporal resolution of approximately 20 seconds 722 for every pair of individuals the full sequence of individual interactions is resolved with starting and final timestamps for every closerange proximity relation these data can be represented as timevarying networks of proximity nodes represent individuals and a link connecting two nodes indicates that the corresponding individuals are in contact ie in facetoface proximity of one another results epidemic processes and activity clocks we probe the temporal structure of the empirical networks with a simple susceptibleinfected process the population of nodes is split into two compartments susceptible nodes who have not caught the infection and infected nodes who carry the infection and may propagate it to others in this simple epidemic model infected nodes never recover a node is randomly selected as the seed from which the infection starts spreading deterministically through contacts between a susceptible node and an infected one transmission events are assumed to occur instantaneously on contact we fingerprint the temporal network structure of the data by computing the times at which the epidemic process reaches the different nodes specifically we focus on the probability distribution of arrival times for the si process unfolding over the temporal network in terms of wallclock time the arrival time at a given node is defined as the time elapsed between the start of the si process and the time at which the process reaches the chosen node it has been shown 26 that the distribution of these arrival times is extremely sensitive to several heterogeneities of the empirical data to the seeding time in general it displays strong heterogeneities due to the nonstationary and bursty behavior of empirical temporal networks that cannot be captured by simple statistical models thus we shift to a nodespecific definition of time each node is assigned its own activity clock that measures the time that node has spent in interaction or similarly the number of contact interactions that node has been involved in the time measured by this clock does not increase when the node is isolated from the rest of the network in the following for clarity we will indicate with time the activityclock readings the arrival time of the epidemic process at a given node is defined as the increase of its activity clock reading from the moment the si process is seeded to when it reaches the node arrival times discard by definition many temporal heterogeneities of the empirical data and usually exhibit a welldefined distribution 26 that is robust with respect to changes in the starting time of the process and across temporal networks of human contact measured in different contexts in the following we use activity clocks based on the number of contact events a node has been involved in the arrival time at a node consequently will be integervalued and will measure the number of interactions each node was part of from the seeding of the epidemic until the node was infected for each empirical timevarying network we generate a hierarchy of synthetic temporal networks using both a topdown and a bottomup approach the synthetic networks are designed to support our analysis by selectively retaining or discarding specific properties of the empirical data topdown approach null models we generate null models by applying to the empirical data randomization procedures that erase specific correlations 24 we keep the topology of the contact network unchanged in the interval shuffling procedure the sequences of contact and intercontact durations are reshuffled for each link separately while in the link shuffling procedure 24 the unaltered sequences of events are swapped between link pairs both procedures destroy the causal structure of the temporal network but they both preserve the global distributions of contact durations intercontact durations and number of contacts the is procedure also preserves for every link the total number of contact events and the cumulated interaction time while the ls procedure does not conserve these quantities at the link level we also consider a global time shuffling procedure we build a global list of the empirical contact durations and for each link we generate a synthetic activity timeline by sampling with replacement the global list of contact durations according to the original number of contacts for that link while the global distribution of contact durations and of the number of contacts per link are conserved by construction all temporal correlations are destroyed and the distributions of intercontact times differs from the empirical one figure 1 illustrates the three randomization procedures defined above all the procedures conserve the topology the distribution of contact durations and the distribution of the number of contacts per link of the empirical networks table 1 summarizes the impact of the randomization procedures on different properties of the temporal networks bottomup approach generative models we also define generative models for random temporal networks designed so that the resulting timevarying networks exhibit specific properties of the empirical data in the spirit of the configuration model for static networks 29 we start by creating a static random erdo ¨sre ´nyi network with the same number of nodes and the same average degree of the temporallyaggregated empirical contact network then we assign to each link a sequence of synthetic contact events according to different strategies in the intercontact time model we impose that the global distribution of intercontact durations is the same as in the empirical data this is an important case to test against as it is often considered in the literature that the distribution of intercontact times plays an important role in determining and constraining spreading processes over temporal networks 26 contact durations are fixed and equal to the average contact duration measured in the empirical data in the intercontact time plus contactperlink model we proceed as in the ict case but also impose that the distribution of the number of contact events per link must match the empirical one in summary in both models the topology and the contact duration distribution differ from the empirical ones table 2 summarizes the properties of the generated temporal networks that are constrained to match those of the empirical data arrival times measured with activity clocks from each empirical network we build synthetic networks according to each null and generative model we simulate si processes on both empirical and synthetic networks for different starting times and for different choices of the seed node we then compute the distributions of arrival times measured in terms of activity clocks figure 2 compares the arrival time distributions from the empirical data with those yielded by the null and generative models the results for the sfhh conference dataset are reported in the si in order to provide a quantitative assessment of the distribution similarity we compute the symmetrized kullbackleibler divergence 30 between the distribution of arrival times for the empirical data and for each model given the relevance of large arrival time values which may be strongly influenced by causal constraints and in general by the peculiarities of the temporal structure of the network we also compute the kullbackleibler divergence between the tails of the distributions to this end we only take into account arrival times longer than a fixed threshold arbitrarily set to 10 we refer to this restricted kullbackleibler divergence as kl101 and we have checked that our results are robust with respect to changes in the threshold table 3 and fig 2 report the symmetrized kl and kl101 divergences for the conference and hospital datasets we consider determinants of the arrival time distribution using kl and kl101 as guiding metrics we use the topdown approach to discard features that are unimportant in reproducing the arrival time distribution and to narrow down a set of necessary features we then use the bottomup approach to find the features that are sufficient to model the arrival time distribution the interval shuffling and link shuffling procedures lead to distributions of arrival times similar to those of the empirical data this indicates that the causal structure of the temporal network has a small impact on this distribution moreover ls does not preserve the specific assigment of cumulated contact durations v ab and number of contacts n ab to individual links we can therefore discard these as explanatory factors of the specific shape of the arrival times distribution according to table 3 and fig 2 the time shuffling procedure yields a very different distribution for the conference datasets and a different tail for the hospital data we know that by design the ts procedure does not preserve the distribution of intercontact intervals which is directly related to the burstiness of contact activity the failure to adequately model the arrival times distributions stems thus from this feature and can be related to previous results 1923 showing that burstiness plays an important role in spreading phenomena indeed the distribution of intercontact interval durations for the synthetic networks are quite different from those measured for the empirical networks in the hospital case this difference between empirical and synthetic intercontact interval durations is reduced leading to the reduced difference in arrival times distributions observed in panel d of fig 2 for the ts model however panels cf of fig 2 also show that the distributions of arrival times obtained for the ict model which is designed to preserve the distribution of intercontact durations exhibit kl differences that are similar or even larger than those of the ts case discussed above the corresponding distributions in panels a and b of fig 2 are indeed much narrower than the ones obtained with the empirical dataset this shows that correctly reproducing the distribution of intercontact durations is not sufficient to adequately model the arrival time distributions in order to achieve that we need to add to the ict model the additional constraint of preserving the distribution of the number of contacts per link ie to use the ict 1 cpl model this model captures the essential features of the data that are sufficient to reproduce the arrival time patterns of the empirical data especially for the tail of the distributions as shown in panels e and f of fig 2 we remark that this model is quite parsimonious as it does not retain the topology of the empirical network nor the distribution of contact durations or cumulated contact durations activitycorrelated classes of links despite the success of the ict 1 cpl model for the conference and hospital datasets which we remark are quite different from one another in the case of primary school data none of these models yields a distribution of arrival times close to that generated from the empirical data as shown in the panel a of fig 3 and table 4 in particular the is and ict 1 cpl models both yield similar narrower distributions compared to the datasets considered in the previous sections the school dataset presents a few distinctive features in the conference cases individuals mix in a rather homogeneous way but most interactions occur at specific moments typically corresponding to social activities such as coffee breaks 722 in the hospital case the interactions display characteristic roledependent patterns but contacts are distributed rather homogeneously during the day 28 the primary school dataset on the other hand exhibits both a strong community structure dictated by class membership and correlated contact patterns across classes determined by the schedule of social activities 27 contacts between children of different classes are possible during specific time intervals only and strongly correlated during such periods because the school schedule controls classbased activities rather than individual activities to tease apart the respective roles of community structure and correlated activity of link groups we study the arrival time distributions in the case of synthetic datasets exhibiting one or both of these for kl101 for the conference dataset and the hospital data in each panel is ls ts ict ict 1 cpl stand respectively for interval shuffling link shuffling time shuffling intercontact time model and intercontact time plus contactsperlink model in the top row data indicates the distribution of arrival times obtained by simulating an si process over the empirical temporal network for each model we consider 20 different realizations of the temporal network for each of these realizations we run 20 different si epidemics each with a different random starting time the arrival times for all those runs are aggregated to yield the reported distributions in the boxplots the box extends from the lower to upper quartiles and the line indicates the median value the whiskers of the box correspond to the 95 confidence interval features these synthetic datasets are created using a toy model that generates temporal networks with tunable community structure and temporal correlations in the activity of intercommunity links to this aim we impose a temporal modulation in the activity of intercommunity links contact events on these links can only occur during specific time intervals we subsequently compute arrival time distributions for these synthetic datasets as well as for the corresponding ict 1 cpl models panel b of figure 3 shows that when activitycorrelated classes of links are introduced the arrival time distributions for the ict 1 cpl case deviates significantly from that based on the corresponding synthetic dataset this is similar to what we reported for the school data and occurs regardless of the presence or a community structure in the synthetic dataset when the synthetic dataset displays a community structure but no correlations between the activity of intercommunity links the same arrival time distributions are indeed observed for both the synthetic network and the corresponding ict 1 cpl model discussion the distribution of arrival times at various nodes of an epidemic process unfolding over a temporal network when measured in terms of activity clocks displays a behavior that is robust across very different settings and for different starting times of the process despite the intrinsic heterogeneities and nonstationarities of the temporal network the arrival time distribution expressed in terms of activity clocks thus represents an interesting tool for investigating the structure of temporal networks beyond their surface features the burstiness observed in many realworld networks indicated by a broad distribution of interevent times is known to be an important feature of temporal networks that influences dynamical processes taking place on them here we have carried out an analysis based on empirical networks of human interactions measured in different social environments and we have used suitablydesigned null models and generative models for temporal networks to show that the burstiness of interevent sequences is not the only essential property that needs to be retained when aiming at a realistic model of timevarying contact networks the heterogeneity of the number of contacts per individual link also plays a fundamental role in determining the arrival times of the spreading process our results show that in fact it is possible to design parsimonious generative models of temporal networks such as the ict 1 cpl model based on just the distribution of interevent interval durations and on the distribution of number of contacts per link the ensuing synthetic temporal networks adequately model the arrival time distributions of realworld networks measured in diverse settings interestingly the behavior of the arrival time distribution expressed in terms of activity clocks is sensitive to complex features of the temporal network data such as the presence of activitycorrelated classes of links as exemplified by the case of the school temporal network where the interplay of the community structure induced by classes and of correlated activity patterns due to schedule activities creates rich temporal structures in the data we have shown that the presence of classes of links that are only active in a correlated fashion during specific time windows has an impact on the spreading time distribution and breaks down the ability to use parsimonious models such as the ict 1 cpl one activitycorrelated classes of links which are arguably common in many realworld social systems are difficult to uncover on the basis of simple statistical observables for the temporal network and their impact on the dynamics of spreading process calls for more research we have shown that arrival time distributions based on activity clocks are a precious tool in this respect as they have the ability to indicate the presence of such complex structures and correlations simple generative models such as the ict 1 cpl model cannot possibly account for these complex structures and should thus be enriched when necessary by introducing additional features such as classes of links with correlated and temporallylocalized activity here we have shown that toy models that minimally incorporate such features yield deviations in the arrival time patterns similar to those observed for the school temporal network overall our results call for more work in the direction of both detecting and modeling complex temporaltopological structures in timevarying networks similarly more work is needed to design minimal generative models that incorporate realistic features found in empirical data from realworld scenarios methods definition of null and generative models here we describe the different shuffling procedures and generative models introduced in the main text for the topdown approach we start from the empirical temporal networks on which we apply the following shuffling procedures interval shuffling the sequence of contact and intercontact intervals of each link is randomly shuffled the original contact durations and intercontact durations are thus preserved given a link with n contact events let us denote the contact intervals by … the set of contact durations is thus given by … and the set of intercontact durations is … we create a synthetic timeline for the link by randomly shuffling the sequence of contact and intercontact intervals and then we randomly and uniformly translate the starting time s 0 0 of the links new timeline within the remaining time interval t 2 where t is the full dataset time interval consistently links with n 5 1 contact events have an empty set of intercontact times and the single contact interval is simply randomly displaced in time link shuffling whole singlelink event sequences are randomly exchanged between randomly chosen link pairs eventevent and weighttopology correlations are destroyed time shuffling time intervals of the whole original contact sequence are randomly shuffled and reallocated randomly to each link retaining the distribution of the number of contacts per link of the original dataset temporal correlations are destroyed the resulting shuffled network is built with a condition of no intersection between contact intervals in the same link in the case of the generative models we start by creating a static random network with approximately the same degree distribution the same number of nodes and the same number of links as the empirical network we want to study then we build a temporal network by associating with each link a sequence of contact events according to the following strategies ict for each link we set the number of contacts per link equal to the average number of contacts per link of the original data each of these contacts is then generated with a duration equal to the average contact duration observed in the empirical data the time between contact events is set by sampling with replacement the distribution of interevent times measured in the data ict 1 cpl the ict 1 cpl model is based on the ict model described above with the additional constraint that for each link the number of contacts is not constant but is set by sampling with replacement the distribution of the number of contacts per link of the empirical data symmetrized kullbackleibler divergence the symmetrized kullbackleibler divergence is defined as div s kl m d k ð þ 12 x i m i ð þlog m i ð þ d i ð þ z x i d i ð þlog d i ð þ m i ð þ ð1þ where d is to the distribution of arrival times in the empirical data and m is the distribution yielded by the models to assess the stochastic variability range of the kullbackleibler divergence we generate several realizations of each null model or generative model we compute the divergence between the distribution yielded by each realization and that of the original data and we show a box plot summarizing the resulting values definition of a toy model with activitycorrelated link classes in order to understand which features of the school data make the distribution of arrival times not reproducible by the synthetic networks of the ict 1 cpl model we introduce a toy generative model that produces temporal networks with some key features of the original school network namely the community structure and the synchronization of the activityinactivity patterns of some groups of links we start by building a static network with a simple twocommunity structure we consider n nodes and divide them into two groups of equal size within each group two nodes are linked with a probability p 1 nodes across the two communities are linked with a probability p 2 p 1 this procedure defines the topological structure of the network we build the temporal network by associating with each link a sequence of contact events these activity sequences are all generated by sampling a poisson process with a rate l 5 00056 s 21 which was chosen to yield an average number of contacts per link of the same order of the school data over the same global time t 100000 s for the crosscommunity links we then remove all events outside of the interval t2 t2 this last condition introduces a temporal modulation for the intercommunity links which are only active in the above time window in the limit d r 1 we recover the nonmodulated case additional information supplementary information accompanies this paper at scientificreports competing financial interests the authors declare no competing financial interests

dynamical processes on timevarying complex networks are key to understanding and modeling a broad variety of processes in sociotechnical systems here we focus on empirical temporal networks of human proximity and we aim at understanding the factors that in simulation shape the arrival time distribution of simple spreading processes abandoning the notion of wallclock time in favour of nodespecific clocks based on activity exposes robust statistical patterns in the arrival times across different social contexts using randomization strategies and generative models constrained by data we show that these patterns can be understood in terms of heterogeneous interevent time distributions coupled with heterogeneous numbers of events per edge we also show both empirically and by using a synthetic dataset that significant deviations from the above behavior can be caused by the presence of edge classes with strong activity correlations t he field of complex networks has recently undergone an important evolution thanks to the recent availability of timeresolved data sources many studies performed under the assumption of static network structures can now be extended to take into account the networks dynamics data on timevarying networks are becoming accessible across a variety of contexts ranging from communication networks 16 to proximity networks 78 and infrastructure networks 910 this avalanche of data is prompting a surge of activity in the field of temporal networks 11 data analysis has shown the coexistence of statistically stationary properties and topological changes as well as the burstiness of interactions characterized by highly skewed distributions of interevent times 114 these temporal features of networks influence the dynamics of network processes just like the topological structure of static networks does 15 as a consequence and similarly to the case of static networks simple dynamical processes such as random walks 16 synchronization phenomena 17 consensus formation 18 or spreading processes 19 20 21 22 23 24 25 can be used as probes to investigate the temporal and structural properties of timevarying networks previous works on the dynamics of spreading processes over complex networks have considered both the topological and the temporal structure of networks 111923 as well as the specific impact that the temporal structure bears on the spreading process the quantities used to quantify the measured effects are typically network averages such as the outbreak sizes of an epidemic or its prevalence these average quantities however fail to account for important heterogeneities in the arrival times of the spreading process recent work 26 showed that the nonstationarity and burstiness of empirical temporal networks lead to noisy distributions of arrival times and that shifting the perspective from a global notion of wallclock time to a nodespecific time based on node activity allows to expose a clear and robust pattern in arrival times here we focus on the distribution of arrival times for spreading processes based on a wide range of empirical data on timeresolved human proximity in particular we seek to identify the dynamic features of the temporal network that are responsible for the observed arrival time distributions to this aim we consider temporal networks of human contacts and we define hierarchies of null models and generative models that selectively retain or discard specific properties of the empirical data we simulate simple spreading processes over these models and perform a comparative analysis of the arrival time distributions our results identify the most salient properties that characterize realistic models of human interaction networks and highlight the properties that control the arrival time distributions with applications to several domains such as opportunistic information transmission and epidemic spread and containment we consider timevarying networks of human proximity measured using wearable sensors the data were collected by the sociopatterns collaboration in different social contexts two conferences in italy ht09 and france sfhh 722 a primary school in france ps 27 and a paediatric hospital ward in italy hosp 28 details on the data collection methods are reported in the supplementary information

study setting with the pandemic restrictions and the diverse location of our participants jk conducted all interviews by way of zoom or telephone as per the participants choice the interviews were completed from feb 9 to apr 9 2022 during the omicron wave of the pandemic participants were given the option to interview in either english or french interviews lasted about 1 hour and were audiorecorded and transcribed verbatim data collection we conducted indepth individual interviews with black stakeholders with insights into experiences of black communities during the pandemic during the interview we asked participants to discuss what they know about online disinformation among black people in canada and the effect of online covid19related disinformation for black canadians and to provide us with their perspective on evidencebased practices to address online covid19related disinformation among black canadians we collected data on sex from all participants and did not restrict demographic questions on sex to binary conceptualizations we disaggregated demographic data by age or sex place of origin location in canada religion vaccination status and role within the black community we also recognize that black communities are a heterogeneous group thus we strived for representation from african immigrants caribbean immigrants members of historic black communities in canada and black people from the united states one author wrote field notes after each interview data analysis the data collection and analysis processes were iterative we conducted an inductive content analysis 15 drawing on analytical resources from intersectionality theory 16 intersectionality spotlights how the diverse elements of peoples unique social identities could overlap to influence their experiences 16 during the analysis we considered issues related to age sex race embedded inequalities and intersecting influences three authors independently read 3 transcripts to familiarize themselves with the data and develop a coding framework the advisory committee and the principal investigator reviewed the draft coding framework and provided input using nvivo 12 software jk read all transcripts and applied the coding framework to complete the data coding and analysis preliminary results were shared with the advisory team members for their feedback to ensure the quality of data research team members observed reflexivity throughout the research process by maintaining subjective awareness of their multiple privileges intentions and assumptions results we reached data saturation after interviewing 30 participants which included 16 males and 14 females our participants were 15 black stakeholders from alberta 10 from ontario 2 from nova scotia and 1 each from british columbia manitoba and saskatchewan all participants chose to be interviewed in english details on the sociodemographic characteristics of participants are provided in table 1 in reporting our results where fewer than 5 participant views are presented we have used the term some and where more than 5 participants are presented we have used the term most we have made it clear for single participants views main themes we identified 2 main themes the nature of online covid19 disinformation and the facilitators of covid19 disinformation participant quotes supporting analysis of data are shown in table 2 nature of online covid19 disinformation and misinformation according to participants online covid19 disinformation and misinformation was widespread in black communities and typically included misconceptions of covid19 as a fallacy and sarscov2 vaccines as ineffective drugs with microchips some participants indicated the belief that covid19 was a hoax at the beginning of the pandemic led to a slower acceptance of recommended public health interventions and delays in seeking health care lack of knowledge on vaccine development led to misinformation about vaccine safety given its fast development as expressed by most participants others believed a person could acquire covid19 by getting vaccinated and that the vaccines were not essential given that vaccinated people were still susceptible to the sarscov2 infection another participant explained that inconsistent information about vaccine dosages raised concerns about the efficacy of the vaccines within the community some participants suggested that black community members believed the sarscov2 vaccine contained microchips that bill gates and other western leaders could use to track people who were vaccinated thus compromising their privacy and increasing their vulnerability to racial profiling hence the sarscov2 workplace vaccination requirements and proof of vaccination to enter public places such as restaurants further increased this suspicion and skepticism among the black population as ex plicated by most participants these misconceptions contributed to vaccine hesitancy in black communities and increased the risks of infection a few mentioned that social media interactions among black people were dominated by a lack of knowledge about the vaccines which raised concerns about vaccine shedding adverse effects on reproductive health and infertility caused by the vaccines other participants cited controversies surrounding previous mandatory vaccine programs in some african countries linking vaccines with antifertility agents moreover some participants believed the vaccines were a scam to depopulate black communities facilitators of online covid19 disinformation and misinformation miscommunication participants identified a lack of credible information sources distribution of unverified information and overwhelming conflicting information as facilitators of the spread of online covid19 disinformation and misinformation in black communities most participants were concerned that credible information about covid19 was not readily available to black communities causing anxieties and panic within black communities and pushing people to rely on social media friends and family for information they indicated that credible information about the disease from governments and health authorities was not accessible to most black community members most participants expressed that black communities prefer facetoface communication but much of the credible information from these sources was distributed by way of electronic and print media such as television and newspaper outlets this made credible information less accessible especially to black people who worked frontline jobs or multiple jobs and lacked time to access these sources some participants asserted that black people with limited digital literacy faced barriers to accessing credible information causing them to depend on covid19 information relayed by others which increased their risk of exposure to disinformation and misinformation black communities also faced many conflicting messages from multiple sources including social media governments health authorities health care practitioners expert opinions and international organizations such as the world health organization some participants indicated that the conflicting messages from these sources degraded the credibility of information from public health agencies this made black communities susceptible to online covid19 disinformation and misinformation including inaccurate messages that downplayed the seriousness of the pandemic and the efficacy of sarscov2 vaccines although most participants predominantly consisted of immigrants who use social media to maintain transnational ties with family or friends residing in their home countries an overwhelming abundance of unverified covid19 information circulated within the networks of black communities regardless of their country of origin with the lockdowns social media platforms such as facebook and whatsapp offered more accessible ways to interact and share the vaccine they say like i think when we got the vaccine the first dose and the second dose and we thought like oh its thats going to be it … and again there is another a third dose … and again theres another fourth dose so we dont know when this is going to end because we still dont know like what is happening but you know the misspread of information on whatsapp led some people to believe that this was some instrument that was being used to control the population by bill gates or you know maybe the western leaders … and for you to get around this you have to get a chip and like this chip they would be able to monitor your activities … and that kind of raised some kind of fears among the community members yeah well it has really created a lot of mixed reaction … canada its supposed to be multicultural and its supposed to be a country that has a choice you make your own choice but during covid i dont think people were given that choice … they were kind of forced to take the vaccine and they have been left with doubt … they think the vaccine is intended to control the population in the black community uh well for females there was like okay there was a fear of if you caught the if you caught the virus you know it could affect your fertility well for starters i think people from my understanding with the africans … there was a time back then when at the point when polio was kind of rampant … so they have a fear that like some people who took the medication or the vaccinations were not able to have kids … and they think that the vaccines made them infertile and it was a way of the west controlling them okay so the misconceptions that i can think we find in our black communities are first of all that like it is something that was created by white people so that they can get rid of us black people facilitators of online covid19 disinformation and misinformation miscommunication the absence of timely ongoing trusted and connected sources of information where people can go and just really understand the fullness of the you know the virus or the vaccines or whats happening in the community in the absence of those kinds of thing folks are folks fill that void either with disinformation assumptions or you know general perceptions that general perceptions or misconceptions that gets spread into the community another thing about the information was that it didnt consider how members of our communities get information so we like 1on1 … so just targeting information in the media i think it did not it didnt reach members of our community and again we are very curious i mean we like to ask questions okay so if you just put information out there without the means of engaging and feedback of that information that will not help us yeah for those that have a challenge to access internet sources yes we can say that there is a gap because it is difficult to access information for those that are struggling to survive and that are working for 16 hours but also at the same time we cant really blame our community members because a lot of the people that came here maybe came as refugees and never had the opportunity to go to school and this is something new to them and they have no idea of what you know peer peer review is what kind of information might be coming from a peerreviewed source which informations reliable or not they lack that you know that guidance and like i said they the yes the government is talking but sometime today they will say a tomorrow they will say b after they will say c so its like they dont know themselves where they are going … now i think people get used with that they dont even listen to them so myself i stopped listening because everybody gets information from social media on various site sources … 1 community member has some information shared on 1 platform and its disseminated without verifying the source cultural and religious factors you know while a lot of us living here we have directly interfaced with what is happening back home … so that link between here and back home has also played a key factor in peoples perception okay … because the information flows not just online alone … because when they get something back home they forward it to those of us who are here and so that was also a means of misinformation but also an opportunity for education that people didnt recognize here because even a lot of the misconceptions and the misinformation were fueled by some religious leaders who felt that the vaccine had something to do with spirituality and the antichrist and so many other things they practice … and theres some churches that even told their members not to take and some of their members did not you know a lot of us or people of african and caribbean or black descent believe in your body acquiring natural immunity plus using natural protective i guess interventions concoctions whether it was laughs the famous ginger lemon and whatever that was going around ive also interacted with community members who had mentioned to me that they have herbs that could protect you from covid19 and as such do not need to wear masks or take any prevention other than those teas … and some of the sources are not verified sources but you know the community consumes a lot of the information that is gotten through social media yeah then some people also were thinking that with herbs you can kill the virus that you dont need to take any vaccination distrust of health care systems so there is a lot of broken trust between the acb african caribbean black communities and the mainstream medical health care because of the medical history between the acb communities and the system the health system … we could talk about the tuskegee experiments … and similarly to look at other black experiences in the health care that we see we could also talk about the mental health you know looking at the trauma you know including medical ptsds posttraumatic stress disorders for those who have experienced medical racism directly or indirectly within the health care system they just dont trust anything that they dont have control over which is not much that black people have control over it they dont trust it they dont trust the systems to me because in their minds the systems always fail black people right they feel disenfranchised or they dont think they are part of the whole world so to say they feel that you know theres nothing you know in the system for them they also go back to lack of trust of the system and also the medical community and ive heard even one of our own saying that you know we dont trust you guys we dont trust you doctors because you just you know you are just a part of the whole conspiracy and then the historical perspective is very very strong… they prefer to get their information online or they also have specific areas where they get their information from but once that was done and when it came to testing distribution of testing kits again we were forgotten you know laughter you know so it was quite incomplete because you see when it came to vaccines yes we were remembered right and those communities were used to disseminate the information that vaccines are available and then when it came to testing kits that would have helped people to kind of keep them safe and right distrust of governments i know it sounds really hard and it sounds bizarre but at the core of it i think is antiblack racism i think when you are a population thats the most hated population when youre a population that faces the most disenfranchisement when youre a population that has next to the indigenous the highest number of people in child in the number of black kids in childcare when you have the highest number of black men incarcerated i think its all that so black people just dont trust i think very specifically as it relates to the vaccine and as it relates to covid19 i think there is a proliferation of disinformation within that community that stems from challenges related to distrust of the state rightful distrust of the state right but i think that its kind of morphed into conspiracy theories that are unhelpful … but nevertheless theyve kind of taken hold as an expression of that distrust but i think that in the context of covid19 those can be really damaging and concerning folks were told to physically distance but there were some folks who had to go to work and you know were being called heroes et cetera and so they would be going to work early morning on the bus but the buses were full folks asked for additional buses so that they could physically distance and the official response from the government was that they werent going to send more buses … this is fertile ground not only for distrust and misinformation for some folks its also fertile ground for um … those health inequities … you know when you parse these things out 1 by 1 disinformation or you know vaccination and mandates were often not getting an understanding of how things coalesce or collocate to create the context in which people like think and act like for instance we found out that during the covid19 spread yeah there have been significant experiences of discrimination among the black people in in thats across the country so that there was significant negative experiences in attempting to receive health care during the covid19 period … so that can help them to accept misinformation if the health care system is not doing what they are supposed to do to support their needs during a critical time of covid19 information about the pandemic therefore some participants explicated that social media became a source of information fatigue through which covid19 disinformation and misinformation spread cultural and religious factors most participants explained how black canadians are highly attached to their countries of origin thus rumours originating in their land of birth spread quickly in the diaspora community because of those strong ties such culturebased disinformation included beliefs suggesting re ligious faith and natural health remedies were more effective than vaccines in combatting the spread of the sarscov2 infection one participant illuminated that because most black people are religious they were readily susceptible to this kind of disinformation and misinformation and even more so if such rumours were spread by religious leaders although all participants reported being vaccinated they observed that some black community members opposed sarscov2 vaccines in particular some black people viewed these vaccines and their developers as antichrist agents misrepresentation of the scriptures created fear and contributed to refusal and a delayed acceptance of sarscov2 vaccines in black communities some participants eluded that consistent with traditional african worldviews black people were inclined to believe misinformation about herbal supplements being an effective preventive remedy or treatment for sarscov2 infection these participants explained that these beliefs mainly spread through social media bringing about a false sense of security that exposed more community members to the disease and discouraging their use of approved care supports distrust of health care systems some participants referenced the history of medical racism and continuous exploitation of black people in the medical system as a factor that diminished trust in governments and health organizations participants referenced past injustices such as the tuskegee experiment in which us public health allowed africanamerican men with syphilis to go untreated as a way of chronicling the progression of the disease participants acknowledged the cumulative trauma to black communities caused by racism in health systems that have continuously failed them these histories increased black peoples skepticism about covid19 and its vaccines rendering them vulnerable to alternative truths about the disease systemic racism has consistently posed challenges to the health of black people and exacerbated the health disparities they face participants highlighted how exposure to racism and discrimination has left the community feeling disregarded reinforcing mistrust of health care organizations and diminishing efforts at increasing vaccine acceptance participants suggested that many black people would rather believe the information obtained from social media than messages communicated by health care professionals this attitude served to undermine public health responses to the pandemic participants also indicated that inequitable distribution of the vaccines and testing kits reinforced the distrust black people had with health care systems specifically despite reporting a higher number of sarscov2 infections and deaths black communities were not prioritized when test kits were distributed yet they were being increasingly asked to get vaccinated thus addressing racism represented a more pressing need for black communities besides adherence to public health interventions distrust of governments participants described disinformation and misinformation within the black community that occurred because of experiences of discrimination and differential treatment based on race and skin colour racism has perpetuated distrust of governments owing to the lack of commitment to addressing inequities faced by black canadians especially in the areas of education employment housing policing child care and health care according to participants black peoples perceptions of government influenced how they responded to public health interventions addressing the pandemic for instance 1 participant explained that more black canadians compared with other ethnoracial groups worked in frontline jobs and used public transportation where a lack of opportunities for physical distancing increased their risk of sarscov2 infection thus the black communities belief that governments are indifferent to their plight increased their skepticism of covid19 interventions including vaccines some par tici pants expressed that governments should address antiblack racism within institutions and should work on building trust with black communities interpretation social media especially instant messaging platforms such as facebook and whatsapp became a conduit through which covid19 disinformation and misinformation spread in black communities this form of information exchange also carried the dangers of disinformation and misinformation affirming the risks of sarscov2 infections and poor health outcomes among black canadians most participants suggested racism and underlying systemic discrimination against black canadians promoted distrust of the government or health institutions and immensely catalyzed the spread of disinformation and misinformation in black communities across canada although our participants were all fully vaccinated they noted that some members of their communities were vaccinehesitant owing to distrust of vaccine manufacturers health care systems and governments they indicated that this hesitancy results from current and historical experiences of racist medical procedures most participants referred to the tuskegee experiments when discussing health disparities and racism in health care in the canadian context it is apparent that the black community in canada strongly relates to the tuskegee experiments and the health care systems history with black communities in canada thus affecting how they respond to the sarscov2 vaccine some participants indicated that communication by health care authorities and the government during the beginning of the pandemic was not culturally appropriate to some black people owing to conflicting messages and language barriers prompting an overreliance on their community members over social media further firm beliefs in cultural practices such as religious faith and natural health remedies contributed to disinformation and misinformation within black communities our findings are similar to other published studies indicating an upsurge in online disinformation and misinformation exacerbated health inequities experienced by black communities and undermined public health interventions to curb the spread and effect of covid19 11 research funded by the rita allen foundation found that antivaccine groups weaponized black peoples historical encounters with health care systems to coerce black communities into rejecting the sarscov2 vaccines 17 our results indicated that some black people were hesitant to receive vaccinations owing to their religious beliefs although previously reported findings showed some religious leaders were noted for encouraging their congregations to get vaccinated 18 there is also evidence showing language barriers during the covid19 pandemic resulted in decreased adherence to public health directives and recommendations 1920 other studies have reported issues relating to biases and lack of culturally appropriate care for black people in canada and the united states 2122 our study shows the need to engage communitybased health care clinics to promote sarscov2 vaccine uptake and eliminate language and cultural barriers to vaccine access for instance such a model in california indicated that communityengaged approaches rooted in principles of authentic partnership that include trustbuilding powersharing and colearning are crucial for addressing public health crises such as the covid19 pandemic 21 this approach identified barriers to vaccine uptake that were then addressed by providing culturally appropriate care 8 there is also a need to use an antiracist and antioppressive framework to guide health agencies in addressing inequalities within the health care system and understand how social and economic conditions structural racism and systemic discrimination can engender qualitydriven trust 23 practices that stress continuity and communication result in a higher level of confidence in physicians which is paramount in promoting the use of preventive services 24 further religion plays a notable role in the black communities rendering the religious institutions essential resources for health care interventions within the black communities 25 26 27 limitations our inability to recruit participants from the caribbean and some provinces with large black populations is a limitation of our study further overreliance on snowball sampling led to a largely homogenous sample in which most participants identified as christian and cisgender the participants were all vaccinated a limitation since their accounts cannot fully represent those in the black community who are vaccinehesitant we acknowledge that older adults are more at risk from covid19 however the analysis of our results was dependent on the perspectives of the participants interviewed we used purposive sampling and snowball techniques to recruit black community leaders blackled organization leaders and black service providers resulting in a younger working age population future research should target older adults by recruiting through communitybased organizations senior adult living or longterm care homes conclusion underlying systemic racism and related inequities in canada created mistrust for public health authorities and contributed to black peoples preparedness for alternative truths about covid19 therefore there is a greater need to build trust and adopt collaborative approaches to addressing community concerns for example having genuine respectful discussions of other topical issues affecting black people such as employment discrimination medical racism and antiracist workplace practices and policies as such we recommend supporting and steadily funding existing black community organizations to develop culturally accessible health education material including health information flyers and infographics funding communitybased health centres may help disseminate and increase the uptake of health information and curb the spread of disinformation ethics approval the university of alberta ethics board approved our study affiliations faculty of nursing and health and immigration policies and practices research program university of alberta edmonton alta obstetrics and gynaecology university of toronto and north york general hospital black opportunity fund toronto ont impact institute of canada intersections of gender signature area university of alberta edmonton alta contributors bukola salami contributed to the conception and design of the work janet kemei dominic alaazi adedoyin olanlesialiu modupe tundebyass and bukola salami contributed to the acquisition analysis and interpretation of the data janet kemei drafted the manuscript all authors revised the manuscript critically for important intellectual content all authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work content licence this is an open access article distributed in accordance with the terms of the creative commons attribution licence which permits use distribution and reproduction in any medium provided that the original publication is properly cited the use is noncommercial and no modifications or adaptations are made see byncnd40 data sharing research data are available on request to bukola salami funding funding was received from the digital citizen contribution program government of canada supplemental information for reviewer comments and the original submission of this manuscript please see e389suppldc1

lack canadians are disproportionately affected by the covid19 pandemic 1 for example as of september 2020 data tracking of covid19 cases in toronto showed black people accounted for 24 of positive cases despite constituting only 93 of the citys total population 2 black people and other racialized communities in canada are also more likely to be admitted to hospital with covid19 than white and east asian people 3 further evidence shows a universal vaccine hesitancy across countries and subgroups 4 disinformation and misinformation about covid19 contributes to health disparities by posing a threat to the acceptance of the sarscov2 vaccine among black canadians 5 6 7 8 9 10 the susceptibility of black canadians to online covid19 disinformation vaccine hesitancy infections and hospital admissions may be attributed to several individualand structurallevel factors including socioeconomic status crowded living environments cultural barriers racial discrimination poor access to health care and poor housing that make it difficult for this population to adhere to public health directives 11 similarly antiblack racism and structural inequities within canadian institutions expose black people to socioeconomic vulnerabilities which increase the burden of covid19 morbidity and death to this population 1213 thus increasing vaccine skepticism and hesitancy on completing a scoping review of online disinformation among black people 14 we wanted to deepen our knowledge and situate the findings from our scoping review within the canadian context despite the negative health behaviours promoted by disinformation there is a paucity of qualitative studies examining online covid19 disinformation in black communities in canada we aimed to describe the nature of online covid19 disinformation and misinformation among black canadians and identify the factors contributing to this phenomenon

introduction almost all politicians in western europe todayfrom across the political spectrumapparently believe that some people are more entitled to inhabit particular places than others their belief is usually based on a form of primordial reasoning we were here first where places are owned by native groups who enjoy specific rights research on childrens ethnic racial and antiimmigrant attitudes has focused on various factors and processes such as socialcognitive development moral reasoning ingroup norms group identification intergroup contact feelings of threat and school composition and educational practices what has received much less attention is the role of socalled lay theories for childrens negative outgroup attitudes there is some work on the ways in which group essentialism beliefs beliefs about the malleability or fixedness of human attributes protestant work ethic beliefs and shared conflict beliefs justify childrens negative attitudes in addition to these lay theories and similar to what is expressed in the quote above children might reason that a place belongs to their ingroup because they were there first and therefore that it is acceptable to exclude newcomers in intergroup research and following anthropological literature this notion of primooccupancy with the related ownership feelings has been labeled autochthony beliefs and these beliefs have been found to be important for adults ethnic outgroup attitudes with three empirical studies conducted in the netherlands the current research examines the importance of autochthony beliefs for majority group childrens attitudes towards immigrants the current aim is to introduce the novel construct of autochthony to the intergroup development literature and to empirically examine its relevance for outgroup attitudes of ethnic majority group children the importance of this lay theory was investigated while considering ethnic identification and by taking perceived multicultural education classroom composition and feeling at home in the country into account the general expectation that was tested is that whereas ethnic identification is mainly relevant for ingroup attitudes autochthony beliefs with their sense of native collective ownership are especially important for attitudes towards immigrant groups more specifically autochthony beliefs are considered to provide a justification for negative immigrant attitudes of majority group children in particular when they at the same time do not feel at home anymore in their own country thus it was hypothesized that autochthony beliefs can serve to justify antiimmigrant attitudes and prevailing social inequalities in short this research breaks new ground in examining the importance of autochthony beliefs for childrens evaluation of immigrant groups and in investigating when these beliefs are particularly important by considering the moderating role of a sense of feeling at home in ones country in doing so we not only introduce the novel concept of autochthony to the literature but also make a contribution to the rather limited understanding of childrens attitudes toward the increasingly important group of immigrants although young children show tendencies to justify group advantages the understanding and endorsement of lay theories that justify advantages appears later it is only at around 8 years of age that children are able to use and weight different forms of information to assess and evaluate claims and rights furthermore compared to objects ownership of a territory might be a rather abstract issue for young children research has shown that childrens knowledge and beliefs about countries as geographical territories develops from around seven years onwards in addition longitudinal research in western europe has shown that early adolescence is a sensitive developmental period for the emergence of negative attitudes toward immigrants therefore the current research focuses on late childhood and there were no reasons to expect meaningful age differences lay theories once learned instigate a distinct and stable pattern of evaluation and judgment with respect to the target group for example research on protestant ethic beliefs and on entity and incremental beliefs indicates that these beliefs tend to function the same in social judgments regardless of age ownership and autochthony beliefs perceived ownership is a pervasive notion that has profound implications for how individuals think feel and behave ownership helps to organize the social and physical environment regulates social interactions and involves normative and moral privileges and responsibilities perceived ownership implies a bundle of rights such as the right to use what is owned and to decide whether to keep the target of ownership or not importantly ownership also implies a gatekeeper right the right to exclude others and to decide whether others are permitted or prohibited to use the object or have access to it considering these implications it is understandable that disputes over ownership of objects and places are among the most frequent and most intense intergroup conflicts also among children although ownership is not an obvious property of objects but rather abstract and imperceptible young children already recognize it preschoolers have a basic understanding of ownership of physical objects and appreciate that owners are entitled to greater control over their property than nonowners by the age of 6 or 7 childrens notions of ownership are also applied to ideas and intellectual property and to places there are many situations in which groups of children make claims on a particular physical place such as when children convert a site in their play area club or hideaway territorial behavior whereby an intruder is excluded or punished for invading our play area has been found in observational and experimental research among children children can infer ownership from seeing someone in possession of an object from verbal statements about who owns an object from observing who decides on whether others can use it and by using principles of past investment and ownership transfer in addition children have been found to judge that an object belongs to the first person possessing it older children and adults argue that the first person seen to possess a previously nonowned object is its owner and the same has been found for the ownership of ideas similarly being first at a particular place is information that children use to infer ownership first arrival indicates ones presence at a place before anyone else and this in itself is an important basis for establishing ownership experimental research has demonstrated that children as old as eight years infer personal and importantly also collective territorial ownership from first arrival in this research first arrival on an island was found to be a consideration that undermines the notion of equal sharing which is a key moral principle for children that is typically applied when there are no other considerations involved such as social conventions group norms interests and personal benefits these findings correspond with anthropological work on autochthony and sons of soil conflicts which demonstrates that primooccupants are considered as rightfully possessing an area this is evident in the moral and legal claims on resources and territory made by indigenous groups and socalled first nations or first peoples the notion of autochthony suggest that first arrival determines place ownership with the related right to usage and to exclude others the term autochthony can be traced back to ancient greece and it means literally being born from the soil it is the belief that a country or a region belongs to its original inhabitants this belief triggers selfevident notions of ownership and entitlements and thereby has an implicit call for excluding strangers whoever they may be in european nonsettler countries this notion has been used to reject immigrants and to justify prejudice towards immigrant groups an immigrant represents someone trying to become a member of ones national ingroup and this typically elicits considerations of collective ownership and territorial belonging autochthony can function as a justifying belief because it makes the more advantaged position of the native majority group understandable and just children as young as 5 appear to be sensitive to these sorts of justifying beliefs and 10year olds have been found to endorse them furthermore lay theories can justify childrens thoughts feelings and behaviors toward minority outgroups it was expected that majority group children who more strongly endorse autochthony beliefs will have a more negative attitude toward immigrant groups and refugees furthermore in study 3 the expectation was tested that the association between autochthony beliefs and outgroup attitudes is especially strong among children who feel less at home in the netherlands social identity development theory proposes that negative outgroup attitudes tend to emerge when majority members feel that their position or wellbeing is undermined in some way by members of ethnic outgroups childrens attitudes and reasoning are influenced by social context and exposure and research has shown that older children are aware of the societal debate on immigration and existing antiimmigration sentiments the dutch immigration debate is typically framed in terms of what immigration means for the country and the widespread sentiment is that the ethnic majority dutch feel estranged and no longer at home in their own country the native dutch it is argued have become like foreigners in their own country feeling what foreigners should allegedly feel not at home research shows that the ethnic dutch do indeed increasingly feel not at home in the netherlands and not feeling at home is higher among adolescents than adults this feeling can be expected to make autochthony beliefs more important for attitudes toward immigrant groups proprietary claims to a country that are accompanied by a sense of estrangement has been found to be associated with more negative ethnic outgroup attitudes theoretically and as indicated in the quote heading this paper it is the combination of autochthony beliefs with the sense that ones ability to feel at home in ones own country is undermined that in particular should be associated with more negative attitudes toward immigrant groups therefore study 3 tested the expectation that autochthony is stronger related to antiimmigrant attitudes among ethnic majority dutch children who have a lower sense of feeling at home in the netherlands ethnic identification autochthony and the related sense of ownership does not have to imply a sense of ethnic group belonging individuals can believe that their group owns a particular place because of firstarrival without having a sense of commitment and belonging to ingroup members research among children has demonstrated that stronger ingroup identification goes together with more positive attitudes toward the ingroup including the national ingroup a positive evaluation of the group to which one belongs provides a positive sense of self this means that it can be expect that in the three studies majority group children with higher ethnic identification will be more positive about their ethnic majority group higher ingroup identification does not have to imply however that outgroups are evaluated more negatively social identity development theory proposes that stronger feelings of ingroup belonging lead to a stronger ingroup orientation and commitment but not necessarily to a rejection of outgroups higher compared to lower ethnic identifiers are predominantly focused upon and concerned about their ethnic ingroup yet when concerns about the outgroup come into play it is more likely that ingroup identification is associated with negative outgroup attitudes according to social identity theory higher compared to lower identifiers are more sensitive to anything that could harm or undermine their feeling of ingroup belonging this means that it can be expected that the combination of autochthony beliefs with a sense of not feeling at home is particularly important for higher identifiers those who feel that the netherlands is no longer their home and also consider being dutch important to their sense of self are likely to base their negative attitudes toward immigrants on autochthony beliefs this expected threeway interaction between autochthony home feeling and ethnic identification was tested in study 3 current study the general expectation tested is that stronger autochthony belief is associated with more negative immigrant attitudes and that this association is particularly strong for children who have a relatively low sense of feeling at home in the country but at the same time care about being dutch in two ways this research tried to provide clear empirical evidence for this expectation first in assessing the robustness of the associations found for autochthony it was examined whether the statistical effects of autochthony was similar for different age groups boys and girls level of ethnic identity perceived multicultural education and classroom ethnic composition the presence of similar effects demonstrates that the role of autochthony for attitudes toward immigrants does not depend on these individual and classroom differences and thereby would underscore the general and robust importance of the construct of autochthony beliefs for childrens immigrant attitudes second given the increased importance of replication in research it is important to ensure that the results could be replicated with different samples of ethnic majority group children and somewhat different measures and operationalizations of group attitudes the expectations were tested in three separate analyses by using data from three different studies 1 on childrens attitudes towards school and their academic engagement in these studies questions on autochthony beliefs and attitudes toward the two most prominent and numerically largest immigrantorigin groups in the netherlands were included these two groups have a history of labor migration starting in the late 1960s followed by a process of family reunification in the mid1970s which means that nowadays majority group children are mostly exposed to second and third generation immigrants study 1 method participants and procedure participants were 345 children who had two ethnic dutch parents and who selfidentified as ethnic dutch these children were from 23 classes in 8 schools in different parts of the country participation in the study was voluntary and anonymous and all children with parental permission participated together with their classmates the children completed a questionnaire in their classroom under supervision of their teacher and a research assistant apart from the study variables the questionnaire contained items on childrens relations with their peers and teachers 2 and experimental vignettes related to diversity originally the sample consisted of 347 ethnic dutch students but two cases that had missing scores on the dependent variables were deleted overall very few scores on the items were missing and littles mcar test indicated that missingness was completely at random χ 2 6390 p 0145 1 the different studies involved three independent data collections two of the schools participated in study 2 and study 3 however there was a twoyear difference between both data collections and for one of the schools the children were in respectively in grade 6 and grade 8 in the earlier and the later data collections 2 in a previous research the immigrant attitude measures analyzed in the current studies 1 and 3 and those from a prior wave of study 2 were predicted from the quality of the studentteacher relationship likewise two of these studies controlled for perceived peer acceptance studentteacher relationship quality and perceived peer acceptance were not included in the present studies as they were unrelated to autochthony it was not theoretically relevant to include other variables from the datasets in the present analyses measures autochthony was measured with two items adapted from previous research the netherlands belong to those who came here first and dutch natives can decide what happens in their country the response scale ranged from 1 to 5 and there was a mediumsized correlation between the items r 032 ethnic identification was assessed with three items that have been successfully used in previous research on a fivepoint scale ranging from 1 to 5 children indicated whether they liked being dutch and whether they were proud to be dutch and whether they found it important to be dutch because the autochthony and identification measures had moderate internal reliabilities latent variables were used in the main analyses in order to correct for measurement error immigrant group attitudes was assessed by using the seven faces scale developed by yee and brown which ranges from a big smile to a big frown children used this scale to indicate their evaluations of respectively dutch and people of turkish and moroccan background all scales were presented on the same page in the questionnaire the evaluations of turks and moroccans were strongly correlated r 081 and therefore averaged into a single measure for outgroup attitude childrens ingroup attitude was substantially more positive than their outgroup attitude t 2504 p 0001 results to examine the distinction between autochthony and ethnic identification and their unique relations with childrens ethnic attitudes structural equation modeling in mplus 7 was conducted as there was no significant classroom variance in the dependent variables and to retain an acceptable casestofreeparameters ratio we did not include the classroom level in the analyses or examine the role of classroom ethnic composition four fit indexes were used the comparative fit index the tucker lewis index the root mean square error of approximation and the standardized root mean residual model fit is considered good if cfi and tli have values of 095 or higher and rmsea and srmr are lower than 005 cfi and tli values larger than 09 and rmsea and srmr values smaller than 01 are considered acceptable first a confirmatory factor analysis was performed to examine whether the autochthony and identification items loaded on two different but correlated factors results showed that the fit of the twofactor model was excellent χ 2 303 cfi 100 tli 101 rmsea 000 srmr 002 and that the two factors were uncorrelated r 014 p 015 3moreover the twofactor model fitted the data significantly better than a model that included a single factor for both autochthony and ethnic identification χ 2 dif 3578 p 0001 these findings demonstrate that for the majority group children autochthony beliefs and ethnic identification were separate constructs next a stuctural equation model was specified in which childrens ingroup attitude and attitude toward immigrants were regressed on the latent factors for autochthony and ethnic identification mlr as an estimator was used as the distribution of the ingroup attitude was nonnormal and one factor for childrens attitude toward the turkish and moroccan outgroups was specified age and gender were controlled for the fit of the sem model was satisfactory χ 2 2331 cfi 097 tli 093 rmsea 0036 srmr 0031 results are shown in table 1 as expected and indicated by the standardized effects autochthony had a moderately strong negative relation with childrens immigrant attitude but was unrelated to their ingroup attitudes conversely childrens ethnic identification was positively related to their ingroup attitudes but it was unrelated to their attitude toward the immigrantorigin groups to examine the robustness of the effects of autochthony on childrens outgroup attitude a sem model was specified in which its interactions with identification age and gender was added none of the interactions were significant which means that the link between autochthony and immigrant attitude was similar for lower and higher ethnic identifiers younger and older children and boys and girls lastly because of the skewed distribution of the ingroup attitude measure an additional analysis was conducted in which this measure was dichotomized and treated as a categorical variable as in table 1 there was a positive effect of ethnic ingroup identification but no effects of the other variables study 2 the first study demonstrated that stronger autochthony belief is related to more negative attitudes toward immigrantorigin groups the association found was relatively strong and robust across age gender and ethnic identification there were four reasons for conducting study 2 first to ensure that the results could be replicated with another sample of majority group children second it could be argued that using two items to measure autochthony in study 1 is limited and also that these items do not explicitly make the connection between being there first and having the right to decide therefore in study 2 a third item to the autochthony measure was added third we wanted to examine whether the results are robust or generalize to a different measure of group attitudes and a different immigrant group therefore in study 2 a measure of trait evaluations was used and the participating children were asked not only about their attitudes toward the main immigrantorigin groups but also toward refugees youth tend to have more positive attitudes towards refugees because of feelings of sympathy and pity however the importance of autochthony beliefs for outgroup attitudes might be similar for both types of outgroups fourth perceived multicultural education as a meaningful factor for childrens immigrant attitudes was considered and the role of classroom ethnic composition was examined as there was significant variation between classrooms multicultural education tries to foster equality and inclusion which tends to improve intergroup attitudes this could mean that the associations found are due to perceived multicultural education as a third confounding factor likewise native majority students in more diverse less segregated classrooms may be more open to ethnic diversity because they have more opportunities for intergroup contact therefore it was examined whether autochthony predicts immigrant attitudes independently of perceived multicultural education and classroom ethnic composition method participants and procedure onehundredandninetyfive native dutch students from 22 classes in 15 schools in different parts of the netherlands participated in this research together with their classmates they took part in a larger shortterm longitudinal study on teachers classroom dealings with ethnic diversity that larger study consisted of three waves and at all waves children anonymously filled in questionnaires in their classroom under supervision of their teacher or a research assistant apart from questions related to ethnic diversity the questionnaires included items on childrens experiences with their teachers and their peer relations again children participated voluntarily and there was consent from their parents and the possibility to opt out in the present study data from wave 3 contained questions on autochthony and were therefore used however the wave 1 data were relied on to select the participants because only these data included information about the ethnicity of the parents at wave 1 ie seven to nine months prior to completing the autochthony and group attitude measures the children were on average 1013 years old to be included in the current analysis the children had to selfidentify as ethnic dutch and to indicate that both of their parents were of dutch origin originally 212 participants were selected in this manner yet as few scores on the variables were missing and the pattern of missing values appeared to be completely at random χ 2 56947 p 030 listwise deletion was used measures autochthony was measured with the same two items as in study 1 plus one additional item namely the people who came to live here the netherlands first may decide what might change the items had a response scale ranging from 1 to 5 and yielded a cronbachs α of 082 ethnic identification was measured in this dataset with two of the identification questions used in study 1 children were asked whether they liked being dutch and whether they were proud to be dutch using response scales from 1 to 5 the correlation between both items was 054 perceived multicultural education was assessed with three items taken from previous research in the netherlands children were asked does your teacher ever say that all cultures should be respected does your teacher ever say that it is wrong to discriminate and does your teacher ever say that people from all cultures are equal the response scale ranged from 1 to 5 with α 083 classroom ethnic composition was operationalized as the proportion of dutch children in each class this proportion was strongly related to the proportion of students who selfidentified as turkish or moroccan but considerably less skewed confirmatory factor analysis in mplus with ml as the estimator showed that the items for the independent variables loaded on three corresponding factors without crossloadings or error correlations χ 2 30007 cfi 0978 tli 0964 rmsea 0060 srmr 0044 immigrant attitude was assessed through trait evaluations of moroccan and turkish peers that have been successfully used in previous research in the netherlands more specifically participants indicated whether they thought that most of the children in each group were honest fun to play with and eager to help you the same traits were used to measure the ingroup attitude the response scale ranged from 1 to 5 for each of the three groups the evaluations yielded a reliable scale cronbachs alpha was 079 for the evaluation of the dutch ingroup and respectively 089 and 088 for the moroccan and turkish outgroups the attitudes toward the two outgroups were strongly correlated therefore and in keeping with study 1 these two measures were averaged in one measure for immigrant attitude attitude toward refugees was measured with two items some people think that there are too many refugees coming to the netherlands and others dont what do you think with a response scale ranging from 1 to 5 and some people think that refugees are helped too little and other people think they are helped too much what do you think with a response scale from 1 to 5 the correlation between these items was 060 items were recoded so that higher scores indicated a more positive attitude confirmatory factor analysis in mplus showed that the items for the dependent variables loaded on different factors for the attitudes toward respectively the dutch ingroup moroccans turks and refugees χ 2 89907 cfi 0956 tli 0936 rmsea 0080 srmr 0030 moreover there was negligible drop in model fit when a higherorder factor was specified for the attitude toward the two immigrantorigin groups χ 2 dif 0026 p 087 which justifies the decision to examine childrens attitudes toward moroccans and turks as a single outgroup results the intercorrelations and means of the main variables are shown in table 2 as in study 1 children reported a more positive evaluation of their ingroup compared to the immigrant outgroups t 1091 p 0001 compared to study 1 the distribution of childrens ingroup evaluation was considerably more normal to examine the unique contribution of childrens autochthony beliefs on their attitudes a multivariate regression model in mplus was specified given sample size restrictions observed variables were analyzed moreover the multilevel structure was taken into account as childrens attitudes toward refugees differed systematically between classrooms because of the limited number of classrooms childrens attitudes toward respectively immigrants and refugees and their ingroup were analyzed in separate models whereas ml was used as the estimator for the first model mlf was used for the ingroup model due to estimation problems in both models these attitudes were regressed on autochthony ethnic identification and perceived multicultural education on the individual level and the proportion of dutch students on the 3 autochthony had a positive effect on the attitude toward the ingroup and moderate and large negative effects on childrens attitudes toward respectively immigrantorigin children and refugees further inspection showed that although the effect of autochthony was larger for refugees versus immigrants the difference between the effects was not significant χ 2 dif 1553 p 022 next and similar to study 1 childrens ethnic identification was related only to their ingroup attitude perceived multicultural education was positively associated with outgroup attitudes and somewhat surprisingly the proportion of dutch students had a positive effect on childrens evaluations of refugees in an additional set of analyses it was tested whether autochthony interacted with ethnic identification perceived multicultural education classroom ethnic composition age and gender and to avoid model underidentification separate models for each dependent variable were estimated none of these twoway interactions were significant p s 015 indicating the robustness of the effects of autochthony on the attitudes towards immigrants and refugees thus the findings in study 2 are consistent with those in study 1 and demonstrate that the importance of autochthony beliefs for immigrant attitudes is independent of ethnic identification perceived multicultural education and classroom ethnic composition and generalizes to another sample of majority group children another group attitude measure and another type of migrant group study 3 the aim of study 3 was to investigate whether feeling at home in the netherlands as a country is a relevant condition for the association between autochthony and immigrant attitudes it was expected that for majority group children with relatively low home feeling autochthony is more strongly negatively associated with immigrant attitudes the reason is that children are more likely to adopt a primordial reasoning when their perceived ownership right to feel at home in their own country is undermined furthermore this is especially likely for children who at the same time consider their dutch identity an important aspect of their sense of self according to social identity theory relatively low identifiers should be less concerned about their ingroup and less inclined to justify negative outgroup attitudes thus a threeway interaction between autochthony home feeling and ethnic identification on attitudes toward immigrant was expected method participants and procedure the sample consisted of 337 ethnic dutch students from 36 classes in 16 schools in different parts of the netherlands these children took part in a shortterm longitudinal study on classroom dealings with ethnic diversity the study consisted of two waves wave 1 was halfway through the school year and wave 2 was at the end of the school year during both waves children were surveyed under similar conditions they completed a questionnaire in their classroom together with their classmates and under supervision of their teacher andor a research assistant as in study 2 the questionnaires included questions related to ethnic diversity and childrens experiences with their teachers and peers participation in the study was voluntary and anonymous and all children with parental consent participated 4 the children were selected based on their ethnic selflabeling at wave 2 but the additional criteria were used that this selflabeling should be similar to that of wave 1 and that both parents of the children should be born in the netherlands originally 359 children could be selected in this way but because there were few missing values on the variables and missings appeared to be at random χ 2 39506 p 049 listwise deletion was used measures all measures were collected during wave 2 except childrens perception of multicultural education which was assessed at wave 1 autochthony was measured with the same three items and response scales used in study 2 ethnic identification was measured with the same three items as in study 1 home feeling was assessed with three items that have been successfully used in previous research among children in the netherlands on a fivepoint scale ranging from 1 to 5 children indicated whether they felt at home in the netherlands whether they were proud of the netherlands and whether they liked it in the netherlands perceived multicultural education was measured with the same three items that were used in study 2 confirmatory factor analysis in mplus showed that these four measures corresponded to four different factors with independent error terms and no crossloadings χ 2 146738 cfi 0930 tli 0903 rmsea 0076 srmr 0057 the fit of this model was substantially better than that of a threefactor model in which ethnic identification and feeling at home loaded on one factor χ 2 dif 104601 p 0001 further because the items for home feeling had a skewed distribution cfa was also conducted with mlr as an estimator model fit was acceptable after allowing an error correlation between the first and the last item for home feeling χ 2 107602 cfi 0946 tli 0924 rmsea 0060 srmr 0053 attitude towards immigrants was again measured with the seven faces scale in relation to people of turkish and moroccan background as these evaluations were strongly related these measures were combined into a single outgroup attitude score in this study the attitude toward refugees was not assessed and ingroup attitude was measured with the same sevenfaces scale results the intercorrelations and means of the main study variables are shown in table 4 as in the previous two studies children reported a more positive attitude toward their ingroup than toward the immigrant outgroups t 2307 p 0001 as in study 1 the distribution of the ingroup attitude was nonnormal to examine the unique contribution of childrens autochthony beliefs on their attitudes a series of multivariate regression models in mplus was specified to account for the nonnormal distributions of ingroup attitude mlr was used as an estimator moreover given sample size restrictions observed variables were analyzed and the multilevel structure was taken into account as there were substantial differences between classrooms in childrens evaluations of the immigrant groups prior to the analyses all continuous variables were standardized at the individual level in the first model childrens ingroup attitude and immigrant attitude were regressed on age gender and the classroom proportion of dutch students as well as on autochthony ethnic identification home feeling and perceived multicultural education the results of the model are shown in table 5 autochthony had a small positive effect on the evaluation of the ingroup and again a mediumsized negative effect on the evaluation of the immigrantorigin groups these effects were independent of ethnic identification which was positively related to the evaluation of the ingroup and in this study also negatively to the evaluation of the immigrant outgroups home feeling was positively related to both ingroup attitude and the attitude toward immigrants additionally boys were more positive about the majority ingroup and similar to study 2 perceived multicultural education was positively related to childrens attitude toward immigrants there were no effects of the proportion of dutch students in the second model the twoand threeway interactions between autochthony ethnic identification and home 5 none of the interactions were significant for the attitude toward the ethnic ingroup however for the attitude toward immigrants the twoway interaction between autochthony and home feeling and the threeway interaction between autochthony ethnic identification and home feeling were both significant simple slope analyses were conducted to decompose these interactions the twoway interaction between home feeling and autochthony was first examined by calculating the effect of autochthony at low versus high versus levels of home feeling as shown in fig 1 this effect was stronger in the former case b 049 se 007 versus b 028 se 008 p s 0001 next it was investigated whether this twoway interaction was different for children with relatively high versus low levels of ethnic identification this showed that the twoway interaction was positive and significant for the high identifiers b 026 se 007 p 0001 but not for the low identifiers b 004 se 006 p 045 figure 2 shows the effects of autochthony on childrens immigrants attitude for different levels of ethnic identification and feeling at home the effect of autochthony on immigrants attitude was strongest at high levels of ethnic identification combined with relatively low levels of home feeling b 066 se 012 p 0001 and weakest at high levels of ethnic identification combined with high levels of home feeling b 014 se 009 p 012 moreover the attitude was clearly most negative among children who endorsed autochthony did not feel at home in the netherlands and considered their dutch identity an important part of their sense of self two further models examined whether autochthony interacted with the remaining predictors by adding these twoway interactions to the previous model none of these twoway interactions were significant finally in light of its skewed distribution a logistic regression was performed on dichotomized version of the fh low fig 1 effects of autochthony on the attitude towards immigrants for low versus high levels of home feeling ingroup attitude variable this analysis failed to replicate the positive main effect of autochthony or 1373 p 029 which means that positive main effect should be interpreted with care the findings of study 3 again show that autochthony is negatively associated with attitudes toward immigrantorigin groups however this association is stronger for those children who have a lower feeling of being at home while at the same time selfidentify as dutch this suggests that autochthony functions as a justifying belief for native children who care about being dutch but do not feel at home in the netherlands discussion the notion of ownership is widespread pervasive and applied to a range of objects including places in childrens lives at home in school their neighborhood and the country they live in furthermore the belief that a territory belongs to those who arrived first is often selfevidently used to claim rights and to exclude outsiders and newcomers those who were somewhere first are typically considered to own the place with the related rights of usage and gatekeeping which provide justified reasons to exclude others yet research on childrens intergroup attitudes has not paid systematic attention to these issues and the current research is the first one that has examined the importance of autochthony beliefs for childrens attitudes toward immigrant groups in three studies it was found that autochthony belief and ethnic identification were empirically distinct constructs and that autochthony was not strongly and consistently associated with ingroup attitude these findings suggest that first arrival is a basis for inferring ownership and not so much for a sense of group belonging or ingroup liking furthermore the findings demonstrate that ethnic majority group children with stronger autochthony beliefs had more negative attitudes toward immigrantorigin groups and refugees which suggests that both groups of newcomers were perceived in similar ways this expected association was found among three different samples by using different measures of ethnic attitudes and by controlling for ethnic identification perceived multicultural education and classroom composition furthermore the importance of autochthony belief for outgroup attitudes was robust across gender age level of ethnic identification and level of perceived multicultural education thus there was clear and substantial evidence that majority children who believe that their ingroup was here first and therefore owns the country have more negative attitudes toward immigrant groups additionally study 3 showed that this association was especially strong among children who felt less at home in their country this finding is reminiscent of the widespread discourse in many western countries that argues that immigration makes majority members feel like foreigners in their own country although they were here first and therefore have the right to feel at home in their own country they do not feel at home anymore and therefore should take back control the argument goes this discourse is particularly appealing to people who identify with the majority group children are aware of the societal debate on immigration and antiimmigration sentiments and similar to the prevailing discourse it was found that especially for children with high ethnic identification the combination of autochthony beliefs with not feeling at home was associated with negative attitudes interestingly in the three studies the importance of autochthony beliefs for the attitudes did not depend on the level of ethnic identification this indicates that autochthony belief is not a more relevant justifying belief for higher compared to lower identifiers however when at the same time there is a sense of not feeling at home the level of identification seems to matter this finding can be interpreted in terms of social identity development theory which proposes that ethnic prejudice appears when children who identify relatively strongly with their group feel that their ingroup position or wellbeing is undermined in some way by members of ethnic outgroups as with all studies there are limitations to our research that provide possible directions for future research first although the findings are consistent and robust across the three studies future research could try to use more extensive measures and try to assess additional constructs which could fig 2 effects of autochthony on attitude towards immigrants depending on ethnic identification and feeling at home with low and high denoting respectively one standard deviation below and above the means increase the explained variance for example the measure of country belonging did not ask whether children felt less at home in their country because of the arrival and presence of immigrant groups considering the societal discourse and research findings this is very likely and the pattern of findings is in agreement with this interpretation but future research could assess this directly future research could also examine the associations longitudinally or using an experimental design there is experimental evidence that children consider first arrival a legitimate reason for claiming personal as well as collective territorial ownership yet in contrast to research among adults there is among children no experimental evidence that collective ownership based on primooccupancy influences outgroup attitudes second the role of autochthony beliefs for attitudes toward immigrant groups in the netherlands was examined similar to most european countries in the netherlands there is a large native majority population this is different from immigration countries such as the united states canada and australia that were inhabited first by indigenous groups of native americans and aborigines this could mean that for the white majority population in these countries collective ownership based on autochthony beliefs is less useful for justifying antiimmigrant attitudes however a sense of ownership with the related entitlements might also be derived from being earlier than later immigrants and from having invested in and developed the land first arrival might be disregarded when later arrivers think that they are the ones who have made the land prosper there will be many situations in which place ownership inferences are not based on the first arrival assumption alone or at all a lay belief can be interpreted and used in more than one way across situations when one of its interpretations is not useful or appropriate in a particular context another interpretation can be invoked future research could examine these possibilities in different national contexts including in contexts of territorial disputes such as in the middle east third autochthony belief was examined in relation to the country but there are many other places in relation to which youth makes first arrival ownership claims such as when children convert a place in their home or outside in their private playing area and in gang behavior among youth having a sense of collective ownership can involve many different settings with similar exclusionary consequences hence it could be examined whether the present findings also apply to neighborhoods schools play areas and other places in which children feels that they own the place because they were there first it is likely that a sense of collective ownership based on primooccupancy is a more general process that has implications for childrens prejudices and forms of social exclusion in a range of settings fourth concern with ownership is already evident in young children but the evidence relates primarily to ownership of objects and ideas and therefore it is unclear how young children reason about place ownership and how this develops we focused on older children and future studies could use a longitudinal design to examine for example at what age children develop an understanding that land or a particular place can be owned and the type of information that they use to infer place ownership and the related entitlements with such a design it can also be examined how autochthony beliefs develop and whether and how these beliefs for example relate to the ethnic and national identity development of youth furthermore such a design would be useful for examining where childrens autochthony beliefs come from and the roles that parents teachers and peers play in developing these beliefs and using them to justify negative attitudes towards immigrant groups conclusion this research has tried to make a novel and first contribution to the intergroup developmental literature by focusing on the importance of autochthony beliefs this literature has examined outgroup attitudes in relation to for example identification processes threats group norms and moral reasoning and there is work on lay theories and justifying beliefs extending this literature to the important field of perceived ownership we showed that being here first is a relevant consideration for childrens outgroup attitudes this corresponds to research among adults that has demonstrated that notions of autochthony are central in sons of soil conflicts and that people use these notions in territorial disputes and in exclusionary behavior and negative feelings towards outsiders and immigrants for children being here first can be an acceptable reason for claiming collective ownership of a place and this claim can have negative consequences for newcomers the reception and accommodation of immigrants and refugees is one of the major social challenges of our times understanding how majority group children think about these newcomers is important for trying to address their feelings and concerns hopefully the current research adds to a further understanding of childrens outgroup attitudes and thereby helps to evaluate and further think about initiatives to improve their attitudes authors contributions all authors developed the questionnaire for this study mv wrote the introduction and the discussion and provided input on the analyses jt performed the analyses and wrote the method and results sections both authors read and approved the final manuscript data sharing and declaration the dataset generated and the analysis of the current study are not publicly available but are deposited at the safe storage facility of the university and they are available from the second author on request compliance with ethical standards conflict of interest the authors declare that they have no conflict of interest ethical approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards informed consent passive parental consent was obtained and all students included in the study participated voluntarily publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations open access this article is distributed under the terms of the creative commons attribution 40 international license which permits use duplication adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made

autochthony belief that a country is owned by its first inhabitants can be an acceptable reason for claiming collective ownership of a territory and this claim can have negative consequences for newcomers children might reason that a place belongs to their ingroup because we were here first and therefore have negative outgroup attitudes in three studies among dutch majority group children n 879 m age 1013 to 1084 sd 082 to 098 497 to 545 girls the expected negative association between autochthony beliefs and attitudes was found for different measures of ethnic attitudes and was robust across gender age immigrant target group ethnic identification perceived multicultural education and classroom composition additionally the association was especially strong among ethnic majority children who felt less at home in their own country but at the same time cared about being dutch it is concluded that a focus on autochthony belief makes a novel and relevant contribution to the intergroup developmental literature and to our limited understanding of childrens attitudes toward immigrant groups and newcomers more generally

socialism 3 back in 2003 lynne haney considered it a prevailing mythology to perceive 1989 as a grand historical marker a rupture in terms of the welfare systems 4 instead it has become the dominant agenda of recent historical scholarship to broaden the scope and examine the historical rupture of 1989 as a reflection of a long process of transformation 5 herein lies the ambivalent nature of 1989 which manifests itself in the fact that it is understood and examined both as an event and as a convenient label for the roughly decadelong process of political social and economic changes that followed the demise of the latesocialist regimes 6 in that vein florian kührerwielach and sarah lemmen suggested to focus on those processes of adaptation rather than solely on the dialectic relationship between continuities and discontinuities 7 recent research attempts to capture the diverse individual responses to the postsocialist transformation in 1999 katherine verdery and michael burawoy called this period an uncertain transition 8 that was not a unilinear one of moving from one stage to the next but a combined and uneven one having multiple trajectories 9 twenty years later jill massino speaks of ambiguous transitions 10 stressing the importance of capturing peoples complex and ambiguous responses to the postsocialist transformation which were shaped by their experiences of both past and present and the disconnect between expectation and reality 11 keeping this complexity in mind childrens encounter with 1989 can also serve as a magnifying glass onto the longer period of political rupture and transformation beyond serving as a container for individual and collective experiences the label 1989 captures well the simultaneity of rapid political and social change 12 as well as the longer process of political and social transformation of political systems and social practices in this double function 1989as an abrupt caesura and a reflection of longterm social negotiationsmanifested itself in the everyday life of children massive privatization high unemployment new housing and living conditionsstandards migration to the west and new pedagogical ideas of childrens care and education brought about fundamental changes to childrens upbringing but how unique was century affected the everyday lives of children our incentive is that the study of political transformations throughout the twentieth century has grown extensively 13 but the experiences of children and young people in the turmoils remain less researched 14 against this backdrop the contributions to this double special issue offer to shed light on three major political ruptures and the longer term transformations these entailed in the twentieth century including their impact on notions and everyday realities of childhood and youth world war i and its aftermath world war ii and its following years and 1989 as the end of the cold war and the beginning of postcommunism while martin conway considered a comparison of 1989 1945 and 1918 a rather awkward triple jump across the 20 th century 15 he and his coeditors still ventured to provide an entangled comparison of these three watersheds he felt that such a comparison could be historically volatile as modern european wars have ragged ends and to seize upon a specific endpoint of these conflicts risks neglecting the afterwars that were such a prominent element of all three conflicts 16 taking up conways proposal this special issue goes one step further and approaches the historical moments 1918 1945 and 1989 not as isolated political ruptures or caesuras instead it explores these key moments as symbolic markers of longer historical processes of political and social transformation against this backdrop the contributions scrutinize how these abrupt ruptures and the longer processes of political and social transformation could become visible in childrens lives we approach the two world wars the cold war and their respective aftermaths as long transformation periods that could affect andor alter childrens everyday lives the articles assembled here encourage us to study what it meant for children that the transition from war to peace and from state socialism to postsocialism was rarely clearcut 17 one polish jewish child survivor of the holocaust felt that the war began for me after the war 18 joanna b michlic argued that for jewish child survivors in poland the early postwar period was still very much a turbulent era full of magnitude of messy and confusing events these events were so decisive for determining the future of these children and how they were to develop both as individuals and as members of national and cultural communities childrens social identities were in the early postwar period still fragile fluid and exposed to many shifts 19 not only the childrens identities were fluid in the postwar but so was the transition from war to peace with this in mind this double special issue pursues three major aims first it proposes to take up the contention that not only the two world wars and the cold war provided a defining framework for the shape of the century their aftermaths and the subsequent transitional periods during which important new structures of power and of organizations became apparent also had similar effects 20 this allows us to not only juxtapose the impact of the two world wars and the cold war on childhood but also integrate the aftermath of these conflicts into a diachronic perspective on longer processes of political and social transformation second it aims to test the usefulness and applicability of the notion of transformation for describing not only the processes that accompanied the postsocialist period but also those that surrounded the watersheds of the world wars as radical system or regime changes which occurred in 1918 1945 and 1989 only take place in a crisis after the prevailing weakening of the ruling regime 21 an analysis of political transformation needs to consider the preceding wars and or the cold war the regime changes during 1918 1945 and 1989 and their long aftermaths we also engage with the question as to how the two world wars 1989 and their aftermaths brought about a social transformation which left an imprint on the everyday lives of children here we examine how these periods of transformation became tangible in childrens lives we are curious to investigate how they transformed family ties and childrens relationships childrens upbringing and education and childrens welfare and third this double special issue uses the lens of childhood to provide a diachronic exploration of the relationship between political and social transformation processes and their implications for childrens lives in the twentieth century judith szalai argued in a united nations international childrens emergency fund report in 1992 that one can hardly find more sensitive indicators of the wellbeing of a given society than those measuring the living conditions and future prospects of the children in that society 22 as modern notions of childhood considered children to be innocent vulnerable pure dependent and ignorant children were to be protected cared for and should enjoy special freedoms for that reason as the childhood historian paula fass stressed it modern states were committed to withdrawing them from certain adult spheres like war and sexuality 23 but if despite such utopian visions wars and political crises invaded childrens private lives their everyday lives reflect well the gravity and scope of political and social ruptures as well as of political and social transformation as childrens everyday concerns were fundamentally tied to and dependent on the overall functioning of societies their lives mirror how political crises and transformations affected societies in general in so far as states also considered children a political tabula rasa 24 or a blank slate 25 that could be used to revolutionize contemporary and envision future societies children also came to gain particular value in processes of transformation childrens new role and reinvented education their new position visàvis the state and their altered everyday lives literally embodied the respective systemic change and the longer transformation process this double special issue offers a range of thematic contributions that tackle selected historical case studies of war and socialist childhoods whereas employing the case study approach offers the opportunity to detail childhoods in their specific historical settings gathering them in a double special issue allows readers to detect similarities and differences among children across time and space and support a thinking of the twentieth century through the lens of transformation the papers combine a topdown perspective on children with a meticulous unraveling of how children experienced their upbringing in times of political rupture and political and social transformation just like the lives of adults the lives of children were influenced by such events and changes indeed children not only experienced situations differently from adults but also often faced other horizons of experience young children for example were often less politically informed and as a result did not understand or share the opinions of adults 26 as children are historical actors with their own ideas intentions and identityforming experiences and not only mere objects of adult design 27 we aim to engage with childrens own subjectivities and their social agency 28 their actual reactions their own wishes and their resilience julia grant accentuates childrens agency with the following words children are unruly unpredictable complex and cannot easily be encapsulated in a historical narrative 29 zsuzsa millei observed that the socialist period of childrens everyday life could not be easily reduced to the dichotomies of official and unofficial the public and the private the state and the people 30 taking childrens perspective into account we have assembled exemplary case studies that explore displaced orphaned uprooted unaccompanied children borderland children young survivors of forced migration jewish child survivors of the holocaust and children of the postsocialist transition through examples of how these children were treated as well as the experiences of these children we engage with changing conceptions and practices of childrens upbringing and institutional care in orphanages and in displaced persons camps engaging with case studies from lithuania russia poland france hungary ukraine and estonia the authors investigate various notions and everyday realities of childhood through the prism of transformation world war i and its aftermath transforming childhoods the great war and its often long and troublesome aftermath had a decisive influence on the way in which children were approached by adults in the political entities that are discussed in this double special issue as well as on how they experienced childhood however these turning points took on different forms for different children 31 many families and children were facing the absence and death of soldier fathers the loss of ones home and house migration and displacement and their new responsibilities even though studies often only address childhood during war 1918 as the wars official end did not end childrens encounter with this violent conflict the postimperial condition of central and eastern europe translated itself in childrens everyday lives in the following ways it caused high infant mortality rates the spreading of diseases and epidemics the decline in birth rates the interruption of childrens education and care and the massive abandonment neglect and displacement of children while childrens experiences with the war and its troublesome aftermath were as complex as the conflict itself they were instrumental in paving the way toward the international recognition that children should be better protected before the war childrens protection was mostly dependent on 32 r barbry the family and on religious associations as the war and its aftermath exhibited childrens particular vulnerability it brought about the evolution and expansion of childrens protection and of child welfare institutions child relief also became an issue of international concern and activism 32 in the postwar period new international relief organizations such as save the children were established and posited children as the principal victims of war who were meant to be rescued and whose relief was considered the best way of investing in peace and promoting international cooperation 33 save the children was instrumental in pushing for the recognition of childrens rights the 1924 geneva declaration on the rights of the child was the internationalist response to the suffering that the war and the postwar years had brought to europes children the declaration demanded that the hungry must be fed the orphan must be sheltered the child shall be the first to receive help and it should receive an education to help itself 34 with that in mind andrea griffante focuses on the way that lithuanian state formation was experimented with through child welfare during the world war the political rupture of the german occupation established in 1915 yielded a transformation in child relief initiatives the lithuanian elite saw an unprecedented chance to include the lower social strata into its ranks and proliferate its ethnonational discourse not only did their initiatives now privilege displaced destitute and or abandoned children above other social groups such initiatives were also organized on a massive scale for the first time lithuanian elite members believed that isolating the young into childrens orphanageshostels was the appropriate solution to execute hygiene control and ensure consistent education in the lithuanian language and what were considered to be lithuanian norms and values interestingly the hosteled children remained largely unaffected by the sanitary catastrophe that led to the death of 9 of the city population of vilnius in 1917 the transformation in child welfare initiated during world war i could however not be implemented fully due to the inadequate supply of the necessary means such as foodstuffs and medical equipment and the insufficient capability of the elite to negotiate the everyday practices in orphanageshostels with the children griffantes analysis of childrens voices provides us a deeper insight into the quality of that transformation by bringing to the fore that the young protested against the living conditions the isolation from social life outside the hostels and even refused to speak lithuanian as a result when lithuania appeared as an independent state on the map of europe following a next political rupture the wartime hostels became the model for how to discipline and normalize prototypical lithuanians however given the fact the disciplining and normalizing ideals had already been hypothetical during the war these were not converted into a convincing set of real practices once that war came to an end leading to the longterm repercussions of the transformation being rather moderate in comparison with as the author indicates neighboring poland to conclude by shedding light on child relief initiatives practices and discourses during the war and its immediate aftermath griffantes article points to the crucial role that the lithuanian elite envisioned children to play for its nationbuilding as well as that elites unfamiliarity in negotiating a modus vivendi with the latter also friederike kindkovácss article concentrates on emerging child welfare during and after world war i but the lens of her analysis is put on the hungarian part of the austrohungarian monarchy and on the constitution of the independent hungarian postwar state she points to the emergence of war orphans as a new category of victims and similar to griffante to the transformation of child welfare through its gradual professionalization as well as the installation of an infrastructure which remained in place once the war had come to an end war orphans became publicly visible as threefold symbols through their destitute or physically harmed appearance they embodied the violence of the war in addition they personified a transformation in their societys attitude their parents were no longer blamed for inappropriately bringing up their children but acknowledged for their participation in the war and the societal need to take care of their children was recognized at the same time children were considered to symbolize the future in which they as young adults would carry their countrys reconstruction on their shoulders this way of thinking provoked the emergence of wartime welfare initiatives in which one experimented with how a future postimperial hungarian nationstate would and should look like although gathering war orphans from different backgrounds was meant to overcome ethnic nationalism tensions between hungarianspeaking germanspeaking and jewish children still filled the papers in 1917 a deep contrast also arose in the depiction of female war orphans and orphans mothers whereas beauty contests were organized to provide girls with a scholarship and remind readers of the countrys wellbeing and future mothers of orphans were negatively stereotyped as being motivated by greed the fear was articulated that the mothers transformation into breadwinners within the wartime economy would have longterm repercussions on gender roles in postwar society a fear that nourished conservative pronatalist policies in the years after the great war machteld venkens article concentrates on the transformation of elite education once the state borderlines of the european continent had been redrawn in the aftermath of world war i in polish upper silesia the change in state sovereignty from german to polish meant a rupture in the political scene but not all the implications for elite education turned out to be disruptive venken finds the transformation phase to have been characterized by highly contested power relations and frequently changed school curricula she also uncovered that radical changes in the schools clientele were a feature of polishspeaking schools in the area while germanspeaking schools could continue to educate the traditional bourgeois strata of society as long as the league of nations executed supranational control the author aims for a better understanding of the multidimensional interwar everyday life in polish upper silesia which in recent historiography has often been analyzed with the help of the analytical category of national indifference by dissecting the practices of local decisionmakers within a sequence of transformative events that inevitably led to a compliance with social norms and within a space considered to be of crucial interest to polish nationalists the article demonstrates that placing oneself outside of the imagined national community or dictating its meaning was no longer an option world war ii and its aftermath rehabilitating childhoods while world war i and its aftermath had invaded family lives extensively tara zahra judged world war ii as having destroyed the family as completely as europes train tracks factories bridges and roads 35 however the end of the war did not mean that childrens lives ceased to be uprooted many had lost close relatives during the war and would grow up within other family setups than before as machteld venken and maren röger observed 36 far greater toll on civilians than the great war 37 but also the wars aftermath continued to cast for many children a more intense or longer shadow over their further lives yet the postwar period also captured a new international moral consciousness and the dedication to the public protection of children as one particularly vulnerable social group when comparing relief in central and eastern europe after the world wars we can detect a shift of attention from childrens bodies to their souls the period after world war ii was invested in the social and psychological recovery of those children that were harmed by the trauma of the war and the holocaust the universal declaration of human rights article 25 claimed in 1948 that motherhood and childhood are entitled to special care and assistance all children whether born in or out of wedlock shall enjoy the same social protection 38 here we also observe a new public obligation to provide longterm social protection to all those children and their mothers who were in need set against this background two articles analyze the lives of children on the move during world war ii while placing spatial reconfiguration center stage the children being brought to france through kindertransport laura hobson faure argues established their own chronologies of war through an analysis of the diaries written by jewish refugee children the author demonstrates how political and personal rupture could relate in different ways and puts forward the thesis that a transformation of childrens everyday reality took place through subsequent political and personal ruptures political and personal rupture could follow each other such as in the case of child diary writer heinz löw lamenting the separation from his loved ones when his train departed in the spring 1939 on which his grandmother had put him after the occupation of austria in 1938 personal rupture could also coincide with watersheds on the global scene such as the outbreak of world war ii which incited this young diary writer to articulate his feelings in writing while his friend illustrated the diary for him afterwards more jewish refugees arrived in france and children with different ideological profiles were put together in childrens homes a development that provoked sharpened or transformed their political awakening when the german army invaded france in 1940 the jewish refugee children were transferred southwards to frances unoccupied zone they found shelter in a predominantly frenchspeaking environment for the first time later when the vichy regime started raids against jews the children had to flee or go into hiding these frequent political ruptures influenced the work of the leftoriented educators who had founded progressive childrens republics in childrens homes upon the arrival of the jewish refugee children while the majority of the children survived nazi persecution others perished by bringing us closer to the inner world of the jewish children experiencing the turmoil of war hobson faure points to the adaptability of children to take over the role of a parent in times of distress another group of children on the move as katharina friedla postulates were polishjewish children born or raised in germany who survived world war ii in the soviet hinterland like the kindertransport children the journey of these children started before the outbreak of the war in the autumn 1938 they were transported to poland after the polish state had revoked their polish citizenship when the german army occupied the western part of poland many of these refugees escaped or were transported to the east eventually reaching siberia in 1941 when the polishsoviet agreement was signed many embarked on a journey to central asia and up to 1000 children later joined the anders army to palestine after the world war many returned to poland but almost all left and traveled overseas within the following years like hobson faure friedla sees a profound transformation of childrens lives emerging as a result of the rapid sequence of political ruptures by the time they had reached central asia these children had taken up the responsibility for their own survival the author also found testimonies of former children who admitted that they had left their parents and had joined an orphanage to receive food other than hobson faure friedla also pays attention to the emotional transition of the children caused by the pain and trauma of their migrations which remained with them later in life as they found it difficult to articulate their memories on one hand child survivors refused to identify as survivors of the holocaust and compete with holocaust memory because their stories only consisted of forced migration humiliation and starvation instead of mass extermination on the other hand since child survivors only remembered fragments of what they had experienced or witnessed through childrens eyes they held the generation of their parents responsible for constituting the collective memory of the polish jews who lived were born or raised in interwar germany the article of olga gnydiuk concentrates on displaced unaccompanied minors and their caregivers in the early aftermath of world war ii the author puts her lens of analysis on the fate of polishukrainian displaced children in the post1945 world who saw themselves cut off from their home grounds when these shifted sovereignty from polish to soviet sovereignty this rupture was accompanied by political transformations as the author defines a gradual process that embraced the continuities of the war period but also reached out in time to have longerlasting effects and took the form of a change of policies humanitarian approaches and social practices as well as crumbling diplomatic relations gnydiuks article provides an example of how child welfare activities after the world war ii did more than provide children material support out of a belief that war had caused emotional damage welfare workers were concerned with restoring victims social and psychological health while welfare workers followed the official principle of international relief that is to act in the best interests of children that principle as gnydiuk argues appeared malleable enough to provide the opportunity to ignore the repatriation dictate to the soviet union included in the treaty of yalta in 1945 and thus led more children emigrate to western countries that child protection takes precedence over the rights of an individual country over its children was an idea developed and practiced in the early postwar period an idea that would pave the path to further developments of childrens rights later the long transformation of 1989 individualizing childhoods the third political rupture and longer transformation process that we center our attention on and which left a particular imprint on childrens lives especially in central and eastern europe accompanied the year 1989 from its very inception state socialism had pushed for an increasing shift from parental care to institutional care childrens everyday lives had turned into a territory of intervention by state authorities and institutionalization was believed to help bring up ideal versions of future generations this conviction was fundamentally questioned by the political rupture in 1989 the collapse of state socialism translated itself in processes of liberalization deregulation and privatization as most of childrens care had been outsourced to state institutions children had been highly dependent on the quality of care in kindergartens orphanages and childcare institutions which had not always been a given it had become apparent that the socialist type of comprehensive child welfare had not only been too expensive but that it was often lacking in quality the economy of shortages had visibly affected childcare provisions and institutions the year 1989 witnessed the beginning of a process of deinstitutionalization yet it also witnessed with the signing of the convention on the rights of the child an international agreement demanding that all states shall ensure that the institutions services and facilities responsible for the care or protection of children shall conform with the standards established by competent authorities 39 in contrast to the earlier child right declarations this declaration called upon the signing states to secure the quality of public childcare what followed in 1989 was an increasing individualization of life situations contra the prior ideal of collectivism and clearcut conception of a normal biography 40 this also comprised a shift from a collective to a more individualized conception of childhood and childrens upbringing and care in the early postsocialist years the state increasingly withdrew from childrens public childcare yugoslavias last generation experienced the postsocialist transformation as marked by a deep sense of uncertainty and instability as everything could be and oftentimes was questioned 41 beyond the topdown political transformation the period was marked by an inner dynamics of transformation and this transformation of the official rhetoric politics and practices could be studied from within the institutional youth sphere where it also unfolded 42 the various postsocialist countries shared these experiences of an uncertain transition which was shaped by the tension between socialist legacies and neoliberal policies much of what children had considered as eternal before 1989 either vanished into thin air or was abruptly devalued 43 the change of school curricula and pedagogic reforms the closure of state kindergartens and nurseries as well as parents losschange of their workplace housing insecurities and processes of increasing social stratification triggered insecurities lack of social integration and feelings of loss this special issue contains two articles breaking new ground on the longterm impact of the collapse of the eastern bloc on children and their caregivers raili nugin examines how the communicative memory of what she coins the 1970s age cohort in estonia presents the collapse of communism as a process rather than a political rupture the author investigates people who enjoyed childhood during soviet times and experienced their coming of age during the 1990s in estonia other than their parents who considered the collapse of communism a political rupture the age cohort born in the 1970s experienced the late 1980s and 1990s as a period of transformation in which a change happened on both personal and social level that was accompanied by a certain sense of moving forward and asking questions about identity the author argues that the way in which individuals of this age cohort communicated their memories of coming of age in the public sphere provoked the development of a generational consciousness they indicated that their soviet memories mobilized them later in life to value freedom and independence and bestowed them with a specific cultural capital and the knowledge of hardship this symbolic resource formed the basis for the cohorts generational discursive capital in addition nugin analyses the interesting discourses of those who were too young to have been potentially able to play a decisive role during the singing revolution due to which they discursively stretched the time period of the emergence of political culture in estonia to the first decade after the countrys independence in this way they molded their personal memories into a discursive tool enabling them to claim a crucial social role for themselves during this process of change anna kozlova builds the argument of her article around the observation that former counselors of the two most prominent soviet pioneer childrens centers did not remember the exact time when the soviet union collapsed and stressed the continuity of the centers activities instead since the thaw in the second half of the 1950s counselors in these pioneer camps had learned to detach rituals from their propagandistic meaning and to bestow these with a selfappropriated understanding that was derived from humanistic pedagogy during the later stagnation inspectors representing the soviet regime were not capable of erasing these seeds of progressive ideals from the minds and practices of individual camp counselors this meant that the systems change in the early 1990s did not significantly affect the camps working by that time indeed these camps had come to function as semiautonomous institutions constituted by the agency of their counselors who gladly reactivated or intensified humanistic practices on the basis of oral history interviews the author unravels individual counselors transformation that is how they supported and developed humanistic pedagogy by means of their daily practices and in this way tried to give meaning to how they had coshaped the camps profiles and activities from the late 1980s into the 1990s and up until today exploring twentiethcentury transformations through childhood gathering a number of exemplary case studies of childrens experiences in periods of transformation this double special issue recommends an understanding of the twentieth century that reaches further than a central focus on the political ruptures of both world wars as well as the collapse of the eastern bloc in 1989 first the contributions follow tony judts observation that the century was characterized by the rise of state involvement 44 second they put children who had been posited as a distinct social group for receiving support from the state throughout europe in the nineteenth century and the beginning of the twentieth century at the center of the historical analysis in this way they aim to demonstrate how these three political ruptures were intertwined with political and social transformation taken together the contributions engage with the various ways in which political rupture and political and social transformation related to one another in different time periods and how they impacted children in different or similar ways the various articles detail these implied personal rupture transformation of the care provided to children and changes in the practices thoughts and emotions of children what emerges from these readings is that an understanding of transformation cannot be reduced to a clearly defined period after a political rupture instead a political andor social transformation could start before and continue during and after a political rupture and that its duration depended on the historical context throughout the twentieth century thus political and social transformations were contingent possessing a time frame that could shrink and expand depending on the circumstances at the time with this investigation of the policies for and practices of children and their caregivers in a variety of local settings during political ruptures and political and social transformations the special issue includes more experiences and voices in the study of our contemporary past

in the past years the socalled east german children of the transition wendekinder have come to raise the question of how 1989 and its aftermath affected childrens lives in the past and how their memories still shape their individual and collective biographies up to today 1 this new perspective on the years of postsocialist transformation allows for the reading of the history of 1989 through a historical exploration of childrens past experiences as jan kubik and amy linch pointed out in 2016 it is no longer of much use to approach the postcommunist transformations as a straightforward uniform linear and easily generalizable progress from totalitarianism to democracy and from command economy to market economy as it was initially proposed by the socalled transitologists of the 1990s 2 neither is it any more helpful to continue centering our attention on single years like 1989 as markers of abrupt and dramatic political and economic change historians such as gregor feindt have challenge d 1989 as a clearcut break and proposed instead to study the long transformation of state

introduction the covid19 pandemic has renewed scholarly interest in the effects of work from home 1 interestingly studies have documented both positive and negative effects of wfh on employees work and home lives but have failed to provide a comprehensive explanation of why employees experience wfh differently for example employees who work from home report difficulty mentally unplugging during breaks and downtime or being interrupted by their partners however employees also report that wfh allows them to spend breaks with loved ones and return to work with renewed energy related research suggests that spillovers at the workhome interface may be the mechanism explaining why employees experience wfh differently the workhome interface encompasses four types of interrole spillovers based on the directionality and quality of the interaction worktohome conflict and hometowork conflict are negative spillovers and worktohome enrichment and hometowork enrichment are positive spillovers although the four spillovers are theoretically and empirically distinct they share some common predictors building on boundary theory we first theorize that wfh intensitywhich is the number of hours worked from homecan trigger all four types of interrole spillovers this view implies that wfh intensity has positive and negative effects on the workhome interface as well as positive and negative downstream consequences second we develop a contingency view to examine the role of situational and personal moderators work equipment room conditions and domain centrality specifically we propose that the quality of ones work equipment can mitigate the worktohome conflict whereas room conditions can mitigate the hometowork conflict in addition we propose that the centrality of the work and home domains can enhance the relationships between wfh and enrichment in the respective other domain third we build on the domain specificity and source attribution models to examine the downstream influences of spillovers on employees satisfaction with their romantic relationships and jobs figure 1 depicts our theoretical model to test our theory we use a unique longitudinal data set that we collected in a twostep random sampling procedure during the covid19 pandemic in the city of munichgermany we test our hypotheses with moderated regression analyses and use multiple mediation models to analyze whether negative and positive spillovers exist in parallel and what their individual and joint effects on satisfaction outcomes are our work contributes to the literature in three ways first we theorize and test how wfh intensity affects all four dimensions of the workhome interface wfh literaturebefore and during the pandemichas primarily studied negative spillovers whereas positive spillovers have received only scattered mentions and less empirical scrutiny the joint consideration of negative and positive spillovers has theoretical and practical relevance theoretically boundary theory predicts that wfh intensity can be a stressor and a resource simultaneously triggering negative and positive spillovers through role integration a onesided focus on negative spillovers does not do justice to the complexity of the theory and might lead to incomplete practical considerations second we test whether domain centrality moderates the relationships between wfh intensity and spillovers thus contributing to an ongoing debate in boundary theory which has competing views on whether domain centrality is more strongly related to positive spillovers in the receiving domain or in the originating domain our focus on workplace characteristics as moderators further provides actionable insights about how the negative consequences of wfh can be mitigated through organizational interventions finally we theorize and test how wfh intensity affects the satisfaction of employees with their jobs and their romantic relationships an important homerelated outcome so far the effects of wfh on the private lives of employees are rather unknown both to research and organizations by examining employees relationship satisfaction we respond to calls to study wfh outcomes that are important but not directly relevant for the profits of organizations theoretical background and hypotheses in research and practice boundary theory has been widely used to understand the dynamics of the work and nonwork domains as well as their interactions specifically boundary theory posits that roles are surrounded by psychological physical and temporal lines of demarcation individuals navigate the boundaries and manage the transitions and interactions between the roles and domains to maintain a balance between the work and nonwork domains we use boundary theory as the overarching theoretical framework of our research in what follows we first explore how and why wfh can blur the boundaries between the work and the home domains with negative consequences for employees workhome interface and their work and home lives work from home intensity and negative spillovers work from home requires employees to integrate their work and home roles because they engage in work activities in physical spaces that are normally dedicated to their private lives in such a situation work roles are necessarilyand often unintentionallyenacted during times that are normally devoted to the home domain and vice versa this is embodied in the concept of boundary control with decreased control over ones boundaries interruptions from partners children and other household members are more likely and can detract employees from work just as home domain activities are more likely to interfere with ones work resulting in hometowork conflict employees engaged in wfh can also experience worktohome conflict the absence of facetoface communications in the office can foster an always connected work culture with an abundance of digital technologies and communication tools available role transitions take place faster and more frequently which in turn increases the likelihood of employees engaging in work activities during times that were traditionally dedicated to the home domain in line with this logic lapierre et al found that mandatory wfh was positively related to worktohome conflict in a sample of financial sales professionals and leroy et al reported that since the onset of the pandemic the number of work and nonwork interruptions has increased which applies equally to worktohome conflict and hometowork conflict therefore wfh intensitydefined and operationalized as the number of hours worked from homecan create negative spillovers wfh intensity will often lead to a stronger wfh concentration such that single days of the week are completely devoted to wfh whereas there are some obvious advantages of intensive wfh it comes along with a loss of boundary control the loss of boundary control increases both the potential of worktohome conflict and hometowork conflict for example when complete days are worked from home employees might find it increasingly difficult to switch off mentally after work such that their nonwork relationships can suffer likewise with more hours worked from home it becomes increasingly difficult to avoid the regularly occurring interruptions of the home domain such as children leaving to and returning from school or household duties like cooking or house cleaning consequently we pose the following hypotheses hypothesis 1 wfh intensity increases worktohome conflict hypothesis 2 wfh intensity increases hometowork conflict boundary conditions of the wfh intensitynegative spillover relationships although it carries the potential for negative spillovers wfh intensity is neither necessarily bad for everyone nor under all circumstances in fact metaanalyses prior to the pandemic have reported a small negative effect of wfh intensity on negative spillovers one plausible explanation is selfselection most employees who selfselected into wfh prior to the pandemic saw primarily the advantages of it whereas many employees who worked from home during the pandemic adapted to the new circumstances only gradually and suboptimally a critical factor determining whether employees see primarily the upsides or downsides of wfh are their working conditions at home including work equipment and spatial situation if employees use lowquality work equipment at home this is likely to impede the proper execution of work tasks and can trigger stressful reactions with increasing wfh intensity stress and negative emotions are becoming more likely leading to more negative spillovers to the home domain in contrast highquality work equipment at home facilitates employees job activities so that they can be performed smoothly and seamlessly which mitigates negative spillovers we propose hypothesis 3a the quality of ones work equipment at home moderates the positive effect of wfh intensity on worktohome conflict such that the effect is attenuated at high levels of work equipment quality a separate office room at home allows individuals to spatially separate from the home sphere which is a common boundary management strategy when employees retreat to this dedicated workspace a boundary is drawn and interruptions from the home domain are mitigated or completely avoided we hypothesize hypothesis 3b the spatial situation at home moderates the positive effect of wfh intensity on hometowork conflict such that the effect is attenuated when employees have a separate home office room work from home intensity and positive spillovers more recent developments in the boundary theory field have highlighted that role integration can also facilitate positive spillovers for example ilies et al note that by integrating work and family domains employees can magnify the benefits of the positive features of work we underline this notion by arguing that wfh intensity can also have positive spillover effects for two main reasons just as wfh intensity increases the probability of interruptions of ones work tasks at home we argue that it can also increase the frequency of positive resource transmissions between the work and home domains some of the interruptions that can cause conflict can actually also provide respite from taxing roles as suggested by the frontiers in psychology 04 frontiersinorg microbreak literature and found by wu et al microbreaks can be used to solve pressing issues that would otherwise lead to mental absence in addition when employees are working from home they and their loved ones can notice cues of challenging workrelated situations and can help each other giving and receiving care feels good and creates positive emotions that can spill over from one domain to the other wfh intensity can also increase the intensity of positive spillovers facetoface interactions transmit affect and information more immediately and effectively than digital textbased interactions or phone calls positive experiences from an enjoyable lunch with ones significant other remain accessible during a work meeting when this takes place in the next room rather than miles and hours away similarly good experiences from work remain fresh and pure when communicated immediately to an accessible partner who can reinforce the positive experience we hypothesize hypothesis 4 wfh intensity increases worktohome enrichment hypothesis 5 wfh intensity increases hometowork enrichment 24 boundary conditions of the wfh intensitypositive spillovers relationship greenhaus and powell propose that resources and affect emerging from role a are more likely to promote high performance in role b when role b is highly salient than when it is not highly salient again we follow boundary theory which takes the opposite perspective individuals are highly motivated to enact highly central roles while being engaged in other roles such that enrichment is most likely to happen from role a to role b if role a is highly central to the individual for instance if role a is highly salient individuals are motivated to create permeable boundaries around role b such that role arelated permeations into role b are permitted for example one might encourage his or her partner to call anytime while being at work this enactment effect as posited by boundary theory has received metaanalytic support work centrality is more strongly related to worktofamily enrichment than to familytowork enrichment and family centrality is more strongly related to familytowork enrichment than to worktofamily enrichment the longer individuals work from home the longer both roles are simultaneously accessible and thus increasingly more possibilities exist to enrich one another for example employees with a strong work centrality who work from home may be able to benefit longer from the positive workrelated emotions because they are motivated to share such positive experiences with their family members we hypothesize hypothesis 6a work centrality moderates the positive effect of wfh intensity on worktohome enrichment such that the effect is strengthened at high levels of work centrality hypothesis 6b home centrality moderates the positive effect of wfh intensity on hometowork enrichment such that the effect is strengthened at high levels of home centrality the relevance of interrole spillovers for satisfaction outcomes in the home and work domain operating through opposing spillover paths wfh intensity can also influence employees homeand workrelated satisfaction relationship satisfaction is an important construct representing the home domain romantic relationships were particularly important during the pandemic when individuals could not easily visit friends or relatives and spent more time with their partners than usual with both positive and negative consequences for instance the german federal statistical office reports a slightly reduced divorce rate in 2020 but the federal criminal police office registered a sizable increase of cases of domestic violence relationship satisfaction is a good indicator of such dynamics as it is often the final pathway that leads to relationship breakdown it is also well suited for our purpose because it can be measured independent of ones broader family and household configuration relationship satisfaction an outcome that is not directly related to organizational performance parameters further allows us to better understand how farreaching the influence of work policies can be job satisfaction representing the work domain is probably the most studied workrelated construct of the social sciences and has important behavioral and organizational consequences such as extra role behaviors inrole performance and withdrawal how do interrole spillovers affect relationship satisfaction and job satisfaction according to the domain specificity model proposed by frone et al spillover effects originate within the source domain and transpire to the receiving domain where they materialize for example worktohome conflict originates in the work domain and manifests in the home domain as decreasing relationship satisfaction an alternative lens the source attribution model suggests that individuals blame the source domain where the spillover effect originates from this perspective individuals blame their job if they experience worktohome conflict therefore conflicting spillovers can also lead to decreasing job satisfaction we integrate both streams and suggest both positive materials and methods sample and procedure we conducted our study in munich germany munich is home to approximately 15 million inhabitants and to the headquarter of seven of the 40 german dax companies as well as to a large number of global firms of all sizes2 as a reaction to the pandemic 10000 of jobs were moved to home offices in and around munich immediately and directly affecting the lives of many employees and their respective households we aimed to collect representative data from employees who had a romantic relationship at the time of the survey to reach the target group we randomly approached munich households through a twostep sampling procedure in the first step 50 of the 755 munich voting districts were randomly selected with the selection probability weighted by the number of inhabitants per district in the second step a random geographic point within each selected district was located between may 12 and may 15 2020 research assistants took randomly determined routes from these points inviting every fifth household to participate in the study by dropping a letter in the mailbox within each selected district 100 letters were distributed delivering basic information about the study a unique qr code and a link to an online survey later on july 20 2020 we invited participants who had provided an email address to participate in a second wave in the letter in reminders and in the survey itself we encouraged respondents who lived in a household with family members or cohabitants to share the survey link with these other individuals specifically with a significant other as an incentive all participants took part in a raffle for vouchers with a total value of €1500 five thousand households were initially approached and 800 individuals from 580 households completed at least 50 of the first survey which translates into a household response rate of 116 we excluded individuals who responded to less than 50 of the t1 survey one individual who responded to the t1 survey twice and one individual who provided implausible responses we further restricted the sample to employed individuals who had a romantic relationship this left us with a final sample of 545 individuals from 375 households in t1 of which 301 individuals from 229 households responded to the repeat survey at t2 the following descriptive statistics are based on the t1 sample 5321 were female the average age was 4404 years on average the participants worked 2259 hours per week from home and the average weekly hours worked including overtime was 3209 2449 were supervisorsmanagers most employees worked in the service industry on average the participants had 043 children under 18 5651 of the participants were married 8477 lived together with their partner see appendix a for further details on the representativeness of our sample and attrition analyses the context figure 2 displays the covid19 situation in germany around the datacollection period the t1 wave of our data was collected about 2 months after the first bavarian state of emergency restrictions were still in place but the registered covid19 cases had already plummeted the t2 data collection occurred prior to another surge and the second state of emergency at this time normality was largely established contact restrictions were relaxed and schools daycare centers and shops were open again therefore our data collections did not occur during extreme situations or periods of volatile adjustments they rather set in when the work arrangements had already been changed and when individuals had adapted to them in this context and at this time decisions on who would work from home and when wfh would happen were made regardless of personal preferences thus reducing the selfselection bias inherent in prepandemic data and metaanalytic results of wfh measures work from home intensity following recommendations we asked individuals to report the number of weekly wfh hours at both points in time at t1 we also asked individuals to report their average weekly wfh hours from before the pandemic see appendix b for additional descriptive analyses negative spillovers we measure worktohome conflict and hometowork conflict with two fouritem german short scales from the german family panel the scales were originally suggested by carlson et al and later translated into german and validated by wolff and höge like and conflicts in my personal life reduce my work performance individuals responded to the items on 5point response scales ranging from strongly agree to strongly disagree 3 positive spillovers to measure worktohome enrichment and hometowork enrichment we translated and backtranslated the two threeitem scales suggested by kacmar et al the translations were performed with the help of two bilingual german native speakers disagreements were resolved via discussions between the authors we replaced family from the original scales with householdhousehold member or relationshippartner depending on whether participants indicated that they lived with many others or only with their significant other example items are the involvement in my household relationship puts me in a good mood and this helps me be a better worker and the involvement in my job makes me feel personally fulfilled and this helps me be a better household member partner satisfaction outcomes we measure relationship satisfaction and job satisfaction with the wellaccepted singleitem measures from the german socioeconomic panel study a prime research resource in the german speaking area singleitem satisfaction measures often correlate strongly with multiitem measures of the same constructs and can have strong reliability and validity metrics research has demonstrated that both singleitem measures of relationship satisfaction and job satisfaction have adequate psychometric properties so we are confident in the benefits of the measures both satisfaction measures have tenpoint response scales ranging from very dissatisfied to very satisfied 3 unless indicated otherwise all item measures have the same response scale workplace characteristics at home we measure the two workplace characteristics at home with the following items at home i have optimal equipment eg internet connection computer to perform my work tasks and at home i have a room where i am not disturbed when i work centrality of the work and home domains we measure work and home centrality using the two twoitem scales by kossek et al an example item is i invest a large part of myself in my work and people see me as highly focused on my familyrelationship common method bias to deal with common method variance we follow the recommendations of podsakoff et al specifically we employ different response formats such as an hour raw count of wfh intensity and varying likerttype response scales for the spillovers and satisfaction outcomes which should effectively reduce artifactual interconstruct correlations in addition the satisfaction measures were collected at t2 8 weeks after t1 to create temporal separation analytical strategy we first use confirmatory factor analysis to establish the discriminant validity of the measures to test hypotheses 12 and 45 we estimate the direct effects of wfh intensity on interrole spillovers using structural equation modeling to test the conditional effects we include the moderators work equipment and room conditions and home centrality and work centrality 4 to test the influence of spillovers on relationship 4 we predict a single boundary condition for each main effect however our proposed boundary conditions might moderate the relationships between wfh intensity and other interrole spillovers as well we test a complete model and report the results in the appendix e frontiers in psychology 07 frontiersinorg satisfaction and job satisfaction we conduct multiple mediation analyses multiple mediation analysis examines the indirect effects of wfh intensity on satisfaction through interrole spillovers and can test whether the spillovers simultaneously mediate the indirect effect all analyses include robust standard errors clustered at the couple level to account for the nonindependence of observations where both couple members answered our survey following graham and newman missing values in all inferential analyses are handled with a full information maximum likelihood procedure the multiple mediation analyses follow the procedures outlined in preacher and hayes and preacher et al due to the nonnormal distribution of the products of coefficients we calculate confidence intervals for the indirect effects using a parametric resampling approach with 20000 repetitions all estimations were conducted in the statistical environment r using the lavaan and semtools packages control variables to alleviate concerns of omitted variable bias and to investigate alternative explanations we estimate our models both with and without several control variables we include as controls individual segmentation preferences using the german version of the fouritem measure developed by kreiner and translated into german by janke et al an example item is i do not like work issues creeping into my home life preferences for segmentation of the work and home domains can cause people to spend less time working from home and they are probably also related to spillovers following previous studies of interrole spillovers and wfh we control for sex individual monthly income after taxes number of children younger than 18 living at home age marital status and whether the respondent lived together with his or her significant other we control for the respondents household composition and for employment characteristics namely whether the participant was a supervisor and whether he or she was fulltime or parttime employed we further include two dummy variables to indicate whether the participant was selfemployed or had some other type of employment with regular employment as the base category we use three industry dummies for the primary and secondary industry tertiary industry and the public sector we also control for pandemicrelated task changes to what extent did your daily work activities change due to the corona crisis using a 5point response scale ranging from my activities did not change at all to my activities are completely different now and include a dummy for individuals on a government sponsored reduced working hours scheme finally we include the number of hours that individuals had worked from home before the pandemic capturing the individuals familiarity with wfh 5 our results did not qualitatively change when the controls were included the changes in the standardized coefficients of interest were smaller than 01 the threshold recommended by becker we therefore follow recent advice and present our final models without the control variables but include the models with the full set of control variables in the appendix results confirmatory factor analysis and correlations the cfa tests whether the four interrole spillover measures individual segmentation preferences and work centrality and home centrality are conceptually different because the worktohome conflict and hometowork conflict measures have two subdimensions each we modeled the subdimensions first and the superordinate worktohome conflict and hometowork conflict factors second the model had a good fit to the data table 1 presents the means correlations and standard deviations of all variables as well as ω reliabilities for all multiitem constructs all constructs showed acceptable to good reliabilities results of hypothesis tests hypotheses 12 and 45 suggest that wfh intensity is positively associated with worktohome conflict hometowork conflict worktohome enrichment and hometowork enrichment in line with hypotheses 1 and 5 we find a significant and positive effect of wfh intensity on worktohome conflict and hometowork enrichment hypotheses 2 and 4 do not receive support as both coefficients are not significant at conventional levels next we tested hypotheses 3a and 3b predicting that the work equipment and room conditions moderate the positive effect of wfh intensity on worktohome conflict and hometowork conflict respectively all continuous variables were meancentered to avoid bias due to nonessential collinearity between the predictors and the multiplied terms in support of h3a we find a significant and negative moderation effect of the quality of ones work equipment on worktohome conflict specifically we find that a 1 hincrease of wfh increases the employees 5 when this control variable is included the wfh intensity effect becomes a change in wfh intensity effect bölingen et al 103389fpsyg20231191657 frontiers in psychology 08 frontiersinorg ω reliabilities are in the diagonal to simplify the table industry contracttype dummies and a dummy indicating the point of reference of the whe and hwe items are not included but used as controls in all analyses 103389fpsyg20231191657 frontiers in psychology 09 frontiersinorg worktohome conflict by 0017 units if they have lowquality work equipment whereas the effect is not statistically significant for employees with highquality work equipment we do not find support for hypothesis 3b though hypotheses 6a and 6b proposed that work centrality and home centrality moderate the positive effect of wfh intensity on worktohome enrichment and hometowork enrichment we do not find a significant moderation of the wfh intensityworktohome enrichment relationship and therefore reject h6a in line with hypothesis 6b we find that home centrality moderates the positive effect of wfh intensity on worktohome enrichment specifically we find that employees who report their home to be less central experience little increase in hometowork enrichment when wfhhours increase employees who report their home to be more central however can benefit from wfh on average their hometowork enrichment increases by 0012 units with each additional hour worked from home figure 4 plots the effects the analyses reveal that wfh intensity has adverse and beneficial effects the positive effect of wfh intensity on worktohome conflict implies a negative effect of wfh intensity on relationship and job satisfaction whereas the positive effect on hometowork enrichment implies a positive effect on both satisfaction outcomes we use multiple mediation models to examine whether these significant paths exist above and beyond each other we do not include hometowork conflict and worktohome enrichment because we did not find direct effects of wfh intensity on these interrole spillovers 6 specifically we reject hypotheses 7b 7c 8b and 8c due to nonsignificant apaths the indirect effects of wfh 6 we also do not find indirect effects of wfh intensity on relationship satisfaction and job satisfaction via hometowork conflict and worktohome enrichment in mediation analyses the insignificant effects of wfh intensity on hometowork conflict and worktohome enrichment are not moderated by the spatial situation or work centrality intensity on relationship satisfaction and job satisfaction via worktohome conflict or hometowork enrichment are statistically nonsignificant to test hypotheses 7a 7d 8a and 8d we estimated a multiple mediation model in which we included relationship satisfaction and job satisfaction as outcomes and the significant mediation paths from our main analyses ie worktohome conflict and hometowork enrichment figure 5 presents the estimated paths and table 3 reports the indirect effects of the multiple mediation analysis we find that worktohome conflict mediates the negative effect of wfh intensity on relationship satisfaction and job satisfaction an indirect effect tells us how much two cases that differ by a unit on x are estimated to differ on y as a result of xs influence on m which in turn influences y for example if two employees have zero versus 2259 wfh hours per week our model predicts that they will differ by approximately 020 job satisfaction units based only on the mediation through worktohome conflict and neglecting other potential pathways this represents about a tenth of a standard deviation of job satisfaction a small but noteworthy effect the indirect effects of wfh intensity via hometowork enrichment on relationship satisfaction and job satisfaction are positive and statistically significant including the previously statistically significant moderators work equipment and home centrality into a moderated multiple mediation model confirms the findings individuals can alleviate the adverse effects of wfh intensity on satisfaction outcomes through worktohome conflict by higherquality work equipment likewise individuals who regard their home as more central have weaker negative effects and can even enhance positive effects through increased hometowork enrichment discussion building on boundary theory this paper argues that wfh intensity results in negative and positive spillovers ie worktohome conflict hometowork conflict worktohome enrichment and hometowork enrichment for each effect we propose a boundary condition we hypothesize that workspace characteristics attenuate the relationship between wfh intensity and worktohome conflict and hometowork conflict in addition we propose that higher home centrality and work centrality enhance the positive relationship between wfh intensity and hometowork enrichment and worktohome enrichment we test the relevance of these effects for satisfaction outcomes namely relationship satisfaction and job satisfaction using a twostep random sampling procedure in munich germany we obtained a diverse sample of 545 employees which we surveyed twice in line with our hypotheses we find a significant positive effect of wfh intensity on worktohome conflict and hometowork enrichment multiple mediation analyses reveal that these effects exist simultaneously and have negative and positive implications for employees relationship satisfaction and job satisfaction surprisingly we do not detect a significant effect of wfh intensity on hometowork conflict and worktohome enrichment we further find that the positive effects of wfh intensity on worktohome conflict and hometowork enrichment can be attenuated through highquality work equipment and are stronger for individuals with a high home centrality respectively we contribute to several current discussions in the literature first our finding of opposing effects of wfh intensity on the workhome interface confirms that wfh is a work stressor and a workrelated resource this aligns with boundary theory which predicts positive and negative spillovers as a consequence of role integration the heterogeneous consequences of wfh intensity warn against a onesided focus on wfh second we contribute to the ongoing debate about positive spillovers by analyzing the role of domain centrality as a moderator candidate following greenhaus and powell hometowork enrichment would be more likely to result from wfh intensity when the work domain is central enactmenteffect logic takes a different perspective according to which individuals seek to enact highly salient roles in other roles therefore individuals with high home centrality should experience higher hometowork enrichment when the wfh intensity increases our findings support the latter line of reasoning and are in line with recent metaanalytic results third we fill a gap and study how wfh intensity relates to relationship satisfaction research has mostly neglected the nonwork outcomes of work arrangements taking an organizational perspective however spillovers from the work to the home domain are increasingly determining how employees experience their jobs and select their employers making it clear that seemingly nonwork outcomes have both individuallevel and organizationallevel relevance given the negative views on wfh as portrayed in the media it is important to understand whether and how wfh affects the home domain fourth we add to current research that examines whether the prepandemic wfh literature can be generalized to the new postpandemic era of wfh in line with other pandemicrelated research we find a robust and significant positive relationship between wfh and worktohome conflict leading to a negative indirect effect of wfh on job satisfaction whereas prepandemic wfh research has found an opposite effect a key difference between preand postpandemic wfh research seems to be that current wfh arrangements do not always increase employees flexibility rather they seem to decrease the employees boundary control surprisingly we failed to find a significant effect of wfh on hometowork conflict which contradicts much of the public debate but aligns with the prepandemic literature practical implications as companies plan to reduce office space and fixed costs wfh is here to stay practitioners argue that more wfh intensity is not exclusively beneficial for companies but has also positive implications for employees work and private life indeed metaanalyses have found small but positive effects of wfh intensity on the workhome interface and effects of wfh intensity on worktohome conflict at lowerand higherquality levels of work equipment figure 4 effects of wfh intensity on hometowork enrichment at lowerand higherlevels of home centrality frontiers in psychology 11 frontiersinorg job satisfaction before the pandemic our findings suggest that this may be true for some employees more importantly however they suggest that reality is more complex on the one hand higher wfh intensity increases employees hometowork enrichment which correlates positively with job satisfaction and relationship satisfaction however increased wfh intensity also triggers worktohome conflict since worktohome conflict impairs central work and family outcomes it is necessary to reconsider for whom the positive aspects outweigh the negative aspects and how to manage employees who work from home in this challenging situation our study suggests some promising interventions our findings indicate that employees specific situations matter employees who have high family centrality are more likely to reap the benefits of wfh to minimize the harmful effect of wfh intensity on the workhome interface organizations can provide employees with improved work equipment we encourage companies and policymakers to study further key mechanisms that could crowd out the negative and crowd in the positive consequences of wfh some companies have already taken steps in this direction by designing software and ittools that enable individuals to better manage their workhome boundaries or by providing employees with a budget for office tools and equipment so that they have what the need to continue working from home limitations our study has limitations first our model is static with predictors and mediators measured at one point in time and outcomes measured 8 weeks later at another point in time this data structure is not sufficient to adopt a dynamic view of interrole spillovers a call we echo second we conducted our study at the beginning of the covid19 pandemic although this setting helped us to control for some empirical issues we cannot rule out all potential biases for example omitted variables may bias the results for example employees resilience and coping skills may affect both wfh intensity during the pandemic and negative spillovers reverse causality can also be an issue for example individuals suffering from high worktohome conflict might be less inclined to choose wfh a quasiexperimental design with initial measures taken before the pandemic and followup measures taken duringafter the pandemic would have been preferred third the contingency view we developed focuses on employeebased moderators but neglects organizationbased and occupationbased contingencies we echo calls to examine how organizational and occupational characteristics influence the experience of wfh finally generalizability may be an issue our study was conducted during the first months of the pandemic in munich germany the timing of the study allowed us to test the effect of wfh at its peak but the longitudinal stability of the effects remains unclear in addition the inhabitants of munich can be described by the weird acronym more studies are needed to obtain a broader crosscultural picture of the role integration demands that the pandemic has triggered conclusion collecting data from a diverse sample of 545 working employees who were in a romantic relationship we found that wfh intensity impacts individuals workhome interface opening the door for negative and positive spillovers and ultimately influencing employees satisfaction with their home and work domains we find that individuals with high a high home centrality experience higher hometowork enrichment with increasing wfh thereby providing sound empirical evidence for the enactmenteffect we further found that the negative effects of wfh intensity through worktohome conflict could be mitigated through higherquality work equipment an actionable insight for both managers and wfh employees in summary these findings propose answers to our initially presented research questions the consequences of wfh are multifaceted with beneficial and adverse effects on employees workhome interface in addition employees experiences with wfh depend on boundary conditions such as the work environment and personal differences data availability statement the datasets presented in this article are not readily available because the raw data supporting the conclusions of this article will be made available by the authors upon request requests to access the datasets should be directed to ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at full supplementarymaterial

why do employees experience work from home wfh differently we draw on boundary theory to explain how wfh influences employees workhome interface wfh intensity increases negative spillovers ie worktohome conflict and hometowork conflict and positive spillovers ie worktohome enrichment and hometowork enrichment between the work and home domains negative spillovers can be mitigated through highquality work equipment and beneficial spatial conditions at home domain centrality predicts who can benefit from increased wfh intensity we test our theory with a sample of 545 employees obtained through a twostep random sampling procedure in the city of munichgermany during the covid19 pandemic we find that wfh intensity increases worktohome conflict and hometowork enrichment affecting employees relationship satisfaction and job satisfaction highquality work equipment mitigates the detrimental effects of wfh employees with a high family centrality can reap benefits of more wfh because they experience more hometowork enrichment the simultaneous desirable and detrimental effects of wfh intensity can partly explain why studies have found heterogenous wfh experiences among employees keywords workhome interface job satisfaction relationship satisfaction work from home technology 1 we use the term work from home for reasons of readability and consistency but acknowledge and include in our review the general literature on telework and telecommuting which can be performed in other places than at home for a review of definitions see allen et al 2015

introduction in the past 40 years of reform and openingup china has undergone rapid economic development accompanied by massive internal migrants the results of chinas 1 population sample survey show that the number of migrants was 246 million in 2015 1 this number is still growing with the latest census data showing that the number of the migrant population has grown to 375 million in 2020 2 report on chinas migrant population development 2018 shows that the percentage of working migrants aged 1659 reached 84 in 2015 and they played an important role in increasing urban labour force participation rate and promoting sustained urban economic growth 3 however with the ageing of earlier migrants and the characterized family migration the number of older migrants continues to grow the number of elderly migrants in china increased from 503 million in 2000 to 1304 million in 2015 4 they are mainly composed of four groups namely migrant workers disabled migrants healthy retired migrants and migrants following their children 3 the interaction between health and migration is complex and dynamic and migration can have an impact on the physical and mental wellbeing of migrants 5 lower healthcare utilization for disease prevention such as screening services and oral health checkups among migrants compared to nonmigrants was found in europe suggesting inequitable access to preventive health services for migrants 67 such results were observed in both developed countries and developing countries in which migrants have fewer medical treatment options and uncertainty about healthcare opportunities and health outcomes ruralurban migrant children were less likely to be fully immunized than urban nonmigrants and the general population in china india and nigeria 8 migrant workers face difficulty accessing medical assistance or delay seeking healthcare during illnesses in malaysia and bangalore city 910 this problem may be more common among older migrants who face physical psychological and economic cost barriers caused by spatial transformation accompanied by the characteristics of increased health risks as they age low education levels low income and heavy burdens of medical expenses the usage of health services is currently limited although these older migrants have high health needs 1112 migration includes the types of international and internal migration where international migrants are defined as individuals who remain outside their usual country of residence for at least one year around the world facing more common cultural and linguistical barriers while internal migrants are defined as individuals move within the borders of a country usually measured across the regional district or municipal boundaries resulting in a change of usual place of residence 13 due to the unique household registration system internal migration is more common in china therefore the participants are the internal migrants in this study according to the hukouchinas household registration systemthe population was divided into household registered and nonhousehold registered based on whether the actual place of residence coincides with the place of hukou registration for ease of understanding they are referred to below as nonmigrants and migrants respectively this household registration system has been reported to be a major barrier preventing internal migrants from enjoying equal rights such as access to housing education social and medical services to nonmigrants in the areas where they live 14 studies from china have reported on the obstacles of the healthcareseeking behaviours among these migrants employed migrants had the lowest recent physician consultation rate and the lowest annual hospitalization rate which might be related to healthy worker effect 15 and migrants were more likely to utilize private rather than public services for general healthcare and delivery care 16 currently studies mainly focus on employees or maternal and child populations and most of them are studies on the utilization of healthcare services 17 considering the important role of physical examination in increased chronic disease recognition and treatment risk factor control preventive service uptake and improved patientreported outcomes 18 it is necessary to analyse the annual physical examination of migrants besides guo reported a low rate of medical behaviour among older chinese migrants 19 but whether there is a difference in annual physical examination between older migrants and nonmigrants in china remains unknown although researchers have analysed the specific differences between migrants and locals in seeking healthcare services when illnesses occur in a particular area 2021 evidence of annual physical examination among older migrants still lacks support from a wider range of data this study aims to explore how different the annual physical examination of older migrants than that of older nonmigrants in china is by using a coarsened exact matching method and to provide some policy implications for improving older migrants health by exploring what factors are associated with annual physical examination of them in china 22 the cmds conducted a special survey for older migrants only in 2015 and collected data on 13043 older migrants from 9242 households the charls collected data on 20284 respondents from 11797 households in 2015 from which we obtained 7385 registered households over 60 years old that were nonmigrants detailed descriptions of the databases are available on the official websites cnwjw dataclassifypopulationtopiclist and charlscharlsdatacompagesdata2015charlswave4enhtml as our study used secondary data in the public domain approval from institutional review boards was not required after handling missing values the sample size in the study was 17242 including 11622 older migrants and 5620 older nonmigrants materials and methods data measures annual physical examination was measured by the question have you had a physical examination in the past year for older migrants in cmds 2015 for older nonmigrants in charls 2015 whether they had a physical examination was based on the response to when did you have your last physical examination only respondents who reported a time within the past 12 months were defined as having physical examination in the past year older migrants were defined by three conditions people aged 60 years old and above people who remained outside their usual hukou location for at least one month and people without hukou for their current living place in contrast older nonmigrants were those aged 60 and above who lived in the location of their hukou the covariates included in the study were age gender marital status educational level employment hukou household economic status which was measured by the per capita monthly expenditures of the family health status based on selfevaluated health and health insurance in addition to explore the factors associated with annual physical examination among older chinese migrants a set of variables was included the main source of income is divided into selfderived family members and others type of migration range of migration years of migration willing to stay in current location having health records in local community and the number of local friends statistical analysis categorical variables were described using rates and examined by the chisquared test considering potential differences between groups from two different sampling databases coarsened exact matching was used to reduce imbalances in the estimation of the differences in annual physical examination between older migrants and nonmigrants cem is a monotonic imbalance constraint class of matching method that reduces the number of potential matches for a given covariate by a set of coarsened potential confounders that are matched simultaneously in order to increase the number of matches achieved 23 it is preferable to other matching procedures in terms of reducing model dependence and estimation error 24 it has been shown to produce good covariate balance between groups and reduce the impact of confounding in observational causal inference 25 to control for some potentially confounding influences of pretreatment variables the covariates on which a match is made are first stratified and then the exact matching algorithm is used to match the objects in each layer according to the empirical distribution of the sample finally the matched research objects were retained and each older migrant was matched to an older nonmigrant who had the same age gender and other covariates in the matched data all analyses were conducted by incorporating matched weights after matching the balance between covariates is evaluated by the l 1 statistic which is based on the difference of all pretreatment covariates in the treated group and those in the control group ranging from 0 to 1 a good match would result in a lower l 1 details of this monotonic imbalancereducing matching method can be found in other literature 26 a logistic regression model was used to analyse the factors affecting older migrants annual physical examination in the unmatched group odds ratios and 95 confidence intervals were reported in the regression results the regression results were twotailed with a significance level of 005 all statistical analyses were performed using stata 140 results the characteristics of the participants table 1 shows the characteristics of the sample the sample was mostly under 70 years old male possessed primary school and no formal schooling education rural married employed lowand middleincome possessed good health status and possessed health insurance there were significant differences between older migrants and nonmigrants in age gender education hukou employment household economic status and health status compared with older nonmigrants older migrants were more concentrated as under 70 years old male middle school and above education urban unemployed possessing poorer to richer household economic status and possessing good health status as shown in table 1 there was no statistically significant difference between older migrants and nonmigrants in annual physical examination difference in annual physical examination between older migrants and nonmigrants table 2 shows the difference in annual physical examination between older migrants and nonmigrants a total of 4139 older migrants and 2007 older nonmigrants reported having had physical examinations migration was not associated with higher annual physical examination in the unadjusted analysis using a logistic regression model after coarsened exact matching 10347 older migrants and 5341 older nonmigrants were matched and the l 1 decreased from 0431 to nearly zero we identified that older migrants had less annual physical examination than older nonmigrants this persisted in the multivariable logistic regression model the multivariate imbalance measure l 1 statistic before and after cem is reported in table 3 notes the mean is labelled in parentheses and reports the difference in means factors associated with annual physical examination table 4 shows the results of the three multivariate regression models the first model incorporated the demographic and socioeconomic characteristics of the older migrants the second model incorporated the migration and social integration characteristics of the older migrants and model iii included all characteristics in model i middle school education was related to higher use of annual physical examination but it was lower for those with a high school and above education higher annual physical examination was associated with urban migrants good selfrated health and health insurance for employed individuals with richer and richest household economic status annual physical examination was lower compared with older migrants whose main source of income was themselves those whose incomes were mainly derived from family members and others presented lower annual physical examination in model ii annual physical examination was higher among urbanurban migrants and lower among ruralrural migrants compared with ruralurban migrants older migrants with a closer migration range have a higher utilization and those whose migrations have lasted 39 years have higher utilization having health records in local community was significantly positively associated with annual physical examination and having more local friends the results of model iii were similar to those of model i and model ii with only one exception there was no significant difference in annual physical examination between older migrants whose income was mainly derived from others and whose income was mainly derived from themselves discussion we conducted secondary analysis using large and nationally representative datasets to explore the differences in annual physical examination between older migrants and older nonmigrants and to investigate the factors associated with annual physical examination among older migrants in china we aim to show the gap in their utilization and to provide a reference for realizing the health equity of older migrants the study found that the annual physical examination rate of older migrants was 356 which is slightly lower than the report from guo 19 and the rate of older nonmigrants was 357 there was no difference in the reported annual physical examination rates between older migrants and nonmigrants however when confounding factors were taken into account the results of both multivariable logistic regression and cem suggested a lower annual physical examination rate among older migrants chinese researchers reported the healthy migrant effect and convergence of health status during chinas internal migration process that is migrants tend to have better health than nativeborn residents initially but this physical health advantage diminished significantly with their increasing length of residence 14 due to poor living conditions insufficient health knowledge and a lack of social support and social integration 27 the migrating population is susceptible to various psychological and physical health problems in addition migrants are often at a disadvantage as outsiders 28 not only are they generally disadvantaged to residents in terms of social resources and human capital but they also face inadaptability in social culture and customs 29 the above factors have caused a higher need for health services and more difficulties in the decisionmaking process of healthrelated issues due to chinas household registration system studies have shown that access to public health services outside the place of hukou is often restricted 30 in response to this problem the social welfare reform in china has taken measures such as encouraging qualified migrants to apply for local hukou but it is still questionable whether older migrants with low education meet the restrictions on settlement clauses in addition some policies aim to expand social welfare such as free physical examinations for all older people in a community 31 but whether they effectively improve the annual physical examination for older migrants needs to be verified by the latest data the results of model i showed that education employment and household economics significantly affected the use of annual physical examinations for older migrants this is consistent with other studies that showed that socioeconomic status such as income and education is an important factor influencing healthcare service utilization 32 surprisingly we observed that although the elderly with middle school education had higher annual physical examination than those with primary school and no formal schooling education for those with high school and above education annual physical examination was reduced other chinese researchers provide similar findings 33 we consider the reason for this difference to be explained by the mediating role of health literacy in the relationship between education and health 34 the elderly with higher health literacy were significantly less likely to have risky behaviours and more likely to undergo health examinations regularly report good selfrated health and access sufficient health information from multiple sources 35 but health literacy is not just the result of formal education 36 findings from a comparative study reported that literacy skills in bermuda better capture healthrelated knowledgeskillsbehaviours than formal education 37 this study found that higher household economic status was negatively correlated with annual physical examination the main reason is that we used expenditures to measure household economics compared with disease treatment physical examination is generally considered to be cheap which partly explains the negative association between family expenditures and physical examination from the perspective of the main source of income of older migrants annual physical examination was lower among those with income coming from family members and others which can reflect that income is an important factor in the use of healthcare services in china 38 the relationship between employment and annual physical examination showed that employed older migrants had lower utilization this could be attributed to the lack of time for employed migrants which is also confirmed in other chinese studies as an important factor preventing migrant workers from choosing medical treatment when getting sick 39 older migrants with urban hukou were associated with higher annual physical examinations compared to the rural group the potential residential gap occurred in the case of preventive care utilization 40 in health knowledge and in the utilization of health services in china 16 this gap could be an example of how rural migrants are disadvantaged in their access to healthcare the annual physical examination of older migrants with good health was significantly higher than that of migrants with poor health which is closely related to selfcare awareness in addition health insurance participation has stimulated awareness of annual physical examination among older migrants which contrasts with previous chinese research 40 although the existing social health insurance does not include preventive health services such as physical examination tumour screening or vision or hearing examination it addresses the health service needs of the insured by providing medical expense compensation when they visit a doctor thereby promoting insured older migrants to adopt active health strategies based on the above analysis of demographic and socioeconomic factors we propose formulating plans to improve health literacy and to improve individuals positive awareness of physical examination based on health education and cultural interventions in addition it is also necessary to formulate health policies to protect older migrants especially to ensure that migrant workers enjoy the right to physical examinations for employees and to promote the realization of social equity by exploring various means such as increasing health insurance benefits and providing transfer payments to older people without fixed incomes in model ii we included features of migration and social integration consistent with our discussion above migrants who came from rural places were more inclined to use less annual physical examination which was reflected in the higher utilization of urbanurban migrants than ruralurban migrants in addition regarding destination for older migrants with rural hukou utilization is lower in those who migrated to rural areas than for those who migrated to urban areas suggesting that there may be differences in healthcare access between urban and rural areas in china 41 this observation is also shown in the utilization of urbanrural migrants although no statistical significance was found compared with interprovincial migrants those with closer distances showed higher utilization this is consistent with the results of other chinese studies 42 as the latter are only influenced by regional segmentation with fewer sociocultural differences 16 older migrants with a longer duration were more likely to use annual physical examination as migrants social integration improves along with their years of residence in their destinations 43 and provides them with a better understanding of local medical service facilities 44 the utilization of migrants with health records in the local community was significantly high indicating the importance of social support for older migrants consistent with other chinese studies 45 we found that migrants with more local friends were more likely to use annual physical examinations than migrants without local friends local friends could help migrants rebuild relatively rich social networks 44 and provide local and useful health information 46 which are important for older migrants to use healthcare services 4647 in model iii we included all features of older migrants the or value with the results of factors were similar to the model i and model ii when the additional factors were included these results have important policy implications for the healthcare system and local governments to promote social equity policymakers need to consider how to formulate targeted social and health policies and establish a more complete rural health delivery network to increase accessibility better information on services should also be provided to migrants thereby improving their overall healthcare access and opportunities for health services in addition in the current primary healthcare reform more resources and attention need to be placed on the migrant population especially those who lag far behind their local peers in the use of services 48 which should not only help them establish health records in the local community to ensure that they can enjoy the same health policy as the locals but also promote social integration by giving them spiritual care and organized community activities there are some limitations to this study first the data for our study came from 2015 this is because the cmds conducted a special survey for older migrants only in 2015 to the best of our knowledge this is the largest and most representative survey data on older migrants in china other than the cmds 2015 the cmds does not currently release updated data on the older migrants to be consistent with cmds charls 2015 was used for older nonmigrants in the study thus the updated largescale survey is needed to this issue second our data were sourced from two different databases although the matching method was used to reduce the variation in the sample it may still lead to biased results besides like other crosssectional studies we could not determine the causeandeffect relationship in addition measures of annual physical examination were selfreported and could suffer from recall bias to capture the use of older nonmigrants the judgement of annual physical examination used the time of their last physical examination some older migrants may be excluded because of uncertain reporting times which may lead to underestimation moreover due to the availability of data some factors that may affect annual physical examination for older migrants are not included such as family income which was measured by family expenditures in the analysis other factors including the role of the family living mode and activities of daily living need to be further explored once the data are available conclusions the annual physical examination needs of older migrants in china have not been fully met older migrants are likely to be unable to enjoy the same annual physical examination as older nonmigrants this requires the government and public departments to adopt active countermeasures to improve the fairness of the use of annual physical examination for older migrants so as to avoid leaving this vulnerable group behind data availability statement the data in this study are available from china migrants dynamic survey 2015 which were used under license in this study and china health and retirement longitudinal survey 2015 which could apply from institution on the website of compagesdata2015charlswave4enhtml data of china migrant dynamic monitoring survey 2015 are available from the authors upon reasonable request and with permission of the migrant population service center of the chinese national health commission on the website of

it has become a top priority to ensure equal rights for older migrants in china this study aims to explore how different the annual physical examination of older migrants is compared to that of older nonmigrants in china by using a coarsened exact matching method and to explore the factors affecting annual physical examination among older migrants in china data were drawn from the china migrants dynamic survey 2015 and china health and retirement longitudinal survey 2015 the coarsened exact matching method was used to analyse the difference in the annual physical examination of older migrants and nonmigrants a logistic regression was used to analyse the factors affecting annual physical examination among older migrants the annual physical examination of older migrants was 356 which was significantly lower than that of older nonmigrants after matching odds ratios 091 p 005 it was affected by education employment hukou household economic status health health insurance main source of income type of migration range of migration years of migration having health records in local community and number of local friends among older migrants in china older migrants adopted negative strategies in annual physical examination compared to older nonmigrants active strategies should be made to improve the equity of annual physical examination for older migrants in china

introduction food insecurity and intimate partner violence are major health issues in the united states 12 food insecurity experienced by an estimated one in nine households in 2018 2 refers to having limited or uncertain availability of adequate food 3 black latinx lowincome and femaleheaded households are among those that bear the greatest burden of food insecurity 2 women living with hiv are also significantly more affected with approximately 40 estimated to be food insecure in the us 4 lifetime ipv prevalence36 for women overall 5 is disproportionately higher for women of color and wlhiv 16 ipv can include physical sexual or emotional violence perpetrated by a current or former intimate partner 7 high rates of food insecurity and ipv particularly among hivaffected populations in the us have significant public health implications both food insecurity and violence are wellestablished determinants of hiv risk behaviors such as condomless sex transactional sex and substance use 8 9 10 11 as well as hivrelated morbidity and mortality 12 13 14 15 16 for example food insecure individuals may increase their risk of hiv exposure by engaging in highrisk sex such as condomless or transactional sex to access food 10 ipv in the form of coerced or forced condomless sex can also directly increase transmission risk 17 food insecurity can lead to poor hiv control by undermining antiretroviral therapy adherence if people living with hiv avoid medication to prevent adverse effects from taking art on an empty stomach 14 additionally plhiv may need to make tradeoffs between spending limited resources on food instead of art or transportation to clinic appointments negatively effecting disease management 1418 reduced engagement in hiv care and treatment can likewise arise from fear of or experiences with ipv women who anticipate a violent reaction from their partner upon learning of their hiv status are less likely to link to and remain in hiv care and treatment 19 20 21 22 23 wlhiv who experience violence are also less likely to adhere to art 1921 24 25 26 27 28 29 30 31 32 33 34 and achieve viral suppression 25 35 36 37 while a large body of research has demonstrated that food insecurity and ipv are independently associated with worse hiv outcomes few studies have explored how intersecting experiences of food insecurity and ipv shape hiv risk behaviors and treatment adherence past research has found that food insecurity and ipv are associated 38 39 40 41 42 with some evidence of a bidirectional relationship 4344 for example in a longitudinal study among women in the us conroy and colleagues found that past and current experiences of food insecurity predicted current experiences of sexual or physical and emotional violence 43 another longitudinal study of mothers in the us found that experiences of ipv predicted an increased risk of household food insecurity two years later 44 a small but growing body of evidence suggests that food insecurity and ipv may be linked through pathways of poor mental health and relationship stress and conflict 44 45 46 47 specifically research suggests that depression executive committee this is a requirement of cohort irb approvals ensuring secure timely and ethical sharing of the cohorts data data access is managed by the macswihs combined cohort study and data requests can be made by contacting mediates the relationship between food insecurity and ipv 44 and that food insecurity may increase ipv through elevated household stress and related conflict 44 45 46 47 however limited research has explored the unique ways in which food insecurity and ipv intersect in the context of hiv or the mechanisms through which food insecurity and ipv may shape hiv risk and treatment behaviors such research is critical given that wlhiv are disproportionately affected by both food insecurity and ipv and each have been shown to be independently associated with hiv risk behaviors and suboptimal engagement in hiv treatment it also aligns with recent calls for syndemic approaches to understanding the intersecting experiences and cumulative effects of food insecurity mental health and domestic violence 48 accordingly we conducted a qualitative study to explore how food insecurity and violence intersect and shape hiv risk and treatment behaviors among women living with and at risk for hiv in the us theoretical framing this study draws upon singers syndemic theory which describes the cooccurrence of two or more disease clusters at the populationlevel whose interaction exacerbates the negative health impacts of each disease involved 49 syndemics can involve health conditions of all types including infectious and noncommunicable diseases and mental health conditions 50 importantly this framework acknowledges that the clustering of such epidemics arise from harmful social and structural contexts such as poverty racism and stigma which contribute to health disparities 4950 the most widely studied syndemic is the substance abuse violence and aids syndemic in which substance abuse violence and hivaids cooccur and mutually reinforce each other in a manner that magnifies worse health outcomes 3549 food insecurity remains an understudied element of syndemic theory 51 despite the critical role it plays in the lives of marginalized and lowincome populations including wlhiv it is important to note that although food insecurity and socioeconomic status are related food insecurity is a distinct construct that warrants its own consideration and examination through a syndemic lens indeed not all lowincome individuals in the us experience food insecurity 52 furthermore studies have found that individuals living in wealthier households can experience food insecurity in the context of unequal household food allocation drought or poor access to healthful foods in their neighborhood 53 54 55 food insecurity has also been found to be associated with poor health outcomes above and beyond the effects of socioeconomic status 56 given the evidence outlined above that food insecurity and ipv are associated with each other and independently associated with poor hiv outcomes it is possible that they could be syndemic factors working together to worsen hivrelated health as such we qualitatively explored the circumstances in which food insecurity and ipv cooccur and the mechanisms through which their convergence influences hiv risk and treatment behaviors among women living with and at risk for hiv in the us methods research design and setting we conducted a qualitative study nested within the womens interagency hiv study now part of the multicenter aids cohort studywihs combined cohort study wihs was a multicenter prospective cohort study of women living with hiv and demographically similar hivnegative controls with a history of sexually transmitted infections or behavioral or demographic characteristics that increased their risk of acquiring hiv in nine sites across the us 57 survey clinical and biological data were collected semiannually from wihs participants in this qualitative study we aimed to explore how experiences of ipv and food insecurity intersect and influence hiv risk and treatment behaviors among women enrolled in the san francisco california and atlanta georgia wihs sites women at the san francisco site lived in the city itself and the urban and suburban settings of the greater bay area women at the atlanta site lived in the city and in the surrounding suburban and rural areas we refer to these sites as northern california and georgia to account for these geographic differences within each site these two sites were chosen due to their geographic diversity and differences in social welfare provision despite high poverty rates in both locations california has above average per capita welfare spending while georgia has one of the lowest per capita welfare spending in the country 58 the large number of wihs women experiencing both food insecurity and ipv at these sites also made our ability to recruit the sample more feasible sampling and recruitment we recruited women from the northern california and georgia wihs sites from january through march 2019 who met our inclusion criteria of reporting 1 physical sexual or emotional violence from an intimate partner in the past year at their most recent wihs visit and 2 marginal low or very low food security as defined by the household food security survey module 359 at or before their most recent wihs visit participants were also purposively sampled so that half were living with hiv this approach allowed us to explore whether experiences of ipv and food insecurity differed by hiv status and how their intersection may influence hiv risk behaviors as well as engagement in hiv care and treatment wihs staff from each site contacted eligible cohort members over the phone to assess their interest in participating in the study if interested the study interviewer contacted them to schedule an interview data collection a semistructured interview guide was developed by the first author with input from sdw aac and pct the guide included broad openended questions that asked about experiences with violence and food insecurity and perspectives on how such experiences influence hiv risk and treatment behaviors for example to explore experiences of food insecurity participants were asked to describe what they ate on a daily basis their perception of the quality of food they ate and any challenges they faced in accessing the amounts and types of food they desired the guide also included questions asking about the circumstances under which women experienced physical sexual and emotional violence from partners the guide included probes to explore the ways food insecurity and ipv might overlap such as experiencing violence in the context of arguments over lack of food or feeling unable to leave an abusive relationship due to reliance on ones partner for food finally the guide included questions designed to explore how experiences with food insecurity and violence influenced womens emotional wellbeing and their ability to manage their health including using condoms attending clinic appointments and taking medication including art participants were also asked about how experiences of food insecurity and violence might influence their engagement in other hiv risk behaviors including condomless sex and transactional sex questions in the guide were informed by a literature review and our prior research on these topics 1345546061 a trained female masterslevel researcher with qualitative interviewing experience conducted the interviews in english in a private office at the local wihs site interviews lasted between 60120 minutes each and were audiorecorded and transcribed verbatim participants were assigned unique identification numbers and compensated 55 at the end of each interview for their time this study received human subjects research approval from the institutional review board of the university of california san francisco and by the wihs executive committee emory university waived approval because the georgia data was collected by ucsf researchers all participants provided written informed consent before starting the interview data analysis data were analyzed using thematic content analysis methodology 62 following an inductivedeductive approach 63 an initial codebook was developed by aml and js based on a priori codes informed by prior research the codebook was iteratively revised during the analytic process by adding new inductive codes to reflect emergent themes identified during transcript review the researchers met regularly to discuss emergent themes and codes and their application until they reached consensus around a final codebook js coded the transcripts using memos to elaborate upon the codes and their application aml reviewed the codes of approximately onequarter of the transcripts and js and aml discussed disagreements in coding and came to a consensus js single coded the remainder of the transcripts once all transcripts were coded aml and jmz analyzed the data coded segments related to our research question describing how violence and food insecurity intersect and influence hiv risk and treatment behaviors were iteratively reviewed key themes were developed and refined with descriptions of common and divergent experiences and perspectives and illustrative quotes representing both common and divergent perspectives the key themes were reviewed by authors with discrepancies resolved through discussion and consensus these results are summarized below with quotes anonymously identified by pseudonym site hiv status raceethnicity and age results we interviewed 12 participants from the northern california site and 12 participants from the georgia site all women were cisgender and the majority reported very low food security meaning that they experienced disruptions in their eating patterns or reduced food intake because they lacked the resources to access food 64 the most common forms of violence were physical violence emotional violence and concurrent experiences of physical and emotional violence nearly half the women described experiences of child abuse the majority of participants reported relying on social safety net programs such as supplemental security income social security disability and supplemental nutrition assistance program to access income and food all participants described these services as insufficient to meet their daily needs half of the sample were living with hiv and most participants revealed that they had other chronic conditions such as diabetes mellitus and hypertension a dominant theme that emerged at both sites was one of cooccurring and mutually reinforcing experiences of violence food insecurity poor mental health and substance use specifically most participants described how intersecting experiences of violence and food insecurity caused or exacerbated poor mental health outcomes and spurred their use of illicit substances as a coping strategy at the same time poor mental health and substance use amplified risks for violence and food insecurity the converging experiences of violence food insecurity poor mental health and substance use were described to increase hiv risk behaviors and undermine optimal health management including hiv care and treatment among wlhiv findings did not differ by site intersecting experiences of violence and food insecuritymaterial deprivation many women described how in the context of food insecurity and other material need insecurities they often needed to rely on intimate partners or strangers to meet their daily living needs women noted how this reliance created unequal power dynamics that left them vulnerable to abuse some women said men coerced them to engage in unwanted sexual acts in exchange for food both in the context of intimate partnerships and sex work we did have conflict over food sometimes because he would bring food into my house and then if i dont have sex with him or something he would want to take it back so that happened several times that he would get mad and say oh im taking my food women who depended on intimate partners to meet their material needs also described feeling unable to leave abusive relationships particularly if they wanted to ensure consistent access to resources for their children wed get just in a bad situation where we think the guys going to help us out and help us with food and our children and stuff and instead it turns into an abusive relationshipsome women just let it happen because these day and time its hard to get a meal some women revealed that their experiences with food insecurity began after leaving an abusive partner whom they relied on to access food for example barbara a 53yearold hivnegative white woman from northern california described how leaving her abusive partner after a particularly violent encounter sent her down a path of food insecurity and homelessness i never went back after that so thats what started my life like being really homeless and hungry and everything another theme was stress over lack of food as a cause of conflict and violence in relationships for example several participants described conflict arising when their partners would eat most or all the food available for the week leaving nothing for the rest of the family it kind of pissed me off cause the way i had to calculate everything its enough just for me and my kids then when my baby daddy back in the day was staying with me hell try to eat up everything but he didnt buy the food and then if he get mad at me and shit he gonna take my shit out the freezer and shit and sell it and he aint thinking about the kids candice revealed that this behavior caused her to fight with her partner in some cases resulting in severe physical violence after one such conflict she described her partner beating her to such an extent that he tried to kill her violence food insecurity poor mental health outcomes and substance use a vicious cycle the majority of women described how cooccurring experiences of food insecurity and violence contributed to feelings of low selfesteem psychological trauma and depression to cope many women described using substances to get rid of the pain at the same time poor mental health and substance use further perpetuated food insecurity and violence mental health experiences the majority of women noted how experiences of violence and food insecurity were associated with feelings of low selfworth and failure sofia a 51yearold woman living with hiv in georgia shared that youll be like man nobody care give a shit about me when reflecting on how experiences with food insecurity made her feel another woman said it has made me feel unworthy you know that i cant get food it makes me feel less of a person im not worthy of getting the basic stuff that i need the experiences of food insecurity violence and substance use caused women emotional pain and longterm mental duress that they struggled to get past for example barbara who became homeless and food insecure after she left her abusive partner and then had to exchange sex for food while living on the streets described how her experiences affected her mental health in the following way its taken a toll on my psyche period because sometimes iand this is the ptsd i can smell something or go past a certain place and i relive everything it just keeps me on pins and needles and i constantly relive it over and over and over again it has taken a toll on my psyche it makes me paranoid some women who experienced severe physical discomfort from extreme hunger also remembered the feeling vividly even years later causing them ongoing distress several women described that the poor mental health effects noted above often led them into bouts of what they described as depression in which they withdrew from life did not see other people and stayed in bed or slept all day when asked about how difficulties accessing food made her feel one woman with very low food security said it deepens my depression definitely and i already have some days where i really dont even want to get up and get out of bed and do anything and it definitely doesnt help my energy or anything like that not to be able to go in the kitchen and fix a nutritious meal some days i might just lay there unless i have something specific to do ill sleep most of the day off so im not thinking about food or whatever else in extreme situations some women felt driven to suicidal thoughts or attempts another woman with marginal food security and a history of violence and substance use said i tried to commit suicide a few times b ecause i didnt want to do anymore drugs i was tired of being on the streets i was tired of being abused i was tired of being homeless i was just tired you know and i felt like if i would just take some pills and just sleep and never wake up substance use as a coping mechanism many women spoke of using drugs and alcohol as a way to cope with the mental health effects of food insecurity and violence shirley who experienced physical emotional and sexual violence from intimate partners and engaged in sex work and begging to procure food while living on the streets reflected on the role of drugs in dealing with trauma from these experiences m ental illness which is all that trauma and drugs go handinhand they go handinhand because mental illness most of the times well for me is what caused me to use dope i wanted to suppress all the shit that had happened and i didnt know no other coping mechanism but to get high dorothy described how she used drugs to cope with her experiences of abuse and her feelings of low selfworth after exchanging sex for food and other resources a lot of times i dealt with the drugs because i didnt want to deal that was my relief you know like i didnt want to feel no pain i didnt want to feel no hurt i didnt want to feel the feelings that i was feeling about myself and sometimes sucking a mans dick outside around the corner in the bushes you know just like bent over it was just degrading where i took myself perpetuating the cycle of food insecurity and violence poor mental health outcomes and substance use were described to perpetuate the cycle of food insecurity and violence some women said that the mental health impacts of abuse and food insecurity rendered them emotionally vulnerable to abusive and controlling men a woman from georgia with a lifelong history of abuse who experienced very low food security said you know the parts of me that felt unloved and low selfesteem allowed me to be in abusive situations several women also described how substance use placed them at risk of violence and exacerbated their food insecurity some women noted how they or their partners would use all of their money on drugs or alcohol and would not have any money left to purchase food leading to conflict there was a time where food wasnt available because of bad habits like drugs and it became an argument about what happened to the food somebody exchanged food for money to get drugs instead of what the family wanted or needed conflict over lack of food could become particularly violent in the context of substance use one time i was hungry and both of us was high but i put the blame on him and it caused an argument we had violence a couple of times we fought one time when we was clean but it wasnt as violent as it was when we was on drugs effects on health management including hiv risk and engagement in hiv care and treatment women described how intersecting experiences of food insecurity violence poor mental health and substance use increased their hiv acquisition risk and undermined optimal health management including hiv care and treatment increased hiv risk women described experiencing sexual violence when they exchanged sex for food andor money thereby increasing their risk for hiv acquisition substance use was noted to amplify these risks by increasing the frequency of sexual exchange for drugs or drug money and by creating dangerous situations in which sexual and physical violence or coercion could occur one woman with a history of exchanging sex for food and money said i think people thats got drugs and alcohol any kind of that substance are more capable of getting infections like that hiv because theyre constantly kind of like numb so i think that it made me more easy to get caught up in situations and especially the guys because they feel real loose and they will rape you and bunches take turns poor mental health outcomes resulting from the intersection of abuse and food insecurity were described to increase the likelihood of future substance use and of risky drug or sexual behaviors due to low selfregard or giving up as noted in the following quote injection drug use carried its own risk of hiv acquisition i used to get so messed up behind these men let me tell you what i did this is how i got it i went and shot dope with somebody i knew to have fullblown aids and i didnt care i wanted to die because of how this man was treating me and kicking me around i didnt know what to do as described earlier poor mental health status also made it more difficult for some women to leave abusive relationships maintaining the cycle of violence andor food insecurity that increased hiv acquisition risk medication nonadherence several women shared that they missed their medication doses during periods of extreme depression when they didnt leave their house low appetite and desire for food during these periods also undermined their ability to take certain medications that required food the stress and emotional upheaval of food insecurity and especially of violence also made it difficult for women to take their medication as prescribed substance use further undermined medication adherence and increased the chances of an empty stomach since women often described forgoing food during periods of intense substance use these factors are captured in the following quote sometimes if i know i havent eaten i might not take a certain medication if im not eating i dont want my stomach to feel really bad sometimes if im going through those violent situations to block all that or to counteract that i might start using and then if im using im definitely not eating or taking the medication another woman living with hiv described how emotional violence poor mental health and substance use prevented her from taking her art they get to call me a bunch of names we get to fighting i go get high and guess what i dont take my medication my viral load and everything it affected me to the point where my doctor told me this is my last regimen she says she aint got no more combinations this is my last one while art nonadherence was more frequently described many study participants also struggled with medication adherence for treatment of preexisting mental and chronic health conditions in the following quote a woman describes how her lack of food and poor mental health stemming from experiences of violence leads her to withdraw and miss her medications for arthritis hypertension depression anxiety and other ailments if i dont eat well i have less energy ill get a headache my stomach starts bothering me it just affects me wanting to get up and take care of myself sometimes i just want sometimes to just lay down and just sleep all day or something like that i take ten pills a day so i have to put something into my system missed clinic appointments finally women described being more likely to miss clinic appointments when they isolated at home during periods of depression due to violence and food insecurity many remarked that if they were actively using substances or hung over after a period of intense use they were more likely to skip an appointment in order to hide this from the doctor well my exhusband wed get in a fight or something and hed get to call me a bunch of maggots and all that kind of stuff then i want to go get high and if i get high im not going to the doctor im not going women also avoided doctors out of embarrassment or shame when they had physical signs of abuse sofia a 51yearold woman living with hiv from atlanta said i couldnt even go to the doctor cause i had black eyes so thatsits very embarrassing other participants described how in the context of food insecurity and hunger they chose to skip clinic visits to access food at food banks or to save the money they would have used on transport to the clinic to purchase food and even with my doctors appointment if its like in the morning time i have difficulty getting there if i havent eaten anything so im hungry and i have to choose and pick whats more important so i choose food women experiencing extreme hunger described sometimes lacking the energy to physically get to clinic appointments for example when asked how experiences of food insecurity influenced her ability to attend clinic visits beth a 71yearold african american woman living with hiv from northern california experiencing very low food security said that she sometimes felt too weak from lack of food that she would stay in bed and miss her appointments discussion in this study we aimed to explore how experiences of food insecurity and ipv intersect and shape hiv risk and treatment behaviors among women living with and at risk for hiv in two geographic areas of the us our findings revealed that converging experiences of food insecurity and violence led to or exacerbated poor mental health conditions and the majority noted turning to substances to help them cope poor mental health outcomes and substance use then continued to perpetuate the cycle of food insecurity and violence ultimately the cooccurring and mutually reinforcing interactions between food insecurity ipv poor mental health and substance use contributed to worse health outcomes by increasing hiv risk behaviors and undermining engagement in hiv care and treatment in line with syndemic theory all participants in this study described lives shaped by structural disadvantage including unemployment poverty unstable housing food insecurity poor overall health status and lifelong histories of violence given that the majority of participants in this study were african american it is also important to acknowledge that the sociostructural context described by participants is largely a product of structural racismpolicies implemented throughout us history that have systematically denied african americans equal access to social economic and health resources 6566 our findings suggest that this constellation of structural disadvantage gives rise to the clustering of epidemics of ipv food insecurity poor mental health and substance use among this population of lowincome largely african american women the synergistic effects of these four epidemics is perhaps best illustrated by the study participant shirley who described acquiring hiv by knowingly injecting heroin with someone she knew to have aids because of her suicidal thoughts driven by intersecting experiences of food insecurity and violence her use of substances to cope with her poor mental health condition led her to consistently miss art doses and fail hiv treatment so many times that she is currently on the last line of hiv treatment available this syndemic and its negative impact on health outcomes may be even more pervasive during the covid19 pandemic emerging evidence suggests that rates of food insecurity ipv poor mental health and substance use have risen substantially since the onset of the covid19 pandemic and associated social distancing policies 67 68 69 thus it is possible that these factors may also synergistically intersect at higher rates among vulnerable women such as those included in the present study to exacerbate negative health outcomes including hivrelated morbidity and mortality indeed recent evidence suggests that engagement in hiv care and treatment has declined among people living with hiv since the onset of the social distancing policies 70 our findings build on past research that has documented a relationship between food insecurity and ipv and their independent effects on substance use mental health and hiv outcomes food insecurity and ipv are independently associated with poor mental and physical health outcomes including depression anxiety trauma low selfesteem and suicidal ideation 60 71 72 73 74 substance use 7475 hiv risk behavior 8 9 10 11 and poor engagement in hiv care and treatment 12 13 14 15 16 substance use and poor mental health in turn are also associated with each other 7677 and independently with hiv risk behaviors 78 79 80 and worse hiv outcomes 81 82 83 findings from the present study extend this past research to suggest that ipv food insecurity poor mental health and substance use cooccur and synergistically interact to exacerbate hiv risk behaviors and worsen engagement in hiv care and treatment our results also expand upon the extensive research into the sava syndemic 3549 which has demonstrated savas impact on increased hiv risk behaviors poor mental health outcomes and worse hiv care and treatment outcomes among us women 358485 specifically our results highlight that food insecurity and poor mental health conditions also synergistically interact with violence substance use and hivaids leading to increased hiv risk behaviors and worse engagement in hiv care and treatment findings from this study highlight the myriad ways in which these factors interact to impact hiv risk and treatment behaviors that quantitative studies have not uncovered to date and suggest that simple associations between two variables may be insufficient to understand the complex lived experiences of women living with or at risk for hiv future quantitative studies should employ a syndemic approach to confirm the intersections uncovered in this paper strengths and limitations our study was limited to wihs participants which includes cisgender and largely heterosexual women who have participated in the cohort for several decades and thus may not be generalizable to all women living with or at risk of hiv in the us our findings are strengthened however by the use of two distinct geographic locations that may offer important insights into common patterns in experiences with potential implications for the broader us context we have provided detailed descriptions of our study context methods and sample to assist readers in determining whether and how our findings apply to other contexts future studies should continue to explore the intersection of food insecurity and ipv among other important populations including undocumented immigrants who face citizenshiprelated barriers to accessing government social services such as food aid 86 and violence support services 87 research is also needed to explore this syndemic among queer individuals particularly transgender women who are disproportionately affected by hiv and ipv 8889 and experience extremely high rates of food insecurity poor mental health outcomes and substance use due to stigma and discrimination related to their gender identity expression 90 91 92 the sensitive and retrospective nature of some of our interview questions may have made our findings less representative of and faithful to the participants lived experience 93 to mitigate this and to increase participant comfort we utilized a sexmatched interviewer trained in qualitative and traumainformed methods including neutral probing and strategies to address participant discomfort and conducted the interviews at wihs offices already familiar to participants nevertheless the similarity and frequency of themes we found among participants both living with and at risk for hiv across both study sites underscores the strength of our findings research implications and conclusions to our knowledge this is one of the first studies to describe a syndemic of food insecurity ipv poor mental health and substance use and its negative influence on hiv prevention and treatment behaviors quantitative research is needed to understand how common this syndemic is and to elucidate the synergistic effects of these multiple factors on hiv outcomes it will also be important for research to examine the social and structural drivers of this syndemic and how policies such those designed to increase food access through the bidenharris administrations newly enacted american rescue plan 94 can address this syndemic and improve hiv prevention and treatment outcomes further while we focused on hiv as the core health issue among these women our findings also suggest that hiv is just one of many health issues affected by the syndemic of food insecurity ipv poor mental health and substance use as wlhiv age and develop other comorbiditiesa rising problem in the us 95 future research should explore how syndemics like the one presented in this paper can impact longterm health and wellbeing findings from this study also point to the need for multilevel and traumainformed interventions that address the social and structural context in addition to individuallevel health behaviors 50 for example interventions could include some of the following components providing food and economic support conflict resolution skills mental health and substance use support and support for hiv prevention and engagement in hiv care and treatment such an approach could also include policies that increase and expand eligibility to snap which has been shown to reduce food insecurity and poverty and improve health outcomes including mental health and medication adherence 96 a traumainformed approach may also be particularly useful to address this syndemic traumainformed care provides a framework to increase providers understanding that exposure to trauma such as ipv and food insecurity impacts all aspects of survivors lives and shapes coping strategies such as substance use and health care avoidance 97 it also enhances providers ability to recognize the signs and symptoms of trauma and guides their responses to include support provision and helping women develop a safety plan when they feel they are at risk of violence traumainformed care has been shown to improve mental health and substance use outcomes and has been identified as a promising approach to improve hiv prevention and treatment outcomes 98 99 100 ultimately our findings suggest that addressing the syndemic of food insecurity ipv poor mental health and substance use among women living with and at risk for hiv in the us may be critical to improving hiv prevention and treatment outcomes among this population data are from the womens interagency hiv study now part of the macswihs combined cohort study ethics

food insecurity and intimate partner violence ipv are associated with suboptimal hiv prevention and treatment outcomes yet limited research has explored how food insecurity and ipv intersect to influence hivrelated behaviors to fill this gap we conducted a qualitative study with women living with or at risk for hiv in the united stateswe conducted 24 indepth interviews with women enrolled in the san francisco and atlanta sites of the womens interagency hiv study wihs participants were purposively sampled so half were living with hiv and all reported food insecurity and ipv in the past year semistructured interviews explored experiences with food insecurity and ipv how these experiences might be related and influence hiv risk and treatment behaviors analysis was guided by an inductivedeductive approacha predominant theme centered on how food insecurity and ipv cooccur with poor mental health and substance use to influence hivrelated behaviors women described how intersecting experiences of food insecurity and ipv negatively affected their mental health with many indicating using substances to feel no pain substance use in turn was described to perpetuate food insecurity ipv and poor mental health in a vicious cycle ultimately facilitating hiv risk behaviors and preventing hiv treatment adherencefood insecurity ipv poor mental health and substance use intersect and negatively influence hiv prevention and treatment behaviors findings offer preliminary evidence of a

introduction community supported agriculture is an agricultural model that reflects growing concerns with the conditions of food production especially the increasing market pressure on producers and their lack of autonomy to opt for climate and environment friendly practices in north america europe and japan where many studies have been conducted csa has been described as direct local and longterm partnerships between producers and consumers csa is often depicted as a communitybased organization of members who share the entire costs of a farm varying between different csa groups a share of the harvest can be prepaid for several months a farming season or a whole year csa is thus a risksharing model in which producers benefit from advance payments as well as commitment of members the main motivations for consumers to participate in csa include their wish to support local farmers knowing where food comes from addressing environmental concerns and access to a wide range of fresh and often organically produced food concerning the transformation of food systems through agroecology gliessman stresses the importance to reestablish a more direct connection between those who grow our food and those who consume it csa has thus been identified as a way to support agroecology defined as a science a set of agricultural practices and a social movement supporting the emergence of a more holistic vision of the food system csa has mostly been directed towards just income for farmers this is encapsulated in the names used to describe csa as an agricultural model for example in germany csa is called solidaritybased agriculture in belgium the chosen term is solidarity purchase groups for peasant agriculture in france they are associations for maintaining peasant agriculture more recently the issue of accessibility from the consumers perspective has gained more prominence for instance the third principle of the french amap charter states that each amap seeks to broaden the accessibility of such food to all similarly the british csa network sets as its 3rd pillar fairness solidarity and reciprocity csa farming … see s healthy food as a right and work s towards equity and sovereignty in our food systems in the united states the csa innovation network emphasizes equity we must first recognize and address the systems of injustice that weaken it even though justice plays a role currently most csa members in the global north belong to a homogenous group with aboveaverage education and income only a small fraction comes from lowincome backgrounds low income has been identified as a major barrier to participation in csa therefore csa has been criticized for not adequately addressing inequalities in the food system few csa programs have been designed to include lowerincome members as lowincome consumers have limited access to local food some csa groups provide opportunities for them for example by offering unclaimed shares or selling discounted shares the literature identified reasons why lowincome households are less likely to become csa members and outline time transportation as well as food habits and preferences as potential obstacles to direct producertoconsumers relationships cotter et al also identified discomfort of having to pay in advance without knowing the content of the box as well as a lack of knowledge about the way csa functions as barriers for lowincome families these uncertainties are difficult to bear as they are constantly on a tight budget and may not be able to afford a backup option in the united states of america lowincome households joining csa through governmentsupported programs reported improved diets increased vegetable consumption a reduction in time spent shopping and less money spent on food for example basu et al suggest that … csabased interventions may be costeffective for improving diets among lowincome persons moreover lowincome households place a slightly higher monetary value on their share … despite their lower incomes and they are just as interested in foodrelated activities thus the inclusion of lowincome households in csas can also be of advantage for farmers pole and grey demonstrated that lowincome households could be more prone to share the risks with the producers even though social support actions in csa have received some attention recently their limits and potentials have rarely been documented moreover a consolidated typology is missing to assist csa groups in their efforts to diversify their membership this research is a contribution towards filling these gaps our main objective is to systematize and appraise social support actions of the csa movement taking the csa principles as a starting point our main research question asks how do social support actions in csas operate in terms of social inclusion and what obstacles and challenges are associated with them the article is structured as follows first we outline the theoretical background of strategic action fields we describe csa as moving from the strategic action field of food sovereignty to the broader field of food justice both concepts will be defined in our theoretical section we then describe our methods and data building on an initial list of support actions we interviewed seven initiatives spearheading social support actions to come up with a classified typology of support actions our results systematize the strategies to diversify membership in csa to address social inclusion and food justice we also discuss the challenges encountered while implementing these strategies in our discussion we reflect upon the shift in strategic action fields to conclude we offer pathways for future research and action theoretical background strategic action fields of csa strategic action fields are the fundamental units of collective action safs offer an analytic frame to investigate how collective actors in social movements try to gain strategic advantage in and through interactions with other groups according to fligstein and macadam social life is structured by a complex web of embedded strategic action fields each social actor is framing her his action in a field where everyone follows common rules depending on the field and where actors position themselves they might be incumbents holding a dominant position or challengers opposing power holders and carrying an alternative vision of how the field should be organized there are also governance units charged with overseeing compliance with field rules and in general facilitating the overall smooth functioning of the system in social movements it is typical for safs to develop around specific issues or concerns safs are dynamic and the order of the field might change with regard to how collective action is organized or embedded fligstein and mcadam identify four characteristics of safs first an understanding of the issue at stake second a variety of actors involved with different degrees of power third the actors involved have a joint understanding how the field operates the rules of the game fourth and last there is an overarching interpretive frame which might be contested from the various actors involved the analytic approach of safs has recently been applied for the first time to the german csa movement in terms of the culture of cooperation we build on this work and focus on the consequences for safs when csas shift their focus from just income for farmers to include a more diverse range of members csa had until recently been framed by csa networks as part of the food sovereignty movement the declaration from the food sovereignty forum held in 2007 in mali defines food sovereignty as the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods and their right to define their own food and agriculture systems food sovereignty is used to reclaim the right for smallholders to selfdetermine the conditions for food production distribution and consumption according to holtgimenez food movements can be placed along a spectrum stretching all the way from a neoliberal to a radical vision of food systems the saf of food sovereignty focuses on a radical systemic change in this field farmers are incumbents that are praised in a narrative with agrarian undertones the contribution of csa to the saf of food sovereignty is clear csas are offering community support to family farmers applying ecological practices and are aiming at restoring the autonomy of smallscale farmers in the food system food sovereignty tends to operate with mechanisms and policies that empower various actors in the food system in csa the particular focus lies on supporting farmers in contrast to food sovereignty the contribution of the csa movement to the more encompassing saf of food justice is still largely uncharted yet there are some developments in the csa movement which aim to broaden the focus of csa not only towards farmers but also towards lowincome consumers food justice advocates perceive the food system as characterized by transnational corporations dominating food production and distribution they are interested in economic pressures and power imbalances in the food system and aim at creating access to appropriate food irrespective of the consumer class race or gender yet the interpretative frame of the field of food justice as well as the interpretation how it operates is different for gottlieb and joshi food justice is an intersectoral normative and egalitarian model aiming at removing all kinds of injustice as for example racial or class injustice food justice aims to ensure that the benefits and risks of where what and how food is grown and produced transported and distributed and accessed and eaten are shared fairly the food justice movement also acknowledges the underlying power structures that are perpetuating oppression and food inequalities and tries to address them here it is where both lowincome households and marginalized producers come into play for example food justice advances the opportunity for the most marginalized in the food systems to make choices about their food by establishing fair relationships with local producers or by growing their own food thus the analytical approach of safs assists in scrutinizing the opening of the csa movement towards the broader issues of food justice provides important insights regarding the dialectics between the obstacles to social support actions and the solutions found to overcome these obstacles in the respective safs we included a variety of initiatives ones with a long and wellrecognized experience in social inclusion like rock steady farm in the us as well as other initiatives which are less vocal about this topic but who stated in their replies to the covid19 survey that they had been implementing social support actions since their creation like the german solawi and the french saintdenis based amap we also included voices from the global south by talking to csa demétria in brazil one interview was conducted with a csa network paniers marseillais with a unique experience of organic solidarity shares this additional network was identified as a particularly advanced initiative a governance unit according to the theory of safs and used to validate some of the results of the previous interviews approach a case study approach has been adopted to build a typology of social support actions the case we focus on is the implementation of social support actions in csa opening up towards a more just food system seven semistructured qualitative interviews were conducted each interview consisted of guiding questions on the social support actions implemented by the csa on the barriers that prevent from becoming members and on the reasons that prevent members from making use of the social support actions the case study approach helps us on the one hand to classify the support actions but also assists in reflecting upon how the csa movement is moving from the saf of food sovereignty towards the saf of food justice it enables us to synthesize for each of the four characteristics of the theorization of saf the main limits faced by the csa movement and to study how the change in the interpretative frame in term of issues at stake power imbalances acknowledging how the food system operates as well as offering an interpretive frame which seeks to address exploitative and unequal issues in the industrial food system materials and methods in order to systematize and appraise the social support actions implemented in the strategic action fields of the csa movement we build upon an initial list of social support actions this list was established in the frame of a report about the response of csa and other local solidaritybased partnerships during the covid19 pandemic this initial list is based on an online survey with 328 replies and an additional 40 interviews conducted with csa network coordinators mainly in europe north america japan china and brazil seven social support actions were identified 1 logistical support to marginalized and vulnerable people 2 food donations to marginalized and people in need 3 food donations to soup kitchens pantries charities 4 integration of migrants asylum seekers in the group 5 discount shares in poor neighborhoods 6 home deliveries to vulnerable and disabled people and 7 cooperation with social projects and social organizations eg join ad hoc solidarity group for this paper we first identified csa groups implementing some of these solidarity mechanisms and contacted them via email seven initiatives located in northand south america as well as in central europe agreed to participate six csas and one local csa network although the sample size is limited it comes with a certain scope both geographically and in terms of the experience and roles taken by respondents in their respective groups hence it than a decade at the international level and has experience and knowledge on the topic based on numerous projects and exchanges during field visits results towards socially more inclusive csa the analysis of the qualitative interviews resulted in the identification of two focal areas that could assist the strategic action field in which csas operate to become more socially inclusive first we appraise social support actions differentiating between emancipatory social actions and those that are rather motivated by charity second we outline challenges faced while implementing these actions typology of social support actions based on the interviews we classified the earlier identified social support actions into two categories the emancipatory support actions empower lowincome households and lead into reconsidering some of the fundamental rules of csa the other category charity support actions support actions that provide shortterm relief that might not affect the way csa functions emancipation is understood as the process through which individuals gain agency by being freed from someone elses control whereas charity is understood as the voluntary assistance of those in need we further distinguish between support actions which are either of financial or of nonfinancial nature by financial support we mean that an action is affecting the contribution paid by the members should it be the amount paid or the calendar of payment by nonfinancial support we mean towards food justice has consequences regarding how these limits can be addressed protocol a consent form was signed by all interviewees the interviews were carried out in april and may 2021 each interview was held via video call and recorded the length of the interviews varied between 28 and 156 min the semistructured interviews were fully transcribed and the qualitative data analysis was supported by the maxqda© software a content structuring analysis grid was designed in order to generate the codes by a combination of deductive and inductive approaches the obstacles to join a csa and the social support actions offered by the csa were all predefined whereas the typologies of obstacles and social support actions and challenges have been derived based on the interviews below are the guiding questions that were asked during the interviews • what mechanisms and social support actions do you implement in your initiative are there factors that are crucial for the successful implementation of social support actions • what barriers still exist that might prevent people from becoming members of your initiative and members from making use of social support actions we analyzed the interviews through coding along the main categories we complemented the interview data with a variety of sources ranging from individual csas to csa networks websites and recordings of a series of webinars on the topic in addition one of the authors has been involved in the csa movement for more stay in the csa or not in order to reduce obstacles for joining csa the purpose of trial memberships is more general than the sole integration of lowincome households it can be used as a strategy to increase membership without taking into account their social background nevertheless our case study stresses flexible payment plans as an efficient tool whereby potential members regardless their social background can learn how to do csa furthermore the respondents from colombia brazil and france remark that food from a csa is not necessarily cheaper than food from the supermarkets but it is cheaper than organic food from other markets the respondent from csa demétria emphasizes the respondent from csa agromandala stresses the specificity of csa in setting up prices over the whole year thus providing an exceptional stability both to producers and consumers this allows members to plan their expenses if charitable nonfinancial support actions csa principles consider an uncollected share as unclaimed and lost in some csa these unclaimed shares are given to a nearby charity rather than being given to another member another option for members is to leave some food from their shares in a basket at the distribution site this allows members to swap food they do not like or food that is exceeding their consumption capacities there are also other forms of donations csa bel aire connects members via an emaillist where they can share clothes or furniture but also apartments or language courses similarly csa agromandala initiated a chat to share recipes for unfamiliar food the respondents indicate that food donations are not only accessible for members of the csa but also for individuals from the neighborhoods or farm workers the farmers are able to donate surplus food instead of selling it on other markets because the csa offers them financial security another nonsystemic support action is voluntary work on the farm mentioned by the respondents from the two german csa groups even if assisting on the fields is a requirement members decide on their own when how often and how long they would like to work there is no connection between the amount of the financial contribution and the number of voluntary working hours in many csa groups the financial contribution is anonymous anyway so that no that an action is not affecting the contribution paid by the members but instead results in inkind social support the distinction between charity and emancipatory social support actions is of analytic nature social support actions might move between these poles depending on the csa and how they have implemented the support action through the lens of safs csa actors who strive for emancipatory actions are embedding the csa movement into the larger strategic action field of food justice charitable financial support actions several social support actions do not address the emancipatory ambition of the csa movement but provide direct and fast help without necessarily implementing pathways towards a more just food system one key principle of csa is upfront payments however the payment frequency varies members might pay on a monthly basis a whole season several months or even a year in advance the aim is to ensure a sufficient budget for the whole growing season and simple accounting for the producer sometimes however members can be late on their payment plans the interviewee from csa ortenau emphasizes that financial difficulties should not be a reason to leave i also had an individual case once that someone signed off during the course of the year and said íve lost my job and can no longer afford to do this and then i agreed with that person to continue and to pay a lower rate now and when that person has a job again to pay more that was accepted and worked out well members of rock steady farm csa have the possibility to sign up for a flexible payment plan members are asked to pay a 20 deposit at the beginning of the season and to pay the rest one or two months later in general members are encouraged to get in touch with the csa if they are unable to pay upfront all respondents stressed that suitable solutions can be found several csa groups offer trial memberships to lift the obstacle of signing up for csa membership this targets individuals who are interested in joining but would like to get familiar with the system first after a couple of weeks or months they can decide whether to stay or quit csa bel aire even increased accessibility by offering a discount for new members a similar approach is provided by csa agromandala in which members who are under contract for at least three months receive a discount this is a way to ensure a stable income for the farmers without forcing subscribers into long contracts moreover some csa groups allow members to decide each month if they would like to steady farm every member chooses the payment level based on their income and wealth guidelines are available on the csas homepage to help members make their choice these guidelines take property occupation health status and social and financial security into account members can choose between four different payment levels the lowincome level includes a 20 discount the middle price called market price point is the breakeven price at which all costs of the farm are covered the upper level requires an additional 20 increase and the contributor level 40 table 2 illustrates the breakdown of contribution levels of csa rock steady farm in 2020 csa rock steady farm members also have the option to receive a smaller share at a lower price if the average contribution ranges below the price necessary to cover the costs the farm has to make up for the gap by using food access funds or by appealing for donations if the csa ends up with more money than is necessary to cover all the costs they add the surplus to their reserve to be able to finance the following seasons thanks to the sliding scale about 57 of the production was shared with lowincome households in 2020 this proportion was reached through a mix of sliding scale solidarity shares and wholesale produce for food pantries the farm had about 310 paying members in 2020 additional 130 households received solidarity shares subsidized by 40100 these are meant for individuals who cannot afford to pay the lower sliding scale level the farm finances such solidarity shares via individual taxdeductible donations grants and sponsorships the farm collaborates with a health center serving hivaids patients with additional health conditions and lgbtqia communities the members facing high medical costs can register for solidarity shares as for the sliding scale the solidarity share classification is also based on trust no proof of income is required the csa provides information to assign oneself to one of the payment levels but the members decide on their own which level they feel they belong to csa demétria offers a single solidarity share for a person who is facing an insecure situation in order to provide the person with a harvest share all members have agreed to pay a slightly higher contribution another differentiated contribution model is the bidding round the respondent from csa trier describes the procedure of the bidding rounds as follows at the beginning of the season the annual expenses of the farm are calculated and a general meeting is organized based on the calculated costs and the number of members an average monthly contribution is announced to provide guidance in the first round members anonymously place their bid they state how much they would like to pay if the costs of the season are not covered a second even one is keeping track of working hours committed by each member the respondent from csa trier said we also explicitly do not want a lower contribution to the bidding round to be linked to working on the field because not everyone is able to do that and solidarity as we see it means that everyone contributes according to their possibilities this also means that if you do not have money and time because you are in a precarious employment situation or are a single parent you still have the opportunity to participate voluntary work by csa members can be considered as a social support action in an indirect way because if many individuals work voluntarily the labor costs and thus the membership fees can be reduced thus members who are physically able to work in the fields and who have the time and resources to do so relieve the burden of those who dont have the same opportunity by so doing volunteers structurally support the csa initiative and its increased openness the respondent from csa trier adds so people who do not want to be part of the garden community but who only want to get the vegetables are also allowed to participate food donations and voluntary work are support actions that although not emancipatory can facilitate access to csa membership at an operational level emancipatory financial support actions besides stable prices the possibility to choose between differentiated contributions is another strategy towards financial support for csa members several social support actions fall in the category of differentiated contributions eg sliding scales solidarity shares bidding rounds and selfassessment which we describe in the following sliding scales are strategies to mitigate economic barriers shares are priced lower for lowerincome households and higher for higherincome households for example at csa rock transparency in a bidding round is the basis for mutual trust talking about income also helps middle class members to appreciate their financial privileges csa ortenau follows a slightly different principle in their bidding round a nonbinding guiding value is determined to assist the members in their decision on how much to contribute the aim is to reach the annual budget without further bids however in some cases the costs of production are not fully covered the members are then asked to slightly increase their contributions neither lower limit nor proof of income are required the respondent from csa ortenau states that often members with fewer resources are also quite willing to pay more figure 2 illustrates the distribution of the financial contributions of csa trier and csa ortenau in 2021 emancipatory nonfinancial support action emancipatory nonfinancial support actions include collaborations with other organizations to achieve greater reach our interviews and findings of other studies show that collaboration with other organizations such as social services health centers or food pantries helps to reach populations that otherwise would not know about csa especially collaboration with governmental aid programs have proven to be helpful this is a way for csa to delegate to professionals the high responsibility to ensure that those who need the csa shares the most eventually receive them csa rock steady farm also supports the project csa is a snap in order to make csa shares more accessible to supplemental nutrition assistance program beneficiaries finally it is important to emphasize webinars and trainings organized by csa networks on the topic rock steady farm and paniers marseillais have both been playing an active role in learning from experienced food poverty organizations sharing their experience and linking with food aid beneficiaries through webinar series in 2018 an additional table was collectively created to provide guidelines on how to selfassess ones contribution the table displayed monthly recommended contributions based on the net income of a single household for example for a person with an income of 1524 euros the guiding value contribution of 95 euros corresponds to 623 of the net income for somebody earning a minimum wage the csa contribution would then be only 7380 euros thus the table also has the important function of showing members that it is acceptable to contribute less due to low financial resources the bidding round does not require a minimum bid value the only rule is that all the farms financial needs must be covered before the farming operation can start the interviewee from csa trier reflects on the principle of the bidding round it is exciting and thrilling every time but everyone has the same interest so everyone wants it to continue so yes everyone pulls together and adds another two euros and if more people with lower incomes would join them that would probably also work out somehow transparency is crucial for a successful implementation the respondent of csa trier notices we have to stop not talking about money´ because i find it very difficult how a society is supposed to change towards more solidarity with bidding rounds when you dont know at all how much i earn and whether the contribution is a lot or it is a small amount clash of food cultures is that some of the solidarity shares beneficiaries are actually dropping out as in the case of agromandala members dont get what they want what they think they want in their heads they dont understand thats what we grow and that s what nature gives to you and it is not enough to explain to them that its not avocados all year … the respondent from brazil points to the wider context … for the people here it is status for example to drink coca cola we have hundreds of varieties of fruits wonderful juices and so on … but you cant get to anybody in the house thats gonna offer you lime juice you know cause thats like hey whats the matter you dont have money to buy a coke … you have to have these things to gain status to show that you have some kind of status interview 2 pos 44 the respondents underline that some new members are not willing to adapt their eating and cooking patterns to what they get from the csa in addition the share also provides members with vegetables that they are not used to eat csa is a strategic action field with rules that are hard to understand for newcomers interviewees see this as a major hindering factor for lowincome households another barrier is reaching the pickup stations it requires time and additional transportation to pickup shares of the harvest the respondent from csa rock steady farm explains we have fruits eggs you know we have a diverse box but it´s always when someone really is strafed on time then they just got to go to the grocery store once they get everything they need as cheap as possible lastly our respondents also mention a lack of public awareness as an obstacle one barrier is that many people still don´t know us during the first few years after we founded the csa we did a lot of information sessions and events but of course you never reach all sections of the society often however there is no effort on communication as csa groups are not able to accommodate more members the example from csa ortenau is interesting in its early 2021 csa network 2021b miramap 2020 solawi trier also conducted a seminar about income and payment levels in csa during this seminar the table showing the levels of differentiated contributions based on the income was presented and discussed collectively challenges for csa to implement social support actions our analysis reveals key challenges and limitations of social support actions the socioeconomic backgrounds of members of the csa groups participating in this study are quite heterogeneous they range from wealthy areas with middleclass members up to one of the poorest suburbs of paris even though this latter csa also predominantly consists of individuals with an academic background and a high social status in this latter case lowincome households from the neighborhood do not join the csa although it is close to their homes in other csas the financial status of the members is mixed but lowincome members are hardly represented a set of factors mentioned by our respondents are eating habits consumption patterns and expectations of size shape and immaculacy of food even if these are general barriers affecting everyone potentially becoming a member they might be particularly challenging for lowincome households the lack of choice was mentioned as a major obstacle in most of the csas although diverse fruits and vegetables are offered the content of the share is the same for all this can come as a surprise for consumers who would prefer to choose food following their personal tastes i think sometimes it can be a little bit overwhelming if someone doesn´t actually eat that many vegetables so we have two different sizes but it´s amazing some people say that even the smaller sizes are too much expectations about preferred foods in csa shares can be both culturally influenced and dependent on the educational background this cultural or educational gap makes it challenging to meet expectations beneficiaries would like to have a choice they dont like to have the composition of the share imposed the farmer who initiated the agromandala project in colombia pointed out that members often do not know how to use and prepare food from the csa because they lack the knowledge to do so this leads to sharing advice with members on how to add unfamiliar vegetables or salads to their daily diet or other cooking methods that go beyond frying she emphasized that individuals with low incomes not only lack the money for healthy food but above all the knowledge about it the result of such a thus the simple fact that being a member is a requirement can be a limit preventing the generalization of social support actions another aspect that limits the use of social support actions is dignity for a lot of potential beneficiaries there is a high risk of being exposed stigmatized as a person in need of assistance the respondent from brazil reports a case in which a person was supported by a solidarity share the person was uncomfortable with the support offered and was even upset that they talked about the financial situation an interviewee from germany puts this challenge as follows the beneficiaries had the feeling of not being an equal member of the community or exploiting us as gardeners in case they pay less this quote shows that members would often find it difficult to pay less than the recommended amount of contribution and thus often prefer to drop out instead of being a perceived second class member discussion the objective of this paper was to categorize and appraise social support actions implemented in the csa movement the results of our analysis emphasize two types of social support actions in the current csa movement first support actions which seem to have the same limitations as other food donations the beneficiaries are put in a passive position they have neither the right nor the power to define the content of their shares these donations perpetuate altruism on the one hand and indignity on the other hand and may lead to dependency of the receivers the second type of social support actions consists of emancipatory actions which can result in revisiting the underlying principles of csa in order to associate more closely the beneficiaries and ensure their active participation in the partnership we also identified numerous challenges for the social support actions implemented by csa in this discussion we contemplate how moving from the field of food sovereignty to the field of food justice can increase the potential for emancipatory support actions the four characteristics of safs assist in thisreflection the first characteristic of any saf is the shared understanding of what is at stake the challenge in csa is that social support actions assisting lowincome households does not necessarily resonate with supporting smallholder farmers the hindering factors of social support actions are in line with previous research about limitations of access to csa the income and the social background are years it focused a lot on advertisement in the region particularly in the countryside even if this csa is still offering guided farm tours and educational work in cooperation with schools shares are already booked so that they do less publicity this results in less opportunities to know about the existence of the csa for individuals outside of the small circle already participating the respondent from the us even considered the ethnic origin as a core cultural element explaining the difficulty for social support actions to be fully endorsed by potential beneficiaries about the csa concept she commented … its the states european its not like global in a way so people might just be like ´whatever thats just not my thing´ you know ´not my culture not my background i am not interested´ another challenge is that the introduction of social support actions requires additional effort members of csa groups appreciate guidance to choose the level of their contributions as they still struggle to assess their financial privileges coming up with such classifications to guide members in their contributions requires an important effort from the core csa group moreover in order to reach individuals of concern easy access to informative content deems to be important prospective members need to know which payment options are available lowincome individuals will not see csa as beneficial if they do not know about the flexible payment options in order to work efficiently including the organization of polls to know what was appreciated and what was not and in order to prepare a regular newsletter the respondent from the us estimates that 25 of the work on the farm is used for communication purposes csa bel aire core group members decided not to work with governmental programs to avoid becoming dependent and overloaded with administrative work the length of the contract term and the requirement to collect the shares from the pickup may be perceived as temporal and spatial barriers adding to this many newcomers feel unfamiliar with the responsibilities that go along with a csa membership we had people who wanted to buy something here and when they found out that you have to be a member it scared them off … by the way i had the same problem at the beginning i also found it a bit strange one is then suspicious what kind of cult is that here you have to be active and active means being a member and paying membership fees and thats the first step from passivity to activity their flagship policy proposal is the creation of a social security for food the french csa movement seems to be passing an alliance with challengers in the field of food justice the third characteristic of safs relates to the rules of the game we witness a lack of recognition of the rules of the game by lowincome households committing on a permanent longterm contract with a csa appears challenging and somewhat risky for consumers who do not have a stable income the membership fee is a frequently mentioned reason why persons with a low income are excluded from csa as the longterm commitment of the membership exceeds their planning horizon moreover the mere requirement to become a member in order to be eligible for a share seems to be repelling many as it is interpreted as a sign of a closed community within the new saf of food justice the csa movement is encouraged to revise the agreed rules of the game and to revisit how csas are functioning in order to enhance the participation of lowincome households our results show interesting examples such as the bidding round system developed in german csas or the sliding scales where higher priced shares subsidize the lower priced shares in rock steady farm as well as the integration of csa in governmental food justice programs these actions are all transforming the structural functioning of csa shifting from food sovereignty to food justice implies revisiting some of the ways of doing csa in particular by involving other organizations getting public support involving food justice organizations in the recruitment of members or asking all members to selfassess their wealth in order to opt for the right income scale the fourth and last characteristic of safs is the overarching interpretive frame confronted with the limits of their social support actions csa coordinators and organizers have been embedding the csa movement into the broader saf of food justice this can be interpreted as a major change regarding the overarching interpretative frame indeed within the interpretative frame of food justice not only the support to producers is at stake but a more inclusive vision of the community in csa and the overall food system the table 3 summarizes our discussion it shows the difficulty identified by our respondents for lowincome households to recognize what is at stake in a csa to find their place as challengers among the incumbents and to align with the rules of the game can csas do better or at least different than food donations by moving to the field of food justice csas are activated as a learning environment the stories told are not only about doing the right thing but also about gaining experiences and skills the theory of safs underlines discriminatory elements as mcguirt et al demonstrate the sociodemographic context impacts the participation in csa programs this is also confirmed with research previously conducted among csa farmers a wellfunctioning csa requires members who are aware of the responsibilities that go along with membership this applies equally to people of all income levels our interviews emphasize the openness of csa members and producers to embark on a new strategic action field they want to learn what is at stake from actors already positioned in the field they are gaining literacy about food poverty a series of online webinars and training sessions were organized on the topic in the us in france as well as in germany they provide interesting examples csa group coordinators and csa network coordinators are willing to be trained in order to learn and to improve their understanding of what is at stake in another field this observation seems to be supporting previous descriptions of csa as a social knowledgesharing space or a selfmanaged research and grassroots innovation movement participating in the coconstruction of knowledge the second characteristic of safs considers the variety of actors with differentiated power our results demonstrate contention in the field of food sovereignty with on the one hand active csa members and on the other hand lowincome households some social support actions can come indeed across with a whiff of paternalism lowincome households consumption patterns are understood by respondents as selfdetermined which can be summed up as they get what they believe they need to get and they thus choose unhealthy diets although csa tries to educate them this seems to ignore the fact that lowincome households are tight on money and time even if they are interested in joining a csa they simply cannot afford to risk a meager or even empty share in contrast middleclass members can afford to get an empty share every once in a while and make up for it with additional food shopping thus it seems csa cannot really welcome lowincome households as empowered actors in the strategic action field of food sovereignty there is a need to move to a different field where the actors are different and include lowincome households as key protagonists as a response to this challenge is the recognition of the need to build equal partnerships with organizations who have a long experience in the field for example within the french csa networks accessibility working group the collective analysis underscores that food justice has been used by a constellation of local initiatives and even by state institutions however the current system is still failing to restore food precarious citizens dignity and agency research one way forward would be to study the reaction of beneficiaries instead of the csa coordinators how do they relate to the social support actions another more ambitious project would be to compare the social composition of a variety of csa groups those with social support actions and those without to see if those implementing social support actions are more diversified than others this would require designing objective criteria of diversification and gathering a large sample of initiatives both with and without social support actions conclusion our main research question asked how social support actions in csas operate in terms of social inclusion and what obstacles and challenges are associated with them we suggest distinguishing between charitable and emancipatory actions within the responses to the issue of access to csa developed by the groups we studied we categorize the mechanisms with differentiated contributions including sliding scales as emancipatory type of action since they closely involve all members and beneficiaries in the design of their contribution often based on a selfassessment of their wealth which includes many different parameters this is similar to equal partnerships with community leaders and organizations representing lowincome households in contrast food donations flexible payment plans trial subscriptions and stable prices are unilateral support actions that do not seem to contribute to restoring lowincome households agency voluntary work on the farm could be considered as emancipatory in some cases but we have no evidence that this social support action has been used for individuals who otherwise would not be able to be part of a csa the broader implications of our findings for practitioners are mostly articulated around the necessity of an increased recognition of the needs of lowincome households a thorough assessment of the potential participants demand that developing emancipatory support actions for food justice requires a capacity to orient oneself in a new field csa farmers and members willing to address the issue of access to healthy organic local food are learning by doing csa groups are answering a living lab do it yourself logic rather than basing their actions on wellcut methodologies as shown in the interviews the approach of csa groups is often spontaneous and might be lacking preparation csa members initially think they can easily open up to new populations by offering discounted or even free shares but they then realize that a process of acculturation of learning about the actors the issues and the common rules is necessary the use of the theory of safs sheds a new light on the csa movement it offers a promising avenue that could be used in future research up to 16 different propositions are presented to describe different dynamics across safs one of the propositions states that safs are generally destabilized by external shock originating from other safs invasion by other groups of organizations or largescale crises further research would be needed to be able to distinguish between the role of the covid19 crisis which was the initial context of the first typology of social support actions implemented by csa partnerships the role of food justice actors who started challenging the traditional definition of food sovereignty is worth further investigation to restore the position of smallholders in the food system a further limitation of this study is that we did not interview lowincome households involved in csas such interviews would be needed to complete the picture the perspective of lowincome households that have been involved in the past that are currently involved or that intend to become involved might draw up a more differentiated picture yet the advantage of our approach is that it illuminates settings from very different angles providing indepth and personal insights into the work and responsibilities within csas the field of access to csa is unstable and subject to major changes there is a lot of space for further food justice table 3 exploring a new field towards food justice and more emancipatory social support actions from a strategic action field perspective considering the 4 main characteristics of safs to social support actions and the consequences of embed should be conducted each member should be recognized as a partner of the farm in an equitable relationship research and action should thus emphasize the emancipatory aspect of csa which lies in a strong relationship between producers and consumers moreover in any move they make for social integration csa groups should not work in isolation they should rather build strong alliances and be part of political coalitions asking for systemic change ideally the initiative for social support actions should come from lowincome households themselves rather than being a process driven by the csa groups to try to attract lowincome consumers 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 orglicensesby40 philipp weckenbrock is a researcher at the professorship for organic agriculture at the justus liebig university giessen germany there and with the research organization die agronauten he has worked on agroecological production and sustainable food systems judith schryro holds a masters degree in nutritional sciences and home economics she has been working at the chair of food sociology at justus liebig university giessen university germany currently she works as a consultant for food and consumer education at the consumer rights agency in berlin

community supported agriculture csa seeks to address injustices in the food system by supporting smallscale farmers applying agroecological practices through a longterm partnership a community of members covers the cost of production and receives a share of the harvest throughout the season in return despite an orientation towards a more just and inclusive food system the existing literature points towards a rather homogeneous membership in csa a majority of csas tends to involve upper middleclass consumers with above average education and income levels low income is still a major obstacle in joining a csa membership diversification through social support actions is one possible way our main objective is to systematize and appraise social support actions of the csa movement taking the csa principles as a starting point our main research question is how do social support actions in csas operate in terms of social inclusion and what obstacles and challenges are associated with them the theory of strategic action fields assists in describing how the csa movement is positioning itself as an actor in and across neighboring strategic action fields the csa movement is clearly positioned in the food sovereignty field by shifting the focus from justice to farmers to justice for members the csa movement is now also exploring the food justice field indeed the csas contribution to the food justice movement is still largely uncharted in our results we identify both social support actions that are already implemented in the csa movement in different countries and the challenges that are associated with these actions we pinpoint a classification of social support actions implemented by csa organizers to increase access to their initiatives we make a distinction between the emancipatory actions that empower beneficiaries and contribute to a systemic change and punctual charitable interventions that neither affect the structure of a csa nor the food system

introduction according to dr apj abdul kalam azad youth below the age of 25 are the most powerful resources on the earth under the earth and above the earth we have to empower them through valuebased education and leadership agriculture along with its allied sectors is the largest source of livelihood in india particularly in rural areas it also contributes significantly to the countrys gdp sustainable agriculture which includes ensuring food security rural employment and environmentally friendly practices such as soil conservation and biodiversity protection is crucial for holistic rural development 12 india has witnessed revolutions in agriculture dairy poultry and fisheries indicating the importance of these sectors this section provides detailed information on agricultural products machinery research government policies schemes loans market prices animal husbandry fisheries horticulture sericulture and morealthough agriculture remains the primary occupation for over half of indias population the involvement of youth in this sector is declining 3 4 5 6 as the youngest nation in the world india has a massive youth resource that could contribute significantly to the agriculture sector however the sector is facing emerging challenges such as land fragmentation labor shortage depleting natural resources climate change low profitability market competition and nutrition and gender issues 7 8 9 to address these challenges the agriculture sector needs new ideas innovations rebranding and revitalization which can be provided by the energy and vitality of the youth however there is a decreasing trend in youth participation in agriculture 1014 given the current scenario and the changing dynamics of agriculture in india it is essential to leverage the potential of youth to bring prosperity to the sector and improve the lives of young people this raises the question of whether there is enough scope to involve youth in the agriculture sector and harness their innovative mindset energy and enthusiasm to uplift the sector it is observed that india has the relative advantage at present over other countries in terms of distribution of youth population indias advantage in young population is also evident when it is compared with other asian countries in comparison to china and indonesia the two major countries which determine the demographic features of asia india is seen to remain younger longer then the other two these three countries together accounted for 68 per cent of the population of asia in the year 2010 and the share of asia itself is about 60 per cent in world population the proportion of females in the youth age bracket is generally lower due to the fact that females tend to live longer than males this gender difference is more pronounced in developed regions but in india the gender differentials are less significant compared to other countries as the population ages and shifts to higher age groups the share of the 1534 age group decreases indicating increased longevity this widening gender difference reflects the aging population and the fact that females typically live longer resulting in a lower proportion of youth among females interestingly in india the similar share of youth among males and females suggests a healthy fertility rate and population growth education plays a crucial role in addressing development challenges in rural areas as it provides a direct link between food security and the education of rural children basic numeracy and literacy skills have been shown to improve farmers livelihoods access to knowledge and information is essential for rural youth to address the challenges they face in agriculture and to influence agricultural policies that affect them such as access to markets finances green jobs and land however in both developed and developing countries rural youth often lack access to even the most basic formal education especially in developing countries where educational institutions are underdeveloped formal primary and secondary education can equip young people with basic skills in numeracy literacy and business management as well as introduce them to agriculture nonformal education including vocational training and extension services and tertiary agricultural education can provide more specific knowledge related to agriculture unfortunately access to information and education is often worse in rural areas of developing countries compared to urban areas and this disparity is evident as early as primary school many rural children in developing countries face hunger and lack the energy to attend school or absorb information during peak agricultural seasons labor shortages may lead parents to prioritize their childrens involvement in household and agricultural activities over attending school additionally rural schools often have poor infrastructure and lack classroom materials while accessibility can be a challenge as schools are located far away from rural communities overall improving access to education and information is crucial particularly in rural areas of developing countries in order to empower rural youth address agricultural challenges and promote sustainable development social media offers a unique opportunity for farmers and ranchers to connect with a diverse audience and share their stories it allows them to build relationships share information and address any concerns or misconceptions about modern farming practices in india the agricultural sector is facing challenges such as a decline in the number of farmers and a growing need for food security encouraging young farmers to get involved and addressing the challenges they face can play a crucial role in ensuring a sustainable future for indian agriculture india is losing more than 2000 farmers every single day and since 1991 the overall number of farmers has dropped by 15 million 15 globally there is a growing interest in finding ways to engage youth in agriculture and social media can be a powerful tool in achieving this goal considering the above facts the present study was conducted with the objective  to study the training needs of rural youth  suggestions of rural youth to promote their participation in agricultural activities materials and methods the study was conducted in the year 20202021 in lucknow district of uttar pradesh of india selected exploratory research design was used for the study there are four tehsils in lucknow namely bakshi ka talab lucknow malihabad and mohanlalganj out of these four tehsils mohanlalganj block was selected for the study for present study 5 villages were selected namely atrauli daudnagar bhadesuwa hasanpur kaneri and barvaliya from each village 21 respondents were selected for the study and information were collected regarding their agricultural activities a total number of 105 respondents were selected through random sampling from eight sample village panchayats data was collected through personal interview with a semistructured schedule from farming and nonfarming youth the reliability and validity of the schedule was checked percentage cumulative frequency and rank were used for calculation and drawing the inferences results and discussion it is noticed from the table 1 that majority of rural youth need training in cashew and mango production followed by identification of pest and diseases and post harvest technology further they need training in vermicompostcompost making integrated nutrients management organic vegetable production and mixed farming while less than half of them need training in spices and medicinal plant intercropping mechanization in agriculture poultrydairy goat farming mushroom production and nursery management this indicates that rural youth are fascinated towards mango and cashew production the probable reason could be that as lucknow district is mango belt so if they get training in mango production they can earn more income also as cashewnut is plantation crop if they get proper training for cashewnut production and processing they can sell it at better rate and earn better income and can raise their standard of living conclusions study found that a significant issue among the farming youth is their lack of awareness about new technologies schemes and policies this lack of exposure to innovative production techniques indirectly affects the productivity of crops additionally the farming youth are generally uninformed about government policies aimed at attracting and retaining them in the agricultural sector and the benefits associated with these policies to address this issue awareness programs camps and demonstrations should be organized by kvks saus and ngos to make the farming youth aware of these initiatives furthermore many farming and nonfarming youth have limited education when it comes to handling smartphones therefore the government should promote adult education specifically through platforms established by kvks it is crucial to strengthen agricultural policies to retain the youths interest and involvement in farming competing interests

indias population is predominantly rural with approximately 689 residing in villages therefore rural india truly represents the essence of our country it is crucial to empower the rural youth by offering them opportunities for growth and wellbeing that align with their aspirations however the modern world demands skilled workers and industries are increasingly reliant on technological advancements particularly in information and communication technology ict this rapid pace of technological change necessitates individuals to possess diverse cognitive skills consequently it is imperative to address these challenges and equip indias rural youth with the appropriate education and skills they need to navigate the demanding global landscape while the government

introduction like other nations in the world china is experiencing a rapidly aging population and the population aged 65 and over has reached 1350 in the latest census 1 chinese women have a longer average life expectancy than chinese men hence elderly 2 of 14 women are significantly more likely to be widowed than elderly men 23 in 2010 chinas sixth census revealed that of the 4774 million elderly widows 3345 million were female such characteristics of femaledominant elderly widows are also reflected in reports from other countries 45 it is estimated that the number of elderly widows in china will reach 9449 million by 2050 2 studies revealed that widowhood in older women is associated with poorer mental health and reduced coping resources compared with those living with their partners 6 7 8 older female widows living alone in rural and remote areas even face more stressors and fewer coping resources in their daily lives compared with their counterparts in urban areas 9 10 11 however studies on the prevalence of and factors associated with their psychological wellbeing for this most vulnerable population are scarce this study addresses the gaps in the research it is wellresearched that elderly widows experience numerous changes including cognitive decline 12 sleep problems 13 and decreased life satisfaction 14 while those changes gradually declined in the majority of elderly widows some of them developed persistent and negative psychological symptoms such as loneliness depression and anxiety that can lead to increased morbidity and mortality rates among older widows 15 16 17 18 main factors affecting society to achieve the who and the un healthy aging and quality of life for older people 1920 loneliness is defined as a psychological condition resulting from the discrepancy between an individuals existing and desired social relationships 21 the prevalence of loneliness among elderly widows in china is 407 22 studies show that nearly 70 of elderly widows find loneliness is the most difficult aspect of daily life to deal with 23 anxiety is defined as apprehensive anticipation of future danger or misfortune accompanied by feelings of unease or physical symptoms of tension 24 depression is often characterized by persistent sadness and a lack of interest or pleasure in previously valuable or enjoyable activities 25 the prevalence of depression is about 1045 in elderly widows worldwide 81026 the social production function theory developed by lindenberg explains the likelihood of negative psychological symptoms in elderly widows living alone from a sociological perspective 2728 lindenberg believes that people are goaloriented and seek to produce psychological or emotional wellbeing 29 a persons psychological wellbeing is determined by physical and social wellbeing the achievement of physical and social wellbeing depends on the achievement of instrumental goals such as comfort to produce physical wellbeing and affection to produce social wellbeing a lack of resources can prevent people from generating wellbeing and induce depressive symptoms being married and living with a spouse is a great resource for generating all the instrumental goals that contribute to wellbeing on the contrary widowhood and living alone are associated with a lack of resources and affection to engage in meaningful physical and social activities thus contributing to poor wellbeing and negative psychological symptoms in this population studies identified that long periods of widowhood declining income or managing multiple chronic illnesses in elderly widows were associated with these negative psychological symptoms 3031 however the mental health of elderly widows attracted less attention in china as evidenced by a relatively small number of studies 10 32 33 34 such a situation also indicates that many elderly widows remain undiagnosed and untreated in china remaining in this situation could increase the burden on chinas healthcare system and hinder the goal of achieving equitable access to healthcare in china the huge disparities in economic development between urban and rural areas cause a large proportion of chinas young and middleaged rural labor force to migrate to urban areas for employment opportunities while most rural elderly widows live alone 35 such internal migration is more prevalent in remote areas where employment opportunities are even less compared with rural areas 3637 chinese remote elderly female widows living alone may experience multiple risk factors of poor health and wellbeing that are widely reported in the literature including older age 3839 female gender 83140 living arrangements 41 and rural and remote region 1042 however few empirical studies have carefully investigated the prevalence of and factors associated with negative psychological symptoms among them therefore a crosssectional study was conducted in remote regions of southeastern china to determine the prevalence and risk factors of negative psychological symptoms including loneliness depression and anxiety materials and methods ethics this study has been reviewed and approved by the ethics committee of xiangya school of nursing central south university participants finished the questionnaires anonymously the questionnaires were then coded uniformly by the investigators participants who scored above the cutoff value on the selfrating scales of loneliness depression and anxiety were offered psychological counseling by investigators within 48 hours investigators assisted with referrals to medically designated institutions or mental health professional institutions for those whose negative psychological symptoms did not improve after psychological counseling study design a crosssectional study was conducted to investigate the loneliness depression and anxiety of remote elderly widows living alone in china this study was conducted from december 2018 to march 2019 study setting this study was conducted in longshan county hunan province china longshan county is located on the northwestern edge of hunan province and is one of the most remote counties in hunan the per capita gross domestic product of longshan county in 2021 is still below chinas per capita gdp and the per capita disposable income is also below the countrys average 4344 longshan county has a relatively diverse population with ethnic minorities accounting for 81 of the countrys total population 45 the proportion of people aged 60 and over in longshan county is similar to the national level in addition the sex ratio of 10466 for the population of longshan county is also very close to that of the country 4647 predicting a similar proportion of remote elderly widows living alone as in china given the same social status and traditions of remote elderly widows living alone in china the survey conducted in longshan county should be representative participants and recruitment based on the list of elderly women registered with the village committee and combined with recommendations from the committee and villagers the investigators invited elderly widows to participate in the study if they met the inclusion and exclusion criteria the inclusion criteria were as follows female ≥60 years old not remarried after widowhood living alone due to widowhood and not accompanied by children or other partners having clear awareness and communication skills and voluntary participation in the study individuals who met one of the following criteria were excluded having a severe psychiatric illness severe acute or noncommunicable disease or having undergone major surgery within the last year in this study the required sample size was calculated using the logistic regression formula from the textbook n 2 p 1 b 2 α 005 48 p 1 is the rate of positivity when x is taken as the mean value and b is the estimated value of the regression coefficient corresponding to x p 1 and b were identified from the pilot study of participants a sample size of 230 was required taking into account a 15 missed visit rate trained investigators explained the purpose and process of the study to remote elderly widows living alone by telephone they were informed that they were at liberty to decide whether to participate in the study without any consequences appointments were made for potential participants who had agreed to participate in the study for an inhome survey after participants completed the informed consent form investigators instructed them to complete the questionnaires the contents of the questionnaires were verified in time after completion to eliminate invalid questionnaires 25 measures 251 socialdemographic and widowhoodrelated information socialdemographic data including age race education occupation acute and chronic medical conditions and the number of children were collected through a selfdesigned questionnaire widowhoodrelated information including the duration of widowhood age at death of the spouse marital happiness living alone period cause of death of the spouse length of the marriage being the primary caregiver of the spouse before widowhood and anticipation of the death of the spouse was also collected the university of california at los angeles loneliness scale the uls8 was used to evaluate the loneliness of the participants 49 the scale consists of eight items and uses a fourpoint likert scale 1 never 2 rarely 3 sometimes and 4 always the total score of the uls8 ranged from 8 to 32 the higher scores the higher levels of loneliness the chinese version of the uls8 demonstrated good reliability and validity the cronbachs α coefficient is 0741 exploratory factor analysis showed that the cumulative variance contribution was 5539 when extracting one common factor from the chinese version of the uls8 scale which was consistent with the theoretical conception of the original scale 50 the cutoff value for uls8 in this study used the 24 points determined in previous studies 5152 shortform geriatric depression scale the gds15 was used to assess participants depressive symptoms during the last week it includes 15 items the response options of yes or no are adopted items 1 5 7 11 and 13 were negatively worded and scored in reverse in a certain order higher scores indicate more severe depressive symptoms 53 the chinese version of the gds15 has good reliability with a cronbachs alpha coefficient of 0793 the activity of daily living scale assessed significant differences in gds15 scores among elderly people with different selfcare abilities demonstrating the gds15 scales good discriminant validity the cutoff value for the chinese version of the gds15 was 5 54 generalized anxiety disorder scale participants anxiety in the past two weeks was measured by the gad7 it consists of seven items whose scores range from 0 not at all to 3 nearly every day a higher total score represents the more serious anxiety symptoms 55 the cutoff value of the chinese version of the gad7 scale score was 9 the cronbachs α coefficient of the scale was 0898 the criterion validity of the chinese scale was high with a sensitivity of 862 a specificity of 955 and a kappa value of 0825 56 data analyses epidata 31 was used for data entry the data were analyzed by spss 260 all measurement data were assessed for normal distribution using the kolmogorovsmirnov test the composition ratio mean and standard deviation are used for statistical description a chisquare test and correlation analysis were used in univariate analysis to test for differences in loneliness depression and anxiety symptoms across sociodemographic factors and widowhoodrelated factors binary logistic regression was used to predict factors contributing to the three negative psychological symptoms the significance level was set as p 005 results sociodemographic characteristics of remote elderly widows living alone a total of 271 remote elderly widows living alone were enrolled in the present study additionally 234 valid questionnaires were returned the mean age of the participants was 7329 ± 737 the majority of participants had acute or chronic medical conditions the vast majority of participants had been married for more than ten years participants who had been widowed for more than three years amounted to 787 almost eighty percent of widows were satisfied with their marriage approximately 603 of the participants were their spouses primary caregivers before they were widowed prevalence of loneliness depression and anxiety the prevalence of loneliness was 81 the mean uls8 score for the lonely participants was 2468 ± 100 almost half of widows had depression symptoms participants mean score of gds15 was greater than the cutoff value the mean gad7 score was relatively low and the proportion of widows with anxiety was 167 comorbidity between loneliness depression and anxiety loneliness and depression are comorbid in 60 of the participants anxiety and loneliness have a 38 comorbidity additionally 150 of participants experienced anxiety and depression there are 38 of participants with all three of these negative psychological symptoms was 167 comorbidity between loneliness depression and anxiety loneliness and depression are comorbid in 60 of the participants anxie loneliness have a 38 comorbidity additionally 150 of participants experience iety and depression there are 38 of participants with all three of these negativ chological symptoms associated factors with loneliness depression and anxiety univariate analyses were conducted to test the differences in sociodemograph widowhoodrelated factors in loneliness depression and anxiety symptoms ac chronic medical conditions marital happiness being the primary caregiver befor owhood and anticipating the death of the spouse were associated with negative p logical symptoms associated factors with loneliness depression and anxiety univariate analyses were conducted to test the differences in sociodemographic and widowhoodrelated factors in loneliness depression and anxiety symptoms acute or chronic medical conditions marital happiness being the primary caregiver before widowhood and anticipating the death of the spouse were associated with negative psychological symptoms loneliness depression and anxiety symptoms were each examined as the dependent variable in a binary logistic regression analysis the univariate analysiss significant variables served as the independent variables marital happiness was found to be the protective factor against loneliness being the primary caregiver of the spouse before widowhood was a risk factor for loneliness marital happiness was also the protective factor for depression and anxiety acute or chronic medical conditions are a risk factor for depression discussion remote elderly widows living alone in china are a vulnerable population however there are few comprehensive assessments of this populations loneliness depression and anxiety prevalence in this study the prevalence rates for these negative psychological symptoms were 81 440 and 167 respectively furthermore comorbidities of these symptoms are frequently present the high prevalence of loneliness depression and anxiety among remote elderly widows living alone suggests that this population has substantial mental health care needs based on previous research elderly widows living alone face numerous challenges and are prone to negative psychological symptoms 841 remote elderly widows living alone lack a supportive environment and adequate resources that can help maintain their physical and mental capacities 57 58 59 the prevalent negative psychological symptoms lead to a decrease in the quality of life of elderly widows and an increase in the risk of hospitalization which is detrimental to global healthy aging 19 in chinas traditional familyoriented culture the elderly place a high value on the daily companionship of their spouse 60 as a result elderly widows in china experience greater symptoms of loneliness than widows in other countries 61 besides in remote areas the willingness of elderly widows to remarry is weak due to the constraints of childrens opposition public opinion and traditional attitudes 6263 few elderly widows had remarried which may also contribute to the high prevalence of loneliness among remote elderly widows living alone local government officials should positively encourage remarriage by shaping public opinion to activate the spouses role in providing moral support additionally other support systems should be bolstered to improve spiritual companionship the government should encourage children to provide financial support or care to elderly widows and foster a harmonious and supportive neighborhood as a result of providing care for their partners older women are more prone to suffering from poor mental health 30 after the death of their spouse they have far less daily contact and communication with their intimate partner which increases their risk for mental health issues 6465 the caregiver role in this study predisposed the experience of loneliness contrary to the results of earlier research 29 our finding indicates that the relationship between the prewidowhood caregiver role and negative psychological symptoms is inconclusive and requires further research the participants pervasive depression and anxiety may result from living alone having no one to discuss their negative feelings about widowhood and the lack of recreational facilities and activities in remote areas 66 additionally remote elderly widows always neglect their mental health and lack the knowledge to utilize the social security system to improve their physical and psychological health 67 village councils need to strengthen social support for this vulnerable group by engaging them in selfcare activities for instance regular seminars on mental health selfassessment of mental health and seeking health from health professionals for negative psychological symptoms secondly healthcare workers in remote rural areas should receive relevant training to enhance their ability to identify and treat negative psychological symptoms in elderly widows they also need to frequently visit elderly widows at risk of developing negative psychological symptoms for instance living alone and having acute or chronic diseases and encourage them to actively seek help from family members and close friends participants who have more acute or chronic medical conditions are suspectable to depression therefore primary care health professionals need to monitor the mental health conditions of this group take preventive measures and provide timely interventions to this group of elderly windows regarding medical care regular free medical checkups for remote elderly widows living alone should be added to public health service programs to reduce the risk of negative psychological symptoms in this population the types of illnesses covered by medical insurance for elderly widows living alone should also be expanded by covering mental health problems we found that marital happiness was a protector for elderly widows from developing negative psychological symptoms in this study the finding is similar to previous studies which identified that marriage could provide the elderly with emotional satisfaction and physical health benefits 296869 nonetheless widowhood dissolves the marriage and deprives the spiritual support of the spouse resulting in negative psychological symptoms 70 71 72 one possible factor contributing to our finding might be that the vast majority had been widowed over 3 years therefore they might have adapted to a new life without their partners we suggest that future studies need to add a qualitative study component to enhance an understanding of the influence of marital happiness on the adaptation to widowhood in the elderly research evidence strongly suggests that negative psychological symptoms were due to the difficulty of adapting to the change in widowhood after being married for a relatively extended period 307374 village councils should assist elderly widows in maintaining contact with friends or family members and meeting their spiritual and material needs moreover early interventions should be developed to aid them in adjusting to widowhood sooner groupbased complicated grief therapy and mindfulness techniques 7576 as well as individual writingbased emotional expression therapy 7778 are effective in adapting to widowhood these evidencebased interventions should be considered as strategies to prevent remote elderly widows who live alone from developing mental health problems szczepanskagieracha and colleagues identified that older womens sense of responsibility for their health through goalfocused group psychotherapy subsequently improved their depression symptoms 79 their studies provided new sight into the treatment of negative psychological symptoms in elderly widows living alone the goalfocused group psychotherapy aims to establish group relationships among older women in similar situations and encourages them to discharge their negative feelings the therapists then help to model older womens right attitudes and motivate them to become more independent in their lives this kind of psychotherapy can significantly reduce depressive symptoms in elderly women and improve their sense of wellbeing moreover szczepanskagieracha and colleagues also identified that the virtual therapy garden provided for older women helped them better recognize and use relevant mental health resources 80 this kind of virtual therapy includes stories and interactions in the virtual therapy garden by which older women realized that there is much they can do to improve their mental health and take responsibility for their future virtual therapy demonstrates a significant reduction in anxiety and depression these evidencebased interventions should be considered as strategies to improve the mental health problems of remote elderly widows who live alone to our knowledge this is the first study to examine depression anxiety and loneliness in remote elderly widows living alone most previous studies focused on elderly widows and explored only a portion of the three negative psychological symptoms 84181 besides participants in this study were well represented longshan county is a typical remote area with backward economic development 82 and the age and gender structure of remote elderly widows living alone are extremely similar to national levels some limitations need to be acknowledged in the current study our research is a crosssectional study thus causal inferences about the correlation cannot be made a longitudinal study should be considered in the future second participants selfrated loneliness depression and anxiety may have been somewhat influenced by recall bias finally the results of this study may only be generalized to areas with similar economies and cultures based on the poor mental health status of this population and the great health care needs there is a request for future research on a wider population conclusions our research revealed that remote elderly widows living alone in china frequently experience loneliness depression and anxiety marital happiness was the protective factor against three negative psychological symptoms elderly widows who have been the primary caregiver for their spouses and suffering from acute or chronic illness are more likely to feel lonely or depressed there is an immediate need for individualized psychosocial intervention programs and related services to relieve these symptoms and improve their life outcomes contributing to the achievement of universal healthcare equality in china data availability statement data for this study are available from the corresponding authors upon reasonable request

1 background research indicates that most elderly widows are at a high risk of experiencing negative psychological symptoms it is common for elderly women in rural and remote areas to live alone without family support to cope with stress due to the mass ruraltourban migration of chinas youth labor force such a situation further worsens their psychological health and wellbeing however the prevalence of and risk factors associated with negative psychological symptoms loneliness depression and anxiety among remote elderly widows living alone in china are currently unclear 2 methods a crosssectional study was conducted in hunan province china the loneliness was assessed through the university of california at los angeles loneliness scale uls8 the depression and anxiety were assessed with the short form geriatric depression scale gds15 and generalized anxiety disorder scale gad7 respectively the chisquare test and correlation analysis were conducted to identify factors associated with negative psychological symptoms logistic regression was performed to predict risk and protective factors contributing to loneliness depression and anxiety symptoms the significance level was set as p 005 3 results a total of 271 remote elderly widows living alone were enrolled in the present study additionally 234 valid questionnaires were returned valid response rate 863 the prevalence of loneliness depression and anxiety was 81 440 and 167 respectively acute or chronic medical conditions marital happiness being the primary caregiver before widowhood and anticipating the death of the spouse differed significantly in the distribution of negative psychological symptoms logistic regression analysis predicted that participants who were satisfied with their marriage had a lower likelihood to experience loneliness depression and anxiety p 005 being the spouses primary caregiver before widowhood was more likely to have symptoms of loneliness p 001 those with various acute or chronic medical conditions were more likely to suffer from depression p 001 4 conclusions remote elderly widows living alone in china are prone to loneliness depression and anxiety symptoms being the primary caregiver before widowhood and having many acute or chronic medical conditions are risk factors for loneliness and depression respectively marital happiness is the protective factor against negative psychological symptoms to accomplish the goal of equitable access to mental health care in china evidencebased policy and resource development to support psychosocial interventions that prevent and manage negative psychological symptoms for remote elderly widows living alone are urgently needed

introduction in china the degree of aging is much higher in rural areas than in urban areas according to the seventh national population census the proportion of older adult people over 60 years of age was 2381 in rural areas while only 1772 in urban areas 1 china has a tradition of filial piety for thousands of years family oldage care has long been dominant in the urban and rural oldage care systems especially in rural societies where the social oldage care system is not well developed and childrens support plays an important role in family oldage care dependence on family for old age is a chinese tradition childrens support plays an important role in the mental health of older people but current research has come to different conclusions one view is that childrens support is beneficial to the older adult in maintaining their mental health scholars have found that childrens financial support can increase the social participation of the older adult and that emotional interactions and caregiving can reduce the negative emotions of the older adult thus enabling them to maintain their mental health in addition childrens support can increase the level of subjective wellbeing of the older adult and enhance their spontaneity willpower and integrity another viewpoint suggests that intergenerational supportive behaviors of children may have a negative impact on the mental health of older adults excessive support from children fails to maintain respect for older people and violates their personal privacy daily caregiving by children may reduce the ability of older adults to live autonomously ultimately decreasing their life satisfaction and increasing their depression furthermore older persons receive financial support from their children which may violate their traditional role as breadwinner and perceive themselves as a burden to their children leading to an increased sense of powerlessness and psychological burden on older persons since the reform and opening up of china a large number of young and middleaged rural workers have moved to the cities to work and do business and the incomplete nature of largescale urbanrural migration has prevented rural family members especially parents from moving with their adult children increasing the physical distance between generations the separation of parents and childrens living space makes the traditional style of family eldercare no longer realistic destroying traditional chinese family structures and endowment arrangements making the older adult more prone to depression and jeopardizing their physical health due to lack of care in rural china the migration of children has made the burden of agricultural labor on the older adult heavy widening the gap between the financial capital of the older adult and that of their children and damaging the selfesteem of the older adult on the other hand childrens migration also has favorable effects on parents migration allows older people to spend more time with friends and to participate actively in social activities adult children are able to provide other forms of support to their parents for example the economic and knowledge transfers of migrant children can expand household budgets promote risk management strategies and increase access to health care migrating children significantly increase the willingness of parents left behind to participate in mutual support for the older adult and promote the development of new models of oldage care throughout the existing literature it can be seen that established studies generally recognize the role of childrens support on the mental health of the older adult but related studies have not reached a consensus conclusion on the impact of childrens support on the mental health of the older adult and the mass migration of children has evolved rapidly in response to social change which has caused an impact on the function of family care for thousands of years in china and it is especially true in rural areas and the impact of childrens support on the mental health of rural older adults in this context there is a paucity of relevant research so this paper intends to use the data from the 2014 china longitudinal aging social survey to analyze the impact of childrens support on the mental health of rural older adults with different migration status of children methods data sources this paper uses data from the 2014 china longitudinal aging social survey the survey targets chinese citizens aged 60 or older and covers 28 provinces in mainland china the questionnaires were collected through household interviews and a total of 11511 resident questionnaires were completed the individual questionnaires for the older adult specifically collect information on the marital status health status retirement planning economic status family and children of the older adult aged 60 or older this study mainly uses the information of older adult personal data in class 2014 firstly screening the older adult population living in rural areas and then screening the data according to the level of depression in the older adult loneliness childrens support and other important research content of this paper and finally get the effective sample data of 4085 in order to study the impact of intergenerational support on the psychological health of rural older adults in the context of childrens migration we defined migrant children as children whose residence are not in the same township as that of his or her older adult parents and categorized older adults into two main groups based on their status of having or not having migrant children namely have not migrant children and have migrant children with sample data of 1047 and 3038 respectively variable setting 221 dependent variable mental health the dependent variable studied in this paper is the mental health of older adults which consists of two main dimensions depression level and loneliness the cesd is a common tool widely used around the world to screen for depressive symptoms in the general population and has good reliability and validity nine questions from the cesd were included in the class questionnaire by which depression levels were measured the responses were assigned a value and the scores of each question were summed up with higher scores representing a more severe tendency to depression in older adults russell developed the third edition of the ucla loneliness scale in 1996 and it was found that the ucla3 had good internal consistency testretest reliability and discriminant validity the class questionnaire includes three ucla3 subquestions which were used to measure loneliness in this study scored in the same way as the depression scale and the scores for each question were summed with higher scores representing higher levels of loneliness in older adults according to the test the cronbachs alpha of the depression scale and loneliness scale were 0917 and 0918 respectively with good reliability independent variables childrens support childrens support is usually analyzed from the perspective of social support which can be divided into economic support labor force support and emotional support economic support is the monetary support given to the older adult by their children labor force support is the life care of the older adult by their children and emotional support is the emotional comfort of the older adult by their children therefore this paper categorizes childrens support into three dimensions financial support life support and emotional support in the class database ask for information on up to five children of older persons the older adult received intergenerational support from multiple children but the questionnaire does not cover the depressive level and loneliness of the older adult when receiving support from a specific child these two variables represent the overall psychological wellbeing of the older adult and this paper examines older adults holistic perceptions of intergenerational support from their children if samples are paired with the older adult and a specific child it would result in different childrens support all pointing to the same mental health status of older adults which is inconsistent with existing research findings and departing from the integrity of older peoples cognition so in this paper childrens support is summed to measure the intensity of support for the older adult financial support was examined and valued using the questionnaire question in the past 12 months has a child given you any money food or gifts and what was the total value of these items life support was measured and valued by the question how often in the past 12 months has a child been able to help you with household chores and the emotional support was measured and valued by the question do you feel that this child does not care enough about you the questionnaire asked up to five children about their support for the older adult and the support of each child was summed to get the scores for the intensity of the childrens financial support life support and emotional support respectively control variables based on research needs the control variables in this paper cover the main sociodemographic characteristics variables of the older adult including age gender and marital status the socioeconomic status variables including education level and incomegenerating jobs and the health status of the older adult including selfassessed health status chronic diseases and the basic activity of daily living the following table shows the scores of all variables research methods the study selected the crosssectional data of class database in 2014 and through the variance inflation factor test the vif values are all less than 5 which means that there is no serious multicollinearity relationship among the variables and the regression analysis can be performed by multiple linear regression model in this study the empirical analysis was conducted through a linear regression model with multiple independent variables with depression level and loneliness in old age as dependent variables and childrens financial life and emotional support as independent variables in the regression analysis the multiple linear regression model was used to analyze the linear correlation between the dependent and independent variables and the model is as follows 0 1 1 2 2 n n y x x x β β β … β ε in the above equation y is the dependent variable x 1 x 2 x n are the independent variables ε is the random error term β 0 is the regression intercept β 1 β 2 β n are the regression coefficients this study first analyzes the differences in mental health between the full sample and the subsample of rural older adults with and without childrens migration in terms of depression level and loneliness using descriptive statistics to preliminarily determine the impact of child relocation on the mental health status of rural older adults then through the full sample multiple linear regression analysis of the mental health of rural older adult to explore the impact of childrens support on the psychological status of rural older adult and finally through the subsample multiple linear regression analysis to further explore whether there is a difference in the impact of childrens support on the mental health status of rural older adult with or without childrens migration this paper uses stata160 software for regression analysis results descriptive statistics in terms of depression level and loneliness the scores of the older adult without childrens migration are higher than those of the older adult with childrens migration in terms of childrens support the childrens financial support of the older persons without childrens regression analysis specifically from the regression results of the full sample of rural older adult childrens financial support has a significant negative effect on the level of depression and loneliness of the older adult population with a greater effect on the level of depression for every unit increase in childrens financial support the level of depression and loneliness of the older adult population decreases by 0106 units and 0038 units respectively namely the higher the number of childrens financial support received by the older adult the better the mental health of the older adult in terms of childrens life support childrens life support has a significant negative effect on loneliness in the older adult population for every unit increase in childrens life support the loneliness of the older adult population were reduced by 0017 units namely the higher the intensity of childrens life support received by the older adult the more the loneliness of the older adult was weakened and childrens emotional support had a negative effect on both depression levels and loneliness in older adults but it is not statistically significant in terms of control variables male rural older adults have better mental health rural older adults with higher education levels have better mental health older adults with better selfassessed health and no chronic diseases have better mental health and basic activity ability has a nonsignificant effect on the mental health of older adults subsample regression analysis of childrens migration as the level of social support and medical insurance for older people in rural china is relatively poor compared with that in urban areas children are often the main providers of support for their old age and largescale urbanrural migration has resulted in an increase in the separation of adult children from their older adult parents which may disrupt this oldage care arrangement and affect the psychological wellbeing of older people in rural areas therefore this paper constructs a grouped comparative linear regression model of the impact of childrens support on the mental health status of the older adult population to study in depth the factors related to the mental health status of the older adult population with migrant children regarding the effect of childrens support on the mental health of rural older adults the regression results showed that for older adults with children who migrated financial support had a significant negative effect on the depression level of older adults while for older adults without migrated children financial support did not have a significant effect on the depression level of rural older adults and the effect on loneliness was also no more significant than for older adults with migrated children life support has a significant negative effect on loneliness only for the rural older adult with children migrated emotional support from children has no significant effect on the depression level and loneliness of the older adult with or without childrens migration which is consistent with the regression results of the full sample discussion according to the results of the above empirical analysis the higher the level of financial support provided by children the more favorable it is for the older adult to maintain their mental health because rural china has long been characterized by a family care model for old age with low levels of social security and support the financial support of children has a greater impact on the quality of life of the older adult in addition the rural older adult have a stronger sense of raising children to provide against old age and increased emphasis on children giving back to their families thus the more financial support they receive from their children the more the older peoples sense of selfesteem and fulfillment is fulfilled which reduces their negative emotions and makes it easier for them to keep their moods happy the result that is in line with the previous study the effect of childrens financial support on mental health was not as significant in the older adult without childrens migration as in the older adult with childrens migration which may be since rural older adult without childrens migration receive lower levels of material support from their children resulting in a weaker contribution of financial support to the health of the older adult the higher the level of life support from children the higher the level of mental health of older persons older adult peoples physical fitness and selfcare ability gradually decline due to physiological reasons and they urgently need the help of their children and their childrens care is more capable of satisfying their life needs compared to outsiders thus the higher the level of psychological health of the older adult and previous studies have also arrived at similar results but in analyzing the heterogeneity of older adults according to the presence or absence of child migration it was found that receiving life support from children effectively reduced the loneliness of older adults with migrated children while it did not have a significant effect on the mental health of older adults without childrens migration on the one hand it may be because the level of childrens life support is higher for the older people without childrens migration and childrens life care for the older people to some extent reduces the strength of the financial support provided by the children which makes its effect on the mental health of the older people not obvious on the other hand in terms of emotional reasons it may be because older people with childrens migration receive life support from their children which means that the children may return home to visit their parents and the meeting with their children makes the rural older people feel happy and thus the life care has a more significant impact on the mental health of the older people the effect of childrens emotional support on the mental health of the older adult is not significant this may be since older people living in rural areas have a restricted social circle and have a stronger need for emotional support from their children but the sense of loss caused by the discrepancy between subjective needs and objective support may substantially reduce the role of emotional support in lowering the level of depression and diminishing the sense of loneliness based on the results of the above analysis it can also be seen that older peoples own characteristics have a greater impact on their levels of depression and loneliness than the impact of childrens support on their mental health and that individual characteristics explain most of the variation in older peoples negative emotions the strength of this study lies in the large size of chinas rural population and the representativeness of research on the mental health of older adults the limitations of this study mainly lie in the following firstly this paper only uses the simple method of multiple regression analysis to analyze the correlation between childrens support and mental health of rural older adult and future research will try to use other methods to do a more comprehensive analysis secondly although control variables were added where possible there may still be omitted variables and future research should test for potential confounders or mediators conclusion based on data from the 2014 class this study used multiple linear regression to investigate the impact of intergenerational support from children on the mental health of older adults in rural china and analyzed the heterogeneity for older adults with different childrens migration status and the following findings were derived from the empirical analysis the higher the level of financial support provided by children the more favorable it is for rural older adults to maintain their mental health which is more pronounced among the older adults with childrens migration the higher the level of childrens life support the higher the mental health of rural older adult but there is no significant effect of childrens life support on the mental health of the older adult without childrens migration individual characteristics of older people have a greater impact on their mental health the mental health of the rural older adult is higher among those who are male have good marital status high education level and better physical health according to the results of the above research this paper draws the following results firstly to better play the role of rural family care rural grassroots governments should actively publicize the culture of filial piety forming a good atmosphere of love and respect for the older adult and encouraging their children to provide support to meet the needs of the older adult secondly the rural social security system should be improved the level of rural oldage insurance should be raised appropriately the level of medical services in rural areas should be raised and village collectives should be used as the basis for introducing modes of onsite service and collective oldage care to satisfy the personalized needs for older adult care of the rural older adult and to promote the sustainable development of both collective and family oldage care thirdly social forces should actively utilize their advantages in resource allocation and combination to provide the rural older adult with cultural and recreational activities legal counseling mental health counseling and other forms of services tailored to different needs to ensure that the older adult have a sense of worthiness and enjoyment and to continually improve the level of mental health of the older adult in rural areas data availability statement publicly available datasets were analyzed in this study this data can be found at index hlen publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at

background family oldage care is dominant in chinese rural society and childrens support is an important force in family oldage care however the migration of a large number of young and middleaged rural laborers has undermined the traditional arrangements for oldage care in rural areas and affected the psychological health of the older adult methods 2014 china longitudinal aging social survey targets chinese citizens aged 60 or older and covers 28 provinces in mainland china in this paper the database of the class was selected for empirical analysis to explore the impact of childrens support on the depression level and loneliness of rural older adults through multiple linear regression and was divided into two groups according to childrens migration to analyze heterogeneity results childrens financial support facilitates the maintenance of mental health among rural older adults childrens support promotes mental health among rural older adults but this association does not exist among older adults without childrens migration individual characteristics of older people have a greater impact on mental health discussion our study firstly compares the differences of childrens migration status between childrens support and mental health among the older adult in rural china in order to improve the mental health of the older adult it is necessary to create a favorable atmosphere of love and respect for the older adult improve the social security system in rural areas and give full play to the strengths of the social forces so as to ensure that the older adult have a sense of worthiness and enjoyment in their old age

introduction caring for elderly relatives represents a serious issue facing caregiving family members in an aging society although caregiving has also a positive aspect for the family members the burden of informal care underscores the need for new methods of enacting sustainable longterm care further in addition to the burden of care experienced by family caregivers due to the care receivers disease such as impaired eyesight pressure ulcer and underlying disease the relationship between care receivers and caregivers has also been shown to play a crucial role in the caregiving process informal care dynamics are complex in the social context of a family family dynamics the interactions between family members and the varied relationships that exist within a family involved in longterm care have been suggested to be influential on the care of frail elderly people however these parameters remain difficult to measure therefore we previously developed a validated scale to describe the relationship between primary caregivers and care receivers before caregiving japan is the worlds fastest aging society with onequarter of the entire population aged over 65 years in 2013 and a particularly high proportion aged over 75 years rapid shifts in demographics have created a situation in which many elderly people receive longterm care from family members who themselves are elderly termed eldertoelder care the nursingcare insurance system was publicly established in 2000 to support this situation in this scheme the municipality review board assesses the physical and cognitive function of older people to determine their eligibility and the degree of care required on an individual basis which by definition defines the extent to which they can avail themselves of formal care services including but not limited to home support care personal care nursing care and respite care although this system has reduced the burden on family members to some degree informal family caregiving is still expected partly because the number of formal care services provided by the nursingcare insurance system is not generally sufficient to cover all the care needs of frail elderly people living at home and partly due to the deepseated desire among many older people to receive care from their family members instead of professionals this rising demand for longterm care in an aging society and the limitations of resources within the field of longterm care have underscored the global importance of the increased burden on family members in caring for their elderly relatives with their holistic perspective on the situation primary care physicians play an important role in designing sustainable longterm care systems given the increasingly important role of family members in caring for elderly relatives in an aging society future longterm care systems should account for the relationships between family members and their charges here to clarify the influence of family dynamics between primary caregivers and their frail elderly family members on the burden of care experienced by the primary caregiver we measured these dynamics using our validated scale of iflong score and examined its association with burden of care adjusting for the characteristics of care receivers and caregivers methods study design we conducted a multicenter crosssectional study at six primary care clinics between july and september 2011 data used in the study were obtained from multiple sources as follows primary caregivers answered selfadministered questionnaires about the nature of caregiving and their burden of care the care receivers primary care physician assessed the family dynamics and the receivers functional and cognitive status and the care receivers care managers provided information on the utilization of formal care services participants and setting we sequentially selected caregivers who mainly cared for their frail elderly family members receiving outpatient or home treatment due to chronic disease at any of six primary care clinics we excluded caregivers who cared for family members being treated as inpatients or living in a nursing home frail elderly in this study was defined as either individuals who were approved to be eligible for nursingcare insurance by the municipality review board or other older people aged ≥65 years who either needed some mobility assistance at outpatient clinics or had been diagnosed with cognitive impairment by at least two physicians main exposure family dynamics our main exposure was family dynamics as measured by iflong this scale was initially developed for use by clinicians generally primarycare physicians with a longstanding relationship with the care receiver and caregiver as it assesses problems or undesirable situations that might be alleviated via intervention through a family system such as family consultations or family meetings the iflong comprises four items inquiring about the existence of certain situations between the primary caregivers and care receivers as follows disengagement scapegoating transfer of problems across generations and undesirable behaviour patterns response options for these four items ranged from 0 to 3 with iflong scores calculated as sums of response values to the four items higher iflong scores indicated poorer relationships between care receivers and their caregiving relatives we tested the reliability and validity of the iflong scale in a previous study care receivers in the present study were divided into three categories based on iflong score tertile main outcome burden of care for caregivers our main outcome was burden of care for caregivers which was evaluated using the burden index of caregivers the bic comprises 11 items covering five subdomains and one domain of total care burden bic scores were calculated as the sum of the response values to the 11 items the bic was assessed via a selfadministered questionnaire for the caregivers other factors information on the characteristics of the caregivers and caregiving was obtained from the caregivers via questionnaire care receivers degree of cognitive impairment was evaluated using functional assessment staging and activity of daily living was assessed via mini functional independent measure by the primary care physicians care managers who create the care plan for care receivers and their family provided further information about usage of formal care services data management and ethical issues we obtained written informed consent from the care receivers and their family members because we used an anonymous questionnaire we printed unique identification numbers on the questionnaire paper and then used the number to link data obtained separately from caregivers primary care physicians and care managers researchers in charge of statistical analysis were blinded to care receivers clinical data this study was approved by the institutional review board of kyoto university statistical analysis we described caregivers characteristics and care receivers minifim and fast scores based on the three iflong score categories we then calculated the mean bic score for each iflong score category and trend tests were performed to examine the dosedependent association between iflong score and bic score we constructed a linear regression model to estimate adjusted mean difference of bic score between categories of iflong score the reference category of iflong score was the best iflong group we included caregiver age and gender duration of care time required for care and care receivers minifim score and fast score in the model to examine the association between categories of iflong score and bic score after adjusting for potential confounders in our initial sensitivity analysis we defined two categories of iflong score and estimated probability of being in the bad iflong group we then used the inverse probability of treatment weighting method to adjust for potential confounders in a subsequent sensitivity analysis we used the multiple imputation method using chained equations to impute missing values of duration of care and time required for care all analyses were performed using stata software with twosided significance set at 005 results characteristics of caregivers and care receivers we asked 249 caregivers to answer the questionnaire and received 199 answers tables 1 and2 show characteristics of caregivers and care receivers overall and by categories of iflong score respectively among all caregivers mean age was 632 years with 40 of caregivers aged over 65 years and 19 of caregivers aged over 75 years a total of 79 of caregivers were female and 64 required regular visits to the hospital themselves mean duration of caring for a family member was 52 years and mean time required for care was 323 hours per week a total of 43 of caregivers cared for their family for more than 3 hours a day time required for care was greater in the worst iflong group than in the best iflong group in terms of care receivers characteristics mean minifim score was 339 and 201 of care receivers had severe cognitive impairment iflong score varied between 0 and 10 points with a mean of 24 the mean scores of the four items of the iflong showed that the worstbest iflong group indicated the worstbest in all of the items burden of care by categories of family dynamics sensitivity analyses we redefined two categories of iflong score and examined the association between group assignment and bic score using iptw to adjust for potential confounders more appropriately associations between iflong score and bic score in this instance were found to be similar to original results and the mean difference between the two groups was 270 in our second sensitivity analysis using the multiple imputation method associations between iflong score and bic score remained similar to original results after imputing missing data mean differences were 152 and 436 in the intermediate and worst iflong groups compared to the best iflong group respectively discussion in summary we found that family dynamics strongly influence burden experienced by primary caregivers regardless of the carereceivers degree of cognitive impairment severe issues straining the family dynamics were found to exacerbate the burden of care we also detected a dosedependent association between iflong score and bic taken together these findings suggest that the relationship between care receivers and their primary caregivers in place before caregiving should be carefully considered when deciding on a care plan for care receivers in the present study we found that caregiving family members tended to be elderly themselves with 40 of caregivers aged over 65 years notably the mean age of caregivers was similar to national figures for japan indicating that our findings were not unique to our study or contaminated by outliers in addition approximately twothirds of caregivers themselves visited the hospital regularly to receive treatment for chronic diseases given this situation in which elderly individuals care for other elderly individuals the burden of care is clearly a key factor for consideration when developing a sustainable care system in an aging society implications for practice and education measuring family dynamics using the iflong score may help primary care physicians identify issues involving these dynamics when developing longterm care plans thereby allowing physicians to support family members through education and family conferences involving all immediate family relevant extended family significant friends and members of the patients support network developing sustainable longterm care in an aging society will require greater emphasis on familyoriented care in which physicians describe the framework of the family and analyse what is happening to the family with respect to their roles in caring for other family members themselves physicians should also evaluate the relationship between family members with respect to the family life cycle and identify potential relationship problems among members through such familyoriented care physicians can determine family dynamics and design specific interventions including target family members and specialized approaches to communication of note the adjusted mean difference of bic between the worst iflong group and best iflong group was similar to that between the normal cognitive group and severe cognitive impairment group as defined by fast score previous studies have shown the impact of fast on care receivers adverse events of mortality and unplanned hospitalization these results may therefore suggest that family dynamics are as influential as severity of care receivers cognitive impairment on family members burden with longterm care strengths and limitations our study had several major strengths first we used our validated iflong score to quantitatively evaluate family dynamics an important but difficulttomeasure concept in familyoriented care second we conducted this study at primary care clinics in japana rapidly aging society this setting ensures that our results can be easily extrapolated to other developed countries with similar aging societies third we obtained consistent results even after using iptw to adjust for confounding however several limitations to the present study also warrant mention first given the crosssectional nature of our study we cant eliminate the possibility of reverse causality specifically a poor family relationship may not be the cause of heavy burden of care but instead the result indeed we observed that the time required for care was longer for caregivers in the worst iflong group than among those in the best group however the iflong questionnaire asks physicians who can determine a familial relationship based on information obtained from the care receiver and their caregiving family during outpatient care to describe the relationship before caregiving second we lacked precise data on what kind of care was given to care receivers although we adjusted for the measured covariate of time required for care marked differences in the contents of care between the worst and best iflong group may confound the association between iflong score and bic however we believe that adjusting for care receivers characteristics may reduce the effect of residual confounding in addition results remained consistent even after adjusting for those confounding factors using iptw given the above limitations interpretation and generalizing our results should be done with care conclusion we found that family dynamics strongly influences the burden experienced by caregiving family members regardless of the carereceivers degree of cognitive impairment these results may underscore the importance of evaluating family dynamics between care receivers and their family when discussing burden of care conflict of interest none

background longterm care for the elderly is largely shouldered by their family representing a serious burden in a hyperaging society however although family dynamics are known to play an important role in such care the influence of caring for the elderly on burden among caregiving family members is poorly understood objective to examine the influence of family dynamics on burden experienced by family caregivers methods we conducted a crosssectional study at six primary care clinics involving 199 caregivers of adult care receivers who need longterm care participants were divided into three groups based on tertile of index of family dynamics for longterm care iflong score where higher scores imply poorer relationships between care receivers and caregiving family best 2 intermediate 2 to 5 worst ≥5 the mean differences in burden index of caregivers bic11 between the three groups were estimated by linear regression model with adjustment for care receivers activity of daily living and cognitive function results mean age of caregivers was 632 years with 407 aged ≥ 65 years bic11 scores were higher in the worst iflong group adjusted mean difference 44 95 confidence interval 12 to 75 than in the best iflong group we also detected a positive trend between iflong score and bic11 score pvalue for trend 001 our findings indicate that family dynamics strongly influences burden experienced by caregiving family members regardless of the care receivers degree of cognitive impairment these results underscore the importance of evaluating relationships between care receivers and their caregivers when discussing a care regimen for care receivers

research has established that housing is a health issue and that the worse the housing situation the worse the impact on health those experiencing homelessness particularly chronic homelessness for instance experience high rates of physical health issues chronic diseases substance abuse and mental health challenges furthermore health issues cause as well as are exacerbated by homelessness 1 housing that is poor quality or in disrepair increases the incidence of injuries asthma cancer cardiovascular disease and other health issues living in unhealthy housing also worsens mental health in part due to the stress of living in unsafe and unhealthy environments conversely affordable housing reduces negative health outcomes because a lower proportion of income is dedicated to housing and greater proportion is available for food and health care 2 accessing healthy living conditions is an economic issue for those most likely to be living in poor housing conditions that negatively impact health to improve health and housing conditions for extremely lowand lowincome families requires addressing both the availability and the access to healthy housing according to the housing alliance delaware report 3 delaware is short more than 21000 additional affordable housing units to meet the needs of extremely lowincome families second affordable housing must be affordable low income and extremely lowincome delawareans need to work more than two minimum wage jobs to afford a fair market rent apartment even if this was reasonable the path to attaining affordable and quality housing is interrupted by the benefits cliff the benefits cliff in simple terms is the point on the economic mobility path where those dependent on governmental benefits and entitlements increase income but not enough to cover the additional expenses associated with the loss of benefits the benefits cliff emerged as an unanticipated consequence of implementing the personal responsibility and work opportunity reconciliation act of 1996 commonly referred to as welfare to work the welfare reform legislation aimed to reduce dependency on government assistance and to increase selfdoi 1032481djph202306010 sufficiency initial studies on the impact of prwora showed significant increases in employment among welfare recipients however the employment was unstable and temporary 4 studies looking at the impact of individual benefit programs on work show that food stamps 5 and housing 6 have negative effects on incentives to transition from welfare to work on the other hand several studies show that although childcare assistance appears to have the most positive impact it also has the largest cliff effects 4 an extensive study in colorado shows how families dependent on government benefits strategize to avoid the benefits cliff and identify the most reasonable and least risky path toward selfsufficiency 7 prenovost and youngblood documented the stress created trying to navigate the benefits cliff 8 significant attention has been given to identifying the point where work pays off referred to as the effective marginal tax rate 49 the emtr is the percentage of any additional earned income that a household pays in taxes or loses in government benefits as dolan notes the emtr creates a poverty trap where the risks and gains of working become disincentives and barriers to selfsufficiency and economic mobility 9 emtr analyses have produced various models of economic mobility out of welfare to selfsufficiency including modeling combining various types of benefits 49 typically however emtr modeling fails to take into account factors associated with the readiness for work as hauan and douglas point out most welfare recipients face at least one barrier and many encounter multiple barriers preventing readiness for stable and sustainable work 10 they identified the most common barriers in order of most frequently identified as not having earned a high school diploma or ged unmet childcare needs mental health issues transportation issues limited work experience unstable housing and physical health problems this research suggests that navigating the benefits cliff requires welfare recipients meet a set of criteria considered necessary for stable and sustainable work a status necessary to access healthy housing assisting residents dependent on government assistance become eligible and prepared to cross the benefits cliff to become economically selfsufficient and eligible for housing that does not negatively affect health has become a critical issue in comprehensive revitalization efforts clearly building new healthy housing is not enough extremely lowand lowincome families need significant assistance becoming economically eligible for the housing reach riversides experience demonstrates the interconnected relationship among poverty health and housing the reach riverside development corporation was formed in 2017 to remove the barriers to prosperity and wellbeing facing residents of wilmingtons riverside neighborhood a community experiencing the devastating impacts of decades of racial discrimination and disinvestment reach is the managing partner of the wrk group a group of three nonprofits working together to implement the purpose built communities model a holistic approach focused on housing education and health initiatives reach is leading a comprehensive revitalization of the riverside community in ne wilmington which includes creating 700 units of mixedincome housing along with education and health oriented initiatives phase one of imani village was completed in december 2022 construction of phase two was finished in may 2023 bringing another 67 units on stream five hundred fifty two more rental units are planned in phases three through seven along with about 100 homes for ownership in support of this transformation in the built environment reach works closely with service partners kingswood community center and the warehouse to provide social service programs for all doi 1032481djph202306010 ages this has included creating a cradletocollegecareer pipeline between kingswoods early learning academy eastside charter school and the warehouse as well as providing onsite medical services to the community through a partnership with christianacare as with all the wrk group efforts the new housing plan prioritizes current residents living in wilmington housing authority housing in assessing eligibility for the new housing approximately 40 of the wha families were not eligible primarily as the result of past due rent and utility bills reach worked with kingswood community center to enroll residents in kingswoods empower program empower assists residents of riverside and surrounding neighborhoods obtain economic selfsufficiency at intake empower clients with assistance from their navigational coach complete a comprehensive assessment a 2023 analysis of intake assessment data showed that over half of the empower clients income situation employment situation andor food situation were assessed as in crisis or vulnerable the credit situation for one third of the clients was in crisis or vulnerable and one fourth were living in housing that was assessed as in crisis or vulnerable the large majority of empower clients are wha residents and for them in crisis or vulnerable housing situations indicates that they are at risk of eviction the intake assessment data underscores the multiple programming needs of extremely lowand lowincome families one of the biggest barriers faced by empower staff and clients in developing plans to achieve economic selfsufficiency to meet the interrelated and multiple needs is the benefits cliff empower clients like many extremely lowand lowincome families cannot simply work more or obtain better paying jobs to become economically independent because they risk losing benefits most significantly those related to childcare and healthcare this barrier to economic stability and selfsufficiency also creates barriers to accessing the new healthy housing designed specifically for riverside residents the empower staff and the reach leadership are actively exploring options for bridges across the benefits cliff but these bridges are in part dependent on policy changes programmatic developments without complimentary and supportive policy changes will be ineffective and possibly infeasible policies to avoid the benefits cliff or mediate its negative effect on the transition to selfsufficiency are limited and vary greatly by state the national conference of state legislatures 11 and the federal reserve 12 produced reports defining and describing the benefits cliff the alliance for strong families and communities categorizes policy efforts into four categories 1 policies modeling or adapting the earnedincome tax credit 2 policies ensuring continued access to benefits 3 policies eliminating some assets such as cars and savings accounts in deciding benefits levels and 4 policies excluding portions of income in benefits calculations 13 the ncsl report provides an overview of state level efforts addressing the benefits cliff the report notes that 16 states enacted legislation to mitigate the impact of the benefits cliff delaware was not one of those states and to date has not proposed benefits cliff mitigation legislation the most comprehensive initiative undertaken by five new england states piloted both policy and program level changes to mitigate the negative effects of the benefits cliff 14 most state level efforts continue to address welfare policies individually when the reality is recipients must navigate the benefits cliff considering all sources of assistance dolan 9 and richardson and blizard 4 suggest that the current benefits system rather than policies is structured in a way that discourages participants from becoming fully selfsufficient prohibiting economic mobility dolan highlights the need to create individualized approaches because there doi 1032481djph202306010 is a matrix of benefits income sources and personal factors that must be considered for a family to traverse the benefits cliff 9 richardson and blizard are bolder in their recommendations suggesting terminating all social programs as an option 4 other options included creating a longer glide path universal basic income and private sector creation of nontaxable fringe benefits such as childcare assistance addressing the housing crisis in delaware as well as improving health and economic stability demands that we address the benefits cliff looming on the horizon for extremely lowand lowincome families struggling toward selfsufficiency effective policies and interventions at a minimum need to be informed by the experiences of those struggling to navigate the benefits cliff and achieve economic mobility in other words policies need to data driven and effective policies and interventions must be integrated siloed policy development will not effectively address the benefits cliff preventing economic selfsufficiency and access to affordable healthy housing there is not a single pathway from dependence on government assistance to selfsufficiency similarly there is not a linear continuum of housing options paralleling a linear continuum of economic mobility multiple entrance ramps with varying lengths across the benefits cliff need to be created in collaboration with housing social services healthcare educational workforce government and private sector partners given our size and promising comprehensive revitalization efforts delaware has an opportunity to model integrated policy changes that bridge the benefits cliff and support extremely lowand lowincome delawareans on their journey toward economic selfsufficiency health and affordable quality housing dr dillard may be contacted at

this commentary introduces the reality of the benefits cliff into the housing and health relationship improving both housing and health requires addressing the benefits cliff facing extremely lowand lowincome people those living below the poverty line are at greatest risk of poor inadequate and unhealthy living conditions they are also the group most at risk for losing benefits and economic supports on their journey toward economic selfsufficiency addressing the housing crisis in delaware demands that we recognize the benefits cliff looming on the horizon for extremely lowand lowincome families struggling toward selfsufficiency effective policies and interventions at a minimum need to be informed by the experiences of those struggling to navigate the benefits cliff and achieve economic mobility and need to be integrated across housing economic benefits and health care

introduction branded as the black swan event the covid19 pandemic has inflicted substantial harm not only on the healthcare sector but also on the broader economy within the global economy encompassing primary secondary and tertiary sectors the pandemics disruptive impact has been felt to varying degrees each contingent on the markets demand and supply dynamics among these the tourism industry falling within the tertiary sector stands out as one of the hardest hit due to the ongoing crisis consequently the turmoil in the tourism industry has cascaded to affect a multitude of stakeholders with social media travel influencers prominently among those bearing the brunt this research article aims to address two primary research questions what were the consequences of the pandemic on indian instagram travel influencers and what strategies did instagram travel influencers in india employ to navigate the global crisis the significance of this research is multifaceted despite the tourism industry being severely impacted by the pandemic there exists a dearth of literature that specifically addresses the issues faced by its stakeholders particularly influencers in its light this study serves as a platform to raise awareness among both the public and government about the numerous challenges faced by the indian travel influencers during the global crisis the study also illuminates innovative strategies employed by travel influencers offering valuable insights for other influencers and individuals considering a similar career path but who may be hesitant due to pandemicrelated uncertainties in the future the article is divided into x sections the first section illuminates the impact of the global crisis on the tourism industry including the travel influencers it walks the readers through peter burns stakeholder map and the stakeholder theory by freeman the second section explicates the methodology including the construction of the social survey followed by data collection and analysis procedures in the third section the ramifications of the pandemic on the travel influencers are discussed followed by the distinct coping strategies used the fourth section suggests a way forward focusing on some innovative coping strategies as adapted from the existing literature followed by the final section underscoring the directions for future research impact of covid19 on tourism industry in the backdrop of covid19 which further divided the already polarised world and accentuated the various social inequalities the workfromhome regime coupled with the social distancing norms became the new normal with over 59 million infected cases globally by the end of november 2020 of which nearly 91 million cases belong to the secondlargest pool of coronavirus india the present impediment appeared to have an unknown expiry date this was when the pandemic was at its peak and numerous industries faced a setback including the tourism industry the tourism industry which accounted for 103 of the global gross domestic product and 66 gdp in south asia in 2019 was amongst the hardesthit ones in 2020 the world travel and tourism council extrapolated a loss of nearly 50 million jobs in the tourism industry all attributed to covid19 with asia being the largest sufferer also the united nations predicted a 6080 loss in international tourism due to the turmoil the blow faced by indian tourism on account of covid19 cloud is in sync with the global trend as is evident through the systemic risk survey which mentioned it to be one of the five adversely hit sectors with over 90 of the respondents estimating its stagnant recovery in the next six months national tourism which generated 81 of the total employment and contributed 92 of indias gdp in 2018 the third among the other 185 countries was forecasted to incur a monetary loss of 75 in the financial year 202021 in their business these statistics throw light on the profound impact of covid19 on the tourism industry the deep wounds on indias tourism tend to perpetuate the pain to its stakeholders who can easily be identified through peter burnss stakeholder map as given in figure 1 travel influencers a stakeholder in the tourism industry from figure 1 we find that the travel influencers occupy a place of primary stakeholders in the tourism industry both in the form of developers and tourism business owners and managers their experiences and reviews are believed to be trusted more by the people in comparison to other online reviews moreover r edward freeman through his stakeholder theory has explained that the only way for a declining business to revive is by managers and entrepreneurs accepting and promoting the interconnections and interdependence between various stakeholders instead of letting them thrive in an isolated ecosystem the study emphasises on the application of this theory in the tourism industry as well who are travel influencers influencers are themselves the consumers but with the fervent following who hold the tendency to shape the opinion of their followers as they have greater expertise knowledge or experience about the product we have observed a paradigm shift from traditional influencers being just celebrities to the recent trend of influencers on social media in todays era of the techsavvy world social media influencers have become an ingrained part of the social fabric of any society with the finnish government calling social media influencers as critical actors to help flatten the curve during the pandemic alongside doctors bus drivers and grocery store workers they play a pivotal role in providing digital information to its followers in realtime before any other form of media or where government communication is not accessible according to influencers perform a rainbow of activities like promotion of digital economy dissemination of information and maintaining public relations a subset of influencers is the travel influencers on social media whose niche lies in promoting the tourism industry through their content which may take the form of social media posts blogs or vlogs these digitalfirst personalities are a major player in todays information ecosystem they usually post their live travel stories and pictures on instagram facebook youtube etc and are not hesitant to show their backstage behaviour a term coined by erving goffman which in turn creates an imprint of legitimacy in their followers a study by lalangan reveals that it is not just the influencers who shape the content but the content also in turn motivates travel influencers to earn a living through their hobby of travelling in addition to having an impact on the audience these social media celebrities may further collaborate with a few brands or companies and promote them in accordance to their experiences with it their importance to tourism can be drawn from considering the example of indonesian government allocating us 52 million to influencers to boost and safeguard tourism from the web of covid19 operational definitions for the purpose of the present study travel influencers and coping strategies are defined as following 1 travel influencers here travel influencers refers to those indian influencers who promote travelling on instagram through content creation in the form of posts blogs vlogs or youtube videos it includes the scope of both who have taken this as a profession as well as as a hobby further it covers tourism business managers and owners who promote their travel businesses through instagram conclusively it refers to all the respondents who had responded to the social survey coping strategies in the present study coping strategies include all the behavioural and psychological efforts put by the travel influencers to minimise the impact of covid19 on them it was measured through the selfdeveloped google form methodology social survey a type of descriptive survey study was conducted to obtain data from the respondents the theoretical framework finds its place through the works of peter burn and r edward freeman the population for the present study included all the instagram travel influencers in india the sample was selected by employing the two types of nonprobability sampling techniques ie snowball and purposive sampling it included the 55 instagram travel influencers in india who had responded to the google form on instagram and email the google form sent to the respondents was in the form of a questionnaire including a total of 14 items it included both open and closedended questions the responses to the openended questions were tabulated and organised in various categories using tally marks which were further converted into frequencies and percentages similarly the responses to closedended questions were also converted into percentages suitable diagrammatic and graphical representations were used to further analyse and draw conclusions from the information the review conducted was used to support the various claims further i added all the 55 respondents to my instagram account and followed their posts for more than three weeks to get a clear picture hence a mixedmethod research was employed ie qualquan the 55 respondents were from different states of india and had a varied following as shown in figure 2 figure 2 reveals that nearly 87 of respondents in the present study had less than ten thousand followers the profile of most of the respondents was public while the majority of the respondents shared only travel content a few respondents shared content other than their travel saga also as shown in figure 3 655 of respondents had their blogsvlogs as well though only 218 of respondents were making money through being an influencer here it becomes important to mention a trend that was observed wherein 9167 of respondents who were earning through being an influencer had their blogsvlogs further only 109 of respondents had made this their profession while the remaining 8909 of respondents took it as a hobby interestingly the study revealed that the number of followers did not have much effect on social media travel influencing to be taken as a profession in contrast to the expected belief it was also observed through the posts of the selected travel influencers that while some respondents were amateur others were professional they were monetising not just through their blogsvlogswebsites but also through collaborations promotion of brands and products paid campaigns freelancing assignments giveaways and travel businesses 6909 of respondents incurred a financial loss due to the pandemic as speculated my intensive following of the respondents on instagram confirmed that it was mainly due to the cancellation of their travel bookings and freelance assignments also 6667 of respondents from the ones who took it professionally were the ones to face the economic blow the change in the followers frequency during the pandemic is given in figure 4 surprisingly nearly 36 of respondents witnessed an increase in their followers in contrast to 6 of the respondents who lost them as seen in figure 4 it indicates that maximum respondents were able to find out ways to engage their audience according to travelburpwithsurya one of the respondents creating content has become very difficult in this pandemic but somehow we are managing it the various coping strategies used by the respondents to get through the pandemic are given in figure 5 research findings analysis and interpretation 1 participant demographics ramifications of covid19 on the respondents coping strategies the coping strategies given in figure 5 coping strategies a responsible tourism 60 of the respondents were still travelling despite the pandemic moreover 8333 of the respondents who had taken travel influencing as their profession were the ones to continue their travel while mannusambyal said that he was following all the standard operating procedures mussafirhunyaro and visualsofmylife said that they were carrying the safety gears and covid essentials while travelling it somehow helped in the adaptation of social distancing norms by their followers as well thereby making it a new trend moreover it was work from the home regime which enabled a few of the respondents like visualsofmylife and akhilesh1125 to travel more b increasing content consumption the respondents were posting the content as shown in figure 6 to keep the audience involved figure 6 shows that majority of the respondents were sharing travel throwbacks while nearly 36 of the respondents did share their present travelling content as well nearly 9 of the respondents changed their content from travelling to something else in order to stay buoyant further 127 and 181 of the respondents were posting advisory content and covid related information respectively with over 12 of the respondents sharing content related to lifestyle and a few others sharing diverse content like motivational quotes reposts photography own pictures and old unpublished travel stuff respondents were doing all they could to increase the content consumption among the followers it becomes vital to mention that 36 of the respondents were not updating anything at all c going local nearly 27 of the respondents started bringing into limelight the local travelling places with dhritikapur rightly saying that it was time to support local travel businesses while karavanlife started exploring new places which are not crowded akhilesh1125 was able to explore the overrated places during covid19 in a much better way d saving money 36 of the respondents saw covid19 as an opportunity to save money for future travels dhritikapur said that she was coping through the pandemic by booking in advance to capture good deals for future travel e positive outlook since every person has a unique defence mechanism coping strategies for some were to stay in the competition and balance out the monetary losses but for the others were to safeguard their mental health 1090 of the respondents looked at the pandemic optimistically and saw it as an opportunity to wind up their pending works while rajeshwarsjamwal saw this time perfect for spending it with his family and pets gobanjare said that for him covid meant taking time off theiffyexplorer did her pending room renovation and meghanagoesplaces got herself indulged in reading about travel followers sustainable options and why it is important to travel slow f stayathome covid19 had drowned 3272 of the respondents in the limbo of an apparent endless pause all of whom reiterated and advised their followers to stay safe at their home hopelessness amidst the respondents was reflected with indiantravellers saying that nothing much was left to do now for travel influencers according to traveldiariesnabanitaroy travel will not be possible in the near future and will have to wait for a long time so like most of us influencers like breathedreamtravelrepeat were also coping up by building immunity praying and hoping g getting future ready 727 of the respondents took out this time to get ready for the future for this a few respondents like misix mywanderinglist and bagsonwheels utilised this time to prepare the bucket list of the places they would like to go postcovid also davidangami said that his travel company was taking this time for advertising places for people to come and visit once travel starts in parallel to this his company was also setting and polishing the travel packages to be covid sop compliant h learning digital skills for 1454 of the respondents coping up through the pandemic was facilitated by learning the essential digital skills while creatingdestinations learnt the various editing skills to help them with their future content jammu360 emphasised on learning those digital skills which would help them monetise their travelling career further hkmurali worked on refining and polishing both his profile and collaborations i promoting engagement one of the respondents trekabreak had found a unique way of coping through the pandemic by working on their social relations with their existing followers and thereby promoting engagement on their instagram page j unpublished content travelure one of the respondents said that i have a plethora of unpublished content so i can go on with or without pandemic and keep bringing out stories to my audience this could be a great insight for somebody who loves travelling and has already travelled a lot but is sceptical about turning into a travel influencer presently given the covid19 situation k webinars indiatrail a travel company had found an innovative way of managing stress during the pandemic by giving and attending webinars and other social online meetups way forward in the postcovid time the travel industry needs a good kickstart however i argue that social media travel influencers can not save themselves or the tourism industry in isolation the need of the hour is a nexus of the various stakeholders in tourism given by peter burns to work collaboratively and cooperatively trends such as increasing ict readiness and destination brand management through a multistakeholder approach can go a long way in reviving tourism from the aftermath of the pandemic thus it would have a high probability of reviving the almost collapsed travel industry in congruence with the stakeholder theory by r edward freeman building on the existing works i suggest the following coping strategies for the travel influencers 1 increasing awareness taking examples from the finnish and the uks government india can also mobilise various social media influencers to not only spread awareness but keep a check on fake news travel influencers can help to a great extent in reiterating the social distancing norms and other safety protocols to be followed while travelling during the pandemic in the long run they can prove to be a vital agent to curb environmental pollution created by travellers thus a collaboration with the government will help the influencers in coping up not just economically but also by becoming mainstreamed in the tourism industry 2 promoting local tourism going a step ahead of travelling locally and taking the idea from mariellen ward influencers can consider launching a digital marketing company or a startup to promote local tourism professionally it can pave a way to preserve the local culture and environment as well along with increased tourism and effective dissemination and knowledge about the local practices to the tourists government funding the indonesian government has already set the benchmark by funding the travel influencers to boost its tourism i suggest a similar type of arrangement for indian travel influencers as well 4 virtual tourism the social media travel influencers may cope up through the cascading impact of the pandemic by being the digital vehicles to promote virtual tourism a perfect example to explain this is the experience mecca app created by a travel company bsocial which provides a virtual tour to all the hajj pilgrimages further companies like andbeyond singita and lewa wildlife have found a temporary fix to rescue kneeling tourism by providing virtual safaris it can provide a great insight to social media travel influencers to work on some innovative ways to thrive and flourish despite pandemic 5 learning from others in conjunction with the stakeholder theory it is suggested that even the travel influencers must learn from each other and mustsee this uncertain time as an opportunity to do so as an example thenomadcouple one of the travel influencers has been reading other travel blogs for pleasure and inspiration during the pandemic to further reinforce the idea of collaboration between the various stakeholders it is suggested to organise frequent webinars it can not only offer a platform to discuss their common problems and ponder over its solutions but also a commonplace to help mitigate their mental health problems 6 weighing the pros and cons finally it is suggested that the travel influencers can utilise this time for spiritual growth and personal journey introspection and selfappraisal along with revaluating choices of the brands they are associated with could be a good way to cope up presently thereby making them futureready further they may work on building new business tieups and collaborations suggestions for future research the present study has some limitations that could pave the way for future research written as follows first the scope of the present study is limited to travel influencers only further studies could be initiated covering influencers from other fields as well along with the various stakeholders of the tourism industry second only the travel influencers from instagram were included in the present study further studies may cover travel influencers from other social networking sites like facebook twitter etc third the study can be improved by communicating directly with the respondents through a blended interview depending on feasibility the present study is limited to collecting responses from travel influencers through a google form in addition to this the some unexpected trends were noticed while analysing the data these include the study did not observe any association between the number of followers and motivation in the travel influencers to take it as their profession and despite the majority of respondents having taken travel influencing as their hobby they did not opt it as their career it calls for future research to unlock if any correlation exists between the number of followers and career choice for a travel influencer further the factors that motivate a travel influencer to take it his profession apart from just hobby may also be looked into intensively

in the wake of the covid19 pandemic the global business landscape has experienced unparalleled disruptions particularly impacting the tourism industry this article delves into the repercussions of the pandemic on indian instagram travel influencers and its subsequent effects on the tourism sector grounded in a social survey encompassing 55 indian instagram travel influencers this study sheds light on the challenges they confronted and the strategies they employed to navigate the crisis the scholarly work by r edward freeman 2009 and peter burns 2013 provides a theoretical framework for understanding the responses of instagram influencers the studys findings reveal that a substantial majority of the respondents faced financial losses due to the pandemic in response these influencers diversified their approaches engaging in responsible and local travel adapting their content to enhance audience engagement acquiring digital skills to prepare for the future and hosting webinars among other measures in conclusion this research presents innovative coping strategies tailored not only to indian instagram travel influencers but also applicable to influencers worldwide who faced similar challenges

introduction the new respiratory disease covid19 is highly contagious disease the rate of its spread is much higher than the previous biological pandemics in order to prevent its outspread ruling authorities across the world have announced mandatory home quarantine as a preventive measure to minimize its spread a temporary shutdown has been imposed nationally in different ways ie closing down of academic institutions ban in public meetings restrictions in social gatherings and social distancing on contrary to the basic instinct of human kind people were obliged to stay physically disconnected while following these preventive measures reports indicate the use of digital apps in connecting people worldwide and providing knowledge to be healthy being in home quarantine and isolation can take a toll on both the mental and physical health various negative feelings such as anxiety depression have been noticed among people during the lockdown period due to the pandemic along with this numerous literatures have emphasized on the psychological effects experienced by individuals during previous pandemic eruptions like ebola merscov sars and h1n1 besides studies have statistically provided evidence of older patients comorbidity of ebola with anxiety depression and posttraumatic stress disorder to be 249 472 and 21 respectively notably even the caregivers of these patients had been diagnosed with depression and anxiety in fact about 45 of them opted for psychological counseling albeit at a later date on the brighter side few studies reported that acts of social wellness such as community support positive interactions with patients and empathy have led to positive psychological wellbeing of patients in such crisis studies like this have illustrated the role of social connectedness to ease psychological impacts during covid19 due to imposed restrictions modern technology could be the only way to maintain social relations thus this study tries to examine the role of social connectedness in social cure social connectedness the feeling of connectedness is the basic need of human beings during this pandemic it has been reinstated since the time people were advised to follow social distancing norms even within the family recent researchers have argued to change the terminology of social distancing to physical distancing which would effectively reflect the actual meaning of the preventive measures to reduce the feeling of social disconnection nevertheless the foremost drawback through the norm of social distancing that has been observed is that people at large began to develop an apathy to social wellness behavior whereby they began to discriminate covid19 patients their family members and at times even the caregiverscare providers ie doctors medical personnel police officers among others however if we were to question ourselves on what is the phenomenon of social wellnesses in order to understand the same one needs to understand the experiences of patients and the attribution of the term social connectedness rossi et al defined it as a persons subjective awareness of being in close relationship with the social world notably this attribution of self reflects cognitions associated with an individuals ongoing interpersonal closeness with the social world therefore social wellness may refer to the way a person develops social health while expanding connection with others in the dwellingsociety it alludes to a person interacting in a positive way while creating and maintaining healthy relationships which in essence serve a meaningful purpose in life thus both social health and social wellness become an essential dimension for emotional psychological as well as physical health research in the past have shown the positive correlation of social connectedness with emotional resilience conflict management life satisfaction and selfesteem richards stated that despite an increase in income the participants of his study were found to be happier when their social connections grew positively which effectively meant that people did value social connections more as opposed to income on the contrary chronically lonely people showed negative health outcomes including the aspect of addiction be it to drugs alcohol and others importantly people with low social connections proved to be more toxic than obesity hypertension and high blood pressure interestingly it was found that people who maintain healthy social connections could actually produce more antibodies through their immune systems which eventually help them to fight diseases and provide longevity to the body studies have also highlighted the role of mirror neurons that help in producing empathy sympathy compassion and a feeling of belongingness within or others often by inducing pain in selves andor others this goes on to prove that the aspect of empathy does make a person take proper moral or humane decisions eventually increasing the feeling of belongingness while triggering an intent to help others psychological researchers have explained this phenomenon as reinforcement and vicarious learning furthermore people having good social connections were found to have better eating and exercise habits which could be the result of reinforcing healthy habits by friends social connectedness and digital technology the smallworld problem hypothesis showed social connections to be so dense that every person on this planet could be connected to just a few intermediaries the experiment six degrees of separation conducted by stanley milgram found that to help a person in receiving a letter from one end of the world to the other there would be in a need of only six hands exchange in other words on an average only the involvement from six people could create nodes in establishing connections researchers have also shown that the smallworld network model could be used to explain social networks computer networks neural networks and wireless networks sohns smallworld network model highlighted the difference in the number of people that could be connected indirectly through social network and a wireless network connection although social connectedness and belongingness has been identified as the third key need postulated by maslow in his hierarchy of needs extensive research has shown and even reiterated the importance of connectedness to maintain a good physical as well as mental health bronfenbrenner also discussed the interpersonal interactions of human at different levels that include micro meso exo and macro systems with modern technology interactions between these spheres have become more compatible the different palette of communication tools such as email text messaging whatsapp facebook etc have all provided a platform to interact across the globe albeit in a virtual mode a few researchers divide social connectedness into two prominent divisions one to one connectedness and large basis of connectedness both one to one and large basis connectedness do help individuals to connect with family friends and the world at large since the outbreak social media has been overembellished with its persisting and exclusive coverage on the pandemic for instance the news18s strange news of two women doctors being threatened and abused and asked to leave the grocery shop and empty their flat on an immediate basis by their neighbors had gone viral in social media on contrary india tv on 23rd april 2020 reported certain pleasant incidents of the warm welcome of recovered patients by the neighbors interestingly the washington post on 8th april in one of its news bulletins opined that such contrary behaviors have been observed across the world social media has been a disseminating tool for both information and news including many fake ones ranging from the recovery rate death rate and vaccine development world health organization team has stated the 2019ncov outbreak and response has been accompanied by a massive infodemic some accurate and some not that makes it hard for people to find trustworthy sources and reliable guidance when they need it the term infodemic was meant to allude to an overabundance of news during this pandemic world health organization prompt response about infodemic calls for ones immediate attention to cross check the reliability of incidents that happen in the community covid19 and digital technology scientists and researchers have used technology ranging from hightech robots to lowtech masks to the best to fight this pandemic robots have been used massively for cleaning sterilizing emitting ultra violet rays and delivering food to patients or the needy during quarantine in order to limit humantohuman contact digital technology has also been harnessed to provide innovative ideas eg when patients were short of ventilators researchers and engineers have formed several online groups on platforms such as telegram facebook instagram etc to share knowledge on manufacturing ventilators this apart artificial intelligence was also used in fact bluedot software had triggered an alert even before who on this pandemic by analyzing data provided by the different agencies the usage of ai for imagebased analysis in computerized tomographyscan understanding the working of coronavirus to produce drugs telehealth has been an immediate relief provided by the technology although largely technology has played an uplifting role it has its own hazards for instance the aspect of individual privacy when the world was facing global lockdowns various countries using technologies such as ai tried to track down its people even though this was intended for a noble cause it is also disadvantageous as it leads to intrusion upon an individuals privacy media coverage especially through television has also worked bidirectionally while this pandemic continues to cause harm to society scientists and researchers are no longer bound by geographies due to technologybased support the technological advancements has helped immensely to provide different covid19 testing aids and treatment facilities across the globe within a short span of time social connectedness and covid19 following preventive measures and use of digital apps help to connect people worldwide and providing knowledge to be healthy being in home quarantine and isolation can take a toll on both the mental and physical health the role of social connectedness cannot be ignored during the pandemic thus this study aims to record insights from the patients and caregivers perception and experiences toward the covid19 as well as the usage of technological aids to maintain social connections in the unforeseen and disastrous situations such as this pandemic in addition this study explores attitudinal differences of people toward covid19 patients the salience of this study is to explore and attempt to understand how social media network and social connectedness aided through digital technology play an important role in maintaining relationships as well as to see if they act as a social cure during the pandemic methods design and participants this study used an exploratory research design to understand the proposed objective the participants of this study were chosen using a purposive sampling method before conducting the interviews informed consent was taken and confidentiality was assured this study included 38 adults across india between the age group of 21 to 40 years having at least graduatelevel qualification out of 38 participants 20 were covid19 recovered patients while 18 were caregivers procedure this qualitative study aims at exploring the firsthand experiences of the recovered covid19 patients along with their caregivers during the pandemic telephonic interviews with the participants were recorded after getting their due consent they were also assured of total confidentiality and were told that the data would exclusively be used for research on an average each interview lasted about 4045 min a set of semistructured questions were prepared to conduct the interviews in consultation with the experts semistructured interview questions were framed after several scrutiny of experts to ensure the inclusion and exclusion criteria few questions were asked initially during telephonic interview for instance a few questions like following were asked during the crisis of covid19 what was your experience of social distancing has it affected your emotional wellbeing and what were your strategies to cope up with the same few questions asked to covid19 patients what was your first reaction the moment you got positive report for covid19 who all has helped you to fight this situation how did they help you and what was the perception of others toward you once you recovered from such illness few questions asked to caregivers what was your experience and approach to help the person who was diagnosed positive for covid19 except being covid19 as a contagious disease what all could be the reason for not helping needy data analysis the data of this study was analyzed using braun and clarkes thematic analysis research method thematic analysis is a method for identifying analyzing organizing describing and reporting themes within a data set the approach of thematic analysis suits to explore and identify prominent themes of the data collected here after each telephonic interview recorded content was carefully converted into verbatim and thoroughly reviewed by the researchers this was done to assure the accuracy of the information provided by the participant transferred to the paper during the analysis of the data researchers have gone through verbatim again and again to refine the understanding of data and identifying the words sentences which were providing similar meaning further responses provided by the participants were noted under different columns each column represented the responses which provided similar meaning and through literature review suitable subthemes and themes were assigned the criteria provided by guba and lincoln for evaluation of qualitative research was taken under knowledge during analysis through data analysis each criterion firstly credibility of information was assured through repeated reviews of data gathered and transferred in verbatim secondly transferability of knowledge via mentioning actual responses of participants their characteristics was assured which could help other researchers to generalize their findings in respective findings the proper division of stepbystep administration by researchers assures the nonbiasing and removes dependability on limited researchers lastly the fourth criterion of conformability was assured when the final result of the data analyzed and the accompanying process involved was reviewed by researchers results and discussion the present situation of covid19 has brought diverse experiences to the human kind this outbreak has led people to follow various preventive measures such as home quarantine them physically distanced from each other at the same time technology is on the peak which smoothen the route to connect with each other which may have positive as well as negative impacts in this research data was collected from 38 participants in which 20 were covid19 recovered patients while 18 were caregivers upon employing thematic analysis four major themes along with 10 subthemes emerged they include psychological experiences attitude toward the patients the description of these four themes and overall 10 subthemes are as follows psychological experiences of people covid19 has affected people both physically and psychologically participants have reported various psychological struggles that they experienced on the basis of which three subthemes evolved such as perceived experiences concern toward patients and the negligence of psychological counseling the significant findings from the experiences that have been observed in the obtained data of this study are mentioned below perceived experiences participants who recovered from covid19 as well as their caregivers had gone through the distressing psychological experiences during the critical time of their illness this primarily included depression and anxiety while some were stressed and a few others traumatized however the causal factors for the disturbances between these two groups were found to be different herein it is vital to note that these experiences were also the result of social distancing home quarantine and unexpected financial crisis faced by the participants however the overall responses under this subtheme of perceived experiences were majorly negative because people were afraid of this uncertain situation this has been also observed in previous epidemics in history unpleasant experiences of patients and caregivers among several psychological distress faced by the participants anxiety was the most dominant followed by depression stress and insomnia rehman et al reported a wide range of psychological experiences such as the perception of risk fear anxiety stress and depression level among the different populous caused by covid19 a male participant ak for instance encountered a lot of anxiety during his selfisolation he stated one day i heard from the cabin man that my neighbors patient suffering from breathlessness and sent to a different ward and it created tremendous anxiety in me i had chosen a single cabin room because i dont want to see the others packed body while a few reported their experiences of anxiety others shared their reactions to various traumatic incidents for example a female participant dk stated i was so much traumatized that everyone came to know about my reports i felt like i cant do anything it was so depressing the anxiety level was higher among healthcare professionals and women during pandemic events however in the present study such genderbased differences could not be found few participants irrespective of them being patients or caregivers experienced higher stress levels for example a male participant nj stated me my wife and my youngest daughter were tested positive for covid19 the day before the report came i had cremated my mother due to this lockdown caused me a lot of financial crisis and the report of my daughter has shaken me inside and made the situation more stressful in certain studies the anxiety level was high among the caregiver community caregivers in specific have reported insomnia symptoms a caregiver sd stated ill get up at two oclockthree oclock she was in a separate room i used to peek from the window itself and come back like the attention apprehension what well happen will she recover or not some of the caregivers claimed that the disturbances were related to the uncertainty of future and fear of loss of their family members these psychological disturbances led the participants to develop insomniac conditions too caregivers in specific have reported insomnia symptoms a caregiver sd stated ill get up at two oclockthree oclock she was in a separate room i used to peek from the window itself and come back like the attention apprehension what well happen will she recover or not the caregivers claimed that the disturbances were related to the uncertainty of future and fear of loss of their family members this category therefore revealed that both patients and caregivers experienced anxiety depression stress and insomnia due to various issues however the causes of experiences differed in both groups while patients psychological disturbances were mostly concerned with isolation and tensed panic environment caregivers anxiety was more associated with an uncertain future and the wellbeing of their loved ones due to lack of proper treatment pleasant experiences of patients and caregivers despite negative psychological experiences a few people found home quarantine and lockdown to be pleasurable in the initial phase as they were having quality time this subtheme emphasizes on the positive experiences of the participants a female participant nj stated my mom cooked a lot so i was so happy i am a very homey type of person stay with my parents so it was very fortunate i enjoyed talking and spending good time with family also i wasnt living in my house for few years and i felt that i need to spend time concisely the participants enjoyed being at home and spending quality time with their families hacimusalar et al noted that the anxiety level was higher among healthcare professionals and women however in the present study such genderbased differences could not be found furthermore findings similar to this study were also noted by cici and yilmazel which stated that the anxiety level was high among caregivers however the overall responses under this subtheme of perceived experiences were majorly negative because people were afraid of this uncertain situation this has been also observed in previous epidemics in history concern experienced by patients while interviewing patients most of them were concerned more about their family members toward covid19 fear for their significant partners and children were more prominent for instance a female participant ny stated my husband did not have any fear of getting corona we had some fear for children because if they got then how to take care of them we cant go near them these findings reflect the phenomenon of higher risk perception that is during the pandemic people perceive more risk of spreading infection this increases the motivation to protect oneself and others to avoid infection notably simione and gnagnarella also found that higher the risk perception in a given group of respondents the higher is their concern toward health perceived severity and selfefficacy have been found to be positively correlated with selfisolation in order to prevent spreading of covid19 negligence of psychological counseling this subtheme focuses mainly on the lack of psychological counseling services that participants thought was necessary the indian governmentinitiated statespecific intervention strategies telepsychiatry consultations tollfree numbers specific for addressing the psychological and behavioral issues faced by the covid19 victims however efficacy of these psychological counseling on patients and caregivers has still been unreported and is thereby ambiguous a male participant pg stated apart from taking medicines there should be a programs like psychological counseling which the govt or anyone can arrange so that they can help covid patients from psychological issues they are facing another caregiver participant ab stated as i say that it is more on the mental side not on the physical side in fact some of the caregivers went on to highlight that although they did not contract covid19 their mental health was as affected as of the patients while patients were being treated by the hospitals there was no psychological support provided from the government for the caregivers das emphasized the need for psychological interventions at a large scale to counter the aftereffects of posttraumatic stress frustration stigmatization etc thus there is indeed a need to have a strong policy for such provisions attitude of others toward the patients and caregivers this main theme which originated based on shared experiences sheds light on attitudes of family members and support from neighbors as well as peers this theme has been subdivided into two ie during recovery and postrecovery which in essence shows the differences in peoples attitudes toward participants both during and after recovery this theme also involves some pleasant as well as unpleasant experiences which are stated as below during recovery this was a time when patients were asked to isolate themselves and avoid making contact with family members and others the differences in the experience of social connectedness have been due to their varied situations such as when the participant was infected by covid19 vis a vis after himher getting cured although family members were concerned about patients another dominant social support system ie the neighborhood was found to be failing in establishing and maintaining social connections with the patients family care in the initial stages parents have had difficulty in accepting their son andor daughter diagnosed with covid19 however family members reported that they gradually provided the required support to the patients with proper care a male participant ak stated they all were just motivating us saying that no problem it happened just happened be positive though family members and near ones initially displayed denial and nonacceptance eventually they accepted and found the courage to support their loved ones which increased their feeling of togetherness societal attitude this subtheme highlights the discriminating stigmatizing and traumatic treatments by the neighbors toward the patient and caregivers world health organization stated that having more ambiguity due to a new disease may lead to unconscious discrimination which reflects through stigma and stereotype a male participant pg stated they ignored memy name was given to the newspaper and people announced it in the whole colony people used to run away from our house as if there is a ghost inside everyone got to know a few statements highlighted the discrimination and stigmatization of the disease resulting in namecalling such as virus home contrary to these negative attitudes a few interviewees indicated a positive attitude by their neighbors also a female participant aa noted one of our neighbors is so good they used to come home only in night till then they took care of children we didnt feel the need for friends our neighbors helped us thoroughly since caregivers were directly or indirectly in touch with the patients the stigma toward patents might have been generalized toward caregivers as well overall the neighbors attitudes toward the patients as well as the caregivers have been negative the behavior shown could also be understood through negative dominance theory which states that when people are fearful they give more weight to negative information and respond accordingly peer support support provided by the friends and colleagues has worked as a healing system to many survivors it has been noticed that friends of the patients have helped their family members too and assured their presence in an emergency a female participant mb noted they were being too supportive actually my mum was home alone my friends used to bring all the fruits and required materials by ordering it online and it would be delivered at home so that was a good thing a positive social connectedness and concern by the friends stayed prevalent during as well as after the recovery period after recovery this second subtheme focuses on the attitude and perception of patients after their recovery in addition caregivers reported that a few neighbors initially avoided them due to risk perception but such behaviors subsided eventually a male participant ak responded since no one in my area had it before me i had become like the godfather for everyone whoever got it later called me for suggestions similar differences in attitudes were observed by caregivers as others sought help to know the ways to maintain hygiene and prevent contracting covid19 from patients this showed that people sought help from both caregivers and patients but for different reasons this could be explained with the mental noise theory which explains that people during a pandemic get stressed and they attend to a great deal of internal mental noise albeit unconsciously which in turn results in a lesser ability to attend to externally generated information notably this indicates the change of behavior in people in which negativity toward someone is not intentional or fabricated but rather a representation of chaos and fear digital technology this main theme highlights the dual role played by the technology the digital technology has worked as a carrier to spread fear as well as knowledge about the disease condition and at the same time extent support to the community in its sub theme at one place social media is working as a carrier to spread fear causing anxiety depression on other hand through ease in communication through digital technology has worked wonders to provide support and strength to the society influence of digital media this main theme emphasizes the influence media has on the individuals thoughts perceptions and behaviors gao et al found that 80 of the participants who were exposed to social media had a prevalence of depression and anxiety das provided evidence that social media news has been the leading cause of overreactive behavior especially of the indian people with technological advancement there are various platforms which provide information to the viewer some platforms are very recent and some have been there for a long time the experience of listening to unpleasant news related to covid19 significantly influenced the people for instance a male participant ld stated in the initial times hearing all such news that is many people died and there is no cure there is no treatment for this disease hearing all those stuffs i was getting disturbed that if i will get what will happen so later i didnt follow them at all to avoid panicking this subtheme showed that most of the people relied on newspapers than on news channels or any social media platform on the contrary the contemporary news feed from digital media platforms such as whatsapp facebook and twitter form to be posing as a major problem than the news from television a female participant st shared i remember someone posted a list with my name i got mad i said okay you take precautions and all but dont disclose the names of people and this resulted in back to back comments and quarrel and i just left that group apejoye stated that information and facts shared through the means of both newspaper and television are more credible than social media platforms the report provided by world health organization regarding infodemic seems to be true in this study also however results of this study show more of the negative aspects of the digital media which is an indication for the government and respective organizations to look upon this issue seriously as news from these sources could be channelized to help create positive influence which would bring the community closer technology aids perception and attitude during home quarantine and isolation the only convenient method to stay connected was through mobile phones and social media platforms this advancement has provided an opportunity to embrace social connectedness in a distinct way chen et al mentioned about the ease provided by technological advancements during covid19 in order to connect with acquaintances the perceived support provided by technological advancement worked as a mental component in recovery of patients the advancement commencing from cell phones to the development of various tools to diagnose covid19 as well as to restrain the spread has created an enormous difference in stalling the pandemic this theme emerged because of shared experiences by the participants about these technological advancements by further focussing on social connection and social media attitude toward treatment and related aids more or less the technology evolved as a companion who provided relief by even connecting the stranded people with their close ones opinion toward treatment and related aids with the advancement in technology treatment to certain diseases has been made possible to diagnose and be cured researchers worked day and night to provide credible diagnostic systems to covid19 the purpose of this cannot meet until the common man does not trust and perceive it as a cure to the disease this subtheme is further divided into two divisions that include the perception of people toward covid19 testing and applications which promote a healthy lifestyle opinion toward covid19 tests two prominent testing ie antigen test and rtpcr test were widely used to diagnose the presence covid19 virus in human body antigen test also known as rapid antigen test provides results within 45 h while the rtpcr test provides results after a span of 23 days it was an attempt to know the patients caregivers perception related to the credibility and reliability of both the tests for diagnosis a male participant kj mentioned what i know is if rapid test there as false negatives as far as i have seen if it comes positive rtpcr also comes positive around 99 cases so if it is negative with symptom better to go with rtpcr on contrary to this a few participants mentioned the use of antigen test as the need of the hour a few reasons mentioned by participants included the point of indias humongous populous coupled with the virus spread being so high they further stated that for the government it would be more convenient to do testing through rapid tests on other hand experimented medicines and treatment provided by the government found to be not more reliable than the ayurvedic kada which is a drink prepared with the use of herbs to boost immunity a female st mentioned i trusted more on ayurvedic treatments opinion toward apps this subtheme emerged in accordance with the claim done by various healthbased applications to provide a good knowledge base to stay healthy in contrast the majority of participants denied the utility of such apps and any exercisebased application most of them favored ancient indian practices to stay fit such as practicing yoga and pranayama and consuming kada or maintain a balanced diet to stay healthy and boosting immunity a male participant pg responded i didnt prefer it that much i used to do yoga and kappalbharti and i have continued that in lockdown also and when i was in quarantine that time also the responses provided by the participants were not in the favor of using any of the healthbased applications husain and spence provided evidence that a few health applications may accurately show some aspects of health but it would not be wise to solely rely on such apps this shows the trust and beliefs of people on traditional knowledge although in this study the advancement of technology has been found to be beneficial in some domains the importance of traditional practices could not be overlooked in support of this the traditional knowledge for yoga exercises and to prepare medicines and khada to cure the illness has also been preferred and given the importance of traditional and indigenous knowledge social connectedness in order to follow social distancing and home quarantine the only way to connect acquaintances was through social media platforms and mobile phones in this theme experiences of patients and caregivers are described which highlights the usage of digital media platform social connection and social media this theme emerged in the viewpoint of an increase in the use of social media as a helping aid for people to connect with others it has been observed that the order of staying at home became easier due to technological aids a male participant for instance reported thank god we have this internet thing otherwise it could be difficult to stay home for so long moore and march found that social media helps to connect people with their loved ones and bring down the feeling of being in isolation during this pandemic most of the recovered patients mentioned that the frequent calls by the acquaintances through social media platforms they received during the lockdowns provided a lot of strength and mental support when interviewees were further probed they revealed that through social media connection and inperson meet they got to know certain new trends being carried around them a female participant ak for instance stated it was a new experience that we were exploring and we were doing something every saturday and sunday there were some tam bola night some other means or some other puzzle game so it was very interactive none of the participants preferred inperson meeting against social media connection and added that it was the need of the hour thus interactions in social media platforms helped people to cultivate a sense of social connectedness preventive measures most of the participants talked about their respective concerns and followed preventive measures such as staying at home in order to restrain the spread of the virus either to themselves or to others a male participant noted home quarantine was mandatory for oneself and others other preventive measures such as wearing masks sanitization and social distancing were acknowledged and approved by the participants some of them even talked about educating others to strictly follow these preventive measures a male participant pg stated we ourselves need to sanitize our society thus people took care of themselves as well as others in order to remain safe from the virus onslaught altruistic volunteers this subtheme has emerged as an additional finding to the primary objectives that were framed although covid19 has been a contagious disease most participants have voluntarily helped others in need the life instincts have been believed to be the cause of such selfpreserving behaviors it is believed that people due to life instinct would selfpreserve themselves mawson explained such contrary behavior by linking it to a massive panic among people during such pandemic on this contrary belief literature shows that prosocial and altruistic behaviors are predominant a male participant pg stated yes me and my social club members used to cook food for 200 people who were migrants it went for 2 months we use to prepare food for two meals it was just a blessing moreover separation and guilt of not helping others is an unbearable psychological stressor than the physical danger this may be attributed to the altruistic behavior shown by most of the participants during this pandemic this kind of helping attitude builds the community as a whole and provides a mental cure that strengthens the feeling of togetherness which possibly plays the lead role in the healing process thus it may be affirmed that social connectedness does enhance the sense of belongingness to the society that can sustain even during a pandemic this study reported that both patients and caregivers have experienced discrimination stigmatization as well as psychological disturbances during the battle against covid19 and find certain meaning to their lives conspicuously negative experiences faced by both the caregivers and recovered patients have felt the need for psychological counseling the changes in the attitude of neighbors both before and after a patients recovery has been seen clearly indicates the necessity of sociopsychological theories and their applications although many caregivers did not contract the disease they emphasized that their mental health was ignored drastically while they were attending to the patients patients caregivers and doctors could interact more feasibly than ever in this pandemic which alters the way to provide support and guidance to the patient and caregiver which impact psychologically importantly this study also highlights the need for counseling and therapeutic services in all the government and private health sectors therefore proper policies strategies must be implemented through topdown approach the study also provides insights regarding the role of selfintrospection to be healthy while enabling others to remain healthy and safe on the contrary negative influence of digital media which highlights the need for the government to implement policies to regulate the information that the media delivers especially social media the conceptual framework derived from the findings of the study could be found in figure 1 the study also provokes researchers employees and health officials to design guidebooks and prepare oneself as well as others to create immediate awareness and knowledge among the common people for any such similar catastrophes in future conclusion the major findings of this study highlighted the positive role of the strength provided by the social connections to the patients and caregivers in the cases where support was not provided although the reasons varied both caregivers and patients did experience psychological disturbances while patients were mostly concerned with isolation and tensed surrounding the caregivers were anxious about their uncertain futures financial crisis and wellbeing of their loved ones although the caregivers were not infected with the virus they reported that they could also not be free from fear and agony due to multiple situational causes further patients opined that adequate counseling services should be mandatory for the patients as well for themselves whereas caregivers shared that their mental health also needs greater attention in addition although family members and friends supported the patients as well as caregivers the support of the neighbors was compromised most of the time due to the fear of contacting the disease however after recovery the neighbors welcomed them to the extent that they sought help regarding preventive measures this study also highlighted the ease to connect with loved ones through digital technology which was found to be a blessing in disguise the voluntary help provided by the participants highlighted the concern for social welfare and shows the positive use of digital technology propounding social connectedness the study also revealed the way the attitude toward the covid19 patients is considerably different among the individuals due to certain existing stigma varied information through social media as well as uncertainty about the prognosis of the disease and their treatment further this states a dire need of proper awareness counseling and several other researches which can bridge the gap between the existing practices varied perceptions and attitude which may further help us in treatment of covid19 as well to enrich the theoretical cultural as well as policybased contributions limitations and further recommendation owing to the tensed situation created by the pandemic and reduced interaction among individuals the researchers experienced difficulty in obtaining a varied representation of sample eg sociodemographics that in essence play a major role in attitudes of individuals toward study variables moreover several important variables such as personality religion caste age comorbidities possible financial constraints and traditional practices to avoid the illness variations of administration to tackle such issue and available resource on or before covid19 could be incorporated in future studies which may provide a cure paradigm for any such calamities in future integration of multiple disciplines ie social science subjects with medical science and technology could be taken together to understand as well as map the understanding of acts toward such situations in the future 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 departmental review board central university of karnataka the patientsparticipants provided their written informed consent to participate in this study supplementary material the supplementary material for this article can be found online at 2021634621full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2021 pandey astha mishra greeshma lakshmana jeyavel rajkumar and prabhu this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

although covid19 pandemic has reorientated humans to be more physically healthy and hygienic it has also persuaded humans to create affiliations and experience a sense of belongingness through social networks and digital technologies however amidst these changes experiences of covid19 patients and their perception of the outside worlds attitudes toward them appears to be less attended in literature which formed the basis for the current studys objectives using qualitative methodology the present study explored the experiences perceptions and attitudes of patients and their caregivers toward covid19 the thematic analysis emerged with four major themes psychological experiences of people was generated prominently with subthemes indicating the perceived experiences like fear of spreading diseases to others and the need for psychological counseling attitude of others toward patients and caregivers revealed that family members and relatives played a major positive role on the patients mental health however the neighbors stigmatized attitude led to several undesired behaviors social connectedness was another major theme derived from the study altruistic volunteers a subtheme of social connectedness have indicated that amidst these negative factors one can spread social harmony by motivating and supporting the victims with basic needs financial support hope and social empathy opinions of participants for digital technology through technological aids and preventive measures emphasized an overall positive attitude as it helped the society in general to maintain social connections as well to curb the rate of covid19 cases

introduction isolation has been defined in various ways in the scientific literature and is often confused with loneliness and exclusion it has been defined as the objective measure of having minimal interactions with others and as the subjective feeling of dissatisfaction with the low number of social contacts maintained 1 social isolation has also been defined as living without companionship social support or social connection 2 as a state in which a person or group feels the need or desire to become more involved with others but is unable to establish that contact 3 and as a state in which the individual lacks a sense of social belonging and bonding or commitment to others and has few social contacts that do not constitute quality relationships 4 along the same lines loneliness or emotional isolation has been defined as the feeling of lack or loss of companionship while they consider that social isolation is the absence of contacts and interactions between an older person and their social network 5 the parallelism between objective lonelinesssocial lonelinesssocial isolation and subjective lonelinessemotional lonelinessemotional isolation is obvious and for many authors shapes the meaning of both terms in general social isolation refers both to the absence of satisfactory social relationships and to a low level of participation in community life several studies analysed the relationship between social isolation and loneliness on the health of the population the review conducted by mushtaq et al 6 found that loneliness and social isolation can lead to various psychiatric disorders such as depression alcohol use disorder child abuse sleep problems personality disorders and alzheimers disease other authors have found that having social support is related to a lower perception of pain 7 and experiencing a greater life satisfaction 89 it should be added that the health and wellbeing consequences of social isolation and loneliness in old age are increasingly being recognized courtin and knapp 10 searched nine databases for empirical papers investigating the impact of social isolation andor loneliness on a range of health outcomes in old age these authors found that depression and cardiovascular health are the most oftenresearched outcomes followed by wellbeing almost all studies found a detrimental effect of isolation or loneliness on health however causal links and mechanisms are difficult to demonstrate and these authors suggest that further investigation is warranted they found a paucity of research focusing on atrisk subgroups and in the area of interventions this also leads to various physical disorders such as diabetes autoimmune disorders such as rheumatoid arthritis and lupus and cardiovascular diseases such as coronary heart disease hypertension obesity physiological ageing cancer poor hearing and poor health in addition the review by crewdson 11 indicates that loneliness and social isolation in the elderly population is shown to be a significant independent risk factor for several conditions such as poor health behaviours physical health problems and psychiatric conditions in addition to this a systematic review and metaanalysis of longitudinal studies 12 report that loneliness was positively associated with an increased risk of dementia while older peoples sense of identity helped them to compensate and adapt to the negative effects of the wellbeing of memory loss 13 in the last 20 years several interventions were developed to reduce the impact of social isolation and loneliness on the health of older people the effectiveness of these interventions has been analysed in various systematic reviews 5 14 15 16 17 18 19 20 21 22 among the conclusions of these reviews are that only a small proportion of these interventions are effective it is observed that the interventions that demonstrated some effectiveness are those that include some educational component social or group activities welltrained staff facilitating social activity or support and those that are aimed at a specific population group in addition when thinking about interventions with people in social isolation who are unlikely to attend a senior centre voluntarily it is important to highlight the more individualized interventions with a home approach by a professional to assess the health and needs of the elderly person in social isolation and to serve as a link between the elderly person and the network of normalized social and health resources in addition interventions seem to be more effective if they include more than one methodology in this same sense outreach processes are not sufficient as the only element of the intervention but can be very useful if they are combined with engagement and intervention strategies in addition the highquality selection training and support for intervention facilitators and coordinators is one of the most important factors underpinning successful interventions on the contrary two factors are noted that make interventions more likely to be successful on the one hand interventions are more effective if the older person is involved in all steps the planning implementation and evaluation of the intervention on the other hand interventions are more likely to be successful if they use community resources and provide the community with tools and the capacity to help fakoya 21 points out that the individuality of the experience of loneliness and isolation may cause difficulty in the delivery of standardized interventions in this regard there is no onesizefitsall approach to addressing loneliness or social isolation hence the need to tailor interventions to suit the needs of individuals specific groups or the degree of loneliness experienced therefore future research should aim to discern which intervention works for whom in what particular context and how furthermore the quality of the evidence base is weak and further research is required to provide more robust data on the effectiveness of interventions 20 based on the above evidence it is necessary to design and implement interventions at the community level to reduce the loneliness and social isolation of older people to order to minimize the negative effects they can have on the health of this population this study aims to describe the components of the psychological support service for socially isolated elderly people as well as analysing the effectiveness of a community intervention based on an outreach strategy to combat situations of social isolation in the elderly population of the city of madrid materials and methods design and procedure for the application of the psychological support service for socially isolated elderly people to design this service on the one hand an extensive search of bibliographic information was carried out with different sources trying to locate research projects or services in operation at a public or private level whose object of intervention was elderly people in social isolation on the contrary a qualitative study was carried out through groups of experts in the area of social exclusion the elderly and other vulnerable groups the result of this work was the proposal of a psychological home care service for elderly people in social isolation this research aims to present the effectiveness of the data after their implementation this service is based on 5 basic principles quality outreach case management personal assistance and continuity of care and it is composed of three protocols contact and engagement evaluation and intervention in this case it is a psychological care service integrated within the municipal care network of madrid city council the general objective of the psie is to achieve an approach to frail elderly people with a clear risk of social isolation that guides their situations towards inclusion and normalization assigning the appropriate social resources in each case or as a last resort supporting involuntary institutionalization andor legal incapacitation the specific objectives are the following 1 to carry out an engagement work on people in social isolation both with the psie and with the normalized socialsanitary network 2 to carry out an assessment that is as exhaustive as possible depending on the case including data on health assessment psychosocial functioning level of disability and unmet needs 3 to carry out a psychosocial intervention to cover the persons needs through a process of inclusion and normalization or as a last resort to support the process of nonvoluntary institutionalization andor legal incapacitation 4 strengthen the social network of the elderly person in isolation working with potential informal support agents in the process of contactengagement assessment and intervention 5 destigmatize the person in isolation both in their community environment and in their family context the three psie action protocols are described below contact and engagement protocol the strategy for approaching the elderly person is through home visits carried out by psie psychologists alone or accompanied by facilitating agents to establish the therapeutic relationship the system of appointments in a centre is not used but instead the professionals of the street team contact the person in the community contact is always made in a persons own environment preferably in their home and if it is impossible to contact them in their home attempts are made in the places in the community that they frequent with total respect and care for data protection and the persons privacy nonfacetoface contact can be carried out via emails phone calls or by sending letters the frequency of contacts depends on the response of the elderly person to the presence of the team however there will always be a minimum of one contact per month either personal or nonfacetoface the objective is to contact the person regularly to help him or she get used to the teams presence and gradually build trust the presence of other professionals during psie visits is assessed according to the intervention needs and the degree of trust and engagement with the elderly person assessment protocol once an initial level of engagement has been achieved the psychological and social assessment of the new case begins in parallel a clinical functional psychological cognitive and social functioning and needs assessment are performed for this purpose the following assessment instruments are used and will be administered in all cases home health outcome scales for people over 65 23 in its spanish adaptation 24 global assessment of functioning 25 in its spanish adaptation 26 who brief disability assessment scale 27 in its spanish adaptation 28 camberwell needs assessment questionnaire for the elderly 29 in its spanish adaptation 30 other assessment scales can be added to this assessment as considered appropriate according to the specific case given the characteristics of the sample regarding the rejection of previous interventions and reluctance to the presence of professionals none of the selected instruments will be completed by the person being assessed instead they will be assessed by the psie professionals based on the information gathered through direct observation and interview both from the user and from other sources of information in this way the process of assessment of this population is simplified intervention protocol during the intervention the main objective of the psie is not to directly treat the social or mental health problems that the person may present instead the priority approach is to normalize the care and connect or reconnect the person with normalized social and health networks where a solution can be given to those social or health problems that the person may present in other words the psie facilitates contact between the elderly person and social and health services in their area so that they can receive the care they need on each occasion in these cases the work of psie focuses on the detection of problems is a social and psychological accompaniment for the beginning and continuity of the necessary treatments and interventions in each case and helps to change the attitude of the elderly person in social isolation encouraging them to accept the help they need which they previously rejected this research of awareness contact with elderly peoples realities and the acceptance of resources is conducted globally through psychological intervention strategies intervention in the clinical area and psychological and cognitive functioning the objective is the acceptance and engagement of the person with normalized health services both at primary level and specialized level intervention in global functioning and disability the objective is the acceptance and engagement of the person in those resources that assist in the activities of daily living both basic and instrumental these services are usually provided by social services but may also come from other organizations such as religious or voluntary organizations etc intervention in social functioning the objective is to create improve andor maintain the persons social support network both at the informal and formal level favouring the persons approach to family and friends or creating new social networks through volunteering municipal senior centres or community associations working on neighbourhood support and the stigma of the person in social isolation in the community and promoting leisure activities etc intervention in the area of unmet needs the objective is to cover the unmet needs of the person this area is transversal to the areas mentioned above for the intervention support will be provided by professional facilitators and the social and family network of the person in social isolation whenever possible psie psychologists participate in training sessions on social isolation in the elderly for professionals of the socialhealth network as well as specific training for professionals involved in specific cases as well as family members friends or other members of the support network of the elderly person in social isolation in those cases in which the level of deterioration is irrecoverable or there is an imminent risk to the health of the person or that of others the opening of a file in the office of the public prosecutor for the elderly will be supported to assess the advisability of nonvoluntary institutionalization in a hospital or residential centre andor legal incapacitation as a protective measure in a situation of clear lack of protection and risk once the intervention has been completed the psie follows up on all cases closed within three to six months after closure the followup consists of retrieving information on the persons served through contact with the user the professionals involved andor the persons informal network to elaborate on this followup the same measures are used as in the assessment protocol if the person has returned to a situation of social isolation the case is reopened by the social services on the other hand if the situation remains nonisolated the psie closes the case definitively leaving the followup to the municipal social services study of the effectiveness of the psychological support service for socially isolated elderly people 221 participants and procedure cases are detected and referred to psie through the general directorate for the elderly and the social services of the madrid city council for the psie to begin its intervention the case must meet certain inclusion criteria be 65 years of age or older live alone or live with other people over 65 have uncovered social andor health needs have little or no social support network refuse the assistance offered to cover their needs from the normalized social andor health services municipal social services have intervened without having resolved the situation of social isolation and consider that all avenues of intervention have been exhausted the intervention was carried out with all the people who were detected and referred to the psie so the sample is incidental the sample of the effectiveness study consists of 68 people over 65 in social isolation in the city of madrid in which the psie carried out the complete intervention until its closure which allowed for the collection of preand posttreatment data all participants in whom at least one posttreatment measurement could be taken were considered for analysis regarding the procedure carried out the premeasures were taken at the initial stages of the intervention reflecting the situation of the elderly person at the time of referral to the psie while the postmeasures were taken 3 to 6 months after the end of the psie intervention given that the conditions of the sample are of great deterioration and chronicity in their state of isolation the posttreatment measures are delayed until a few months after the end of the intervention to assess not only the achievement of the intervention objectives but also their consolidation in the medium term for ethical reasons it was not possible to have a control group since given the seriousness of the situation of the cases of elderly people in social isolation detected and referred to the psie the intervention was started for all of them informed consent was requested from the people in the sample the study was conducted following the declaration of helsinki and the protocol was approved by the department of programming evaluation and development of the general directorate for the elderly of the madrid city council code 0010852330148901 measures the following instruments were included in the assessment health and psychosocial functioning through the use of the spanish adaptation of the health outcome scales for people over 65 24 an outcome assessment instrument for the elderly population consisting of 12 scales that assess various physical and psychosocial problems which are scored in a range of severity from 0 1 2 3 to 4 with a total sum score added scores range from 048 points with higher scores indicating poorer health and functioning the spanish adaptation of the scale 24 has adequate psychometric criteria global functioning using the spanish version of the global assessment of functioning 26 this scale included in axis v of the dsmivtr diagnostic manual measures the psychosocial functioning of the individual through the assessment of the severity of symptoms and activity impairment it is designed for the general population it is a 100item scale in which scores close to 0 indicate poorer functioning it has good psychometric properties with an intraclass correlation coefficient of 057 disability using the spanish adaptation of the who disability assessment short scale 28 the short version of the semistructured interview whopsychiatric disability assessment schedule it consists of 4 areas to be assessed by the clinician during the interview based on the information obtained the clinician must score the persons impairment on a visual analogue scale from 0 to 5 according to defined criteria it has good psychometric properties with an intraclass correlation coefficient ranging from 040 to 074 so that half of the specified disability categories have kappa values above 050 and the other half between 040 and 050 social health needs using section 1 of the spanish adaptation of the camberwell needs assessment questionnaire for the elderly 30 this instrument is specifically designed to measure the needs of people with a possible mental disorder over 65 years of age section 1 was used which consists of 24 areas of assessment relating to the userpatient plus another 2 that refer to the main caregiver but have not been included in the present study given the special characteristics of isolation of the sample and the lack of a main caregiver each of these 24 areas is scored 0 1 2 the spanish version of the scale has a good concurrent validity high testretest reliability and high interrater reliability 30 data analysis descriptive statistics were calculated for sociodemographic and psychological variables an analysis was carried out to study the possible influence of gender in the initial sample on the different variables assessed using chisquared and students ttests for independent samples with measures of effect size in each case a study of the effectiveness of psie was carried out with an analysis of preand posttreatment measures students t statistic for related samples was used as well as the effect size of cohens d statistic for the assessment of the possible influence of gender on the results of the intervention a 2 × 2 repeated measures anova was carried out all analyses were conducted using spss v 220 31 results sociodemographic data of the sample the sample contained a majority of women and the mean age was 818 years the majority of the sample did not have a partner 721 lived alone and 794 did not have children regarding mental health 652 of the sample presented symptoms compatible with a severe mental disorder the most frequent being psychotic disorder alcohol use disorder personality disorder anxiety disorders and mood disorders in 667 of the cases this mental health disorder had not been detected before the psie intervention and only 48 were receiving some type of mental health treatment fortyseven per cent of the sample presented moderate tosevere cognitive impairment this level of serious deterioration concerning the mental health of the sample is reflected in the fact that 206 of the persons attended by the psie already had an open judicial file requesting protection and custody measures at the time of referral concerning health and psychosocial functioning it can be seen that the scales where the lowest scores are found are those related to depressive disorders psychotic disorders and suicide risk on the other hand the sample presents moderatetosevere difficulties on scales 9 10 11 and 12 related to constructive leisure and social support activities of daily living and living conditions this result is supported by the mean score on the gaf instrument close to 50 indicating any severe impairment in social or occupational activity scale 5 related to physical health problems and disability also shows a high mean indicating relevant problems in this area these data are corroborated in the disability scale whodass where the difficulties in the four subscales reach a mean of serious disability regarding the needs assessment the sample shows an average unmet needs score of almost 11 which is a high level of need considering that the instrument includes such basic needs as food medical followup or housing conditions description and analysis of gender differences in psychological variables as mentioned above the percentage of men and women in the sample is very different with a greater presence of women an analysis was carried out to study the possible gender differences and their relevance with respect to the initial situation of the sample the results are shown in table 3 there are statistically significant differences in the five measures first cognitive impairment had a higher percentage of moderatesevere impairment in women than in men however if we look at the effect size the relationship of this measure with the gender variable is not very strong medium effect sizes are found in the other four measures problems associated with alcohol use showed a mild alcohol use problem in men and was close to 0 in women problems related to hallucinations or delusions showed a mild problem in women and was close to 0 in men other mental problems showed mild problems in both cases but slightly more pronounced in men and an average level of disability in terms of personal care and survival was higher in men than in women in the rest of the measures evaluated there are no statistically significant differences according to gender regarding the reasons for the closure 633 of the cases were resolved after taking legal protection actions to ensure the wellbeing of the elderly and in the remaining 367 the situation of social isolation was redirected towards normalization through the acceptance of formal aid andor the strengthening of the social network of the elderly effectiveness study health and psychosocial functioning the general trend is towards maintenance or improvement in all variables of the honos65 scales in all of them the mean score decreases indicating improvement significant differences are found between preand posttreatment in 7 of the 12 scales included in the instrument the differences are found both in scales of psychopathological symptomatology and behavioural alteration such as scales 1 3 6 and 8 scales of functioning more related to social aspects such as scales 9 and 12 and scale 11 more related to housing conditions both in terms of hygiene and habitability decoration stimuli present etc concerning the total score of the honos65 significant differences were also observed between pre and posttreatment showing a significant improvement of the sample in this variable mediumtolarge effect sizes were found in all scales where there were significant differences with the largest being found in scales related to social support leisure activities and living conditions differences in the honos65 total score also indicate a large effect size global assessment of functioning the general trend is towards improvement in global functioning with a higher posttreatment mean these differences between preand posttreatment are statistically significant and have a medium effect size disability the prepostdata in the whodass instrument are for 46 persons there are significant differences and large effect sizes in the four areas of disability included in the instrument with the trend in all of them being towards improvement that is towards the more adequate functioning of the persons in the sample in all of them the mean score decreases which indicates an improvement since in this scale lower scores indicate lower levels of disability for the analyses carried out with this instrument obvious disability to maximum was chosen as the criterion for the highest severity since from a score of 2 on this scale interference with a persons social adaptation begins to be considered social health needs in the 24 areas of need the score 0 indicates that there are no needs 1 means that the need exists but is covered and 2 indicates that the need is not covered the general trend is towards fewer unmet needs decreasing from an average of 1068 unmet needs at pretreatment to an average of 144 unmet needs at posttreatment study of the influence of gender on intervention outcomes the gender variable does not seem to have an influence on any of the outcome measures studied except for alcohol use in this variable the results indicate that a reduction in use was achieved in both men and women but in women a total reduction in alcohol consumption was achieved discussion this study aimed to describe the components of the psie and to analyse the effectiveness of a community intervention the sample shows a moderatetosevere level of mental health deterioration with high percentages of symptoms compatible with at least one severe mental disorder including psychotic symptoms alcohol use disorder personality disorders anxiety and mood disorders the high presence of moderate and severe cognitive impairment and even judicial records requesting protection measures before a referral to psie given the characteristics of the sample of isolation and rejection of social and health resources in most cases they are not receiving any mental health treatment the data highlight the need for mental health care in this population in addition the people in the sample of this study had a very high mean score of unmet social and health needs before the intervention compared to the average in the general population 32 concerning interventions the duration and number of contacts required in each case will depend on the individual characteristics of each person treated as evidenced by the variability in the minimum and maximum ranges of both the duration and number of contacts however the data point to interventions of a medium and long duration with frequent contacts men seem to show a tendency towards greater alcohol use and greater difficulties in selfcare while women in the sample present a worse cognitive status and a greater presence of problems with hallucinations or delusions however it should be noted that the results of the analysis by gender show that the differences in this variable in most of the measures are not significant and the effect is low or medium the results of the effectiveness study indicate that the psie is an intervention programme that serves to improve the scores of the people in the sample in all the variables studied regarding the changes in the measure of health and psychosocial functioning the general tendency is towards maintenance or improvement in all the variables of the honos65 scales with significant differences in 7 of the 12 subscales it should be noted that the intervention is effective for reducing behavioural disturbance alcohol use psychotic symptomatology other emotional problems such as anxiety and depressive symptomatology as well as improving the frequency of social contacts a persons living environment and participation in leisure activities the latter being where the intervention shows the clearest effects these achievements were made possible because the psie has engaged with elderly people in a situation of social isolation and is able to put them in contact with regular health and social services in this way many people with mental disorders have received care from mental health services which has led to a reduction in mental health symptoms on the other hand the psie has facilitated the acceptance of different social resources by people in social isolation such as the home help service for household chores personal hygiene shopping medical appointments the home meal service the tele assistance service or access to a residence for the elderly this could explain the improvement in the honos65 subscales of living conditions occupational activities and social relations in addition these social relationships may also have been improved by the inclusion of volunteers in the cases of people in whom emotional loneliness was detected on the other hand some honos65 subscales have not experienced significant improvements such as cognitive problems and problems of disability and functioning in activities of daily living it seems reasonable that this last aspect would be improved by incorporating a person from the home help service however the home help service was accepted on many occasions for cleaning the home but not for personal hygiene this could explain the limited improvement in this variable as for the more general measures of functioning and disability statistically significant changes and medium and large effect sizes were obtained so it can be affirmed that the psie being an intervention that connects the person in social isolation with regular social and health services helps to improve general functioning in the specific areas of personal care occupational family and leisure functioning finally the psie has proven to be effective in meeting most of the 24 needs identified by the cane with a general trend towards fewer unmet needs decreasing from an average of 1068 unmet needs at the preintervention time to an average of 144 unmet needs at the postintervention time it should be noted that the psie has served as a link to cover these needs by encouraging the elderly person in a situation of social isolation to accept different services from social and health professionals facilitating the social support of people in their neighbourhood and resuming contact and relationships with family members regarding the effect of gender on the results of the intervention we only found an effect on the alcohol use variable psie has achieved positive results in both men and women without gender appearing to be a relevant variable in these results studies included in systematic reviews and metaanalyses on the effectiveness and efficacy of interventions to reduce social isolation do not examine gender as a predictor of intervention outcomes 14 15 16 17 18 19 20 21 22 this makes it difficult to compare our results on gender differences with previous studies previous studies are interested in the analysis of variables such as the intervention type or the variable age as possible predictors of the effectiveness of the interventions future research should focus on the study of the gender variable as a predictor of the effectiveness of interventions that aim to reduce emotional loneliness and social isolation in the elderly in order to better plan interventions to prevent situations of loneliness and social isolation the effectiveness of psie might be because it is a programme that includes many of the ingredients recommended by different authors in different metaanalyses and reviews regarding the effectiveness of interventions to reduce social isolation and loneliness 5 14 15 16 17 18 19 20 21 22 some of the components of psie that could explain its effectiveness are individualized interventions with a homebased approach by the professional aiming to assess the health and needs of the older person in social isolation and serving as a link between the older person and the normalized social health network of resources in addition psie has carried out highquality selection training and support for the facilitators and coordinators of the interventions another factor to be taken into account in the approach to older people in social isolation is the need to involve the elderly person in all steps from the planning implementation and assessment of the intervention this factor is relevant in the psie always respecting the times and rhythms of change established by the people in social isolation finally a decisive factor in the effectiveness of the service is the use of community resources that have served to provide tools and support the capacity of the community itself a strong aspect of the present study is that it has been applied to a large sample of elderly people in social isolation and that it is one of the few studies that has been applied in the environment of the elderly person and not in a social or health centre in other words it was possible to access people in a situation of extreme social isolation who do not ask for help and who refuse any service one of the main limitations of the study that we found was related to the lack of a control group for ethical reasons it was not possible to have a control group since given the seriousness of the situation of the cases of elderly people in social isolation detected and referred to the psie the intervention was initiated in all of them regarding future research directions it is important to include efficacy studies with a control group in addition to conducting studies with even larger samples that include sufficient numbers of men and women to perform genderdifferential analyses on the other hand since the covid19 pandemic it seems interesting to promote the study of the efficacy of remote interventions to mitigate emotional loneliness and social isolation in the elderly 1718 33 34 35 36 information and communication technologies and other traditional networks can foster social support to deal with social isolation and loneliness further research is required to provide more robust data on the effectiveness of interventions including gender differences it is interesting to further develop theoretical understandings of how successfully interventions mediate social isolation and loneliness conclusions older people in social isolation in the city of madrid are in most cases women living alone without children and with a high percentage of severe mental disorders this study was able to demonstrate the effectiveness of a psychological intervention with elderly people in social isolation with some specific components such as individualized attention intervention in the persons own home and environment the engagement of the elderly person with the normalized social and health care networks to meet their needs and an additional intervention strategy focused on training and support for both the professionals involved in the case and the elderly persons informal social support network data availability statement the datasets used during the current study are available from the corresponding author on reasonable request

loneliness and social isolation in the elderly population can be shown to be a significant independent risk factor for several conditions such as poor health behaviours physical health problems and psychiatric conditions although in the last 20 years several interventions have been developed to reduce the impact of social isolation and loneliness on the health of older people however only a small proportion of these interventions are effective this study aims to describe the components of the psychological support service for socially isolated elderly people psie in addition to analysing the effectiveness of a community intervention based on an outreach strategy to combat situations of social isolation in the elderly population the sample consisted of 63 people over 65 years of age from the city of madrid spain detected by the sociohealth services as people at risk of social isolation sociodemographic mental health health and psychosocial functioning global functioning disability and sociosanitary needs were evaluated with observational scales descriptive statistics were calculated for sociodemographic and mental health variables an analysis was carried out to study the possible influence of gender in the initial sample on the different variables assessed using chisquared and students ttests for independent samples with measures of effect size in each case a study of the effectiveness of psie was carried out with an analysis of preand posttreatment measures a students ttest was used for related samples as well as the effect size of cohens d statistic for the assessment of the possible influence of gender on the results of the intervention a 2 × 2 repeatedmeasures anova prepostmeasures × gender was conducted regarding mental health 652 of the sample presented symptoms compatible with a severe mental disorder the most frequent being psychotic disorder 227 alcohol use disorder 167 personality disorder 152 anxiety disorders 104 and mood disorders 104 the gender variable does not seem to have an influence on any of the outcome measures studied the results of the effectiveness study indicate that the psie is an intervention programme that serves to improve the scores of people in the sample in all variables that the programme studied some of the components of psie that could explain its effectiveness are individualized interventions with a homebased approach by professionals serving as a link between the older person and the normalized socialsanitary network further research is required to provide more robust data on the effectiveness of interventions

introduction as a standpoint for the development of modern society a smart city is also an important part of modern society with the development of the internet in recent years there has been a lot of room for development in community construction innovation especially in the construction of smart communities ecological construction for the elderly and community grid construction 12 e smart community mainly has the following factors e first is to make full use of modern science and technology the second is to achieve the integration of resources the third is to improve the comprehensive level of social governance the fourth is to enable the modernization and facilitation of residents lives 3 so in this sense smart communities are a relatively new type of new concept of social governance building an intelligent community can not only improve the overall construction level of the community but also reduce the cost of social governance and maximize the improvement of residents living services with minimal investment so as to better build a multilevel intelligent social service system 45 driven by new social governance development requirements and a new round of technological and industrial revolution smart communities will become an important way to innovate community governance improve community services and meet the needs of peoples good lives smart communities rely on advanced technology information technology and infrastructure to effectively integrate the needs of the communitys property services convenience services government affairs medical treatment communication and communication in an intelligent information system to provide community residents with more convenience and comfortable efficient and safe living environment so as to realize peoples daily life and services in an intelligent and convenient way e development of a smart community is not only the result of the continuous maturity development innovation and change of the community but also the extension of intelligence in the field of social governance 6 e smart community service system is jointly constructed by the government and the social forces under its leadership 7 it relies on advanced information technology and infrastructure in the smart community to meet the diverse and multilevel needs of community residents 8 e goal is to live and innovate the community governance model to provide community residents with various community service systems and operating mechanisms niaros et al 9 have proposed a multidimensional multilevel study on the construction of smart communities e research content includes support at the government level socioeconomic needs the dimension of the construction environment and the level of interconnected transportation aiming at the dimensions of individual needs intelligent community management and familylevel dimensions american administrative scientists li et al 10 and ted krivý 11 proposed that public services are not necessarily fully provided or directly provided by the government e government provides this function of public services a variety of other more efficient ways of providing services can be sought by community workers within the community 12 raven et al 13 pointed out that nonprofit organizations should provide community services as the main body and the role of the government is mainly to advocate and support verrest and pfeffer 14 believe that the government market community and other entities should complement each other and establish a multicenter supply model community services should not be a single or onetoone supply model emphasizing the diversity of supply 15 barns et al 16 believe that the smart community is an autonomous system that can be thoroughly perceived and interconnected by relying on advanced scientific and technological information technologies such as the internet of ings and cloud computing is system has many functions such as community home detection emergency alarm and nursing services 17 eckhoff and wagner 18 have used the perspective of distance learning to build a model of smart community network learning which includes the three dimensions of smart community development knowledge innovation and coaching and learning support and explain the connotation of smart community from a content of smart community sandulli et al 19 believe that a smart community is a kind of converged network built in the context of the internet of ings e structure of a smart community is a network architecture which is malleable and inclusive 20 kumar et al 21 believe that smart communities are different from traditional communities ey are provided for the residents of the community ey are a united front and are efficient healthy safe lowcarbon energysaving and environmentally friendly living environment and methods e construction of smart communities should adhere to sustainable development sookhak et al 22 considered that smart communities are key construction subprojects of smart cities and analyzed the connotation of smart communities from the perspective of smart cities as a component of smart city construction kitchin 23 believes that a smart community is a community security network integration system e construction and development of the community should first consider the issue of community security 24 using wireless sensor technology a sensor network can be built and community security can be placed in it e research on smart communities has covered many aspects including the basic concept connotation information technology support and standards construction status issues and countermeasures and smart community evaluation e theoretical framework of the smart community has been gradually improved but the service system of the smart community is the core component of the smart community its research is still in the exploratory stage and there is less research in this area concentrating on the research of a single part of the service content such as oldage care and medical care the research is relatively scattered there are many deficiencies and there is a lack of systematic analysis and design if smart communities rely solely on technology and do not cooperate with the appropriate service system they will restrict the development of smart communities hinder the intelligent development of social governance and build a process of coconstruction and shared governance e selection of this paper is mainly based on the intelligent management of the community as the research target e theoretical concept of smart city construction under dynamic games is combined with the specific construction practice of the smart community to analyze the problems and shortcomings of the current status e research in this paper has both a certain theoretical significance and corresponding practical value on the one hand it can enrich the united front related theories of social services and community governance and on the other hand it can provide some data theory and practical experience to the latecomers studying smart communities study on community governance of smart city construction in dynamic game analysis of the game relationship between smart city construction and community governance smart city planning and construction groups business groups and social public groups are the most important stakeholders in urban planning and construction e three groups decisionmaking interaction directly affects the process of local urban planning and construction smart city planning and construction groups make decisions intending to maximize the public interest in the region ey are the leaders guides and maintainers of urban planning and construction ey regulate the production and living behavior of enterprise groups through effective policy regulations and incentives decision making with the goal of maximizing benefits is the main body and promoter of green production and determines its production strategy according to market preferences and government policies social public groups make decisions with the goal of maximizing personal interests and are the supervisors and markets of society of consumers 2 complexity determining their decisionmaking behaviors based on the utility of the goods to themselves and the individual gains and losses in social construction due to different interest preferences among the three major groups different strategies will be selected which will affect the effectiveness of urban planning and construction erefore by establishing an interactive game model among the three main bodies a united front is formed using evolutionary game method to analyze the strategy evolution process and trend of each group has positive significance for the optimal mechanism design and system construction of urban planning and construction is draws an expanded game model for participation in smart city construction e smart community service system is a system architecture and operating mechanism for smart communities to implement community governance and services it aims to provide community residents with efficient convenient and intelligent services through information technology and facilities e smart community service system is supported by technology and information such as the internet of ings information technology and urban big data it is the responsibility of the government rough various methods such as government purchase it integrates the multiresources of community neighbourhood committees enterprises social organizations and community residents to jointly achieve and provide diverse and multilevel services such as government services life services elderly services united fronts medical services volunteer services and property services integrate the realization of various services and use information technology and infrastructure to create online intelligence e service application platform and offline intelligent service management platform provide various types of quality services to community residents through two major platforms community residents can participate in community governance through online smart service application platforms and offline smart service management platforms or by directing prosecutions and expressing opinions and satisfaction with service subjects e operation mode of the community service system is shown in figure 2 to meet the needs of residents is the fundamental purpose under the new public service theoretical framework that advocates service instead of helm and pursuit of public interest the construction of a smart community service system should take service as the king and pursue the public interests of community residents as the foundation it is necessary to accurately grasp community residents demand for various services such as public service government affairs social security employment services family planning and other services convenient water and electricity provision communications pensions medical care housekeeping shopping and other services to understand the degree of community residents demand for various services supply methods and efficiency of service delivery keep up with the times dynamically update and continuously optimize the service supply methods to improve service levels e construction of a smart community service system should focus on the needs of residents build highrise houses formulate toplevel designs and arrange service methods and approaches experiment apparatus hypothesis 1 ere are two important groups in the process of urban planning and construction group a is the department responsible for urban planning and construction group b is a relevant functional department that belongs to group a and involves urban planning and construction ey each have two decisionmaking schemes group a can choose to actively implement the countrys construction requirements for urban planning or passively implement this requirement while group b can choose to support group a work or not to support group a work individuals in both groups have limited rationality and will adopt imitation strategies to adjust their game strategies based on the choices of others in the group hypothesis 2 e cost of group as active execution is c 1 which is expressed as the human and financial input for execution at the same time it will receive the opportunity benefit i 1 which is expressed by the superior governments reward and the governments reputation improvement at this time if group b supports they will get auxiliary gains which shows that they have saved manpower and material resources when group a performs negatively it will be punished by the higher government for future financial penalties which will be recorded as a fine l 1 ⃞⃞ hypothesis 3 e cost of group bs support for construction is c 2 which is also manifested in human and financial input at this time when group a is actively performing it will also receive opportunity income i 2 which is shown as an increase in reputation and political performance when it is not supported if group a insists on actively implementing the financial penalty l 2 for group b it will show the reduction of financial support for the next year ⃞⃞ hypothesis 4 in the process of comprehensive urban planning the proportion of group a which chooses to actively execute the strategy is represented by x and the proportion of people who choose to execute the passive strategy is e proportion choosing to support the construction strategy is represented by y and the proportion choosing not to support the construction strategy is table 1 shows the model parameters based on the above assumptions list the game matrix between groups a and b as shown in table 2 e x1 � y i 1 c 1 a 1 􏼁 i 1 c 1 l 2 􏼁 e expected return from negative construction can be expressed as e x2 � y l 1 􏼁 l 1 􏼁 e average expected return can be expressed as 4 complexity e x � xe x1 e x2 � x y i 1 c 1 a 1 􏼁 i 1 c 1 l 2 􏼁 􏼂 􏼃 y l 1 􏼁 l 1 􏼁 􏼂 􏼃 write the replicated dynamic equation of group a ⃞⃞ g � dx dt � x e x1 e x 􏼁 � x i 1 c 1 l 2 ya 1 yl 2 l 1 􏼁 4 it is not difficult to find that the independent variables in this equation only exist in the part of x so let the part that has nothing to do with x be expressed by a formula erefore the expected return of group bs choice of transformation and upgrading strategy can be expressed as e y1 � x i 2 c 2 􏼁 c 2 􏼁 e expected benefits of choosing a nontransformation upgrade strategy can be expressed as e y2 � x l 2 􏼁 e average expected return can be expressed as e y � ye y1 e y2 � y x i 2 c 2 􏼁 c 2 􏼁 􏼂 􏼃 x l 2 􏼁 􏼂 􏼃 write the replicated dynamic equation of group b g � dy dt � y e y1 e y 􏼐 􏼑 � y xi 2 c 2 xl 2 􏼂 􏼃 by analyzing the evolutionary system composed of dynamic equations g and g we analyze the evolutionary stability strategy of group a and group b and the equilibrium point stability of the system can be determined by referring to the local stability analysis method of the jacobi matrix e jacobi matrix of the game is listed as jacobi � α x a 1 l 2 􏼁 y i 2 l 2 􏼁 β 􏼠 􏼡 9 determinant of j traces of j det j � i 1 c 1 l 2 yr 1 yl 2 l 1 􏼁 xi 2 c 2 xl 2 􏼂 􏼃 y i 2 l 2 􏼁x r 1 l 2 􏼁 10 tr j � i 1 c 1 l 2 yr 1 yl 2 l 1 􏼁 xi 2 c 2 xl 2 􏼂 􏼃 result analysis analysis of evolutionary stability in dynamic games to more intuitively express the evolution process of emergency decision information sharing behavior this paper uses matlab simulation tools to simulate conclusions 1 2 and 3 at different initial points under different circumstances and evolve to the aggressive strategy in figure 3 the horizontal axis represents time and the vertical axis represents the proportion of active strategies selected in smart city planning and construction or number to govern at is when the value of the parameters meets the above conditions the evolutionary stabilization strategy of smart city planning and construction is active integration for the convenience of analysis under the conditions that the above evolutionary stability strategy is satisfied it is assumed that the parameter value is e � 3 α � 04 β 1 � 08 β 2 � 02 p � 05 l � 06 c 1 � 15 it can be seen from the evolution process in figure 3 that no matter what the initial proportion of the active integration strategy for smart city planning and construction is the final evolutionary stability strategy ratio converges to 1 that is the active integration strategy it can be seen that the smaller the initial proportion of smart city planning and construction the faster the convergence rate and all the curves will not cross before reaching stability e cost of actively integrating information in smart city planning and construction is less than the benefit of information value brought about by the improvement of the ability of community governance to actively share information and transform it regardless of the initial proportion of community managements choice of active sharing strategy the final evolutionary stable strategy ratio converges to 1 that is the active sharing strategy it can be seen that the smaller the initial proportion of community governance the faster the convergence rate and all the curves will not cross before reaching stability at this time the risk brought by enterprises to reduce the density of information is greater than the net income of active sharing and less than the sum of the net income of active sharing the reward of active sharing and the penalty e evolutionary stability strategy for smart city planning and construction is 1 and the evolutionary stability strategy for smart city planning and construction is 0 e evolution diagram is shown in figure 4 it can be seen from figure 4 that when the initial proportion x0 of the smart city planning and construction cluster is greater than 072 that is 08 and 09 in the figure the final evolutionary stability strategy of the smart city planning and construction cluster is 1 when the initial ratio x0 of the planning and construction cluster is less than 072 that is 02 04 and 06 in the figure the final evolutionary stabilization strategy for the planning and construction cluster of the smart city is 0 in the same way under the abovementioned prerequisites the evolutionary stability strategy of community governance clusters under different initial proportion conditions when the cost of integrating information in the smart city planning and construction department is low enough the strategy of smart city planning and construction has nothing to do with the choice of community governance strategies active integration of information is an evolutionary and stable strategy for smart city planning and construction that is the difference between the benefits of actively integrating information and the cost of actively sharing information when it is large enough the strategy of community governance has nothing to do with the strategic choice of smart city planning and construction active sharing of information is an evolutionary and stable strategy for community governance in the planning and construction process of smart city we need to plan and construct information integrate cost share information of community governance and improve the ability of information conversion improving information hiding coefficients and actively integrating information conversion capabilities and smart city planning and construction government incentives both the level and the active sharing of profits by enterprises can promote the evolution of smart city planning and community governance to a dualpositive strategy forming a united front analysis of dynamic game decision methods e effectiveness of the corresponding emergency plan for different levels of community governance e the prior probability is p of the four levels of community governance in the first stage and when the actual level of the nuclear accident is i but the joint meeting judges the level of accident the conditional probability is p e above data in the actual nuclear emergency are discussed and decided by the emergency decisionmaking group that is the joint meeting on countermeasures for atomic disasters relying on the judgment of experts in nuclear emergency decisionmaking e analysis of this example mainly explores the operability and theoretical feasibility of the model to facilitate the analysis the above three types of fuzzy data will be assumed it is assumed that the corresponding scheme corresponds to the utility e of different levels of community governance as shown in figure 5 it is also assumed that when the actual level of the nuclear accident is i the conditional probability that the 6 complexity joint meeting judges that the level of the accident is j is p and the value of the conditional probability is shown in figure 6 according to the calculation steps all posterior probabilities of the four levels of nuclear accidents can be calculated as shown in figure 7 dynamic game optimization analysis e effect of the users strategy level on the expected equilibrium benefits of community governance is mainly studied through numerical simulations in order to control the impact of the data transmission rate ratio on the experiment the data transmission rate ratio in the experiment is fixed at 07 e abscissa of figure 8 represents the users strategy level and the ordinate represents the expected total benefits of community governance e image visually shows that the expected total benefits of community governance in both communities decrease as the users policy level increases is is because a higher user policy level implies that more users will choose to delay access to the edge network erefore the users strategy will reduce the expected total benefits of community governance in the competitive pricing model next compare the differences in expected equilibrium returns of community governance in the face of irrational users and strategic users as shown in figure 9 e abscissa indicates the users strategy level and the ordinate indicates the percentage difference in the expected equilibrium benefits of community governance from the transition from irrational users to strategic users it can be found from the figure that the image function values are all below 0 which verifies the previous conclusions the users strategic behavior will reduce the equilibrium benefits of community governance in addition it can be found that the higher the users policy level the greater the loss of community governance benefits because strategic users will choose to delay access to the edge network making the price elasticity of demand greater changing the value from 0 to 1 we found that the simulation results are consistent with the above so this simulation result can explain the problem because the distributed dynamic optimization scheme we proposed is cooperative each independent subsystem has its own objective function but in the cooperative dynamic game optimization calculation all the subsystem goals are to make the entire overall optimization performance of the system the largest so the objective function used by each subsystem is to improve the optimization performance of the entire system and should be consistent for the selection of the objective function the general approach is to linearly add the objective functions of each independent subsystem and the coefficients are determined according to the actual production conditions situation and united front erefore we integrate the above three objective functions into the overall objective function of a large system as shown in figure 10 under the rcgo dynamic optimization scheme the iterative convergence and number of iterations of the optimization solution in each optimization cycle are shown in figure 11 e euclidean norm is that of the difference between the optimal controls obtained by the last two consecutive iterations in each optimization cycle e numbers are all less than the set iteration termination tolerance ε � 0001 is means that in each optimization cycle the rcgo dynamic optimization solution can successfully converge when solving largescale dynamic optimization problems of process networks at the same time the number of iterations of the optimization solution in each optimization cycle is less than the set maximum number of iterations e results of these numerical simulations show that the rcgo dynamic optimization scheme can effectively solve largescale dynamic optimization problems next we compare the economic performance indicators of the process network closedloop control performance indicators and realtime calculation performance indicators to the advantages and disadvantages of rco and rcgo dynamic optimization solutions when the rco and rcgo dynamic optimization solutions are used to solve the largescale dynamic optimization problem of the process network the economic benefit indicators of the process network are 13541 and 09160 respectively and the closedloop control performance indicators of the process network during the 100s online optimization operation are as shown in figure 12 from the results of the above numerical simulations it can be seen that when the rco scheme is used to solve the largescale dynamic optimization problem of the process network the economic benefit indicators and closedloop control performance indicators of the process network obtained are optimal is is because the rco scheme simultaneously considers all the control variables in the process network when optimizing the solution so the results of the optimization solution under this scheme often take when using the rcgo scheme the scheme considers not only the overall optimization of the process network but also the optimality of each subsystem is will cause the global optimality of the process network dynamic optimization problem to be often not guaranteed in other words the quality of the economic benefit index and the closedloop control performance index of the process network is the result of weighing the optimality of the subsystem and the overall optimality of the process network when using the rco scheme the average optimization calculation time in each sampling period is longer than that using the rcgo scheme in each optimization cycle the rco scheme needs to solve a largescale dynamic optimization problem due to the large scale and complexity it often takes more time and cost at the same time the average optimization calculation time in each sampling period under this scheme will complexity exceed the sampling period length which means that the rco scheme will be difficult to apply to the realtime solution of the process network dynamic optimization problem when using the rcgo solution the system model size of the optimization solution is smaller and the solution complexity is lower than that of the rco solution erefore the solution can guarantee the realtime solution of the dynamic optimization problem of the process network in summary when solving complex largescale dynamic optimization problems the rcgo scheme has greater advantages than the traditional centralized optimization schemes in the comprehensive index consisting of system economic benefits closedloop control performance united front achievement and optimization realtime performance conclusion is article summarizes the theoretical research of smart communities identifies and classifies the main interests of local smart cities based on previous studies and finally determines that smart cities and community governance are the main objects of this research secondly based on the assumption of bounded rationality this study builds a dynamic game model between smart cities and community governance and finally draws the stable evolution conditions of the ideal equilibrium ess guiding the behavior of smart cities mainly depends on establishing appropriate incentive mechanisms guiding smart cities mainly depends on setting up a reasonable reward and punishment system e enthusiasm for stimulating public participation is to increase their recognition of smart city construction strengthening social supervision is beneficial for local governments to change their behaviors and fulfil their regulatory responsibilities en for local governments to carry out research on the game of interests among their internal departments the attitude of community governance is crucial whether it is an internal department or an external department the degree of cooperation has a positive impact on the attitude of community governance construction e concentration of regional environmental functions is more conducive to advancing the united front of smart cities data availability e data used to support the findings of this study are available from the corresponding author upon request conflicts of interest e authors declare that they have no known conflicts of interest or personal relationships that could have appeared to influence the work reported in this paper

we present a research on smart city planning and community governance using dynamic game methods analyze the current status and problems of the current smart community service system and put forward countermeasures and suggestions based on the global smart community development experience rough smart city planning and construction the game model of government governance and information sharing between communities and decision making is obtained and the twodimensional replication dynamic system equations of smart city planning and construction agencies and communities are obtained from smart city planning and construction e evolutionary stability strategy and a united front are analyzed e strategy achieves the ideal stable conditions we define the relevant definition of a smart community and discuss the purpose and significance of the research especially the importance and necessity of the construction of the smart community based on the current situation of the construction of smart communities we conduct specific research discuss the deficiencies and shortcomings in the current construction of smart communities and find out the causes of these problems finally based on learning from the relevant work experience corresponding improvement measures are proposed for the existing problems from the united front toplevel design social participation platform construction and talent training

background both malaysia and singapore inherited the britishstyle national health service and continued to finance its healthcare system from its revenue 1 over the years the dissimilarity in the rate of socioeconomic development has significantly impacted the way resources being channelled to public services particularly the health service the malaysian government funded medical and public health services through revenues derived from taxes government revenues and income earned from government corporatised enterprises 2 while in singapore it adopts a hybrid system to finance the health system whereby strengths and limitations of this study ► the unprecedented crossnational comparison of patients with hypertension sharing similar sociocultural background but different economic and health financing environment contributes to this studys strength ► the study examined the sociodemography and disease characteristics factors which influenced hypertension selfcare profiles domain scores in malaysia and singapore among people aged 40 years and above ► large overall sample size has enabled indepth analyses of the individual domain of the htnscp ► crosssectional study design implies associations but not causation and does not allow conclusions about changes in behaviour during the course of illness ► the sample size and recruitment methods differ between the countries suggesting that the results may not be generalisable to the national population and the htnscp domains mean scores comparison between the two countries must be interpreted with caution on february 18 2024 by guest protected by copyright bmj open first published as 101136bmjopen2020044192 on 14 june 2021 downloaded from open access the cost of care is funded jointly by the government and the individual through insurance revenue from taxes and personal medical saving accounts 3 the intent to cultivate personal responsibility towards taking charge of an individuals health underpins the shared healthcare financing concept such an approach is postulated to shape an individuals overall perceptions and attitudes towards selfefficacy and selfcare 4 which is pivotal for the successful management of long term noncommunicable diseases such as hypertension hypertension is a significant cause of morbidity and mortality arising from cardiovascular and kidney disease 5 the prevalence of adults with hypertension as 30 in malaysia and 215 in singapore 6 7 however a significant proportion of the affected population has yet to attain treatment goal in singapore 497 of patients treated for hypertension in primary care were reported with good blood pressure control 7 while in malaysia the proportion of patients with good hypertension control is lower at 374 8 the differences in the proportion of good bp control warrants a comparison of their health behaviour profiles in the two countries as they have similar multiethnic background and culture the management of hypertension does not only encompass pharmacological treatment prescribed from the attending physician but patients themselves are required to perform selfcare measures to improve their bp control 9 selfcare includes maintaining a healthy diet performing regular physical activities achieving ideal body weight and avoiding unhealthy lifestyle such as smoking 10 the success of these activities requires behaviour change motivation and selfefficacy hypertension selfcare profile among adult with hypertension aged 18 years and above were found to be moderate 11 to date such data in singapore are relatively lacking this study aimed to compare the sociodemography disease characteristics and htnscp between malaysia and singapore and to determine the factors influencing hypertension selfcare among study populations in malaysia and singapore among people aged 40 years and above methodology the studies were crossnational surveys of selfcare profiles of patients with hypertension conducted among two study populations in two countries between october 2016 and june 2017 in malaysia the study was conducted in three urban primary care clinics in selangor malaysia and a polyclinic in bukit merah singapore the studies inclusion criteria were adults aged 40 years and above with underlying hypertension diagnosed by a physician pregnant women and those with underlying psychiatric illness or cognitive impairment were excluded from this study the estimated sample size in malaysia was 720 based on the mean score of selfcare management among hypertensive aged 60 years and ≥60 years 12 using lemeshow et al formula 13 with 95 confidence level 90 of power and 20 of nonresponse rate however in comparison with our previous reporting in this study we only include people aged 40 years and above which gave us a total of 702 participants in malaysia as the singapore study had no prior literature on the percentage of patients with high selfcare 50 was adopted to obtain the maximum sample size with a 95 ci estimate and 5 precision the sample size required was 385 the sample size was increased to 450 to account for 15 incomplete data and nonresponse rate study instrument in this study the hypertension selfcare profiles was used to assess the hypertension selfcare profile in this tools development two underpinning theories were orems selfcare model and motivational interviewing 14 15 orems model described how people enabled selfcare by performing specific actions to manage their illness 14 understanding the reason behind these actions were crucial to selfcare mi facilitates the selfcare process by promoting commitment and developing confidence for a behaviour change 15 thus using htnscp tool uses the domains of behaviour motivation and selfefficacy to assess selfcare among patients with hypertension 16 the htnscp tool is a reliable tool with good internal consistency 16 it consists of 60items and three domains which are behaviour motivation and selfefficacy it has been validated in singapore 17 18 19 and the cronbachs alpha for the subdomains ranges from 0857 to 0948 for the malay version the cronbachs alpha for the subdomains ranges from 0851 to 0945 whereas for the mandarin version the cronbachs alpha ranges from 0838 to 0929 18 19 there were 20items in each domain and the score of each domain ranges from 0 to 80 as each question using a 4point likert scale higher scores indicate a higher level of selfcare behaviour motivations and selfefficacy a pretest of the questionnaire involving 30 participants was conducted in malaysia to determine the questionnaires feasibility following the pretest minor changes were made to the questionnaire the questionnaire was available in three languages which are english malay and mandarin for participants to select their preferred version 17 18 19 it consists of three sections sociodemographic characteristics medical profiles on hypertension and the htnscp tool bp reading was taken from the patients medical records the definition of body mass index was based on the who recommendation for asian population 20 underweight is defined if bmi 185 kgm 2 normal weight is defined if bmi is 185229 kgm 2 overweight is defined with bmi 23274 kgm 2 and obese is defined if bmi 275 kgm 2 the definition of controlled bp was based on the joint national committee eighth guidelines 21 the bp of patients with underlying hypertension without diabetes was considered controlled if their bp 14090 mm hg regardless of age open access data collection malaysia in malaysia participants were recruited using a systematic random sampling method a sampling interval of two was used as a constant difference between participants the first patient was chosen using a draw lot method subsequently every alternate patient was approached for study participation singapore in singapore potential participants were screened for eligibility at the waiting area outside the clinic consultation rooms and were invited to participate in the study patients gave written informed consent to join the study we obtained their sociodemographic data via selfadministered proforma the htnscp questionnaire was administered through a facetoface interview we verified the patients clinical information through their latest medical records data analysis we used spss v220 in the data analysis we used descriptive statistics to describe the demographic and disease profiles of the patients we used percentages and frequencies for the categorical variables mean and sd were used for the continuous variables if they were normally distributed the normality of the continuous data was based on zscore of skewness and kurtosis kolmogorovsmirnov histogram and qq plot we used independent ttest or oneway anova to determine the association for numerical data we performed a χ 2 or fishers exact test for the categorical data the significant level was set at p 005 multiple linear regression model was performed to determine the predictors for hypertension selfcare variables with p 025 from the univariate analysis were included in the mlr model level of significance was set at p 0005 the mlr results were reported as beta coefficient se and 95 ci patient and public involvement this research was done with the involvement of the patients as research participants they were not involved in the study design recruitment interpretation of the reports results and writing results a total of 1123 adults with hypertension participated in this study of which 702 and 421 were malaysians and singaporeans respectively the response rate in malaysia was 938 nonparticipations were due to language barrier and time the response rate was not reported in singapore the proportion of participants aged 60 years and above was higher in singapore than malaysia more female participants were recruited among the singaporeans and malaysians more malays in the latter whereas in the former chinese ethnicity constituted the highest proportion more participants were married in malaysia than those in singapore more patients had tertiary education in singapore versus those in malaysia table 1 summarises the characteristics of the study participants a higher proportion of the participants from malaysia were on three or more than four antihypertensive medications compared with singapore regarding bp control to target malaysia had a significantly lower proportion of the treatment goal compared with singapore significantly more malaysia participants had diabetes mellitus compared with singapore participants table 3 illustrates the score of the htnscp of the participants the mean total score of htnscp was significantly higher among singapore participants compared with malaysia participants similarly for all the subdomains mean scores motivation domain selfefficacy domain and behaviour score were significantly higher among the singapore participants compared with malaysia participants detail results of associations between htnscp behaviour motivation and selfefficacy scores and sociodemographic factors and disease characteristic in participants are in online supplemental files 13 as shown in table 4 in both countries the factors that were significantly associated with htnscp behaviour mean scores were participants aged 60 years and above of indian ethnicity and those with tertiary education for malaysia malay ethnicity also was associated with higher htnscp behaviour mean scores for singapore other factors associated with htnscp behaviour were women participants of other ethnicities and those with secondary education table 4 summarises the association between htnscp motivation mean scores and sociodemographic and disease characteristics among malaysia and singapore participants in both countries the htnscp motivation mean scores were significantly associated with indian ethnicity for malaysia malay ethnicity also was associated with higher htnscp motivation mean scores table 4 summarises the association between htnscp selfefficacy mean scores and our participants sociodemographic factors and disease characteristics in both countries the factors that were significantly associated with htnscp selfefficacy mean scores were participants of indian ethnicity and those with tertiary education for malaysia malay ethnicity and women were associated with higher htnscp selfefficacy mean scores for singapore other factors associated with htnscp selfefficacy were of other ethnicities and those with secondary education discussion summary of findings compatible with the national population composition more malays and chinese are present in the respective malaysia and singapore study populations demographically the singapore study population comprised higher proportions of those who are age 60 years and older who were educated up to secondary level nearly half of the participants from both countries were treated with at least one antihypertensive medication with a significantly higher proportion of those from malaysias study population on three or more such medications in terms of control more than half of singaporean participants attained bp control goals based on jnc 8 guidelines with fewer in malaysia attaining the mark 21 singapores participants in this study had significantly higher mean total htnscp scores in both countries htnscp behaviour motivation and selfefficacy were associated with indian ethnicity and tertiary education the htnscp behaviour score was associated aged 60 years and above in both countries the htnscp motivation mean scores were associated with secondary education level in both countries for malaysia malay ethnicity was associated with higher htnscp behaviour motivation and selfefficacy scores other factors associated with htnscp behaviour and mean selfefficacy scores were of other ethnicity and those with secondary education for singapore women were associated with higher htnscp behaviour mean scores in singapore and htnscp selfefficacy scores in malaysia open access hypertension the impact of selfcare on health outcomes in terms of control threequarter of the singaporean participants in this study significantly attained bp control goals based on jnc 8 guidelines with fewer in malaysia reached the mark the possible explanation could be due to the higher tertiary education background and lesser patients with diabetes among study population from singapore in this study singapore participants attained significantly higher mean total htnscp scores than their counterparts in malaysia these results apply to all the domains of the tool behaviour motivation and selfefficacy nearly twothirds of singaporean participants achieved bp goal versus onethird of those from malaysia these findings were similar to the prevalence of bp controlled to target in populationbased studies 17 those with higher hptscp scores reflects their higher levels of selfefficacy and selfcare selfefficacy empowers them to take on daily selfcare measures to control their bp and reduces cardiovascular risks 22 the higher total hptscp scores in singapore patients may be partly due to its healthcare system and policy 23 it is designed to enable the population to take on higher responsibility to manage their health through coshare healthcare financing comprehensive individual and community empowerment and selfmanagement programmes 24 25 26 nevertheless the implementation of these programmes 27 28 remains challenging with hindrance to reaching out to all patients particularly those with lower health literacy and motivation 29 30 comparing selfcare profiles in this study being of indian ethnicity is associated with better selfcare scores in all hptscp domains for both countries than chinese and malay ethnicities despite good progress in healthcare accessibility ethnic health disparity is still a challenge in both countries while good selfcare will result in better health outcomes studies have shown that the incidence of metabolic syndromes including raised bp is high among indian ethnicity with significant mortality risk in both indian and malay ethnicities 31 32 33 although there may be a potential cultural influence of reporting desirable outcomes among patients of indian ethnicity further exploration may be of value to look at other factors including the role of genetics on cardiovascular outcomes we also found that malay ethnicity in malaysias study population had better selfcare scores in all hptscp domains than singapores study population these findings may be related to ethnicity and medium of language used by healthcare staffs in the primary care setting the majority of malaysian healthcare staff are of malay ethnicity with malay language as the primary medium of communication the similar medium of language used may have eased the access and understanding of health education across all aspect of selfcare provided by the system 34 behaviour mean score was significantly associated with participants aged 60 years and above in both countries older patients with hypertension were reported to be more compliant in their bp monitoring and were more motivated to maintain weight 35 36 the longer duration of diagnosis increased their engagement with the health system over time thus this might improve their knowledge about hypertension and improved their coping skills to manage a chronic condition studies have shown that higher education level is associated with adherence to selfcare activities 30 37 38 as reflected in this studys results being more educated allows people with hypertension to access and understand health information and resources to better manage their health better 11 39 they may be mindful of higher healthcare expenditure if they are hospitalised for hypertensionrelated complications such as stroke and maybe more conscious of the cost of maintaining their health 4 thus those with better education may be more likely to be motivated to adopt selfcare practices to avoid such complications in this study women had a significantly higher mean score for behaviour domain scores in singapore and malaysias selfefficacy studies have found that women are likely to adopt the behaviour leading to favourable lifestyle change and the selfefficacy to monitor their bp 38 40 it has been shown that monitoring bp alone is not enough to improve cardiovascular outcomes 9 selfcare is not just about an individual responsibility to care for their health 41 based on this study selfcare may be supported by the education policy and the healthcare system 23 through better access to education and reducing gaps in health inequalities that is ethnicity and gender holistic management of hypertension is multifaceted including behaviour change approach and raising the motivation level enhancing selfefficacy to actualise selfcare is one prerequisite for costeffective and optimal longterm control of an individuals bp strengths and limitations the unprecedented crossnational comparison of patients with hypertension that shares similar sociocultural background but different economic and health financing environment contributes to this studys strength this is a study of comparison between two populations from two different countries but not a comparison between two countries it adds to the literature on the association between selfefficacy selfcare and bp treatment goal achievement large sample size has enabled indepth analyses of the individual domain of the htnscp this study is not without limitations the crosssectional study design does not allow causal effect relationship to be determined the difference in assumptions resulted in different ways the sample size were calculated in both countries nonresponse rates adopted by the countries affected the sample size in each study the small sample size in one country may inadequately power the study as for recruitment selection bias is inherent for convenience sampling in one study centre suggesting that the results may not be generalisable to the national open access population due to these reasons the htnscp domains mean scores comparison between the two countries must be interpreted with caution we excluded an essential social variable household income due to the differences in how socioeconomic categories being determined in each country malaysia has a national standard to categorise actual household income into three different levels and singapore uses tax payment or housing type to ascertain this conclusion patients with hypertension in singapores study population have a better overall selfcare profile across behaviour motivation and selfefficacy in both study populations being of indian ethnicity and having tertiary education were predictors of higher selfcare scores selfefficacy and skills in selfcare are potentially modifiable future intervention to improve selfcare among people with hypertension may need to be tailored to their behaviour motivation and selfefficacy levels this studys findings may be of interest for public health measures to tackle health inequality in multiethnic settings globally competing interests none declared patient consent for publication not required ethics approval we obtained ethical approval from the medical research ethics committee of the ministry of health malaysia the study was approved by the singhealth centralised institutional review board provenance and peer review not commissioned externally peer reviewed data availability statement data are available upon reasonable request the data used in this study are available from the universiti putra malaysia and singhealth polyclinics these data are not publicly available therefore restrictions apply as to its availability however the datasets during andor analysed during the current study available from the corresponding author on reasonable request and with permission from universiti putra malaysia and singhealth polyclinics supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

comparing and determining factors associated with hypertension selfcare profiles of patients in two multiethnic asian countries crosssectional studies between two study populations

introduction studies in both developed and developing countries has shown that education is an effective strategy to escape from poverty as bettereducated individuals earn higher wages experience less unemployment and work in better occupations than their lesseducated counterparts 1 2 3 though studies on the economic value of education for people with disabilities particularly in developing countries are rare some studies have found education to be crucial not only in increasing the employability of this group but also in improving their occupational options for example by providing the opportunity to obtain whitecollar or fulltime jobs 4 however the value of education for people with disabilities is not widely recognized especially in many developing countries the prevailing belief is still that even if people with disabilities are educated they will be less likely to make use of their education or will not be useful in the workforce 5 one of the major obstacles to challenging this notion is the limited number of empirical studies on disability and the nexus between education and labormarket participation resulting mainly from a lack of credible data this is particularly the case for lowand middleincome countries these countries have indeed significantly limited information on the socioeconomic status of people with disabilities 67 on the other hand return to investment in education has been quantified for nondisabled people since the late 1950s 8 9 10 there have also been numerous studies showing the link between education and employment for females several studies observed that compared to their male counterparts female participation in the labor market appears to depend much on the social environment in the developing countries 11 12 13 this implies that for disadvantaged or marginalized groups such as people with disabilities ethnic minorities females or even merits 2023 3 683 migrants laborforce participation is not only determined by levels of education but is also influenced by discrimination and the support they receive in their direct environment furthermore there are some studies on the labormarket participation of people with disabilities in lmics for example filmer 14 stated that young people with disabilities are less likely to start school and in some countries have lower transition rates resulting in lower attainment this study went on to observe that disability status has a stronger effect on school enrolment and participation than do gender and other socioeconomic statuses likewise mitra and sambamoorthi 15 compared wage disparities between males with and without disabilities in tamil nadu in india their study suggested that differences in education across disability statuses or labormarket discrimination were among the factors accounting for the employment gap between males with and without disabilities they also examined the magnitude and determinants of wage differentials by disability status in the context of an agrarian labor market in india 16 as a crosscountry analysis mizunoya and mitra 17 examined differences in employment rates between persons with and without disabilities in 15 developing countries and showed that people with disabilities have lower employment rates than persons without disabilities in nine countries there have been some studies examining the return to investment in education for people with disabilities hollenbeck and kimmel 18 performed studies in the us lamichhane and sawada 19 for nepal albert et al 20 for the philippines pinillaroncancio et al 21 for latin american countries and tiwari 22 for subsaharan africa stern 23 examined the problems of measurement and endogeneity when creating a definition of disability for censustaking purposes while deleire 2425 and hotchkiss 26 investigated employer discrimination in the labor market the above study in nepal 19 provides evidence on the return of education for persons with disabilities by over 193 percent their estimated return is significantly higher than that of their nondisabled counterparts 27 but none of the studies have considered gender and disability in estimating the return of education although the literature has shed light on many aspects of disability education and employment in the developing world studies examining the laborforceparticipation gap between males and females with disabilities are rare labormarket participation of females with disabilities is challenging due to the possible double disadvantage they face first as females and then as females with disabilities merits 2023 3 for peer review 2 or even migrants laborforce participation is not only determined by levels of education but is also influenced by discrimination and the support they receive in their direct environment furthermore there are some studies on the labormarket participation of people with disabilities in lmics for example filmer 14 stated that young people with disabilities are less likely to start school and in some countries have lower transition rates resulting in lower attainment this study went on to observe that disability status has a stronger effect on school enrolment and participation than do gender and other socioeconomic statuses likewise mitra and sambamoorthi 15 compared wage disparities between males with and without disabilities in tamil nadu in india their study suggested that differences in education across disability statuses or labormarket discrimination were among the factors accounting for the employment gap between males with and without disabilities they also examined the magnitude and determinants of wage differentials by disability status in the context of an agrarian labor market in india 16 as a crosscountry analysis mizunoya and mitra 17 examined differences in employment rates between persons with and without disabilities in 15 developing countries and showed that people with disabilities have lower employment rates than persons without disabilities in nine countries there have been some studies examining the return to investment in education for people with disabilities hollenbeck and kimmel 18 performed studies in the us lamichhane and sawada 19 for nepal albert et al 20 for the philippines pinillaroncancio et al 21 for latin american countries and tiwari 22 for subsaharan africa stern 23 examined the problems of measurement and endogeneity when creating a definition of disability for censustaking purposes while deleire 2425 and hotchkiss 26 investigated employer discrimination in the labor market the above study in nepal 19 provides evidence on the return of education for persons with disabilities by over 193 percent their estimated return is significantly higher than that of their nondisabled counterparts 27 but none of the studies have considered gender and disability in estimating the return of education although the literature has shed light on many aspects of disability education and employment in the developing world studies examining the laborforceparticipation gap between males and females with disabilities are rare labormarket participation of females with disabilities is challenging due to the possible double disadvantage they face first as females and then as females with disabilities therefore this paper aims to at least partially fill this gap in existing knowledge by comparing the estimates for the wage return of education for males and females with disabilities in the philippines the central research question posed in this paper thus is empirical does gender have any effect on the return to investment in education for persons with disabilities we believe that the empirical work in this paper will help governments and other concerned authorities design policies to mitigate poverty among females with disabilities who are regarded as one of the most underserved groups there are some important features of this study to begin with we use the data from persons with hearing physical or visual difficulties living in metro manila in the philippines the dataset was jointly collected by the institute of developing economies and the philippine institute for development studies using carefully structured questionnaires the philippines was ranked 116th in human development in 2021 28 and is behind in many of the humandevelopment indices but surprisingly the situation of females in general is favorable even compared to other developed countries according to the global gender gap report by the world economic forum 2022 29 the philippines is among the top five countries in the world for female rate of participation in economic activities female educational attainment political empowerment and access to other opportunities the philippines has kept a higher rate of participation by females in the labor market than that of other countries in asia due to this unique situation for females in this country we are interested to see if the situation of labormarket participation is same for females with disabilities compared to their male counterparts furthermore to carefully check the dual effects of gender and disability on the returns to investment in education various methods of estimation are utilized first estimations are completed with standard ordinary lest squares and type1 tobit where education is defined as a continuous variable and an interaction variable with sex and each disability is also included second redefining education as a discrete variable we examine the role of the signaling effect in the returns to education similarly we employ quantile regression for each conditional quantile wage group rather than the mean regression analysis which enables us to address the more detailed relationship between schooling and wage and in particular to check whether schooling would have an impact within levels of wage inequality or not beyond these methodological aspects the topic of this study itself can be regarded as important as stated above to the best of our knowledge there are no studies examining whether gender has any effect amongst persons with disabilities participating in the labor market on obtaining wage return to investment in education while it is generally accepted that females with disabilities face a double disadvantage first as females and then as persons with disabilities the higher rate of females participation in the philippiness labor market indicates that there is no negative effect of gender for the general population in this context it is therefore important to examine whether disability has any negative effect on females labormarket outcome we hypothesize that the higher rate of labormarket participation by filipino females is not mirrored by females with disabilities it is plausible that due to the impairment parents put less faith in their children with disabilities and thus give them a lower priority for education compared to their children without disabilities consequently females with disabilities suffer from having fewer years of schooling which may result in the lower wage return of education compared to their male counterparts with disabilities studies such as lamichhane and takeda 30 have shown that parents positive understanding of their childrens disability is correlated to further years of education when we are in the middle of implementing sustainable development goals building human capital for females with disabilities should be given equal footing as other central development goals from this perspective this study is relevant in providing important new insights regarding the role of education in the labormarket participation of females with disabilities the structure of this paper is as follows section 2 presents the dataset from the philippines section 3 describes the empirical strategy the results and findings are discussed in section 4 and finally in section 5 the concluding remarks are presented dataset from metro manila in the philippines we use a dataset on disability collected jointly by ide in japan and pids the field survey was conducted in metro manila in the philippines in august 2008 metro manila is the capital of the philippines which is composed of units of seventeen cities called local government units among the seventeen lgus makati pasay quezon and valenzuela were selected for this survey they represent a spectrum of metro manila the basic data for the sample was randomly selected in metro manila each city has many villagestowns which are called barangays in the philippines a barangay is the minimum political unit for the philippine government system the population of each barangay varies respectively importantly each of the cities had enough people with disabilities and that includes those with hearing physical and visual impairments so after making a special unit for this survey with the same population size as these barangays the survey team performed the random selection of the units the ide and pids collected the data on disability acknowledging that the philippines do not have complete registers of pwds 31 considering some possible flaws in the potential sampling frames the surveymanagement team of ide utilized the verified national statistics office list supplemented by the lgu lists the initial list of pwds prepared by nso based on the 2000 cph results were verified by the lgu partners with the help of the research staff from the pids lists of pwds from lgus are basically administrative registers that have recently been developed by the local socialwelfare units which take the lead in the provision of services to pwds within the locality a total of 360 pwds were targeted to be sampled through the assistance of the nso 120 pwds represented each of the three types of impairment in this survey physical impairment refers to loss of one legfoot or both and quadriplegic is loss of one armhand or both visual impairment refers to total or partial blindness or low vision hearing impairment refers to total or partial deafness or hard of hearing for the sampling operations neighboring barangays in each of the four cities were formed into groups of barangays in such a way that each group of barangays would have at least 300 of the targeted pwds residing in those areas this then comprised the primary sampling units at least five psus were designed to be selected within each city with probability proportional to the total number of pwds ten to fifteen pwds were to be selected within each selected psu taking into account the expected nonresponse and migration of pwds as well as the proposed sampling design the nso was tasked to assist in drawing a list of 900 total possible respondents and the targeted 300 pwds for each type of impairment were distributed across the four cities based on the structured questionnaires the survey team interviewed a total of 403 respondents 125 in makati city 122 in quezon city 84 in pasay city and 72 in valenzuela city the survey covers a wide variety of questions including demographic education and labormarketrelated information together with information on disability questions were also included to capture the information of other members of the household of the respondents prior to the implementation of the final survey the questionnaire underwent scrutiny from the statistical survey review clearance system which is undertaken by the technical committee on survey design of the national statistical coordination board ssrcs is a mechanism through which all surveys and censuses are to be conducted by or for all government units in the philippines out of 403 participants we used information on 365 respondents with hearing physical and visual impairments to clearly investigate the gender effect in disability in the labor market of the philippines we have excluded some participants from our analysis on the basis that information was missing some are excluded as the participants had multiple impairments table 1 shows the descriptive statistics of the total of 365 participants they ranged in age from 15 years to 67 years with the average age of 378 years the majority of the respondents were male and the remaining 38 percent were female the disabilities of the participants were classified into three categories hearing physical and visual impairments among the respondents 29 38 and 33 percent had hearing physical and visual impairments respectively participants completed the average of 843 years of schooling and males with disabilities on average completed more schooling than females 877 and 787 years respectively irrespective of the type of impairments only a small percentage of participants completed their college level of education our results highlight the difference between females with and females without disabilities females with disabilities are less likely to achieve more education than those without disabilities who are shown to have equal levels of education to their male counterparts in the philippines 32 moreover we also observe wage difference between them the average wage for females is php 50216 while it is php 67167 for males additionally figure 2 presents them in a bar chart that shows the magnitude of the gender gap the data also include information on the age of onset for the three types of impairment revealing that the average age of onset of physical and visual impairments is 231 and 262 years respectively hearing impairments were categorized according to the linguistic approach ie born deaf before 3 years old or after 3 years old the survey also reveals that 33 30 19 and 18 percent of the respondents were from makati quezon valenzuela and pasay respectively centage of participants completed their college level of education our results highlight the difference between females with and females without disabilities females with disabilities are less likely to achieve more education than those without disabilities who are shown to have equal levels of education to their male counterparts in the philippines 32 moreover we also observe wage difference between them the average wage for females is php 50216 while it is php 67167 for males additionally figure 2 presents them in a bar chart that shows the magnitude of the gender gap the data also include information on the age of onset for the three types of impairment revealing that the average age of onset of physical and visual impairments is 231 and 262 years respectively hearing impairments were categorized according to the linguistic approach ie born deaf before 3 years old or after 3 years old the survey also reveals that 33 30 19 and 18 percent of the respondents were from makati quezon valenzuela and pasay respectively empirical strategies mincerian wage equation with continuous education to establish the empirical settings the return of education is estimated and we define education firstly as a continuous variable using the following equation to regress log earnings on years of schooling log w i α ρs i βx i δ k y ik ε i the equation is a standard mincerian wage equation used by the existing studies 389 with an underlining assumption that the return on schooling is the same for different attainment levels starting with the ols model of earning functions for male and female respondents a linear relationship is specified in equation where logw i is the log of individuals earning and α is the intercept this equation is added to s i years of schooling ρ represents the returns to education ie how much the wage rate increases in response to an additional year of schooling x i is a set of covariates for each person β is its coefficient to be estimated and ε is an error term using these specifications we obtain baseline estimations however one of the potential econometric problems is that the crosssectional correlation between education and earnings may differ from the causal effect of education owing to the correlation between the years of education and the error term that involves unobserved factors such as abilities in order to mitigate endogenous concerns in this context with gender and disability we employ the following steps first three main disabilityspecific dummy variables for each gendervisual hearing and physical impairmentsare included to carefully identify disparities between males and females with disabilities y ik is a set of dummy variables with males with visual impairments as the baseline and y i1 and y i2 representing hearing and physical impairments in males respectively y i3 y i4 and y i5 represent visual hearing and physical impairments for females respectively second as establishing schooling effect is difficult and the existing studies have shown the possibility of inconsistent parameter estimation due to schooling years which may be endogenous the use of instrumental variables is preferable for credibility 83334 in examining return of education there are several candidate instruments for example using familybackground variables is one of the credible instruments and trostel et al and söderbom et al used parents educational levels 3536 for disability and return of education the age at which the individual became impaired can be utilized as an instrumental variable lamichhane and sawada controlled for endogenous bias arising from years of schooling and decisions by employing this novel instrument 19 we use parents years of education as the family background in our iv estimation in our iv strategy we did not use the age at which the individual became impaired because in this dataset the onset year for those with hearing impairments is classified as birth before 3 years old and after 3 years old and thus the age at which a person became impaired is not obtained however this classification is not suitable for our analysis another econometric consideration is that of sampleselection bias since many people with disabilities are unemployed in the philippines we cannot ignore the endogeneity problem arising from labormarket participation decisions in order to control for the sampleselection bias we employed amemiyas type 1 tobit model with endogenous regressors 37 however we acknowledge that we do not have a control for general health conditions which may affect females more than males discontinuous wage earnings and the signaling effect the return of education does not necessarily increase in a continuous linear fashion there is a possibility of discontinuous increases or decreases in wages we also define another equation that is different from the mincerian earning function described in section 31 and as the model relaxes as does the assumption of the linear return of additional years of education in this analysis we also check the signaling effect in the return of education and determine whether the possibility of obtaining a diploma serves as a signal of productivity or not the signaling model 38 39 40 suggests that being certified as having completed an educational course is likely to reveal more to an employer about a workers ability and productivity than a record of how many years the person has attended classes the studies mentioned in section 3 above have clarified the signaling effect a smaller body of literature compares the signaling effect for persons under double disadvantage some of them have focused on the socially disadvantaged people mentioned in section 32 however to the best of the authors knowledge none of the papers have examined the signaling effect focusing on double disadvantage arising from gender and disability especially in developing countries the analysis in this section provides another insight which is different from section 31 if the general model of signaling is reasonably linked with the difference in finding jobs and earning wages or promotions it is expected that the return for females with disabilities becomes higher if they obtain diplomas rather than drop out while males with disabilities who are still considered to be favorable by the labor market may enjoy a constant level of return even if they drop out thus we also check whether obtaining diplomas has a different effect on wages for males and females with disabilities hungerford and solon 41 proposed two earning factions to be formulated in order to capture any possible signaling effects first choice is the spline function which assumes that log earnings for any given amount of schooling grow linearly while the inclination of the earning rates depends on the level of education completed ie elementary school high school or university the other choice is the use of the step function that treats log earnings as a function of years of education with a separate step for each year without specifying particular function forms for more flexibility setting a step function for our analysis we first classify each educational level to check the possibility of nonlinearschooling return for respondents then we classify 10 groups according to the educational attainment for each gender to address the extent to which the return changes discontinuously based on the categories below 1 individuals with no education 2 individuals who do not complete either elementary or high school 3 individuals who graduate from elementary or high school and obtain either diploma 4 individuals who do not complete higher education such as college university or graduate school and 5 individuals who graduate from college university or graduate schools using the above classification we add this new specification d is designating females with no education as the baseline and using educationallevel dummy variables to measure the effect of both higher and lower levels of education in equation below log w i α φ s d is βx i γ k i ik ε i where the dependent variable is the natural logarithm of annual earnings and the data on highest qualifications enable the dummy variables to be defined for both males and females of particular interest for us is whether there exists any difference between the effects of lowerhigher certificate dummies and notcompleted dummies unlike most studies the signaling effect in our analysis is not estimated indirectly from nonlinear wage return to years of schooling that correspond to the usual time taken to complete a qualification as such methods are likely to be biased by measurement errors 42 the carefully structured questionnaires used by this papers directly ask respondents whether or not they completed school and if so the level from which they graduated which enables us to directly search for the signaling effect ϕ s coefficients estimate the marginal effect of each level of education as based on the excluded group that has no school qualifications the effects of disabilities are classified as follows γ k γ 1 is for visual impairments γ 2 for hearing impairments and γ 3 for physical impairments if empirical findings result in showing the signaling effect we may conclude that there possibly exists imperfect information between employers and employees with disabilities quantile regression finally the last part of our analysis deals with wage inequity separately among males and females with disabilities while estimating how school resources on average affect educational outcomes yields straightforward interpretations this study investigates wage dispersion by employing the quantile regression approach since the quantile regression approach analyzes the relationship between the conditional distribution of the response variable and the set of covariates it offers more detailed insights into the effects of these countermeasures than the mean regression model it could be the case that these dispersions vary across educational levels which results in an impact of schooling upon the wage distribution through its inner channel following martins and pereira 43 the quantile regression model is written as equation log w i β θ x i u θi with quant θ β θ x i where x i is the vector of exogenous variables and β θ is the vector of parameters quant θ denotes the θth conditional quantile of logw i given x i the θth regression quantile 0 θ 1 is defined as a solution to the problem that follows min β∈r k ∑ i ρ θ where ρ θ is the check function defined as ρ θ θ ε if ε 0 or ρ θ if ε 0 this can be solved using linear programming and standard errors are calculated using bootstrap methods 44 we obtain the estimates for different quantiles by setting the first quantiles as 025 second as 05 and third as 075 the empirical results are obtained by replacing the coefficient equations and as the coefficient defined in equation above eg the standard mincerian wage equation is replaced by the following log w i α ϑ ρ θ s i β θ x i δ θ y ik ε i where θ 025 05 075 are the quantile for our analysis unlike ols the quantile regression model allows for a full characterization of the conditional distribution of the dependent variable results and findings the results for the mincerian wage equation on continuous education table 2 summarizes our estimated results of wage earning equations modeled by section 31 with the first specification based on ols estimates column 1 and 6 of table 2 and shows a 249 percent rate of return of education which is relatively higher than those for persons without disabilities as was explained in previous studies such as psacharopoulos and patrinos 27 however these returns are consistent with the returns for persons with disabilities as shown in developing countries 19 and developed countries 18 while controlling for the endogenous sampleselection bias using the tobit model and the estimated returns of education become slightly higher in addition the range for iv ols and iv tobit become slightly high and in the test of endogeneity a durbinwuhausman test shows the possibility of schooling years being endogenous the sargan test has been used for overidentification and we do not thus reject the overidentifying restrictions although the partial r squared is around 008 and this casts concern over the strength of the instruments an f statistic over 10 suggests the instruments are strong next to estimate the effect of double disadvantages we categorize each impairment type for males and females and classify the gender dummy variable and the interaction dummy variable for both male and female respondents with visual hearing or physical impairments we provide the point estimate of these dummy coefficients in table 2 as visual impairment and males visual impairment are used as base outcomes a comparison of the coefficients of different dummy variables among the different estimations in ols imply that females have more negative coefficient and females with physical impairments are most seriously and negatively affected in the labor markets the second most severely affected are females with hearing impairments while coefficients of both males and females with visual impairments are not statistically significant this is consistent with the casual observation that there exists a lot of barriers in the labor market in developing world lamichhane 45 showed that students with disabilities face problems such as inadequately available materials in sign language or braille or in the case of those with physical impairments inaccessible buildings lamichhane and okubo 4 further discussed the labormarket participation of people with disabilities in nepal and the role of education and found that people with physical impairments have lower levels of labormarket participation than their visually impaired counterparts and argued that disabling barriers were the most serious constraints for these people our findings in the philippines suggest that the situation is likely the same as long as disabling barriers are not removed through the provision of facilities for communication including sign language and other supports based on the reasonable accommodations outlined in the convention on the rights of persons with disabilities education alone may not be sufficient particularly for those who have severe impairments on the other hand our findings observe the decreased likelihood of persons with visual impairments getting a job regardless of gender status this finding is different from those reported by lamichhane and okubo 4 and lamichhane 46 in nepal where teaching has been promoted by the governments affirmative action plans as a main job for educated individuals with visual impairments this study indicates that some kinds of jobs that are promoted by the governments affirmative policies may not be available for this group in the philippines from the questionnaires for this survey on the particular job distribution for each respondent with impairments we find that a large portion of participants with visual impairments work in the massage and acupuncture sectors the findings are that around 65 percent of persons with visual impairment work as masseurs while persons with hearing and physical impairments were unable to find any particular jobs a similar situation is reported in the country report of philippines which identifies massage as a dominant source of employment for people with visual impairments 47 the figures in parentheses are robust standard error the coefficients with and are statistically significant at respectively the 001 005 and 010 levels of probability specifications and are based on the firststage regression and the default category dummy 1 if visually impaired in dummy 1 if visually impaired male in and dummy 1 if in the pasay area in specification in the variable names represents interactions the results for discontinuous wage earnings and the signaling effect the findings of discontinuous wage earnings in the return of education are shown in table 3 as defined in section 32 we relax the assumption of linear educational returns and categorize each educational level in order to check the possibility of nonlinearschooling return for whole respondents subsequently we use the lower and higher educationaldiploma dummy variables when they graduated and obtained diplomas and notcompleted dummy variables eg when a person leaves school during the lower or higher educational stage before obtaining a diploma for both male and female 3 and table 3 compares different characteristics of the level of educational specifications and several points emphasizing the results in each educationallevel setting we observe the clear difference of educational returns and next we check the differences using an educationaldiploma dummy and notcompleted dummy variables based on females with no education the coefficients of levels of education for females are only positive and statistically significant at least when their educational attainment is either of a lower or higher diploma if they do not complete these educational levels the same result cannot be obtained second the coefficients on levels of education for males are always positive and statistically significant even if they drop out before obtaining a diploma third the increasing of educational returns indicates a convex relationship between education and wages moreover coefficients at all education levels are still significantly higher for males than females except at the lower diploma level when the tobit model is employed the equivalent results are obtained alike considering all of these findings it can be argued that the disadvantage might be profound for females with disabilities as it is observed that obtaining a diploma may reduce asymmetric information while not completing school does reduce earnings for only females which may be a barrier that excludes females with disabilities from participating in the labor market furthermore the result for males with disabilities in our analysis is consistent with the existing literature as schady 48 found the convexity and the signaling effect in earning function for filipino males these findings lead to further questions about the possibilities for filipino females this is important to address because the philippines represents a unique case in which females receive more schooling than males the results for quantile regression we present the results of the quantile regression on sections 31 and 32 for the models of continuous educational returns and the other model of educational attainment levels which relax the assumption of a linear increase in wages in table 4 we show the regression results of the specified quantiles ie 025 050 and 075 the findings of our analysis provide several characteristics of returns to education and the effect of gender in disabilities on conditional wage distribution which appear in the quantile regression we first show the estimations of quantile regression with gender and each disability dummy variables to check the possibility of inequality within levels the estimation of schooling years varies from 42 percent at 25 decile to 1006 percent at 75 decile in specification then we present the results of the coefficients of quantile regression estimates corresponding to equation in section 31 as reported above in section 31 the average estimated educational return is 204 percent whereas the return at 025 decile reaches 297 percent and 104 percent at 075 decile in specification we observe that returns to educations are higher at lower points of the conditional wage distribution this suggests that there is heterogeneity in the return of education which is larger for individuals at the lower quantile of the conditional wage distribution this result is not yet well explained by the existing literature most of which reports that schooling returns are higher for the more educated and more skilled individuals 42 from another angle we would say that lowerwage workers achieve more educational returns another important finding regards the disparity of the coefficients on disabilities dummies for males and females using the ols as baseline we see the huge difference between each quantile at different points of the wage distribution at the lower end of the distribution the most severe case is found for females with physical impairments for whom the coefficient is statistically significant and which is below the estimate of average estimated returns in section 41 while the least severity is observed at the top of the conditional distribution the similarity of findings is also consistent for the other impairment groups regardless of gender likewise our analysis shows the coefficients of quantile regression estimates corresponding to equation in section 32 as discontinuous wage earnings a remarkable finding is the coefficient of each educational level at the 025 quantile the coefficients for males in each education level are relatively larger and significant for the bottom tail of the distribution than the estimates from 32 the coefficients for females are only larger and statistically significant when obtaining lower or higher diplomas an implication of our results is that the signaling effect may appear for the lower part of the conditional distribution which implies that the effects of asymmetric information tends to increase in the lower conditional distribution concluding remarks in this paper we estimate the gender effect on return to investment in education among individuals with hearing physical and visual difficulties in the philippines after adjusting for sample selection to address endogenous labor participation and accounting for the endogeneity of schooling decisions our estimations indicate a remarkably high rate of returns of education ranging from 249 to 384 percent however upon classifying disability dummy variables for each gender we observe a compounded effect of double disadvantage in the labormarket participation of females with disabilities furthermore our examination of the potential nonlinearschooling returns suggests that the impact of disability is more pronounced for females compared to their male counterparts these findings point to the existence of a double disadvantage and signaling effect for females with disabilities moreover the wage disadvantage associated with disability and gender is disproportionately distributed within the population while return of education is higher at lower points the coefficients on disability dummies for females are more severe at the lower end of the distribution the sizable gender gap in the laborforce participation for females with disabilities after education indicates that education alone cannot translate into labormarket returns in the same way as they do for male counterparts our research therefore underscores the importance of not only enhancing educational opportunities but also significantly improving employment prospects particularly for females with disabilities this necessitates the implementation of equal opportunity provisions such as antidiscrimination measures an expansion of the quota system to enhance employment prospects addressing accessibility issues and subsidizing private sector employment additionally our study highlights the importance of adopting an intersectionality framework as posited by brown and moloney 49 females with disabilities face greater workplace disadvantages compared to males with disabilities and those without disabilities irrespective of gender in recent years there has been an increased awareness of intersectionality emphasizing the urgent need to understand and address the multiple forms of inequality and discrimination arising from both disabilities and gender it is crucial not to overlook these aspects in the formulation and implementation of policies aimed at increasing labormarket participation for females with disabilities 50 finally our study is limited to the urban area of the philippines with a dataset comprising only persons with disabilities therefore we suggest further research in this area utilizing a nationally representative dataset considering the washington group on disability statistics instruments including the recently developed washington groupilo disability module as lamichhane et al 51 emphasized efforts should be made to design surveys allowing data disaggregation by disability status and a range of contextrelevant demographic characteristics and equity dimensions to gain a deeper understanding of labormarket gaps by disability and gender data availability statement the data presented in this study are available on request from the corresponding author author contributions conceptualization kl methodology tw software tw validation kl and tw formal analysis tw investigation kl and tw data curation kl and tw writingoriginal draft preparation kl writingreview and editing kl and tw visualization tw supervision kl and project administration kl all authors have read and agreed to the published version of the manuscript funding this research received no external funding institutional review board statement this survey was approved by the national statistical coordination board of the philippines under nscb approval no pids081501 it is important to note that nscb has later merged into the philippine statistics authority establishing the legitimacy of the survey as recognized by the philippine statistical authority further details on this organizational change can be found here furthermore the survey adheres to ethical principles to safeguard the privacy and rights of the participants participants were informed that their involvement in the survey is entirely voluntary and they may choose to participate or withdraw without facing any negative consequences furthermore it is essential to emphasize that any information provided by the respondents will be treated with the utmost confidentiality the collected data will be used exclusively for research purposes only and respondents identities will not be disclosed in any document resulting from this survey informed consent statement informed consent was obtained from all subjects involved in the study

utilizing a dataset from metro manila in the philippines we estimate the impact of gender on the return of education for individuals with disabilities specifically focusing on visual hearing and walking difficulties controlling sample selection to address endogenous labor participation and accounting for the endogeneity of schooling decisions our estimations reveal a significant rate of return to education ranging from 257 to 381 importantly examining the potential for nonlinearschooling return we observe a more pronounced effect of disability for females compared to their male counterparts suggesting the presence of dual discrimination and signaling effects for females our research emphasizes the urgency for the philippine government to not only improve educational opportunities but also to enhance employment prospects particularly for females with disabilities some of the policy recommendations would include the implementation of equalopportunity measures including antidiscrimination policies an expanded quota system to boost employment opportunities efforts to address accessibility issues and subsidies for privatesector employment are also necessary for the economic empowerment of females with disabilities

introduction our understanding of how disease knowledge and many other phenomena spread through a population can often be improved by investigating the populations social or other contact structure which can be naturally conceptualized as a network in the case of human populations this contact structure is often gathered through the use of questionnaires or surveys that typically ask respondents to name some of their contacts generating populationlevel network structures from such data requires one of two possible approaches one approach is to delineate a population of interest interview every person in the population and collect unique identifiers for each respondents contacts this allows the mapping of the true sociocentric network within that population the alternative is to sample the population of interest and collect information about each respondent and his or her contacts this results in a collection of egocentric networks from that population either approach enables the extraction of network features that can be used to fit a graph model such as one of the models in the family of exponential random graphs which allows the subsequent generation of network graphs consistent with the fitted features of the observed networks the features that may be extracted from egocentric networks are however quite limited making sociocentric networks the preferred design resources allowing both egocentric and sociocentric approaches can place a considerable burden on the respondent to recall numerous contacts and describe each in detail as a result most sample survey questionnaires in both egocentric and sociocentric designs limit the contacts sought from a respondent for example by the content intimacy level geographic location or time frame of the relationship elucidated a common method is to limit the number of contacts a respondent describes this may be done directly eg by asking who are your five closest friends with whom you regularly socialize it may also be done indirectly eg by asking who are the friends with whom you socialize but then only asking followup questions about the first five named a lesscommon variant of the second approach is for the interviewer to ask followup questions on a random subset of named contacts all of the above approaches potentially lead to truncation of the number of observed contacts there is longstanding concern within the sociological literature that such truncation might affect estimates of network properties including various forms of centrality however there are countervailing resource and data quality benefits to avoiding respondent and interviewer fatigue via truncation while investigating the effect of degree truncation on observed structural properties of networks is an important problem substantive interest often lies in making inferences about how a dynamical process on the network such as the spread of an infectious disease might be affected by truncation surprisingly while both the impact of degree truncation on structural properties of networks and the impact of structural properties on the spread of a dynamic process through a networked population have been investigated the joint implications of the two processes have not yet been elucidated to integrate key ideas from the two corpora we review first the literature on the impact of truncating reported contacts on structural network properties and second the literature on the impact of structural network properties on spread dynamics to arrive at hypotheses regarding how truncation might change expected spreading process outcomes while our work is motivated by epidemic disease processes our analysis should be applicable to any process that can be modeled using compartmental models of a spreading process we test the predictions of our hypotheses with simulation models using both synthetic structured networks and empirically observed networks spreading processes on networks can be modeled on ensembles of networks using ergms or in a bayesian framework however using this modeling approach to explore the impact of truncation would conflate two processes the truncation process and the network generation process in order to focus on the former we generate multiple realizations of synthetic fullnetwork datasets with specific network properties and additionally utilize a collection of empirically observed sociocentric networks that can be interpreted as multiple network realizations from a larger metapopulation as a result we are able to isolate the effect of degree truncation and explore its impact on predictions of spreading processes on networks with very different structural properties the impact of contact truncation on structural network properties limiting the number of connections reported by a respondent is known as a fixed choice design this limitation rightcensors an egos outdegree in sociocentric studies outdegree truncation may in turn reduce the indegree of others because some true incoming ties may end up unreported due to the constraints on outdegree sociocentric networks are commonly analyzed as undirected networks in which an edge exists between two nodes i and j if either node reports it in such an undirected network each nodes total degree will consist of the union of all indirected and outdirected nominations fcd causes this total degree to be lowered in some circumstances specifically when both i and j fail to report edge e ij between them this can occur only when k i and k j are both larger than k fc the fcd truncation value and thus both potentially will not report e ij if k i and k j are both larger than k fc then whether e ij is observed will depend on how fcd is carried out fcd can be conducted in two ways as outlined above the morecommon approach of focusing on the first k fc or fewer names reported is likely to lead to bias towards stronger contacts since stronger ties are likely to be more salient to a respondent here e ij is more likely to be reported if it has higher weight this approach should thus maximize the proportion of a respondents social interactions that is captured the lesscommon approach of drawing a random subset of all named contacts will provide a broader picture of the types of contacts a respondent hasnotably increasing the chance of observing weak tiesat the cost of observing a smaller proportion of the respondents total social interaction here whether e ij is observed depends on chance a body of research has highlighted the substantial impact of sampling on network structural properties for example a recent study of nine different sampling methods found substantial variability in their ability to recover four structural network characteristics fcd is known to impact several network characteristics but its effects depend on the structure of the complete network graph we consider next some key properties degree distribution and assortativity fcds impact on the network degree distribution is almost always to reduce its meaninsofar as edges are droppedand varianceinsofar as higherdegree nodes will be forced to underreport outgoing edges flattening the distribution this latter published online by cambridge university press effect will be strongest in degreeassortative networks where both ends of an edge may be unable to report the connection in contrast in degreedisassortative networks then edges that might be censored by the highdegree end are likely to be maintained by the lowdegree end fcd may therefore significantly affect human contact networks which are typically somewhat degreeassortative degreeassortativity itself is not systematically affected by fcd unless individuals preferentially report stronger connections and ties between individuals of similar degree are more likely to be strong in which case fcd may raise degreeassortativity clustering local clustering can be measured in at least two different ways triadic clustering the mean of local clustering coefficient c i where c i is the proportion of all the possible edges between neighbors of node i that are present focal clustering the level of global triadic closure that is the ratio of triangles to paths of length two clustering can also occur at higher levels of aggregation for example in the presence of network communities where loosely speaking the density of edges within a set of nodes belonging to a community is higher than the average density of edges across the whole graph unweighted fcd truncation should reduce clustering at the triadic and community levels as it effectively results in random edge removal when truncation is weighted however fcd might lead to an increase in clustering if withincluster edges are stronger than others they are more likely to be preserved path lengths in removing ties unweighted fcd will reduce the fractional size of the largest connected component s lcc and will often increase the average path length between nodes of the lcc lcc insofar as the increased length between some pairs of nodes due to loss of edges is not offset by reductions in length due to peripheral nodes being dropped altogether from the lcc these results are seen asymptotically for random and power law graphs and via simulation of edge removal on empirical networks if fcd is weighted this second factor will be stronger as peripherally connected nodes are preferentially dropped from the lcc the impact of structural network properties on spreading processes there is a burgeoning literature on the effect of various network properties on spreading process outcomes we consider three key spreading process quantities focusing on two aspects of an epidemic the early stage and the final state to simplify our analysis we follow the tradition in this literature and focus on models that assume degree infectivity where an infectious individual can infect all their neighbors in just one time step rather than unit infectivity where they can only infect one of their neighbors per time step quantity one is the basic reproduction number r 0 the number of new incident cases arising from each currently infected individual in a fullysusceptible population r 0 is defined as a function of β the product of the probability of infection per period and the number of contacts per period and ν the rate at which individuals recover in a homogeneous massaction model for an infection where recovery leads to immunity ie a susceptibleinfectedrecovered model r 0 βv where r 0 1 ensures a large epidemic with nonzero probability quantity two is the initial exponential growth rate of an epidemic r 0 this growth rate is conceptually equal to β in the first period but thereafter is not welldefined analyticallyeven in homogenous models it is typically measured empirically as the second moment of the epidemic curve in its initial growth phase quantity three is the attack rate a the proportion of the population ever infected under assumptions of population homogeneity relatively simple solutions can be found for key network properties however these results rarely hold with nontrivial network structure we consider how key structural network properties impact the above spreading process quantities degree distribution and assortativity r 0 can be viewed as the average number of edges through which an individual infects their neighbors across the whole period of their infectiousness if all their neighbors are susceptible the probability of infection for each node can conversely be conceptualized in terms of their degree and their neighbors infection statuses the more degreeheterogeneous a network is the higher the likelihood of a large epidemic occurring since r 0 is a function of the first and second moments of the degree distribution similarly higher degreeassortativity increases the expected epidemic size since the probabilistic threshold for epidemic takeoff has a lowerbound of the average degree of nearest neighbors this is intuitive since the number of ones neighbors bounds the number of infections one can generate conditional on the number of nodes and edges in a network degreeassortative networks will have a faster initial growth rateoccurring within a dense core of highdegree nodesbut a lower attack ratedue to having longer paths to peripheral lowdegree nodes where chains of infection are more likely to die out clustering for any given degree distribution triadic clustering reduces the average number of infections each infected person causes r e this reduction is due to newly infected individuals having fewer susceptible neighbors the contact who infected you is likely also have had the opportunity to infect your other contacts this will slow the epidemic growth rate r 0 since newly infected individuals in clustered networks have fewer susceptible alters and while not lowering r 0 clustering will increase the epidemic threshold in the same manner that a fall in r 0 would in many networks for a given network density increased clustering also leads to a smaller s lcc which necessarily reduces the maximum possible attack rate although this result appears to be a byproduct of clustering leading to increased degreeassortativity overall cliques alone appear to have marginal effects on epidemic dynamics however the processes which drive clique formationsuch as homophily by nodal attributes or geographic proximitymean that networks displaying clustering also often contain topological features such as degreeassortativity or heterogeneity that do significantly affect epidemic as a result processes on clustered networks can look very different from those on nonclustered ones broader community structure acts in much the same fashion as cliques reducing r 0 due to limited capacity to pass infection from one community to the next although epidemics are unhindered or even sped up by intercommunity ties when communities are overlap path lengths although networks with increased lcc will often have lower r 0 much of this effect is due simply to lower network density for lccs of equal density high lcc is likely to be due to a dense core with long peripheral arms in such a scenario r 0 will be high once the epidemic reaches the core but will take longer to reach all parts of the lcc however since random spreading processes rarely follow shortest paths between any two nodes the shortest path typically underestimates the length of the path taken by a spreading process since truncation inflates the length of observed shortest paths the shortest path seen in truncated networks may paradoxically more closely reflect actual path lengths taken than those observed in fully observed networks as a result the lower r 0 predicted from truncated networks may in fact be more accurate potential impact of degree truncation on spreading processes based on the above results we formulate some initial hypotheses about the likely impact of outdegree truncation on predictions of the behavior of spreading processes on the resulting network first and foremost truncation will reduce the number of edges in the network since some edges are now not observed this leads to a reduction in mean degree and is likely to increase average path lengths and reduce the size of the s lcc as a result both r 0 and a will be reduced the reduction in r 0 may however be offset by reduced variance in degreesince outdegree variance is strictly reduced by truncation and indegree variance is likely to drop too second degree truncation by tie strength may lead to an inflation of degreeassortativity if assortative ties are stronger on average and thus more likely to be preserved this should lead to smaller faster ending epidemicsespecially if assortativity is created by preferentially dropping coreperiphery links finally degree truncation by tie strength will have an unpredictable effect on clusteringdepending on the fig 1 schematic of study methodology for synthetic networks 100 degree sequences were generated for the karnataka village data 75 empirical village datasets were used and step 2 skipped each degree sequence was converted into a network graph using the configuration model and then each synthetic graph was calibrated based on target network values all networks were truncated at twice mean mean and half mean degree 100 spreading processes were run across each full and truncated network relationship between tie strength and community structure notably if the two are strongly positively correlated truncation may increase community structure as weak ties are preferentially dropped if clustering is increased both r 0 and a are likely to fall methods to test the above hypotheses about the impact of degree truncation on predicted spreading process outcomes we simulated a tiestrength truncation process on a range of networks simulated a spreading process on the original and truncated networks a large number of times and compared spreading process outcome values for the full and truncated networks in the following we describe in detail the following the network generation process the truncation process and the spreading process network structures we considered four types of synthetic networks that we call degreeassortative triadic clustering focal clustering and powerlaw networks and in addition we considered networks based on empirical data the empirical social networks were collected from a stratified random sample of 46 of households in each of 75 villages in karnataka india which were surveyed as part of a microfinance intervention study in 2006 we defined an edge between two individuals in the sample to exist if either person reported any of the 12 types of social interaction asked about in the study we began synthetic network construction by generating a collection of degree sequences where a degree sequence is a list of node degrees of a network to generate 100 degreeassortative triadic clustering and focal clustering networks each consisting of n 1000 nodes we drew 100 degree sequences of length n from a poisson distribution p where φ 8 as an approximation to a binomial distribution with large n we used the configuration model to generate an initial graph realization for each degree sequence and then rewired the networks edge by edge in order to obtain a collection of calibrated networks such that each network closely matches a target value of a chosen characteristic specifically 1 degreeassortative this was achieved by selecting two disjoint edges and uniformly at random computing whether removing the two edges and replacing them with edges and would increase network assortativity and if so making this change 2 triadic clustering this was achieved by choosing an ego i and two of its alters j and k who were not connected to oneanother adding the edge to the network thus forming a triangle and removing an edge selected uniformly at random conditional on that edge not being part of a triangle thus ensuring increased triadic clustering 3 focal clustering this was achieved by selecting three nodes i j and k uniformly at random adding edges and if they did not already exist choosing uniformly at random in the network the same number of edges that were just added and in the selection computing whether removing this second set of edges would result in a net increase in focal clusteringif so removing them if not repeating steps and we generated three versions of each type of synthetic network by calibrating assortativity triadic clustering and focal clustering to the minimum median and maximum values of these quantities observed in the 75 karnataka villages to generate powerlaw networks the fourth type of synthetic network we drew degree sequences from a powerlaw distribution p ∼ k γ using the values 3 25 and 2 for the degree exponent γ we discarded any ungraphable sequences ie those where any value greater than n 1 999 was drawn we again used the configuration model to generate an initial graph realization for each degree sequence note that lower values of γ are associated with degree distributions that have increasingly fat tails for each of the four types of synthetic networks for each level of calibration we generated 100 independent representative networks using the above methods for a total of 1200 networks mean values for a range of network characteristics for each set of 100 networks are shown in table 1 truncation we simulated degree truncation of the form typically seen in surveys by placing a ceiling on the number of contacts k fc that can be reported by a respondent and then reconstructed the contact graph created from all sampled contacts to do this we first converted the network into a directed graph we then selectively removed directed edges starting from each individual i beginning with the edge having the smallest edge overlap value we used edge overlap as proxy for tie strength defined as the fraction of shared network neighbors of a connected dyad o ij n ij n ij where n ij is the number of neighbors i and j have in common and k i and k j are their degrees overlap has previously been shown to be strongly correlated with tie strength as conjectured by the weak ties hypothesis several decades earlier we were thus conducting truncation by tie strength we truncated at k fc qk taking values of q 05 1 2 so that the maximum outdegree of individuals was half the mean degree in the full network the same as its mean degree or twice its mean degree after truncating each individuals outdegree we collapsed the directed graph into an undirected one based on all remaining ties examples of this truncation process on 20node networks are shown in figure 2 we measured a range of network properties for each full and truncated network including mean degree degreeassortativity triadic and focal clustering s lcc and a measure of community clustering normalized modularity q n this last based on a graph partition for each network using the louvain method spreading process we ran a sir model using degree infectivity on the networks defined by the perperiod probabilities β 003 and ν 005 these values were not selected to mimic any particular disease but were rather chosen to give a high probability of epidemic takeoff in untruncated networks without regularly hitting the ceiling of 100 cumulative incidence in our networks with a mean degree of eight these values give a mean infectious period of 14 time steps and an r 0 of approximately 28 each spreading process began with five initial infections chosen uniformly at random among the nodes of a network and each sir model was run 100 times on the full and degree truncated variants of each of the 100 networks we measured two categories of outcomes across all of the 10000 runs of each synthetic network type including results from those runs for which at least 10 of individuals were ever infected first time to infection of the 10th percentile of the population and second the proportion of nodes ever infected results summary statistics for all networks at all levels of truncation are shown in table s1 in all networks both synthetic and empirical outdegree truncation consistently reduced mean degree as expected most strongly in powerlaw and focal clustering networks truncation strongly reduced degreeassortativity in all cases except for powerlaw networks which were already degreedisassortative overwhelming any differences originally seen across levels of calibration this effect was weaker for the karnataka networks than for synthetic networks other than powerlaw modularity increased with truncation in all networks except for degreeassortative ones with the exception of powerlaw and karnataka networks where modularity rose smoothly with increasing truncation most of the increase only occurred once networks were truncated at half mean degree both triadic and focal clustering fell and the lcc rose consistently with increasing truncation for all networks in which clustering was initially present when spreading processes were simulated on the full networks at least 10 of the network became infected in almost every simulation with the exception of degreeassortative networks where only around 90 of simulations reached a 10 truncating networks at 2k had almost no impact on the proportion of epidemics with a 10 for any network fig 3 epidemic outcomes for simulation runs infecting at least 10 of the population across six network structures proportion of all nodes ever infectious time to infection of 10 of all nodes figures show mean and 95 ranges for all runs from 10000 simulations for which at least of 10 of individuals were ever infected simulation types are defined by outdegree truncation all network structures are those with highest network properties in each category empty lines represent simulation types where no runs reached the 10 threshold but further truncation led to a sharp falloff at 05k truncation none of the clustered network epidemics reached a 10 and only the powerlaw networks the degreeassortative networks calibrated to the lowest level of assortativity and the karnataka networks had more than 2 of their epidemics reach the a 10 threshold without truncation 10 of all nodes were infected within 20 time steps on all networks except for the degreeassortative oneswhich also showed the greatest range of initial epidemic growth rates truncation at 2k increased r 0 in all cases but not by large amounts however truncation at k raised both mean r 0 and its variancenotably in the cases of degreeassortative and triadic clustering networks for those networks in which any runs reached a 10 at 05k truncation both the mean and variance of r 0 increased as networks became highly fractured network structure had a greater impact on a than on r 0 with clear differences even on full networks truncation at 2k had almost no impact on a except in the cases of powerlaw and to a lesser extent degreeassortative networks however truncation at k leads to a mean a roughly halving for all cases except the karnataka networks where a only falls by about a quarter once truncation reached 05k no network type averaged a 16 discussion simulating a generic spreading process on a range of networks containing different structures we find that truncating the number of contacts that each person can report via a fcd has a substantial impact on both initial growth rates and attack rates even at the commonly used level of k our investigations show that the level of inaccuracy introduced into predicted epidemic outcomes by a given level of truncation varied depending on the structure of the network under consideration partly due to the impact of truncation on network properties and partly due to the impact of network properties on process outcomes truncation on all network types eventually led to underpredictions of both r 0 and a however the level of underprediction at each truncation level and the level of truncation at which such underprediction became substantial varied across network types notably our ability to predict process outcomes is degraded more rapidly on stylized synthetic networks than on a set of empirical social contact networks from villages in karnataka state india central to understanding the effect of outdegree truncation on predictions of spreading process outcomes is the transition when the network becomes fragmented and the size of the lcc rapidly decreases in our analyses the powerlaw and degreeassortative networks showed slow declines in predicted process outcomes as truncation increased while the loss of accuracy was more rapid for both triadic clustering and focal clustering networkswhich lost fidelity early onand the karnataka networkswhich maintained fidelity for longer the speed of initial growth was notably more variable for degreeassortative compared to all other network types for both no truncation and truncation at 2k reflecting the importance of the initial infection sites when networks contain both highly and lowly connected regions this variation in findings suggests that knowledge of the structure of a network for which one wishes to predict process spread is crucial in determining the level of resources that should be placed into measuring the full extent of the network itself locally clustered networks may require more contacts while those with fattailed degree distributions may require fewer of course knowing the mean outdegree of a network is a prerequisite to determining the level of truncation that can be tolerated in contrast to our conjectures in no case did truncation increase the speed of process spread the impact of truncation in reducing the number of observed ties appeared to overwhelm all other processes not least by affecting the network characteristics of the truncation networks truncation at k led to the degreeassortative networks being entirely nonassortative and the triadic clustering and focal clustering networks displaying very limited clustering only modularity appeared to be maintained or even increased as the fcd threshold was loweredpotentially because of the breakup of the network into increasingly numbers of unconnected components further investigation might find levels of truncation at which epidemic severity is overestimated but in practical terms our findings point to a consistent underestimate of speed and attack rate using data truncated by strength in addition to networklevel outcomes it is instructive to consider variability in outcomes at the individual level while it is clear that individuals with higher outdegree are more likely to become infected it is also likely that those with moreconnected neighbors will become infected more often since these connected neighbors are more likely to be infected in the first place this association can be seen in figure 4 for the karnataka networks low degree individuals are unlikely to be infected regardless of how wellconnected their neighbors are but for our exemplar infection neighbor degree has little impact for those with own degree greater than 10 as truncation increasesand has a disproportionate impact on ties dropped to higherdegree neighborsindividuals with lower mean degree neighbors are predicted to be infected less often than those with the same degree but lower mean neighbor degree and this effect is particularly visible at the common fcd value of k these findings highlight that not only can truncation impact populationlevel predictions of infection risk but they may also differentially affect individuallevel predictions there are several ways in which this analysis could be extended first it might be informative to consider unweighted rather than weighted truncation weighted truncation is likely to minimize misestimation of local spreading processes since closeknit groups are likely to be maintained at the expense of a realistic picture of crosscommunity connections unweighted truncation in contrast is likely to reduce the speed of process spread generally but maintain weak ties that span structural holes in the network second one could investigate spreading processes based on edge weights or using unit infectivity third it might be worthwhile to run these analyses for a wide range of truncation levels in order to evaluate which networks have more or less rapid transitions from relatively accurate spreading process predictions to relatively inaccurate ones and at what level of truncation these transitions occur such an analysis would be particularly useful in the context of a specific empirical network and spreading process rather than in the theoretical cases presented in this paper as a precursor to the conduct of data collection in a survey while we have used a range of network structures and a standard spreading process our results are limited to the cases we have considered and notably to a single level of network density and thus investigation of other structures and processes might be worthwhile finally we used only one set of transmission parameters and thus the absolute impact of truncation may well be different for other infection processes nevertheless we would not expect different transmission rates to change our central finding that network structure is an important determinant of the impact of truncation on predicted epidemic outcomes the ultimate goal of our analysis is to arrive at more accurate predictions of process outcomes in the context of truncated contact data the type of data that are common in the study of infectious diseases and public health interventions in addition to our simulation approach there is the potential for analytic work to evaluate the level of misprediction likely to arise under a given level of degree truncation for given network structures ultimately this should allow for us to adjust predictions for truncation such an approach might use statistical or mechanistic network models to simulate full networks congruent with both the estimated rate of truncation and observed characteristics of the truncated network simulations could then be run on these simulated networks to predict process outcomes as noted above although we have framed outdegree truncation here as resulting from the adoption of fcd our methods are agnostic to the cause of truncation consequently our results may generalize to settings where some other mechanism such as social stigma in the case of selfreported sexual networks might lead to outdegree truncation additionally we have focused this work on sociocentric network fig 4 mean neighbor degree vs own degree for full and truncated karnataka village contact networks all plots are heatmaps ie depth of color represents frequency of occurrence at the given location density of ties in full graph mean proportion of all runs in which the node was infected the black diagonal line shows points of equal node and mean neighbor degree in the full graph most nodes are infected most of the time except those with either very low degree or very low mean neighbor degree when truncated at mean degree those with middling degree and mean neighbor degree are infected less often when truncated at half mean degree almost no nodes are ever infected data collection truncation and edge nonreporting may also arise within egocentric data collection requiring the use of ergms or other methods to infer global network structure while beyond the scope of this paper investigation of the impact on epidemic prediction of degree truncation within egocentric data collection may also be of interest similarly empirical networks also often suffer missingness due to other mechanisms such as missing nodes reporting of nonexistent alters and edges linking population members to nonmembers future investigation of the impact these mechanismsboth alone and in concert with truncationmay be an important avenue of investigation in evaluating possible errors in predictions of spreading processes finally while our focus here has been on degree truncation in sociocentric studies resulting from study design effective truncation may occur in sociocentric networks for other reasons for example there has been increasing research activity in the past few years into digitally mediated social networks such as those resulting from mobile phone call and communication patterns social networks are constructed from these data typically by aggregating longitudinal interactions over a time window of fixed length where the features of the resulting networks are fairly sensitive to the width of the aggregation window this leads to effective network degree truncation that is not a consequence of study design per se but rather is induced by the network construction process it seems plausible that some of the insights we have obtained here as well as some of our methods could be translated to this research context conclusion we have shown via simulation that truncation of a network via fcd has a systematic impact on how processes are predicted to spread across this network reducing predicted speed of epidemic takeoff and the final attack rate relative to values obtained from a fully observed network however the degree of impact varies strongly by the level of truncation and we find that the transition levelat which impact on predicted process outcomes shifts from small to considerablevaries by network structure supplementary information on the structure of the full networkpotentially estimated from past egocentric or sociocentric studies in the same or similar populationswill thus often be crucial for increasing the accuracy of predictions of process spread for truncated network data ranges for all runs from 10000 simulations for which at least of 10 of individuals were ever infected note that the proportion of retained networks falls as the level of truncation rises empty cells represent simulation types where no runs reached the 10 threshold all network structures are those with highest network properties in each category supplementary material to view supplementary material for this article please visit nws201730

understanding how persontoperson contagious processes spread through a population requires accurate information on connections between population members however such connectivity data when collected via interview is often incomplete due to partial recall respondent fatigue or study design eg fixed choice designs fcd truncate outdegree by limiting the number of contacts each respondent can report research has shown how fcd affects network properties but its implications for predicted speed and size of spreading processes remain largely unexplored to study the impact of degree truncation on predictions of spreading process outcomes we generated collections of synthetic networks containing specific properties degree distribution degreeassortativity clustering and used empirical social network data from 75 villages in karnataka india we simulated fcd using various truncation thresholds and ran a susceptibleinfectiousrecovered sir process on each network we found that spreading processes on truncated networks resulted in slower and smaller epidemics with a sudden decrease in prediction accuracy at a level of truncation that varied by network type our results have implications beyond fcd to truncation due to any limited sampling from a larger network we conclude that knowledge of network structure is important for understanding the accuracy of predictions of process spread on degree truncated networks

introduction studies of money management and control would have more crosscultural relevance if they considered the family context of money across generations much previous research on money management has focused on the married couple and at one point in time however for a fuller understanding of the variations of money management and control in diverse family structures and practices we need to look at the wider family and take a crossgenerational perspective in some countries in the west men and women use money as a means by which they construct themselves as a couple in many countries in the asiapacific and africa it is essential to go beyond the couple in the household to understand the allocation of household money for money can be one of the ways people present themselves as a family we illustrate the usefulness of this broader family approach to money through a focus on urban middleincome indian patrilineal nuclear and joint family households in north india unlike money in middleincome angloceltic families in australia and the united kingdom there is a twoway flow of money and information between parents children and other kin the generational perspective is important in extended family households for it distinguishes between money management and control at the level of the component couples and the household we argue that a focus on generation and gender in money management and control will better address the complexities of money and power in transnational families as well as diverse versions of the extended family across cultures money management and control in the literature the current typology is built around the distinction between money management and control money management is widely interpreted as organising money in the household on a day to day basis whereas money control is linked to the power to make major financial decisions or prevent discussion about these decisions the initial thrust of the study of money management and control particularly in the united kingdom was to go beyond the household as a black box to study the allocation of money between the marital couple jan pahl writing in 1989 distinguished between the whole wage system where the husband gave most of his wages to his wife to manage and the housekeeping allowance system where the man gave his wife an agreed amount to cover household expenses sometimes it included a margin for personal spending money about half the couples used pooled systems sharing overall management and control this collective approach to money differed from the more individualistic partial pooling where some money was shared and the rest kept separate and independent management and control more recently the focus has moved to charting the more individualistic management and control of money in intimate relationships particularly among younger and more affluent couples cohabiting couples prefer separate money as a reflection of equality even if it does not make for equity in relationships this tension between equality and equity was seen particularly among childless and postmarital cohabiting unions this conflict between equality and equity is also found in sweden where couple relationships present themselves as equal despite inequalities in male and female earning power part of this tension is because of the perceived ownership of money remarried couples also preferred a more individualised approach to money as they addressed financial obligations arising from previous relationships there is some discussion that the individualisation thesis paints too monochrome a picture as it does not capture money relationships in transnational families where family and money relationships continue across national borders pahl says that assumptions about family finances developed in europe and north america may not apply in other parts of the world she continues we need to move from seeing the household as a bounded unit towards a view that stresses its permeability and its links with wider social and economic structures it is particularly important in asia the pacific and africa to recognise that the boundaries of domestic money can be broader than the couple and the nuclear household unit in order to adequately study money within the household it is important to study the money flows between the household and the wider family a 1991 study of the aboriginal ngukurr community in southeast arnhem land showed that money was distributed within the fluid household cluster rather than the household senior et al said this cluster may vary in composition from a couple nuclear family extended family through to one based on a set of siblings or other close relatives gifts mainly of money comprised an average of 16 per cent of the income of the household cluster to understand maori money it is also important to take into account the money that goes from households to the whānau a group of kin descended from a common ancestor or an extended family group money is gifted up and down generations with younger people giving to parents grandparents or others in their parents generation as well as to brothers sisters or cousins money is gifted to the whānau for ritual gatherings to mark crises in the lives of whānau members the obligation to gift money for the funeral meeting at the whānau takes priority over every day household expenses there is such a strong moral imperative to share money with extended kin and clan networks that migrants from many countries in africa are subject to intense pressure somali refugees in london remit money not only to parents and siblings but also to uncles aunts inlaws nephews nieces grandparents cousins and others a study of dinka migrants in the united states shows how a dinka man is expected to contribute to bride price for three immediate generations on his fathers side he also has obligations to his wifes kin akuei speaking of one of the participants says within the first two years of resettlement to san diego joseph became directly responsible for 24 male and female extended family members and indirectly 62 persons displaced across a number of locations not meeting these obligations means that he is not a good moral person in fiji and tonga remittances also go to nonmigrant households nearly 20 and 80 per cent respectively the indian joint family in this paper we focus on the indian patrilineal joint family household as one example of the generational complexities of an extended family household and the broader boundaries of domestic money the most common form of the indian joint family household is a three generation household marked by male descent it comprises parents sons and their children it is this patrilineal joint family household which stands for the indian family celebrated in popular culture the matrilineal joint family marked by female descent is more narrowly distributed in india among castes such as the nayars in the south and the khasis in the northeast the tarawad among the nayars is the most celebrated form of the traditional matrilineal joint family household it used to have 2030 members or more owned property in common and consisted of all the matrilineal descendents of a common female ancestress women had greater rights and entitlements to property than in the patrilineal joint family though it was the senior male a womans brother who controlled the affairs of the tarawad the sisterbrother tie was the central one with the husband living in his own tarawad rather than with his wife the importance of the tarawad has been declining as the bond between father and child gains more importance joint family households have always been outnumbered by nuclear households though it is likely that most people in india live in the bigger joint family households particularly in rural areas and in north india the joint familys importance is greater than its actual prevalence at any one point of time for most individuals spend some part of their lives in a joint family household women most often start their married life in the patrilineal joint family household when the joint family household disperses over time it gives rise to various combinations of joint andor nuclear family households ties of property and norms of joint family etiquette often remain sociological literature has confirmed the popular picture of the male control of money and property in the family money in the indian family is studied with reference to women and paid work in middleincome households gifts and presentations related to life cycle events the discussion of women and property and the impact of remittances on womens money management roles in the household in the following sections we describe how our qualitative study of money and information in indian urban family households helped us recognise the wider importance of the familial context of money and generational complexity in joint family households we then detail the implications of these dimensions for the analysis of the management and control of money in the concluding section we propose a broader crosscultural typology to study money management and control in diverse forms of family across cultures the qualitative study of money in the indian family we conducted openended interviews between november 2007 and january 2008 in english hindi and punjabi with 40 predominantly middleincome and upper middle income persons from 27 households the interview sample includes 25 people living in metropolitan delhi which in 2001 had a population of 129 million seven in a periurban area that is being developed into urban housing in the delhi region and eight people from dharamshala a small himalayan town in india with some 20000 people in 2001 these three sites also broadened the study to include metropolitan periurban and small town family households we chose these three sites because both of us had personal family and professional connections in these places and so were confident we could have access to suitable participants we did not interview members of our immediate family or close friends but sought references from family friends and colleagues to direct us to their networks their reference assured the participants about the nature of our study and allowed us access to examine the private nature of money in families having these connections with the participants meant that we did not ask about the quantum of money earned spent or saved but talked of broad ranges of household income how information about money was shared and how they perceived money was managed and controlled in their household the interviews ranged from 35 hours to just more than half an hour usually conducted in the persons home most interviews lasted an hour to an hour and a half with the formal interview flowing into a social visit in 13 of the 27 households we interviewed more than one person 12 married couples and in one household a motherinlaw and daughterinlaw when husbands and wives were interviewed together we most likely got a different picture of household money than if we had spoken to each of them individually we also recognise we would have heard different representations of control and management if we had talked to all the adults in the household or had been able to observe the management and control of money in the household our focus on representations of money management and control in the urban patrilineal joint family household in north india arose from an initial interest in the privacy of money in urban middleincome family households hence our initial questions related to the way information about money was or was not shared across gender and generations within the household and wider kin group we asked about bank accounts and what happened to money earned by members of different generations in the household these questions led to the family context of money and further probing of the generation and gender divide in information and access to money money and information flows within the two three and four generation joint family households were particularly complex in our study 14 of our 40 participants lived in joint family households and 17 had experience of them the participants the characteristics of our participants are set out in table 1 thirtyfive of the 40 people in our study defined themselves as upper middle middle or lower middle we used the national council of applied economic researchs definition of the middle class in 20002001 as having an annual household income of between inr 210 lakhs i we also used our participants perception of where they fit using a mixture of income and the capacity to spend table 1 here there are more women in our study reflecting that as female researchers we had easier access to women men were often unavailable at the time of the interview in two cases the women said their husbands would be uncomfortable talking about money our participants are predominantly from urban north india it thus excludes the rural agrarian patrilineal joint family households and the matrilineal joint family households found in south and northeast india this sample is not representative of indian joint family households however the sample is diverse enough to cover varied dimensions of money management and control in the urban indian patrilineal joint family coding and analysis in the grounded study this is a grounded study in that the emphasis is on a transparent fit between data and theory rather than a testing of hypotheses we recorded and selectively transcribed the interviews noting aspects of the interview that were more like a social visit we used a computer program nvivo 7 for the analysis of qualitative data the use of the computer program involved a broad coding of data analysing the coded data for the main themes and transparently fitting the data to theory the program allowed us to identify not only what was said about money management and control but even what was not said it was in this process of coding the flow of information and money outside the household in both nuclear and joint family households that we realised representations of money control at the household level needed to be distinguished from those pertinent to the couple and the individual the focus had to be on generation as well as gender management of the household was also not unitary managing the kitchen did not necessarily translate to managing household or couple money the family context of money people in our study speak of the importance of financial obligations to family this is true for our metropolitan periurban and small town participants money is shared between parents and adult children and in some cases between siblings this is a key family practice irrespective of whether it is a nuclear or joint family household this sense of filial obligation and mutual help is an important factor behind the estimated us 55 billion in international remittances that flowed primarily to families in india in 2010 a twoway flow of money between parents and children is central to family money parents acknowledge an obligation to help their adult children adult working children particularly sons including those not living at home recognise an obligation to help their parents even when their parents can do without this obligation is couched in terms of duty on the childrens part and a right on the parents part in our study there are five instances where a parent has a joint account with his or her adult children making it easier for money to flow between parents and children the twoway flow is accepted by parents and children our participants tell of money that is offered rather than requested in our study we have two cases of upper middleincome parents who have the ability and the wish to be financially independent saying how their adult children keep offering them money the family context of money means information about money is shared beyond the couple and the household with wider kin unlike middleincome anglo celtic couples information about money is not private to the marital couple this family context may mean that information is shared across generation between father and son and between brothers on the other hand information about money may not be shared between husband and wife leading to a greater gender divide in the management and control of money urmila 55 in a dharamshala middleincome nuclear family household says she and her husband have substantially helped with building her parentsinlaws house they have also helped with the marriages of her two sistersinlaw and a brotherinlaw urmila is one of the few persons in our study who has not previously lived in a joint family household as her husband had a transferable job deepak in his early 30s a high earning professional in delhi living in an upper middleincome joint family with an annual household income of more than inr30 lakhs says in my house they expect me to give and i also want to give … we have to take care of our elders deepak and his wife had recently taken money out of their savings to put towards another house his father bought deepak says we bought the entire house together in dads name he will give it back to me in a couple of years it is all in the same family the money also flows from parents to children as jagdishs story shows jagdish 74 retired from a senior government position and now working as a consultant says his fatherinlaw helped them with money for building their house he later returned the money his daughters do not give them money and jagdish and his wife do not ask but one daughter makes her car and driver available to them and also paid inr 30000 for jagdishs recent extra hospital expenses mutual financial help between male and female siblings on the husband and wifes sides is shaped by relationships of reciprocity need and capacity it is usual to discuss money with kin from whom a person can expect help and advice ritu 45 a school teacher in the delhi metropolitan region relates how her brother and father helped substantially with money when ritu and her husband were building their house so she shares information about money with her brother and father money conversations do not take place with her husbands brothers as they were neither asked nor did they offer to help with the house tara in her early 50s in dharamshala also received help from her husbands brother and sister when taras husband had to be hospitalized she says together they were able to pay the inr 70000 that was needed this expense represented most of her households annual income her husbands siblings and her sister helped with taras sons first year expenses for the engineering college the norms did not work out as expected in santokhs family and for avinash and asha santokh 81 is from dharamshala with an annual household income of below inr 90000 loans to family members had not been returned and adult children continue to remain financially dependent on their parents he therefore talks of money only with his wife and not with his children and their families avinash and ashas story is one where the family context of money led to intrigue lost business and inheritance adoption and return brother against brother and parents fearing the loss of home even as the wider family unravelled avinash 62 and his wife asha 60 received money from their parents for their business the building of their house and the wedding expenses of their daughters now that their daughters are married avinash and asha watch whether their children are doing without so that they can help management and control of money in nuclear and joint family households in our study we linked money control with the power to make major financial decisions or prevent discussion about these decisions having information about money was a necessary condition for the control of money we asked our participants about recent decisions about savings and investments we also asked them how they saw the control of money in the household based on these factors the households were seen to have male female joint or independent control we initially approached money management as organising money in the household on a day to day basis we saw women as managing the money if they had regular access to money either through the whole wage housekeeping allowance or a banking account access to money for personal expenditure was a key factor in womens representations of money management we then discovered that in the indian family there was another category the irregular dole the irregular dole differs from the whole wage and the housekeeping allowance systems in that money is given as a gift rather than an entitlement it is similar to what happened in the 19 th century in the united states the woman has to ask for money and justify the need in our joint family households in periurban delhi and dharamshala women have the keys to the kitchen but the management of the kitchen does not translate to managing the money in the household or the couple that is organizing the routine grocery and household purchases payment of bills and doing the banking women may have individual or joint bank accounts but they do not regularly conduct transactions or receive information from these accounts where women managed the kitchen only and had no regular access to money we have classified it as male management women have least influence on money in the household when male control is combined with male management the generational dimension of control and management in the joint family household the generational dimension is important for probing the characteristics of money management and control in the joint family household money control and management at the household level may be follow the same pattern for the junior and senior couples as happens in the joint family households with male control and male management however in our study we also have two instances where the management and control of money for the joint family household is different from that followed by the junior couple the junior couple contributes a part of their money towards household expenses this means that the couple continues to be able to control a substantial part of their money in one case at the household and senior couple level control is joint with female management but with the junior couple though the control is joint money management is independent in the second case it is female control at the household and senior couple level but the senior woman thinks her son and daughterinlaw control their money jointly we also have two cases where the widowed motherinlaw has her own income and controls and manages her own money whereas the junior couple jointly or independently control their money and that of the household being aware of the generational dimension of money management and control in joint family households ensures that variations within the household are taken into account patterns of money control and management male control of money is the dominant pattern and found in about half the households we studied joint control was found in a third of our households independent control and female control were of lesser importance with two and three households respectively female management was found in nearly threefourths of our households when accompanied by male control it was predominantly the housekeeping allowance with one household following the whole wage system when found with joint independent or female control women accessed money through separate or joint bank accounts table 2 here as noted above we also found male management of money in our nonmetropolitan joint family households ranging from the middle class to those that categorised themselves as strugglingdeprived the women received money through the irregular dole male management was always accompanied by male control there were no upper middle class households who had male control and male management of money the incidence of male management of money among our households was greater than joint management which was only found in three of the 27 households male control and male management in nonmetropolitan joint family households in the periurban and small town joint family households male control is accompanied by male household management male control and management are found at both the levels of the household and the component couples this pattern is different from western studies of money which show that male control is often accompanied by female management via the whole wage management and the housekeeping allowance male control in our study has a greater spread across household income than in the west it is found among the middle class lower middle and the struggling households rather than just in the lowest income group male management and control is not found among households that categorise themselves as upper middle class or global only one metropolitan upper middle class nuclear household has male control though accompanied by female management the woman in this case sees it as her choice not wanting to know more about household money as it is complicated since her husband is in business with his father they previously lived in a joint family household in joint family households with male control and male management all or a major part of the money from the other members of the family is given to the male who is in control of the joint households expenditure savings and most of its investments the male who does not control the household income controls whatever money is left for the couple women in joint family households with male control and male management have little information about money in the household or money that belongs to the couple information about money flows between the father and son or among brothers women also do not have assured access to money despite the motherinlaw being the archetypal figure representing power in the indian patrilineal joint family household our interviews show that in the nonmetropolitan joint family households with male management and control both the motherinlaw and daughterinlaw depend on the younger andor older generation male for the irregular dole both the motherinlaw and the daughterinlaw have minimal access to money or information as shown in the stories of amar and amrit and rana and rina below amar is over 65 years old and lives in dharamshala with her son daughterinlaw and a grandson in a middle class household amar says when her husband was alive he …used to keep the money he used to buy the rations if i wanted to spend i would ask for what was needed amar only discovered she and her husband had a joint account after he died now her son looks after the money in their joint account her daughterinlaw amrit a graduate in her late 40s or early 50s says the pattern is the same with me even in this generation …i take from my husband what i need… it is not that i get a certain amount every month if i need to buy a shawl i ask for money if he says no then there is no money amrit says she knows about the major investment decisions in the household such as the purchase of land but only after the fact though she helps out occasionally in the family business the information about business money is shared between the father and son amrit says he speaks with his son not with me i am also not interested in finding out even if i did take an interest he will say it is not your concern why do you want to know what will you get if you know rina is similarly excluded from information about money she is 24 also a graduate and lives with her husband rana 28 in a three generation household which includes her parentsinlaw ranas younger brother and sister and rina and ranas two sons one and three years old rana controls the household income and is responsible for all the expenditure his father gives his salary to rana according to the custom of his village but keeps the tips from his government job and the revenue from land in the village for himself and his ill wife ranas father manages and controls the money that is with him rana discusses his income and investments partially with his father but is not sure about his fathers money the gender divide in information about money is impermeable rana does not talk of money with his mother or his wife rina does not have a bank account she also does not ask him questions about money in his account she says if i ask he would feel that i am trying to know his inner most secrets all i have to do is cook and feed the family joint and independent control in metropolitan delhi joint and independent control is found mainly in upper middle class households in metropolitan delhi one of the 11 households is in the small town of dharamshala only one of 11 households in this category sees itself as lower middle class the women in 10 of the 11 households are graduates in the joint family households this is true of women of both the senior and junior generations the woman in the 11 th household has an advanced diploma the three instances of female control belonged to middleclass households of these three households one woman was a single parent the other two women were in salaried paid work with the husband either not wanting to manage and control the money andor recognising that the wife was more expert at it most of the women in the households with joint or independent control 8 of 11 are in paid work in households with joint control and joint management and independent control all the women are in highly paid jobs outside the home the women have access to money through personal andor joint bank accounts information is shared between the husband and wife this picture is the one that is closest to that found among middleincome and affluent couples in the west analysing patterns of money management and control these patterns of money management and control are primarily explained by the same two factors that explain the allocative systems of the west but in different measure as vogler says these systems are largely the result of two interrelated factors first the relative economic resources each partner contributes to the household and secondly cultural ideologiesdiscourses of gender particularly those of male breadwinning versus newly emerging discourses of coprovisioning in our study the role of the ideology of male dominance looms large and can lead to women not being permitted to work outside the home this ideology of male dominance is central to male control across a broad spectrum of household income ranging from struggling households to middle class households this pattern goes against the pattern in the united kingdom where male control and the whole wage system is found only with the lowest household income the ideology of male dominance often prevents women earning an income outside the home a womans income contribution to the household becomes possible not only with education but also with an ideology that values womens work and one where marriage is seen along the lines of a partnership this is found mainly in metropolitan middle and upper middle class households with female joint and independent control linking the ideology of male dominance and male control the ideology of male dominance expresses itself in the ownership of property male dominance of the public sphere particularly that of money the man as the breadwinner with the woman looking after the family and home being a good son and brother can take priority over being a good husband particularly in the context of the joint family unlike the pattern in the west male control is not confined to the lowest income group among our households the ideology of male dominance is most prevalent among the middle lower middle and the struggling households particularly in nonmetropolitan delhi women with a bachelors degree are prevented from going into paid work for their primary role is to look after the family women in nuclear families may engage in small scale business activities at home but even this is not permitted in the joint family households we studied when male dominance is linked to male management then a womans access to money and information about money is minimal an ideology of male control was important in 10 of the 13 households with male control in three of the eight nuclear households it was the women who said the husband knew more about money and handled it in the interests of the whole household in the fourth jagdish and jayas household jagdish 74 assumed that women were not interested in controlling money the fifth case is that of peu 24 in a lowermiddle class household in periurban delhi who wants a career as a beautician her parentsinlaw told her our daughtersinlaw have to observe purdah and cannot venture out on their own she says her husband does not object for the present peu continues to be a housewife saying her son is still too young they are still linked financially with the parentsinlaw as they have only recently separated from the joint family household the remaining three households differ as to the reasons for male control in two households in dharamshala with an annual household income of less than inr 2 lakhs there was little money to control in the third household navin 29 newly married hopes that his wife naina 24 would begin to be independent with money once she finishes her law degree and gets familiar with metropolitan delhi in the five joint family households male control was accompanied by male management the ideology of male dominance and the womans place in the home is the common factor none of the junior or senior women are in paid work even if they have skilled qualifications and would like to be in paid work balbir and binas story below illustrates male control across generations and the role of ideology balbir and binas story balbir 28 and bina 23 live in a three generational patrilineal lower middle income joint family household in a periurban area near delhi in a house that balbirs grandfather built balbir and bina have been married for a year and live with balbirs parents two sisters who are still going to university and two brothers still in school balbir continues to give all his monthly salary of inr 50006000 to his father and then gets back from him some money for himself and his wife he is also doing his mba balbirs father controls the household money and the money for himself and his wife he makes all the decisions on major expenditure items an ideology of partnership and womens paid work it is mainly in the upper middle class families that we heard stories of womens work being valued women were seen and saw themselves as partners in marriage and the household women in these families were highly educated and earned salaries that allowed them to manage their money independently if they so chose the ideology of the partnership of marriage does not focus solely on the togetherness of the couple but is placed within the context of a harmonious extended family in the west the move is from an ideology of marriage as an equal partnership to the growing importance of independence in relationships unlike the discussions about equality and equity partnership and individuation among couples in the west in our study we heard more about the couples place in the wider family this is true of nuclear and joint family households it is important to remember that 11 of the 18 nuclear households we studied used to be part of joint family households the conversations then are of managing and controlling money so that the couple can help parents on the one hand and adult children on the other the story of deepaks family is very different from that of amar and amri illustrating the difference between the ideology of male dominance and partnership deepak is in his early 30s and works with a multinational company he belongs to a two generation upper middle class joint family household when deepak began working he used to give his whole salary to his mother he got married seven months ago he and his wife who is in financial services jointly control their money while his parents jointly control the money of the household deepak and his wife have separate accounts where their individual salaries are deposited neither controls the others personal spending the separate accounts earmark separate salaries for taxation purposes they also have a joint account where they are saving for a future home and children deepak and his wife discuss their future in the context of the joint familys welfare as noted above they jointly decided to contribute to the house that deepaks father was buying they also openly discuss the amount of money they need to contribute for the running of the household deepaks story is replicated in preetas story below where preeta and her husband jointly control their money and preeta manages the household that includes her motherinlaw generational change in the management and control of money people often describe their present money management and control in the context of generational change people in the 11 nuclear households that were previously joint usually begin their story with money management and control in the joint family though some joint families have continued with the tradition of male control and male management in some joint families this pattern has changed over the generation to one of joint control and female management of the joint family household this is illustrated in preetas story below preetas story preeta in her late 40s or early 50s is part of an upper middleclass threegenerational joint family with an annual household income of over inr 30 lakhs she is married to the only son of the family her motherinlaw lives on the first floor preeta her husband and their two boys still in school live on the ground floor they have all their meals together on the first floor preeta and her husband jointly control the money for the household and for themselves preeta manages the money for the household and manages the couples money preetas motherinlaw controls and manages her own money preetas management role has emerged over time as her motherinlaw has withdrawn from the role because of old age illness and the death of her husband when preetas motherinlaw got married her husband a professional would give most of his money to his mother he gave his wife a small amount when he wanted to if she wanted anything above that amount she had to go to her motherinlaw and ask her then the motherinlaw would give her money if she was in a mood to it was only after preetas motherinlaw died that preetas fatherinlaw began giving his wife the money he earned but even then he discussed his investments with his son but not with his wife preetas fatherinlaw and motherinlaw had a joint bank account but the family only discovered it after the fatherinlaws death however her motherinlaw at that stage was placing money in fixed deposits for herself or together with her daughters preeta says her fatherinlaw felt it was very important to be a good son he forgot it was important to be a good husband as well unlike her motherinlaw preeta has had no problem with personal spending money preetas husband gave preeta the money to give to his mother preeta has access to and transacts via the joint account she and her husband have together she says she knows absolutely what my husband has she keeps herself well informed so that she can be part of the decision making about money the key to this generational change is neither income nor education for both preeta and her motherinlaw had a ba degree and were part of highincome households preeta says the shift happened because her husband thinks it is equally important to be a good son and a good husband conclusion our study of money in urban indian middleincome patrilineal households has added two additional ways of examining money management and control the family context and the generational dimensions of money these two factors are important for the crosscultural study of families and particularly for extended family households the family context of money recognizes that across cultures the couple is not men controlled the money in nearly half the households we studied in our joint family households in peri urban delhi and dharamshala male control was accompanied by male management where the woman received money by irregular dole the male control of money was found in households with the ideology of male dominance with the womans place being in the home this ideology was found across a broad spectrum of household income and actively prevented educated women from paid work patterns of joint and independent money control and management were found in a smaller proportion of our households this pattern is most often found in higher income households where the women are in paid work and earn an independent income it mimics the demographics for independent management and control in the west the difference is that the ideology behind a couples joint control and management of their money is the welfare of the wider family rather than only signifying the couples togetherness independence andor equality a broader framework of money that includes the family and the generational context of money will help us understand the control and management of money across cultures it will also connect the literature on money management and control with that on the transnational family where money flows across generations and borders once the frameworks are in place it will be possible to undertake generalisable studies of the management and control of money in asia the pacific and africa we will then be able to examine patterns of money management and control against the role of ideology household income womens education paid work active bank accounts and information about household money we may find that the meanings of jointness and separateness in relationships are different within and between cultures these studies will help us understand the relative influence and demographic spread of ideologies and world views thus placing western literature in a more global context references

studies of money management and control will have more crosscultural relevance if the family context of money across generations is taken into account the study of money management and control in middleincome nuclear and joint family households in urban india illustrates the importance of examining money flows within the wider family context because there is a twoway flow of money beyond the married couplebetween parents and adult children siblings and other members of the extended family in the three or four generational joint family control and management at the household level is not necessarily duplicated for the constituent couples we draw on openended interviews of 40 persons from 27 urban middleincome households in north india between november 2007 and january 2008 to show that the male control of money is the dominant pattern this pattern is linked to the ideology of male dominance that is found among the middle lower middle and struggling households particularly in nonmetropolitan households the upper middle class households predominantly in metropolitan households show a pattern of joint or independent control the focus is on the couples money decisions within the context of the wider family

background in brazil an increase in life expectancy and a decrease in the fertility rate have led to a significant aging population in south america the aging populationproportion of older people is increasing at a more rapid rate than in most developed countries 12 aging is a complex phenomenon that requires increasing numbers of multidisciplinary studies the term active aging which was adopted by the world health organization involves optimizing the opportunities for health participation and security to improve the quality of life as individuals age 3 the challenge for aging studies is to understand the conditions associated with aging as a positive process and old age as a stage of life in which health wellbeing pleasure and qol can be increased 4 5 6 the qol of older adults could be good or at least preserved provided they have autonomy independence and good physical health and provided they fulfill social roles remain active and enjoy a sense of personal meaning 7 epidemiological populationbased studies are important for identifying the determinants and etiological factors associated with aging to investigate the determinants of aging questions must be answered using longitudinal surveys 8 longitudinal studies specifically designed to assess health qol and associated risk factors are not abundant in the literature particularly those performed in underdeveloped countries in which poverty and a low educational level might lead to a different set of variables that affect the aging process 9 in brazil a country that is rapidly aging and that suffers from large inequalities the study of the qol among aged people is important for the future health this study sought to examine the association between qol gender and physical and psychosocial health among older brazilian communitydwelling adults with the aim to identify potential factors associated with better qol methods the aging gender and quality of life study is an observational cohort study of a communitydwelling population aged 60 years and older the sample is representative of the city of sete lagoas in the state of minas gerais brazil which has a population of approximately 21000 older adults 10 this city is divided into 17 administrative regions one district and four rural areas 11 sample a complex sampling design was adopted for this study and consisted of a combination of probabilistic sampling methods for selecting a representative sample of the population 12 for this sampling the following two calculations were performed an estimation of the number of older adults and an estimation of the number of households to be visited the sample size calculation was performed to compare genders by considering the prevalence of functional impairment in instrumental activities for males and females 13 the estimated error was up to 5 with a power of 80 at 95 confidence intervals when considering a design effect of two an estimated additional 20 of the sample size was added to compensate for refusals the samples from each group were stratified by age in relation to the population and were corrected based on the probability of dying of the total potential participants living in the selected dwellings 25 were excluded because they could not answer the questionnaire or because of cognitive impairmentdementia or difficulty speaking one hundred and twentyfive subjects refused to participate in the study and 100 could not be located or had died the final sample consisted of 2052 individuals of whom 597 were female the sampling process was conducted in two stages the census tracts were first selected and the households within each sector were then selected 10 in each household all residents aged 60 years or older were interviewed regardless of marital status or kinship data collection a pilot study including 107 older adults was conducted prior to data collection all of the instruments were validated for portuguese in brazil and the testretest method was used to assess reliability and concordance coefficients greater than 080 were obtained and included a weighted kappa value of 081 and an adjusted kappa value of 086 the data collection was conducted in the homes of the older adults between january and july 2012 and involved household interviews and examinations conducted by three examiners and three annotators all persons 60 years in the selected households were informed of the study and were asked to sign an informed consent form that had been previously approved by the ethical committee of the federal university of minas gerais the interviews lasted 40 to 60 minutes at the end of the interviews each subject in the city received guidance regarding health care and activity options as well as the personal contact information of the researcher responsible for the questionnaire measures the socioeconomic and demographic data included age gender marital status income categorized by the median value years of education residence and occupation most independent variables were dichotomized to enhance the interpretability of the logistic regression coefficients physical activity and social participation were measured using a single question with a dichotomous answer the healthrelated component included selfreported health conditions which were assessed using a likert scale and access to and utilization of health services for this study the categories were grouped into poor regular and good with regard to the chronic diseases previously reported to be most relevant to the loss of functionality in aging subjects the number of diseases was recorded as 0 1 or ≥2 functional limitations were evaluated by combining the participants responses to questions about six basic activities of daily living 14 and seven instrumental activities 15 to evaluate the cognitive status of the older people we used the mini mental state examination which has been validated in brazil 16 and has a cutoff of 2122 points 17 a score ≤21 indicated cognitive impairment the presence or absence of a functional limitation was determined depending on the type of daily living activity and cognitive status as adapted from albala 18 the subjects were classified as restricted if they had one or more limitation in basic or instrumental activities or if they had cognitive impairment the presence of depressive symptoms was assessed using the short version of the geriatric depression scale 19 with a cutoff of 56 a score ≥6 indicated suspected depression family functioning was assessed using the fiveitem family adaptability partnership growth affection and resolve scale which measures the satisfaction of older adults in relation to various aspects of family life 20 the responses consist of values between 1 and 3 and the total score ranges from 5 to 15 a score ≥10 indicates family satisfaction 21 qol we used the world health organization quality of life assessmentbrief instrument 22 and the world health organization quality of life instrumentolder adults module to evaluate qol 23 the first instrument is composed of 24 facets that are grouped into four domains that focus on physical psychological social and environmental aspects there is no total score for this instrument and each item contains five likert response options that are recorded as scores of 15 the whoqolold module consists of 24 items that are divided into the following six domains sensory abilities autonomy past present and future activities social participation death and dying and intimacy the scores of all domains are combined to produce an overall score for qol in older adults with higher scores indicating good qol the instruments were previously validated by fleck et al 2425 and showed good reliability and validity in the assessment of qol of brazilian older adults statistical analysis spss software version 190 was used for the analysis and included χ 2 tests and ordinal logistic regression kmeans clustering analysis was used to obtain three groups by considering the better distance between the mean scores of the four dimensions in whoqolbref and the mean of the total whoqolold score the f test was used to analyze the differences and characterize the groups with a significance level of 5 this type of analysis is an analytical statistical tool that is used to define the development of mutually exclusive significant subgroups based on the similarities among individuals without prior knowledge of the allocation within the groups in cases in which the grouping of the data is successful the groups are internally homogeneous but have high external heterogeneity 26 canonical discriminant analysis was used posteriorly to validate the cluster analysis described by two functions the objective of discrimination is to maximize the variance between and within groups and to verify the efficiency of the overall correct classification of the model 26 the qol level among the clusters was adapted from oliveira et al 27 for all the whoqol domains there was a group with good qol scores a group with intermediate qol scores and a group with worse qol scores ordinal logistic regression was used to test the association between qol and physical and psychosocial health after controlling for age and socioeconomic status all analyses were performed separately for each gender in this study we applied the polytomous universal model which incorporates the ordinal nature of the dependent variable in the analysis thus a logistic regression model with proportionalodds and logit function 28 was performed the odds between the categories of the dependent variable were compared by calculating the crude and adjusted odds ratio and tests evaluating the homogeneity of slopes and multicollinearity were conducted using pearsons adjustment to analyze the validity of the model to ascertain the possible interference of a small number of observations we used residual analysis for ordinal data as proposed by mccullagh 29 all of these tests showed that the model satisfied all of the assumptions and the effect of the complex sample design was considered in all of the analyses results the age of the total sample at baseline ranged from 60 to 106 years old and the mean age of all participants at baseline was 7089 ± 814 years table 1 shows the descriptive statistics of the socioeconomic and health conditions of the participants according to gender thirty percent of the participants were more than 74 years old and 317 older adults were octogenarians most men and women were between 60 and 74 years old and there was no difference in age distribution between genders fortyeight types of living arrangements were identified among older adults in the city under study when taking the three groups of living arrangements that were established in this study into account it was observed that the majority of older adults who lived alone were women whereas 755 of men lived with their partners there were no differences in the years of education between the different genders however 104 of men and 86 of women had completed over 4 years of study additionally there were significant differences related to marital status income retirement and living arrangement between genders the majority of men in the sample were married while 617 of women were single separated or widowed most older adults had low monthly income and this percentage was higher for females compared to males the selfperceived health status was different between men and women while 508 of men rated their health as good most women rated their health as fair or good only 159 of the older adults did not have chronic diseases however the percentage of women with more than two diseases was statistically higher than that of men the prevalence of cognitive impairment was 353 with a slightly larger proportion of women than men reporting this condition in relation to depression there was a 302 prevalence of depressive symptoms and a statistically significant difference between genders there was a high prevalence of functional limitations and a significant difference in functional limitations between men and women cluster analysis resulted in the formation of the following three groups of older adults in relation to qol subjects with poor fair and good qol the majority of the older adults were included in the fair qol group which corresponded to the average level of scores in the whoqol the group with worse qol included 371 people whereas the good qol group included 627 subjects the results of the test for equality of the group means between the groups were significant indicating that the groups differed in all qol domains the overall correct classification of the canonical discriminant functions was 979 with a correlation coefficient of 089 differences were observed in all of the qol variables except for those of retired individuals in this case the socioeconomic distribution between the genders was reversed with 477 of the older adults in the higher qol group being male and 677 of those in the lower qol group being female additionally there was a gradient association between low qol and worse health perception cognitive impairment depressive symptoms family dysfunction and functional limitation most of the older adults who reported two or more chronic diseases were allocated to the low qol group the results of the ordinal regression model which estimates the or of good qol by gender are shown in table 4 age marital status income and cognitive impairment did not remain associated with qol in the final model there was an education gradient for the qol of men men with 14 and 5 years of education were 22 and 42 times more likely to have a better qol than illiterate men similarly women with five or more years of education were associated with good qol retired men had better qol when compared to nonretired men but this association was not observed in females men living in mixed arrangements and women who did not practice physical activity tended to have a poorer qol as shown in table 4 there was an increase in the or for the association between qol and selfrated health for both genders once the model was adjusted for demographic variables and psychosocial health men with fair health and in particular good health were associated with good qol women with good and fair health were 42 and 30 times more likely to have a good qol respectively for both genders there was a robust association between qol and all psychosocial variables except cognitive impairment men without depressive symptoms and women without family dysfunction were 36 and 30 times more likely to have good qol respectively discussion the physical and psychosocial health and sociodemographic variables examined in this study were evaluated using ordinal logistic regression which resulted in the following five variables being associated with good qol for both genders selfrated health depressive symptoms years of education chronic diseases and family dysfunction additionally good qol for men was associated with retirement mixed living arrangements and physical activity whereas good qol for women was associated with physical activity these results are similar to those of other studies 273031 these factors represent targets for policy action because they have the potential to affect the health of older individuals in the general population a number of studies have been performed on qol in older adults this study is original and innovative because it used a representative sample to provide information regarding an ordinal positive relationship between qol and selfrated health furthermore our results indicate that the most important factors for a good qol for both genders is a good health perception and a lack of depression even when the model was adjusted for socioeconomic conditions we observed a significant difference of 44 when comparing good selfrated health between the low and high qol groups in the ordinal regression the men and women who reported having good health were 57 and 42 times more likely to have good qol respectively previous studies on qol in older adults have also shown a direct relationship with selfrated health 273233 in particular older adults who evaluated themselves as having good health tended to have good qol 27 the perception of health in older adults was generally positive because most of the older adults in this sample rated their health as good including 580 of the men and 482 of the women however the percentage of poorer selfrated health was higher in women compared to men this study provides further evidence that qol can be explained by selfrated health and its associated factors among older men and women in the sabe study in são paulo brazil 89 of women and 72 of men demonstrated poor health in other sabe study countries the participants reporting goodvery good health ranged from 279 of women to 690 of men 2 a previous study on the components of selfrated health among adults suggested that physical health most likely comprises the majority of an individuals perception of health status 34 and this result was observed in this study health perception involves an individuals evaluation of hisher body in relation to hisher feelings including feelings regarding health and wellbeing and this perception can be altered by environmental stressors and the social context 35 for older adults the concept of selfrated health remains stable despite significant health problems although over time there might be a reduction in the standard of good selfrated health 36 selfrated health has been shown to be a reliable method for measuring health status 37 and to be a consistent predictor of mortality in older adults 38 it is essential to use the association between perceived health and qol in patients especially in regards to the dual direction of this association we observed a very strong association between qol and depressive symptoms which corroborates the findings of other studies 32333940 thus the choice of good qol was 36 and 22 times higher for men and women without depressive symptoms than for those experiencing depressive symptoms respectively this finding could be explained by the high prevalence of depression in this sample this figure reached 344 in women and 704 in women with poor qol these disorders are more prevalent in females but this gender vulnerability varies with age 41 in a study conducted in łódź poland 309 of older adults were found to suffer from depression according to the authors the chances of good selfrated qol were 99 times higher in older adults without depression 42 considering the importance of the physical and psychosocial aspects of active aging and of qol in older adults other results of this study should be briefly discussed in this study an increase in the number of chronic diseases was associated with a decrease in qol and statistically significant gender differences were observed between chronic diseases and qol most women who reported two or more diseases were classified as having poor or fair qol in general the prevalence of chronic disease among older people in brazil is high and differs between genders 11 resulting in negative repercussions on qol 43 preventive actions and the promotion of policies for controlling the effect on health conditions could result in good qol in this population 30 physical activity is a protective factor for qol and has been previously discussed in the literature 4445 for women we observed a significant association between qol and physical activity ie the choice of good qol was 14 times higher for women who practiced physical activity however this association was not accurate once the confidence intervals included a value of 10 physical activity was measured using a single yesno question which is an important limitation of this study because these results assume that any level of physical activity will be associated with health we did not observe an association between marital status and qol although we observed an inverse association between qol and family dysfunction men and women who were satisfied with their family relationship had 18 and 30 times higher odds of good qol respectively frequent contacts and visits with friends or family have been shown to motivate activity and increase selfrated qol 46 additionally we found a high percentage of individuals with poor qol living in mixed arrangements ie sharing the household with their sons and frequently with sons and grandchildren this situation which is common in other brazilian regions is in contrast to the living arrangements in developed countries 11 as shown in table 4 men living in mixed arrangements had worse qol than those living alone in our dataset most men who lived in mixed arrangements had functional limitations and reported more than two chronic diseases it is possible that men in our sample could have been living in mixed arrangements because they had poorer health and therefore needed daily assistance however these results should be interpreted with caution as there was a low percentage of men living alone size sample stratification and corrections minimized these effects thus permitting comparisons in this study a mixed living arrangement could have a negative effect on the older population 2047 however living alone presents a greater risk of loneliness and isolation because loneliness increases as the social contacts of older individuals decrease 46 similar to the results of other studies 334849 we found an association between qol and education sete lagoas is a brazilian city with high life expectancy and good social indicators 50 in addition illiteracy is high in this sample compared to the current national data 51 these results are often found in most latin american countries 2 and in some regions in brazil where very different educational opportunities are available for the rich and poor a low level of education is an important aspect to be considered when developing public policies for older adults and a proposed collective action in our study the illiteracy rate was similar between genders a previous study investigated trends in educational inequalities in terms of oldage mortality in norway from 1961 to 2009 and the authors observed that relative educational inequalities in oldage mortality were increased for both genders 52 the association of years of education with qol was different between the genders we observed an ordinal crescent impact of years of education on qol for men indicating that education can be a protective factor for good qol among men the qol among women with 14 years of education was no different than that of illiterate women our results correspond to the baseline data reported for the ageqol study however the lack of understanding of the ways in which specific levels of education interfere in the association between ses and qol is the first limitation of this study a longitudinal followup study of older adults would permit better comparisons of this study with others although such comparisons might be hampered by differences in the qol models and measures that are employed across studies it is not yet possible to determine whether there is a temporal relationship between the studied variables the response rate in this study could be considered high therefore this study is one of the few studies that have been performed using a probabilistic sample of older adult community residents with an adequate number of participants to perform an ordinal logistic regression our results are valid and representative of the population living in the community that lacks significant cognitive andor physical deficits in addition to the limitations of this being a crosssectional study it should be emphasized that the evaluation of qol presupposes the quantification of a construct that is sensibly marked by the subjectivity of individual experiences beliefs expectations and perceptions 24 in this sense it is necessary to discuss the instruments used to measure qol in older adults we used the whoqolbref and whoqolold which were developed by the who are widely reported in the scientific literature and have been validated in brazil 2425 the results of this study corroborate those reported by the brazilian whoqol group for older brazilian adults a positive qol includes several aspects such as activity income social life and family relationships whereas a negative qol is related to poor health which differs between individuals 53 whoqolold is a supplementary module for older adults and can be added to the existing whoqol instruments 22 bowling 7 compared generic qol scales used for older adults and showed that the whoqolold was the most comprehensive instrument the questions in this instrument are based on measuring suffering but the questionnaire is relatively long and the likert scale format might be boring to the subjects additionally bowling emphasized the need for a generic truly multidimensional qol measure with minimal respondent burden for evaluating the outcomes of health and social care in older populations 7 the reason for the existing difficulties in the assessment of qol that limits its inclusion in clinical practice and public health services is relevant 54 to minimize these limitations one specific method of analysis was conducted in this study based on a brazilian study 27 we used cluster analyses and canonical discriminant analyses to compile both whoqol instruments into a unique measure for qol this analysis was performed to provide an ordinal variable with three internally more homogeneous groups that were distinct from each other additionally we minimized the variations between the mean scores of the five dimensions of qol that were considered we found a high percentage of correct classification and a high correlation coefficient which indicated the likelihood that we had constructed a good measure of qol for older adults in this sample in future studies we suggest replicating this statistical model considering gender and age stratification variations and including other independent variables concerning nutrition and lifestyle adaptation and resilience might also play a role in maintaining good qol 55 despite these limitations this study confirmed that the qol of older adults differed between the three clusters that were formed with a good qol being strongly associated with good selfrated health the absence of depressive symptoms and family satisfaction overall the results demonstrate that active aging in sete lagoas brazil does not occur evenly across genders better healthcare requires the inclusion of such differences as part of the comprehensive evaluation of older adults 56 the discussions of aging in the different genders in relation to living conditions and perceived health that are presented in this study need to be further explored as there are particularities of each group that may have been missed during routine analysis we believe that this study may contribute to the formulation of new public health and social care policies for older adults in the medium and long term older adults will benefit from interdisciplinary monitoring that focuses on promoting health improving qol and active aging conclusions we conclude that there are gender differences related to better qol in this sample cohort women with good physical and psychosocial health are more likely to have a better qol for men the best qol was associated with high socioeconomic conditions and good physical and psychosocial health we hope that our study contributes to future discussions on the most important predictors for assessing qol in older adults and on longterm changes in the perception of qol in this population competing interests the authors declare that they have no competing interests

background in brazil a rapidly aging country suffering from large inequalities the study of the quality of life qol of aged people is important for the future health the aim of this study was to examine the associations among qol gender and physical and psychosocial health in older brazilian communitydwelling adults to identify factors that are associated with better qolthe aging gender and quality of life ageqol study which included 2052 respondents aged 60 or older was conducted in sete lagoas brazil between january and july 2012 the respondents answered questions regarding their socioeconomic and demographic information health and social situations cognitive impairment depressive symptoms and family satisfaction the authors also applied the brazilian version the world health organization quality of life qol assessmentbrief instrument whoqolbref and the world health organization quality of life instrumentolder adults module whoqolold ordinal logistic regression with the proportionalodds and logit function was used to test the association between qol and physical and psychosocial health according to age and socioeconomic status results older adults of both genders with five or more years of education good selfrated health an absence of depressive symptoms and no family dysfunction reported better qol retired men had a better qol compared to nonretired men or 22 95 ci 1432 but this association was not observed in females men living in mixed arrangements or 05 p 0033 and women who did not practice physical activity or 07 p 0022 tended to have poorer qol conclusions we conclude that there are gender differences related to better qol in this sample women with good physical and psychosocial health are more likely to have a better qol for men the best qol was associated with high socioeconomic conditions and good physical and psychosocial health

i introduction engineers play a crucial role in solving complex sustainability problems such as climate change resource scarcity and social injustice 12 these problems are characterized by a high degree of uncertainty ambiguity and conflicts of interest and are therefore often called wicked problems 3 unfortunately most contemporary engineering education does not adequately prepare students to address wicked problems and thus to assume professional responsibility for the societal and environmental impacts of technological development 45 emotions play a vital role in engineering education that aims to prepare students to address wicked problems 67 and in ethically responsible engineering work 89 at the same time engineering education and practice are often described as purely rational activities 10 and there is very little research on emotions in engineering education this study contributes to an emerging body of research on the role of emotions in engineering education we use positioning theory 11 to explore the role of emotions in learning to address wicked problems in engineering education more specifically we use the concept of emotional positioning which refers to the construction and negotiation of subject positions in and through emotion discourse 12 ie emotional subject positions 13 we answer the following research question how do engineering students construct and negotiate emotional subject positions in discussions about wicked problems ii background almost all of the few existing studies on emotions in engineering education have focused on emotions as individual competencies or experiences such as empathy 14 shame 15 and frustration 16 however research has also suggested that expressing emotions in social contexts may play an important role in explicating personal values 17 and ethical judgment 810 such explicit discussion of values has in turn been described as an important precondition for constructive and collaborative discussions about wicked problems 18 there is therefore a need for research in engineering education that studies emotions in and as social interaction 19 for example from discourse analytic perspectives 2021 a discursive focus is particularly important for studying the role of emotions in teaching and learning processes involving controversial topics and high levels of social interaction 22 such as discussions about wicked problems iii theoretical framework our starting point is that addressing wicked problems is an inherently social process and therefore needs to be studied in social interaction 1821 we explore this interaction through the lens of positioning theory 11 positioning theory is based on social constructionist perspectives of identity and learning as constructed and negotiated in and through interaction and therefore offers a suitable lens for exploring emotions as discursive phenomena 12 positioning theory provides a practical analytic tool to study discourse through triangulation of three units of analysisstorylines positions and speech actswhich are often illustrated in the form of a positioning triangle 2324 storylines are collaboratively constructed narratives about what is going on in the interaction these storylines make available certain positions that people can relate to in different ways each position is characterized by a set of rights and duties to perform certain types of speech acts but not others speech acts are understood as socially constructed meanings of actions of speech but also nonverbal communication such as intonation pausing body movement facial expressions and gestures 2425 in this paper we apply the positioning triangle specifically to the analysis of emotions 12 in the remainder of this paper we therefore use walton et als 13 term emotional subject positions and we talk of emotionacts rather than speechacts we further differentiate between two forms of emotionacts we use the term emotion discourse to denote emotionacts that express something about emotions through verbal communication for example using words that explicitly refer to emotions such as happy or frustrated cf 26 we use the term emotional discourse to denote emotionacts that express emotions through nonverbal communication for example through verbal stress or facial expressions cf 27 fig 1 the positioning triangle as described by davies and harré 24 iv methods we analyzed empirical material from a previous study 7 for which ten thirdyear engineering students were individually interviewed about how to they would address the wicked problem of watershortage in jordan during the interviews the students received a problem description and a set of solution alternatives they were then challenged to discuss the problem from as many different perspectives as possible to fully appreciate not only the technical but also the social and environmental complexity of the problem during the interviews both the students and the interviewer expressed a range of emotions related to the problem and the task of addressing the problem each interview lasted for about one hour and was videorecorded and transcribed verbatim we read through the transcripts multiple times and selected all excerpts in which students used emotion discourse in talking about engineering engineers andor the wicked problem to identify these excerpts we used hufnagel and kellys 20 description of indicators of emotional expressions which include semantics prosody facial expressions gestures and linguistic features in analyzing the selected excerpts we used storylines as the primary unit of analysis because they provide the necessary narrative context within which positions and emotionacts can be understood and described 2428 thus we first formulated preliminary descriptions of emotionrelated storylines based on these descriptions we then developed preliminary descriptions of emotional subject positions in each storyline and emotionacts through which the suggested storylines and positions were constructed and negotiated if necessary we divided excerpts into subsections with different storylines and analyzed each subsection individually in an iterative process we refined the descriptions by constantly comparing and triangulating across the three units of analysis 23 v results the results provide illustrative examples of how the dominant discourse of rationality is reconstructed and thus perpetuated in engineering education the results also provide examples of how counterdiscourses are used to construct emotions as important for engineers and engineering in this section we will first illustrate the indepth analysis with one empirical extract storylines and we have therefore divided it into three parts and analyzed each part separately in each of the three storylines at least one emotional subject position was made available table ii below we explain how emotionacts contribute to constructing these storylines and subject positions in lines 12 the words coldly and warmly are clear examples of emotion discourse these words construct an opposition between emotional and rational approaches to problem solving in the storyline this opposition is strengthened through the use of emotional discourse both words are spoken with verbal stress which contributes to constructing them as belonging to a pair of opposites in lines 38 the students use of emotion discourse constructs a focus on rationality and efficiency for example the expression exactly what i was thinking focuses the discussion on cognition and the expressions cold and left right no matter no matter reduce lives lost tap tap tap construct a focus on rationality and efficiency again emotional discourse strengthens the storyline the words coldly and exactly are spoken with verbal stress which respectively constructs rationality and precision as importantand which thus strengthens the focus of the storyline on rationality further the expression that starts with left right … is spoken in a rapid voice which strengthens the focus on efficiency in lines 915 the student uses a lot of explicit emotion discourse to construct emotions as something that should be avoided in problem solving they state that i dont want to be influenced by emotions people who dont do that turn a deaf ear and look away they become engrossed by every little concern and ill take some of my coldness to solve something the focus is on actions and outcomes rather than emotions the student wants to solve and do at the same time the expression turns a deaf ear and looks away carries negative connotations and thus constructs complete emotionlessness as undesirable similarly the use of emotion discourse in a terrible situation constructs empathy as generally importantif one is able to bracket this emotion during problem solving the student constructs their own position as someone who is able to consciously choose between being empathic or rational in extract 1 as a whole the student thus constructs an overarching storyline according to which engineers are competent problem solvers who solve problems rationally and efficiently rather than allowing themselves to be influenced by emotions the student positions the ideal engineer as a highly intelligent rational problem solver who wants to do the best for society from a utilitarian perspective to be able to solve problems the ideal engineer needs to bracket both their own and others emotions and concentrate on identifying the most efficient solution for achieving a predefined aim such as minimizing the risk of losing human lives in contrast to the ideal engineer the student positions others as reasonably intelligent but prone to becoming overly emotional which reduces their ability to solve problems finally the student positions themselves by combining aspects of the two prior positions as someone who is able to switch between acting as an engineer who is able to rationally solve problems and as an empathic and emotional human being thus the student simultaneously draws on the dominant discourseengineering as purely rationaland a counterdiscourseemotions in this case empathy are important for engineering work discussion in this workinprogress research paper we have presented results from a pilot study that aimed to explore the role of emotions when engineering students discuss wicked problems it should be noted that the results are preliminary and that the analysis does not cover all types of storylines and positioning that can be expected to be present in the data most importantly the analysis has only focused on emotional storylines related to the students positioning of themselves engineers and others an exhaustive treatment of the empirical material should include an analysis of how the interviewer is positioned 29 for example in lines 12 the interviewer could be said to be positioned as someone who should tell the student whether they should approach the given problem emotionally or rationally transferred to an engineering education context such a positioning could imply that students expect instructors to specify what emotionapproach students should use for a given problemin much the same way as instructors often are expected to specify the algorithm that students should use to solve problems in engineering education 30 an interesting result is that students often draw on several conflicting discourses on the one hand they construct the ideal engineer in a way that mirrors powerful cultural stereotypes of engineers as emotionless and sometimes excessively rationalmuch like the cartoon character dilbert or the star trek series character mr spock this image of the ideal engineer also matches previous descriptions in the literature according to which engineering often is described as purely rational 810 on the other hand the students seem to perceive these stereotypes as problematic several students carefully position themselves as not quite like this typical engineer instead of positioning themselves as rational beings they position themselves as able to choose a rational approach in order to solve a problem but as also able to choose an emotional empathetic approach this double positioning is particularly clear in extract 1 where the student explicitly positions themselves as someone who is able to consciously switch between rational and emotional approaches to problem solving as far as we know this more nuanced emotional positioning of engineering students has not yet been reported in the literature another interesting conclusion from the results is that students in this study talked about emotions in a rather unnuanced way they talked about emotions as if all emotions were the same and as if they would have the same impact on problem solving emotions are also described in a dualistic manner as something that is either switched on or off and that can be consciously controlled this unnuanced understanding of emotions is in stark contrast to how emotions are described in the educational research literature 31 however the analysis also suggests that at least some students have an intuitive understanding that emotions may be important for some aspects of engineering work such as managing others emotions deciding between different solution approaches encouraging professional responsibility and strengthening personal motivation to do good and solve problems these results broaden descriptions in previously literature according to which emotions are important for addressing sustainability problems 67 and ethically responsible engineering work 89 strengthen some tentative implications for practice can be drawn from the results presented in this paper first engineering students should receive explicit teaching on the role of emotions in problem solving to allow them to develop a more nuanced understanding of emotions to do so engineering educators could build on the intuitive understandings that some students have of situations in which emotions are important for engineering work second engineering educators should help students to develop their ability to identify and apply an appropriate emotionapproach to a given problem students need to learn to take responsibility for how they use and communicate emotions in engineering problem solving third engineering educators should involve students in discussions about common stereotypes of what an ideal engineer is if students have a false image of the ideal engineer as someone who is unemotional they may feel alienated from engineering and even choose to not complete their studies andor not work as engineers after graduation in future research we want to explore engineering students emotional positioning in group discussions such an approach is particularly important in analyzing students positioning in discussions about sustainability problems addressing such problems requires discussion and collaboration among multiple stakeholders and is thus an inherently social process that should be studied in social interaction we also expect that studying positioning in group discussions makes it possible to explore how multiple competing storylines are constructed and negotiated and what kinds of storylines become dominant or inferior 32

progress research paper describes the results from a pilot study that aims to explore the role of emotions in engineering students discussions about a wicked sustainability problem ie a problem that is characterized by a high degree of uncertainty and ambiguity and for which it is not possible to develop a perfect solution there is strong evidence from educational research that emotions are important for learning at all levels of education and particularly in education related to sustainability and wicked problems at the same time dominant discourses and stereotypes in engineering and engineering education construct engineering as purely rational and unemotional in this study we explore how engineering students reconstructbut also challengethis dominant discourse in interviews about a wicked problem we use discourse analytic tools from positioning theory to analyze how the students construct and negotiate emotional subject positions for themselves and others the results provide illustrative examples of how emotional positioning can strengthen andor challenge the dominant discourse examples from the dominant discourse illustrate how students position emotions as irrelevant or even detrimental for engineering work while examples from the counterdiscourse illustrate how students sometimes construct emotions as part of what it means to be an engineer and as important for engineering work

introduction respect for teachers varies worldwide with some countries like japan holding teachers in high regard for their contribution to students integrity and achievements which might result in teachers job satisfaction 1 however in many countries including the united states 2 china 3 and south korea 4 despite cultural respect for this profession teachers have experienced incidents of teacherdirected violence 5 or teacher victimization 67 encompassing physical social verbal and cyber violence sexual harassment and personal property offenses 8 teacherdirected violence or teacher victimization is a relatively new research field that has recently received considerable attention especially when national surveys revealed that in some countries eg the usa the majority of teachers had experienced some form of victimization at school including verbal harassment theft damage to property or physical abuse 2 many recent studies have reported that teacher victimization is related to adverse outcomes eg lower job satisfaction and reduced school connectedness 79 which might eventually affect the school climate 10 student achievements and teachers educ sci 2024 14 163 2 of 19 life satisfaction 11 however the links between different forms of teacher victimization by students their parents and school staff and teachers life satisfaction are still underresearched the purpose of this study was to examine the links between various forms of teacher victimization by students their parents and school staff and teachers life satisfaction teacher victimization teacher victimization is a multifaceted phenomenon 12 13 14 15 that refers to situations where teachers experience various forms of mistreatment harassment or aggression in the workplace coming from various sources including students parents colleagues or administrators 3 16 17 18 19 teachers may be victimized by student misbehavior including verbal abuse disrespect bullying or physical aggression 318 teachers may also face conflicts with parents including confrontations accusations or disrespectful behavior arising from misunderstandings academic concerns or disagreements about teaching methods 1920 interactions with colleagues involving bullying undermining behavior or conflicts can also contribute to teacher victimization 42122 finally teachers may feel victimized by administrative decisions or actions and by a lack of communication or appreciation that is perceived as unfair or unsupportive 23 on the whole teacher victimization can take the form of workplace bullying which involves repeated mistreatment humiliation or intimidation coming from colleagues administrators students or their parents and can have broader psychological effects 122425 the categorization of teacher victimization encompasses various forms of teacherdirected violence such as physical social verbal and cyber violence sexual harassment and personal property offenses 78 the prevailing socioecological conceptual framework suggests that schools implementing positive evidencebased strategies and fair discipline policies promote positive interactions between students and teachers 26 previous studies have provided significant insights on teacher perceptions of victimization and safety school hardening strategies to increase physical safety school programs or policies to enhance school climate positive discipline policies as well as teacherstudent relationships 2326 previous studies have also revealed that teachers suffering more forms of violence increases the risk of suffering any future violence 27 besides teachers who reported recent or multiyear victimization had lower connectedness to school and job satisfaction and more often thought about ending their teaching careers 1525 studies have consistently shown an association between higher levels of bullying and teacher victimization and lower levels of teacher job satisfaction 28 additionally teacher victimization experiences have been correlated with lower selfreported job performance diminished student trust a perception of reduced safety at school and an increased likelihood of contemplating leaving the profession 2930 moreover schoolviolencerelated stress was found to be negatively associated with teachers quality of life acting through mechanisms such as coping selfefficacy and job satisfaction 31 numerous studies have revealed that teachers who experience mistreatment at their workplace may suffer from stress anxiety depression burnout 243233 and a decline in overall psychological wellbeing 34 so the impact of teacher victimization extends beyond the professional realm victimized teachers are more likely to suffer from psychological distress impaired personal relationships and heightened fear all of which harm job performance and relationships with students 4 35 36 37 teacher victimization has been consistently linked to adverse effects on emotional and physical wellbeing job performance and retention 11253035 verbal and physical aggression by students have been found to be highly correlated with teachers emotional distress 36 38 39 40 bullying experiences during teacher training have been associated with adverse outcomes including compromised job satisfaction and a diminished general health state 41 addressing teacher victimization is crucial for creating a positive and supportive educational environment as teacherdirected violence impacts school climate and even student academic and behavioral outcomes 910 42 43 44 45 46 exposure to violence emotional exhaustion and low professional achievement by teachers contribute to poor student performance in school 4748 research has shown that teacher victimization can significantly impact student academic and behavioral outcomes as well as the schooling recruitment and retention of highly effective teachers 84950 violence against teachers predicts physical and emotional effects as well as negative outcomes in teachingrelated functioning with women reporting higher levels of physical symptoms compared to men 51 serious acts of violence against teachers have been found to affect their performance at school and can lead to absenteeism due to fear and safety concerns 52 while some studies found no significant differences in stress for teachers who experienced teacherdirected violence compared to those who did not experience it 5354 other studies revealed that teacherdirected violence significantly impacted teacher wellbeing recruitment and retention 31618195556 selfblame predicted negative affect which in turn predicted the majority of outcomes after experiencing violence against teachers 95758 the relationship between schooland teacherlevel factors including those related to victimization and teacher job satisfaction has been consistently established in the literature 59 60 61 teachers who feel supported by the administration and work in environments where rules are consistently enforced are less likely to fall victim to teacherdirected violence 46 62 63 64 the lack of support from administrators has been identified as a factor that negatively impacts teachers feelings interpersonal challenges and school systems and policies 2723446566 perceived school support has been identified as having a direct effect on exposure to school violence subjective wellbeing and professional disengagement in teachers 67 next urban schools have reported the highest levels of teacherdirected violence followed by rural schools and then suburban schools 54 a significant relationship has been detected between teacherdirected violence and factors such as gender and the education sector 68 male gender and urban settings have been associated with a higher likelihood of teacher victimization 69 previous studies have suggested a negative impact of teacher victimization on teachers wellbeing 25 teacherdirected violence has consistently been associated with adverse effects on emotional and physical wellbeing 53 verbal and physical aggression by students have been found to be highly correlated with teachers emotional distress 36 while perceived teacher stress has been directly associated with emotional and physical violent discipline mediated by job perceptions 7071 additionally teachers sense of disempowerment after experiencing incidents of violence was associated with turnover intentions and decisions 72 finally teaching satisfaction has been found to be positively correlated with selfesteem but negatively correlated with psychological distress and teaching stress and teachers wellbeing was correlated with the belief in a just world 73 teachers life satisfaction teacher life satisfaction is affected by a variety of antecedents 3563 74 75 76 and understanding these factors is important for creating a positive teaching environment research has evidenced several factors contributing to teachers life satisfaction firstly positive and supportive relationships with colleagues contribute significantly to teacher life satisfaction 5377 adequate support from school administrators including clear communication recognition of achievements and fair policies is also vital for teacher satisfaction 2 adequate and fair financial compensation along with competitive benefits plays a role in teacher satisfaction and policies that support a healthy worklife balance such as flexible schedules and reasonable working hours positively impact teacher satisfaction 23 additionally studies have revealed that teachers who have a degree of autonomy in decisionmaking and classroom management often report higher levels of job satisfaction 23 next manageable workloads that allow for a balance between professional and personal life as well as access to continuous professional development and opportunities for career advancement contribute to higher satisfaction levels 12 teachers who feel that their values align with the mission and values of the school are more likely to be satisfied with their job 78 perceived job security and stability can also contribute to satisfaction reducing stress related to employment concerns 74 most importantly teachers who have positive relationships with their students and colleagues often experience higher job and life satisfaction 76 positive studentteacher relationships as well as recognition and appreciation from students parents colleagues and administrators contribute to a more rewarding teaching experience and life satisfaction 77 the literature underscores the farreaching consequences of teacher victimization on various facets of teachers lives 79 80 81 82 including life satisfaction studies have regularly shown that teacher victimization has a significantly negative effect on job satisfaction 1217 victims of bullying in the teaching profession are more likely to report poor selfrated health and life satisfaction with compromised relationships with parents teachers and peers partially mediating these effects 83 teacher victimization experiences along with the fear of crime have been found to have a strong direct link to job and employer satisfaction 84 additionally the perception of victimization increases the probability of teachers leaving both the school and the profession 13 1530 however the relationship between victimization and overall life satisfaction is complex with data showing mixed results 85 school violence has an indirect effect on life satisfaction through school satisfaction for those who have experienced victimization 86 teacher victimization is highly correlated with emotional distress and factors such as gender a studentoriented approach and incident characteristics predict the extent of this distress 3687 while teacher victimization is linked to heightened stress associated with teaching some evidence does not support a specific link between the fear of victimization and teacher stress 88 on the whole victimization has a negative relationship with life satisfaction and a positive relationship with emotional difficulties with hope and school connectedness identified as potential mediators 89 in some research teacher victimization has been associated with the stress faced by teachers 50 high stress levels were positively linked to negative affect but selfcontrol and organizational social support were identified as factors that can contribute to life satisfaction among teachers 76 present study several decades ago research evidenced that teacher victimization experiences are negatively associated with job and employer satisfaction 84 years later it was found that victimization impacts multiple domains but the data on the relationship between victimization and overall life satisfaction were mixed 85 some recent research found no significant differences in stress for teachers who experienced teacherdirected violence compared to those who did not experience it 5354 however the majority of findings suggest that teacher victimization could be related to diminished life satisfaction and imply negative links between teacher victimization and satisfaction with life understanding and addressing teachers life satisfaction especially teacher victimization by students their parents and school staff can provide insights into preventing a victimization culture at school this creates a more supportive work environment for teachers ultimately enhancing their overall life satisfaction and subsequently positively impacting students achievements and wellbeing educational institutions that implement positive evidencebased strategies and fair discipline policies promote positive interactions between students and teachers as suggested by the socioecological framework 26 however it could also be assumed that teacher victimization by school staff is related to teacher victimization by students and their parents and this premise is grounded in the organizational climate theory and social learning theory organizational climate theory suggests that workplace victimization can create a hostile environment fostering negative interactions among individuals within that environment 90 91 92 teachers who experience victimization by school staff may develop a heightened sensitivity to aggressive behaviors leading them to perceive and react to similar behaviors from students and their parents social learning theory posits that individuals learn from observing and imitating others 93 and in the educational context if individuals witness aggressive behaviors they may be more likely to engage in similar behaviors moreover the school environment functions as a microcosm of society and patterns of aggression and victimization may permeate various relationships within the school community therefore teacher victimization by school staff could presumably impact the overall interpersonal dynamics within the school potentially affecting the relationships between teachers and students or their parents this crosssectional study intended to contribute by exploring teacher victimization within this specific framework furthermore if teachers experience victimization by school staff this may create a negative emotional climate that permeates their interactions with students and their parents and this negative climate in turn can contribute to strained relationships further affecting teacher life satisfaction moreover presumably victimization can have cascading effects on wellbeing as negative experiences in one domain can spill over into other areas of life influencing overall life satisfaction so it is important to shed light on the potential mechanisms through which teacher victimization by school staff could be related to broader aspects of teachers lives therefore this study aimed to reveal the role of teacher victimization by school staff followed by teacher victimization by students and their parents in teachers life satisfaction the following hypotheses were examined h1 teacher victimization by students and their parents is negatively related to teacher life satisfaction h2 teacher victimization by school staff teachers and administrators is negatively related to teacher life satisfaction h3 teacher victimization by school staff is related to teacher victimization by students and their parents h4 teacher victimization by students and their parents mediates the link between teacher victimization by school staff and teacher life satisfaction of those 1059 participants were females 85 were males and 2 preferred not to disclose their gender the survey sample reflects the demographics of lithuanian teachers based on official statistics the mean age of participants was 51 years according to the official education indicators of the republic of lithuania the average age of teachers in lithuania at the time of the survey was 5116 years the sociodemographic characteristics of the participants at baseline are presented in table 1 participation in the study was anonymous and voluntary and the respondents did not receive any compensation an invitation to participate in the study was sent to the official teacher communities allowing all lithuanian teachers to voluntarily participate in the study the questionnaires heading introduced the purpose and the need for the study victimization was discussed in a few sentences thus providing teachers with an introduction to the phenomenon of victimization this studys data were taken from a more extensive study on lithuanian teachers victimization experiences and wellbeing the data collection mode was computerassisted and it took about 30 min to complete the survey data show that 1328 teachers completed the questionnaires on the online platform however only 1146 questionnaires were completed fullycorrectly before the data collection the basic principles of research ethics were discussed and the research instrument was approved by the scientific committee of the lifelong learning laboratory at mykolas romeris university on 2 october 2023 under protocol no mvglab202301 materials and methods the sample instruments to reveal teacher victimization by students their parents and school staff and the links with teachers life satisfaction this study used several previously validated instruments the translated lithuanian version of the satisfaction with life scale 94 and the translated lithuanian version of the multidimensional teacher victimization scale 20 the original items of both instruments were translated into lithuanian and backtranslated to assess teacher victimization by students parents and school staff we applied some additional questions constructed by the authors of this study the satisfaction with life scale was applied to assess teachers life satisfaction this scale is a 5item instrument designed to measure global cognitive judgments of satisfaction with ones life 94 the response pattern follows a 7point likert scale ranging from 1 to 7 the swls has been validated in many previous studies and contexts 9495 the multidimensional teacher victimization scale was used to assess teachers opinions on the forms of violence they most frequently experience from students in schools 20 this scale encompasses various forms of violence perpetrated by students each statement follows a 5point likert scale ranging from 1 to 5 the multidimensional teacher victimization scale was initially validated in previous studies 20 the verbal teacher victimization by parents scale was created by the authors of this study based on the multidimensional teacher victimization scales verbal teacher victimization by students subscale the scale consisted of 4 items students parent laughed at my looks dress or other personal characteristics students parent made fun of me by calling me names students parent threatened me students parent swore at me each statement followed a 5point likert scale ranging from 1 to 5 to assess teacher verbal victimization by school staff or bullying by school staff two questions were applied as a teacher i was bullied by another teacherteachers as a teacher i was bullied by the administrative staff each statement followed a 5point likert scale ranging from 1 to 5 in the results section we included cronbachs alpha and mcdonalds ω values and model fit indices for the confirmatory factor analyses of the instruments used in this study statistical analysis spss v260 amos v260 jasp v18 and jamovi v221 software were applied to analyze the data jasp v18 software was applied for confirmatory factor analyses jamovi was applied for mediation analysis amos was applied for structural equation modeling 96 and spss was applied for the rest of the analyses 97 in sem model fit was evaluated based on the cfi the normed fit index the tuckerlewiss coefficient srmr rmsea and the χ2 was presented for descriptive purposes 98 the values higher than 090 for cfi and tli and values lower than 008 for rmsea and srmr are considered indicative of a good fit and pvalues lower than 005 are considered to be statistically significant 99100 results in the preliminary analysis the internal consistency and validity of the instruments used in this study were assessed and the descriptive statistics were calculated in the main analysis the hypotheses on the links between the study variables were tested preliminary analysis initially several confirmatory factor analyses were performed and cronbachs α and mcdonalds ω values were calculated to examine the reliability and validity of the instruments as can be seen in table 2 the internal consistency of the instruments is good moreover the results confirmed the validity of the sixfactor multidimensional teacher victimization scale 20 additionally the results revealed that a seventh factor could be added to this scale namely verbal tv by students parents the data distribution and descriptives of the study variables are presented in table 3 the results revealed that the data exhibited a departure from normal distribution the prevalence of different forms of teacher victimization by students their parents and school staff in the lithuanian sample is presented in table 4 the results revealed that 385 percent of teachers had experienced bullying by school staff while slightly fewer teachers 339 percent experienced verbal victimization by students parents the results revealed that 385 percent of teachers had experienced bullying by school staff while slightly fewer teachers 339 percent experienced verbal victimization by students parents overall teacher victimization by students in the lithuanian sample reached 658 percent with the highest rates of verbal tv and social tv and the lowest rates of cyber tv among other tv forms main analysis firstly to examine the links between different forms of teacher victimization by students their parents school staff and teachers life satisfaction correlational analysis was performed correlational analysis revealed that life satisfaction was statistically significantly negatively related to verbal tv social tv bullying by staff parental verbal tv personal property offenses sexual harassment cyber tv and physical tv bullying by staff was significantly positively related to parental verbal tv social tv verbal tv sexual harassment physical tv personal property offenses and cyber tv to examine the hypotheses and explore various aspects of the relationships among the study variables we conducted a structural equation modeling analysis utilizing sem offers several advantages as it allows for the assessment of the meaningfulness and significance of the theoretical structural connections between the constructs in this study we employed the covariancebased structural equation modeling approach chosen specifically because our research necessitated a comprehensive measure of goodnessoffit at a global level standardized results of the model are presented in figure 1 the findings revealed that the fit of the model was acceptable χ the estimates of the model of associations between the study variables are displayed in table 6 table 6 scalar estimates of the model of associations between teacher victimization by staff victimization by children and their parents and life satisfaction the estimates of the model of associations between the study variables are displayed in table 6 the sem findings suggested that teacher victimization by school staff followed by teacher victimization by students and their parents plays a significant role in teacher life satisfaction the mediation analysis results indicating the role of overall victimization by students are presented in table 7 the indirect direct and total effects were significant even though the r 2 for life satisfaction was just 0064 and the r 2 for overall victimization by students was 0155 to summarize h1 which assumed that teacher victimization by students and their parents is negatively related to teacher life satisfaction was confirmed the results also confirmed h2 which presumed that teacher victimization by school staff is negatively related to teacher life satisfaction and h3 which stated that teacher victimization by school staff is related to teacher victimization by students and their parents next the findings confirmed h4 which assumed that teacher victimization by students and their parents mediates the link between teacher victimization by school staff and teacher life satisfaction discussion this study focused on a significant yet often overlooked aspect of the educational environment teacher victimization although conducted within a lithuanian context it offers some significant insights into the importance of addressing teacher victimization the purpose of this study was to examine the links between various forms of teacher victimizationby students their parents and school staffand teachers life satisfaction as well as to reveal the prevalence of teacher victimization in lithuania previous surveys have revealed that the prevalence of violence against teachers varies in different countries 305156101 this study revealed that the prevalence rates of various forms of victimization faced by teachers including bullying by school staff verbal victimization by students parents and different types of victimization by students in the lithuanian sample are alarmingly high with over a third of teachers experiencing bullying by colleagues and verbal victimization by students parents and nearly twothirds by students although the rates of teacher victimization in lithuania are relatively lower than demonstrated by previous research in other countries still the rate of around 40 could be considered worryingly high because of its potential negative effects on teacher wellbeing school climate teaching quality and overall educational outcomes as it signals a need for intervention support and a combined effort to foster a positive and respectful work environment within educational institutions the findings of this study align with the literature that recognizes the multifaceted nature of workplace victimization which can stem from multiple sources including colleagues superiors and even external sources like parents 12 14 15 16 17 4988102103 thus a substantial proportion of teachers in lithuania have experienced different forms of victimization with the highest being verbal victimization and the lowest being cyber victimization next this study demonstrated that various forms of teacher victimization were significantly negatively related to life satisfaction which also aligns with previous research 11123174 specifically negative correlations were found with bullying by school staff and parental verbal victimization as well as victimization by students verbal and social victimization personal property offenses sexual harassment and cyber and physical victimization a clear and significant negative correlation between different forms of teacher victimization and life satisfaction suggests that experiences of victimization whether verbal social physical or cyber could adversely affect the wellbeing of teachers which was also indirectly indicated by other studies 38 39 40 104105 the stronger the victimization particularly in forms like bullying by staff and verbal victimization the greater the possible negative impact on life satisfaction still it is important to note that this study was crosssectional and suggests only the links between teacher victimization and wellbeing but the nature of these associations could be multifaceted and reciprocal indicating alternative explanations for the findings as there was a significant negative correlation between different forms of teacher victimization and life satisfaction the findings support the assumption that teacher victimization could negatively affect their life satisfaction however the crosssectional design of this study limits making definitive causal claims and indicates that this assumption to some extent evidenced in previous research 103473106 requires validation through stronger longitudinal designs furthermore this studys finding of a negative correlation between various forms of teacher victimization and life satisfaction is consistent with the broader literature on occupational stress research has long established that workplace bullying and victimization have detrimental effects on an individuals psychological wellbeing 103107108 this underscores the necessity for interventions focusing on the mental health and wellbeing of teachers additionally the findings of this study revealed that teacher victimization or bullying by school staff was significantly positively related to verbal victimization by parents and various forms of victimization by students social victimization verbal victimization sexual harassment physical victimization personal property offenses and cyber victimization these findings suggest a complex interplay between different victimization experiences within the school environment as evidenced by previous research 40104 109 110 111 112 113 114 115 116 117 118 119 120 121 122 the sem analysis which is valuable as it allows for the examination of complex interrelationships between variables 100 provided a more nuanced understanding of the relationships between different types of victimization and life satisfaction the findings suggested that teacher victimization by school staff followed by victimization by students and their parents plays a significant role in teachers life satisfaction hypothesis 1 which posited that teacher victimization by students and their parents is negatively related to teacher life satisfaction was confirmed the results also supported hypothesis 2 which assumed that teacher victimization by school staff is negatively related to life satisfaction and hypothesis 3 which stated that teacher victimization by school staff is related to teacher victimization by students and their parents finally the findings confirmed hypothesis 4 which suggested that teacher victimization by students and their parents mediates the link between teacher victimization by school staff and teacher life satisfaction the findings suggest a possible cascading effect where victimization by school staff is related to victimization by students and parents further deteriorating life satisfaction this could imply that a hostile or negative environment enabled by staff may be a contributing factor or a marker of a broader culture of victimization that also involves students and parents these implications align with the previous studies on victimization culture 83121123 however the crosssectional design of this study implies that the findings should be regarded with caution and need further validation one of the critical findings from the sem analysis is the mediating role of victimization by students and parents this suggests that the impact of staff victimization on a teachers life satisfaction could be not just directly but also indirectly influenced by the additional victimization experienced by students and parents in other words teachers who are victimized by colleagues are more likely to experience victimization from students and parents which could further damage their life satisfaction these findings underscore the importance of nonviolent communication 124 and policies in educational environments starting from schoolstaff interactions to create a supportive and compassionate school climate for the flourishing of teachers and students 104445111113121 thus this study highlights the need for effective interventions and policies to prevent teacher victimization which could include professional development for teachers and administrators on identifying and addressing bullying creating supportive networks within schools and fostering a school culture that values respect compassion and inclusivity as outlined in previous research 113125 therefore this study revealed a complex network of relationships where teacher victimization in various forms is significantly and negatively associated with life satisfaction and provided a comprehensive picture of how different forms of victimization collectively relate to teachers life satisfaction the findings emphasize the importance of addressing teacher victimization in its various forms as a key factor in improving the quality of the work environment and the overall wellbeing of teachers 13 14 15 16 4988126 moreover the findings of this study also contribute to the academic discourse on teacher victimization which is a critical issue in educational research as teacher victimization can have farreaching consequences not only affecting the psychological wellbeing of the teachers but also impacting the educational environment and student outcomes 1828456264127 in the broader context of educational research these findings align with the existing literature that emphasizes the importance of a safe and supportive work environment for teachers 26377113125 previous studies have shown that teachers wellbeing is crucial for effective teaching and positive student outcomes and teacher victimization can lead to increased stress burnout and even attrition from the profession 2432334174 the findings from this study underscore the importance of addressing teacher victimization as a critical factor in ensuring a healthy and productive educational environment and call for a comprehensive approach that includes awareness prevention support and intervention strategies to safeguard teachers wellbeing and by extension enhance the quality of education 1924345255617680115 overall the findings of this study indicate a need for comprehensive educational policies and practice strategies to address teacher victimization including professional development for staff support systems for teachers and interventions that foster a positive school culture 82363110112 limitations and future directions the results of this study provide some valuable insights into the relationship between various forms of teacher victimizationby students their parents and school staffand teachers life satisfaction but there are several limitations firstly this study lacks a stronger theoretical and methodological background using validated scales to assess multidimensional teacher victimization by students parents or school staff and controlling for additional variables that might confound the relationships would provide more valuable insights into the links between different forms of tv and teacher life satisfaction the next significant limitation of this study was that this research hypothesized links between the study variables although causality or directionality based on the methodology of the survey cannot be specified this study identified several significant relationships but it is crucial to investigate the causality and directionality of these relationships longitudinal studies or experimental designs could help uncover causal links and the generalizations based on the findings of this study should be made with caution moreover longitudinal studies could provide insights into the longterm impacts of teacher victimization on life satisfaction furthermore further research can explore potential antecedents of multidimensional teacher victimization by students their parents and school staff such as cultural factors personality traits or adverse childhood experiences as well as potential consequences of tv such as burnout or posttraumatic stress as attempted in previous research 24 in addition although these findings contribute to the global understanding of teacher victimization they are specific to a lithuanian sample and caution should be exercised when generalizing the results to other cultural or educational contexts as the unique cultural and institutional factors in lithuania may affect the dynamics of teacher victimization differently than in other regions thus it is important to consider cultural and contextual factors in interpreting these results comparative studies across different cultural contexts could help in understanding the universal versus contextspecific elements of the phenomenon of teacher victimization by students their parents and school staff crosscultural studies in educational settings could highlight how educational systems and cultural norms are related to the manifestation of teacher victimization finally presumably only those teachers for whom the experience of victimization was not so pronounced or painful were willing to participate in the study in contrast teachers who were more sensitive to the phenomenon may have been inclined to refuse to take part in the study so the results might not accurately reflect the real situation and may not be representative moreover participants might underreport or overreport certain experiences due to social desirability or other factors and future research could benefit from additional data sources such as observer ratings or administrative records to enhance the robustness of the findings in conclusion although this study contributes to the understanding of teacher victimization and its association with teacher life satisfaction it underscores the need for systemic approaches to address multidimensional teacher victimization and highlights the importance of future research to promote teacher wellbeing and the overall climate of educational institutions conclusions this study highlights a critical issue in the educational sector in lithuaniathe widespread victimization of teachers by various parties within the school environment and its significant negative associations with teachers life satisfaction a significant portion of teachers in lithuania experience victimization in various forms the findings demonstrated that 385 of teachers have been bullied by school staff and a slightly lower percentage have faced verbal victimization from students parents the most prevalent form of victimization is by students affecting 658 of teachers with verbal and social victimization being the most common the findings revealed a clear and significant negative correlation between different forms of teacher victimization and life satisfaction the stronger the victimization particularly in forms like bullying by staff and verbal victimization by students the lower the teachers life satisfaction this study indicates that bullying by staff is not only detrimental in its own right but also relates positively to other forms of victimization such as verbal victimization by parents and multidimensional victimization by students this interrelation suggests a complex and pervasive problem within the school environment where different forms of victimization are interconnected this study confirmed that teacher victimization especially by school staff followed by victimization by students and their parents significantly relates to teachers life satisfaction moreover teacher victimization by students and their parents mediates the relationship between teacher victimization by school staff and teacher life satisfaction this implies that the negative impact of staff victimization on life satisfaction can be exacerbated by additional victimization from students and parents these findings call for urgent attention and action from educational policymakers and school administrators to address and mitigate teacher victimization thereby improving the overall wellbeing of educators data availability statement data will be available upon request from the corresponding author

the links between different forms of teacher victimization and teachers life satisfaction are still underresearched to highlight teacher victimization by various parties within the school environment and its associations with teachers life satisfaction the satisfaction with life scale the multidimensional teacher victimization scale and some additional measures were applied the findings based on a lithuanian sample n 1146 revealed that a significant portion of teachers have experienced victimization in various forms 385 of teachers have been bullied by school staff 339 have faced verbal victimization from students parents and victimization by students affected 658 of teachers with verbal and social victimization being the most common an sem analysis χ 2 355787 df 33 cfi 0928 tli 0902 nfi 0922 rmsea 0092 00840101 srmr 00432 revealed that bullying by staff is not only detrimental in its own right but also relates positively to other forms of victimization including verbal victimization by parents and multidimensional victimization by students as teacher victimization by students and their parents mediated the relationship between teacher victimization by school staff and teacher life satisfaction the findings suggest a complex problem within the school environment where different forms of victimization are interconnected and call for urgent attention and action from educational policymakers and school administrators to address and mitigate teacher victimization

introduction a substantial evidence base supports the population benefits and costeffectiveness of harm reduction interventions for people who use drugs 1 2 3 from an instrumentalrational perspective such evidence should translate directly into policies that institutionalize harm reduction services as routine interventions in health systems however these services have been contentious and implementation of them continues to be haphazard 4 5 6 7 8 the literature on morality policy is helpful for understanding this disconnection between evidence and haphazard implementation of harm reduction services 910 scholars in this area propose that when decision makers must reconcile conflicting public values over the legitimacy of providing health or social services to target populations they strategically downplay instrumental support in favor of policy designed to serve rhetorical symbolic functions 1112 this insight has informed the canadian harm reduction policy project a mixedmethod multiple case study drawing on four data sources to analyze how policies governing harm reduction services are positioned within and across the canadian provinces and territories in previous work charpp analyzed harm reduction policies written by governments and health authorities two studies confirmed that policies were largely produced for rhetorical rather than instrumental purposes as revealed in documents that avoided clear governance statements and failed to name or support specific harm reduction interventions or key international tenets of harm reduction 1314 a complementary charpp study interviewed governmental officials health system leaders and people with livedliving experience confirming that canadian policies offer weak instrumental support for harm reduction policy actors expressed ambivalence about the utility of formal policy and described how they adopted pragmatic strategies to support harm reduction services in morality policy environments 15 finally charpp analyses of 17 years of canadian newspaper coverage concluded that harm reduction was rarely portrayed negatively or from a criminal perspective volume of coverage tracked major events but dramatically overemphasized supervised drug consumption and naloxone programs at the expense of other harm reduction services this limited sense of newsworthiness may have perpetuated a morality policy environment for harm reduction by reducing public awareness of the full range of evidencesupported harm reduction services that could benefit pwud 16 public acceptability is of course a key consideration in developing policy frameworks for harm reduction services and is the focus of the present study canadian and australian research has documented substantial public support for a variety of harm reduction services including supervised injection programs 17 18 19 20 21 22 needle distribution 19 23 24 25 26 and safer inhalation programs 2527 however research is limited because public opinion has been described regionally within those countries and typically for select newsworthy harm reduction services rather than the full spectrum of evidencesupported interventions nationally representative surveys of us adults revealed that most respondents were either neutral or opposed toward needle distribution and supervised injection programs 192326 but no similar research has comprehensively described national and regional public opinions toward harm reduction in canada the literature on public views toward harm reduction is also limited because few studies have examined correlates of public support extant research has emphasized sociodemographic correlates revealing that liberal political views higher educational attainment and income are positively associated with public support for harm reduction 17192325 however little work has tested plausible theoretical models that could inform intervention strategies to modify public opinion to address this gap we propose a social exposure model depicted in fig 1 wherein four constructs influence public support for harm reduction services drawing on theories in the morality policy intergroup relations addiction and media communication literatures our model proposes that stigmatized attitudes toward pwud are a proximal determinant of public views on harm reduction services this prediction reflects a key tenet of morality policy studies 9 namely that emphasizing the ostensibly immoral deviant behaviors of a target population renders evidence on intervention effectiveness irrelevant thus calling into question the legitimacy of offering health services to them when opponents of harm reduction services adopt this position they essentially view pwud as a stigmatized outgroup unworthy of receiving effective interventions thus we hypothesize that stigmatized attitudes toward pwud will be inversely associated with public support for harm reductiona prediction that has been supported in two recent us studies 1923 stigmatized attitudes may in turn be influenced by level of familiarity with pwud the intergroup relations literature has provided empirical support for the contact hypothesis according to which greater exposure to and familiarity with outgroups facilitates empathic personal attitudes toward outgroup members 28 29 30 thus we hypothesize that personal familiarity with pwud will be inversely associated with stigmatized attitudes and positively associated with support for harm reduction although not previously investigated beliefs about addiction and in particular disease model beliefs may also be relevant for understanding stigma toward pwud and public views toward harm reduction services harm reduction programs are contentious in part because pwud do not need to abstain from substance use in order to receive them this key tenet of harm reduction problematizes disease model thinking according to which drug and alcohol dependence is chronic relapsing brain disorder 31 that can only be mitigated by complete abstinence 32 from this perspective harm reduction services are problematic because they enable substance use and perpetuate the disease thus we hypothesize that disease model beliefs will be positively associated with stigma toward pwud and inversely associated with support for harm reduction finally cultivation theory proposes that exposure to media shapes peoples views on policy responses to contentious social issues 33 for example exposure to violent media programming is positively associated with beliefs that one will become a victim of violence and also with support for punitive and retributive legislation 34 although not previously investigated we hypothesize that exposure to media reporting on harm reduction will be inversely associated with stigmatized attitudes toward pwud and positively associated with support for harm reduction objectives our first objective was to describe the nature and extent of public support for harm reduction as a broad approach to substance use in canada and also in relation to seven specific harm reduction interventions supervised consumption syringe distribution naloxone low threshold opioid treatment community outreach drug checking and safer inhalation services our second objective was to test our social exposure model specifically we sought to answer three research questions implied by our model including whether stigmatized attitudes toward pwui are inversely associated with public support for harm reduction whether personal familiarity with pwud disease model beliefs about addiction and exposure to media coverage on harm reduction are positively inversely and positively associated with support for harm reduction respectively and whether these distal social exposure variables operate indirectly to influence public support for harm reduction via stigmatized attitudes toward pwud materials and methods sample and procedure participants were recruited from an online research panel and the survey methods were designed to produce generalizable estimates of public opinion toward harm reduction at both national and provincial levels using a twophased sampling procedure in phase 1 randomlydrawn canadian adult panel members were invited to participate until a quota sample of 2002 respondents matching the age and sex distributions of canadian adults residing in each major region of canada were not invited to participate in either sampling phase the final sample included 4645 adults 18 years of age or older analyses of the phase 1 subsample provided nationally representative estimates analyses of the total sample provided provincially representative estimates in order to provide accurate parameter estimates and to avoid errors in calculating variances survey weights were converted to normalized weights for each respondent relative weights were calculated by dividing the survey weight of a respondent by the mean of all survey weights 3536 the sum of the survey and relative weights in the nationally and provincially representative datasets each equaled their respective sample sizes and as such the original sample weights were used for subsequent analyses sample characteristics are provided in table 1 in both sampling phases panel members received email invitations which included a personal identification number along with a url link to an information letterinformed consent procedure consenting participants completed the survey online at their convenience from may 31 june 25 2018 and had the ability to leave the survey and complete it at another time 36 in order to maximize participation and minimize nonresponse bias email reminders were sent approximately three days following the initial invitation and an incentive was provided to all respondents who completed the survey measures items and scales used in the present study were drawn from four survey modules opinions on national and provincial responses to substance use opinions on harm reduction as an approach to substance use and seven specific harm reduction interventions personal experiences with and attitudes toward substance use and addictions and sociodemographics general support for harm reduction three survey items assessed public views toward harm reduction as an approach to substance use these questions were preceded by a definition of harm reduction which was neutrally framed to acknowledge supportive and opposing positions respondents rated their level of personal support for harm reduction responses were recoded as 1 oppose 2 dont know no opinion and 3 support respondents who endorsed prefer not to say were recoded as missing and removed from weighted parameter estimates regarding that particular question two questions assessed support for government action on harm reduction each followed by six responses responses were recoded as 1 disagree 2 dont knowno opinion and 3 support respondents who endorsed prefer not to say were recoded as missing and removed from weighted parameter estimates regarding that particular question support for specific harm reduction interventions participants provided their views on seven harm reduction services supervised drug consumption syringe distribution naloxone low threshold opioid treatment community outreach drug checking and safer inhalation kits each service was defined for respondents followed by one item assessing support responses were recoded as 1 oppose 2 dont know no opinion and 3 support respondents who endorsed prefer not to say were recoded as missing and removed from weighted parameter estimates regarding that particular question stigmatized attitudes toward pwud stigma was assessed using four social distance items modified from the world psychiatric associations schizophrenia open the door project 37 would you be afraid to talk to someone who has a substance use problem would you be upset or disturbed to be in the same room with someone who has a substance use problem would you make friends with someone who has a substance use problem and would you feel embarrassed or ashamed if your friends knew that someone in your family has a substance use problem each item was accompanied by a 6point response scale respondents who endorsed prefer not to say were recoded as missing for model testing the third stigma question was reversecoded so that higher scores were indicative of stronger stigmatized attitudes level of familiarity with pwud respondents completed the level of familiarity scale 3839 modified in this study to assess how familiar respondents were with people who have substance use problems the scale includes 11 dichotomous items ranging from no familiarity with additional items assessing moderate familiarity respondents indicated whether each statement was true or false for them and an overall lof score was assigned based on respondents highest level of familiarity for example if a respondent indicated that they watched a documentary about persons with a substance use problem and also indicated that they have a relative who has a substance use problem that respondent would receive a lof score of 9 respondents who endorsed none of the above were recoded as missing disease model beliefs respondents completed the 7item disease model beliefs subscale from the short understanding of substance abuse scales 3240 items assessed agreement with views that addiction is a chronic relapsing disorder that can only be ameliorated with abstinence response options were recorded using a 6point response scale respondents who endorsed prefer not to say were recoded as missing for model testing media exposure to harm reduction two survey items developed for this study assessed respondents exposure to harm reduction via the media specifically participants indicated whether they had ever seen or heard media coverage of harm reduction and media coverage featuring bereaved mothers who had a child die from a fatal drug overdose sociodemographics participants sex age and educational attainment were collected as part of the survey sampling procedures in addition a single survey item asked participants to identify their political views annual household income and whether they lived in a rural or urban area substance use and for seven specific interventions to account for the complex survey design standard errors and 95 confidence intervals for weighted proportions were estimated using a set of 500 bootstrap weights computed using mplus version 84 36 the survey design stratified respondents by age and sex within each province or region a stratification variable was created in which each respondent was placed into one of six strata based on age and sex the primary sampling units for weighted estimates for the phase 1 sample were region whereas the psus for the total provincially representative dataset were the ten canadian provinces province was defined as a cluster variable for the provincial analyses of the entire dataset while region was defined as a cluster variable for the national analyses using the representative canadian subsample these clustering and stratification variables were used to create 500 bootstrap weights for the entire dataset and the nationally representative canadian subsample and to estimate variances once standard errors were produced using 500 bootstrap weights a coefficient of variation was calculated for each weighted proportion by dividing the standard error by the weighted proportion to derive the sampling variability percentage using statistics canada criteria parameter estimates exhibiting sampling variability of less than 166 were considered acceptable while estimates with variability greater than 165 but less than 333 were classified as moderate and were annotated with an interpret with caution descriptor all weighted estimates of population proportions had sample sizes of more than thirty individuals 41 objective 2 mplus version 84 and r version 361 were used to evaluate the hypothesized model predicting public support for harm reduction depicted in fig 1 first in order to describe the relationship between latent variables presented in fig 1 and their indicators a measurement model was estimated 42 constructs that were assessed using preexisting scales drawn from the literature were treated as single composite indicator scale scores while constructs assessed using new indicator items developed for this study were treated as latent variables due to the borderline alpha coefficient observed for its 4item composite scale we also treated the stigma construct as a latent variable in our analyses and investigated the measurement structure of those items factor loadings and correlations between indicators and latent variables were assessed these each latent constructs followed by confirmatory factor analysis second a structural equation model was estimated to evaluate direct and indirect effects of the constructs depicted in fig 1 results for this model were compared to a second sem that included four covariates to produce covariateadjusted estimates a weighted least squares means and variance adjusted method was utilized to accommodate missing data and categorical variables in evaluating both the measurement and structural models maximum likelihood estimation was used to calculate the correlations among continuous variables and account for missing data shapirowilk tests of normality were conducted on each independent variable to assess whether they were normally distributed model fit was evaluated using several indices title national survey of public opinion on harm reduction services and drug use study id pro00080911 results objective 1 describing public support for harm reduction canadians were generally supportive of harm reduction as an approach to substance use public support varied across different harm reduction services with more than three quarters supporting community outreach and over 70 supporting naloxone distribution and drug checking interventions needle distribution and supervised drug consumption programs received lesser though still majority support lowthreshold opioid agonist treatment and safer inhalation kits received the least amount of support among canadians at the national level public views at the provincial level revealed some regional diversity specifically respondents residing in the atlantic region of canada and british columbia reported most support for harm reduction compared to other provinces and regions while central canadians tended to view harm reduction more moderately respondents living in the canadian prairie provinces reported the lowest levels of support for harm reduction compared to other regions level of familiarity with pwud was assessed using a single continuous indicator variable lof scores disease model beliefs were assessed using a single continuous indicator variable disease model subscale scores the latent media exposure to harm reduction construct was assessed using two categorical items whether or not respondents reported ever seeing or hearing media coverage featuring harm reduction and bereaved mothers who had a child die from a drug overdose stigmatized attitudes toward pwud was treated as a latent construct measured using four continuous indicator variables drawn from this module of the survey shapirowilk tests of normality revealed that each study variable was nonnormally distributed however estimates of kurtosis and skewness for these variables indicated that these data were within the acceptable nonnormal cutoff points recommended by kline 43 our latent outcome construct support for harm reduction was assessed using three continuous indicator variables overall support for harm reduction support for increased federal investment in harm reduction and support for increased provincial investment in harm reduction correlations among continuous indicator variables along with their accompanying descriptive statistics are presented in table 2 the average age of participants was 482 years respondents were slightly positive toward harm reduction on the response scale and also on whether the federal or provincial governments should increase financial and other supports regarding harm 2 variables provhr1 and fedhr1 were highly correlated with one another while the remaining interitem correlations were less than 085 43 we also compared median scores on our three indicators of support for harm reduction across four sociodemographic covariates annual household income education political views and respondent sex median levels of support for harm reduction were consistent across all covariates except for political affiliation where we observed differences in median levels of support were observed such that respondents who identified with very and mostly conservative political views reported lower median levels of support toward harm reduction compared to those who endorsed more liberal political affiliations measurement model the latent constructs were correlated with each other a confirmatory factor analysis revealed that the standardized factor loadings for the stigma toward pwud support for harm reduction and exposure to media coverage on harm reduction latent variables in the hypothesized model were acceptable to high with the exception of the third stigma item 44 the low factor loading of the third stigma item suggests that it was a weaker indicator of the stigma construct and was dropped from the model 44 factor variance for the media exposure construct was set to 1 with the loadings freely estimated 43 an initial confirmatory factor analysis for the hypothesized measurement model indicated poor global model fit the model was then respecified by removing the third scale item from the stigma latent construct given its low factor loading a second confirmatory factor analysis indicated that the overidentified model exhibited good global fit closer inspection of local fit also revealed that the model had good local fit while all factor loadings were considered acceptable to high and statistically significant 4344 structural model a structural equation model incorporating the survey weights was fit in order to examine indirect and direct effects of level of familiarity disease model beliefs exposure to harm reduction media and stigmatized attitudes toward pwud on public support of harm reduction each path was tested to see whether it was nonzero and if so whether the valence of the observed association confirmed theoretical predictions results from this sem were compared to a second sem that included sociodemographic covariates to obtain adjusted estimates in both analyses data were weighted by age and sex the final weighted unadjusted structural model table 3 presents indirect direct and total effects of the study variables on stigma and support for harm reduction inspection of direct effects in the structural model indicated that disease model belief about addiction were positively associated with stigmatized attitudes toward pwud in the unadjusted and adjusted models while level of familiarity with pwud was inversely associated with stigmatizing beliefs toward pwud in both the unadjusted and adjusted models additionally media exposure to harm reduction was inversely associated with stigmatized attitudes in both the unadjusted and adjusted models when evaluating direct effects on support for harm reduction disease model beliefs about addiction exhibited the strongest inverse association with support for harm reduction compared to stigmatizing attitudes toward pwud conversely level of familiarity with pwud was positively associated with support for harm reduction contrary to prediction we observed no direct association between media consumption and support for harm reduction we also assessed whether exposure to media reporting on harm reduction was associated with support for harm reduction via an indirect pathway ie via stigmatizing attitudes media exposure exhibited a small though statistically significant indirect effect on public support for harm reduction via stigma discussion to our knowledge this is the first national study to provide population estimates of public support for harm reduction as a broad approach to substance use and in relation to seven specific harm reduction interventions results indicated that about twothirds of canadian adults were supportive of harm reduction as a general approach to substance use importantly these estimates were obtained using a neutral assessment strategy ie a question that provided a substantive definition in conjunction with popular reasons for support and opposition to harm reduction opponents argue that harm reduction programs encourage crime and drug use and should not be offered our results are consistent with previous research that similarly documented substantial public support for harm reduction in select canadian regions 1718212527 the present study replicated and extended those findings using survey methods that provided both nationally and provincially representative population estimates previous survey research investigated public support only for specific highprofile harm reduction services 18 the present study addressed this limitation by assessing views on a broader range of harm reduction interventions our results showed that five of seven interventions were supported by over half of canadian adults with strongest support reported for outreach naloxone and drug checking followed by syringe distribution and supervised injection programs two intervention strategieslow threshold opioid agonist treatment and safe inhalation interventionsdid not receive majority support in this study those results are consistent with charpps analysis of canadian newspaper reporting on harm reduction which demonstrated that these interventions received among the lowest coverage rates over a 17 year period 16 taken as a whole our findings that most canadian adults support or strongly support harm reduction as an approach to substance use and most harm reduction services could reflect public awareness of canadas innovative approach to services for pwud canada is widely recognized as an international leader in harm reduction starting with early adoption of needle distribution programs in the late 1980s and more recent implementation of north americas first supervised drug consumption program in vancouver in 2003 and north americas first clinical trial of prescription heroin in 2005 4546 however previous charpp studies documented relatively weak rhetorical public policy frameworks governing harm reduction services produced by provincial governments and health authorities 13 14 15 further research is needed to explain this disconnect between inadequate policy supports for harm reduction despite broad support in the general population if policy makers are insufficiently aware of such support they may inadvertently perpetuate a rhetorical morality policy environment for these services cultivating robust knowledge exchange opportunities between governmental and health system decision makers and population and public health researchers investigating determinants of attitudes toward harm reduction services could enhance policy makers access to accurate information about public views to support the policy development process the second objective of this study was to evaluate a social exposure model predicting public support for harm reduction drawing on theories in the intergroup relations addiction and media communication literatures our model hypothesized that three distal variables influence support for harm reduction directly and also indirectly via their effects on stigmatized attitudes toward pwud overall our resultswhich were adjusted for covariates typically considered in this literature provided substantial support for the proposed model as predicted we observed a significant inverse association between stigmatized attitudes toward pwud and public support for harm reduction these results replicate us studies which similarly reported that stigma toward pwud appears to undermine public opinion toward harm reduction services 1923 drawing on the intergroup relations literature our results also confirmed an inverse association between personal familiarity with pwud and stigmatized attitudes toward this outgroup as well as a significant positive association between familiarity and support for harm reduction these results are consistent with the contact hypothesis according to which greater exposure to and familiarity with outgroups facilitates empathic personal attitudes 28 29 30 one implication of these findings is that efforts to enhance support for harm reduction could focus on programs to strengthen social contact between the public and pwud eversman 47 notes that the very nature of addiction and how best to treat it divides harm reduction supporters and opponents yet to our knowledge no previous research has examined the role of disease model beliefs about addiction in relation to public support for harm reduction results confirmed that greater endorsement of disease model beliefs was associated with greater stigmatized attitudes toward pwud as well as lesser support for harm reduction these findings have not been reported in the literature to our knowledge and suggest that efforts to enhance support for harm reduction usefully could problematize certain disease model beliefs finally drawing on the media communication literature we also predicted that exposure to media coverage of harm reduction would be positively associated with public support toward these services contrary to our prediction we observed no direct association between media exposure and support for harm reduction instead we observed an indirect effect such that greater media exposure to harm reduction was associated with lesser stigmatized attitudes toward pwud which in turn was associated with greater support for harm reduction those results are consistent with cultivation theory 33 according to which exposure to media shapes personal opinions on contentious social issues by altering beliefs about outgroups our finding that media exposure to harm reduction was inversely associated with stigmatized attitudes toward pwud suggests that media can play an important role in promoting support for harm reduction by reducing stigma toward drug users to that end media gatekeepers could support efforts to promote positive public views toward harm reduction by prioritizing coverage of pwud accessing these services who experience positive life changes thus challenging disease model beliefs about addiction study limitations in general the crosssectional research design used in this study precludes casual claims as well as assessing directionality future research should attempt to replicate our theoretical model using longitudinal study designs given that our social exposure model is exploratory in nature further research is also needed to replicate the specific associations observed in this study results may change when the measures are administered to populations outside of canada another limitation of the present work is that adults living in the canadian territories were not included in the sample future research should therefore refine and replicate these methodologies and incorporate those populations finally the constructs in our social exposure model collectively accounted for only 17 of variance in our outcome measure of support for harm reduction although we adjusted for political viewpoints income education level and sex of participants those results imply that there are additional influences on public views not measured in the present research that may also be associated with public support for harm reduction conclusions despite generally favorable opinions toward harm reduction across canada weak and rhetorical public policy frameworks currently govern harm reduction services 1314 the present study advances this area beyond past efforts to identify sociodemographic correlates of public views of these contentious services such as political affiliation education or age our social exposure model suggests that efforts to change views on these services could focus on problematizing certain disease model beliefs and creating opportunities to reduce social distance between pwud the public and policy makers data are available from xhtmlpersistentiddoi107939dvnbz7ogl ethics statement the study procedures and measures were approved by the university of alberta health research ethics board ethics approval was obtained from the university of alberta under the

we described public views toward harm reduction among canadian adults and tested a social exposure model predicting support for these contentious services drawing on theories in the morality policy intergroup relations addiction and media communication literatures a quota sample of 4645 adults 18 years randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across canadian provinces was recruited in june 2018 participants completed survey items assessing support for harm reduction for people who use drugs pwud and for seven harm reduction interventions additional items assessed exposure to media coverage on harm reduction and scales assessing stigma toward pwud α 72 personal familiarity with pwud α 84 and disease model beliefs about addiction α 79 most 64 canadians supported harm reduction provincial estimates 60 73 five of seven interventions received majority support including outreach 79 naloxone 72 drug checking 70 needle distribution 60 and supervised drug consumption 55 lowthreshold opioid agonist treatment and safe inhalation interventions received less support 49 and 44 our social exposure model adjusted for respondent sex household income political views and education exhibited good fit and accounted for 17 of variance in public support for harm reduction personal familiarity with pwud and disease model beliefs about addiction were directly associated with support βs 07 and 010 respectively and indirectly influenced public support via stigmatized attitudes toward pwud βs 001 and 001 respectively strategies to increase support for harm reduction could problematize certain disease model beliefs eg there are only two possibilities for an alcoholic or drug addictpermanent abstinence or death and creating opportunities to reduce social distance between pwud the public and policy makers

introduction the cultural transformations that have taken place since the popularisation of the internet and the world wide web in the mid 90s are numerous and deal with issues relating to the technological social economic ethical political environmental and aesthetic domains these transformations are often happening at the intersections of individuals and organisational structures where for example the roles of users and producers have become increasingly difficult to differentiate or the role of cultural institutions and art in general has been constantly challenged and reconsidered at the same time cultural spaces and practiceshow and where culture takes placebeing producedbeing formed have changed dramatically all the above are the direct result of a world changed by information and communication technologies along with significant events and changes in the economic and political spheres of geographies around the world the results of this transformation are full of complexity and contradiction by being a cultural product of life with and after the internet internet art symbolises the drastic changes that took place on and to the internet postinternet refers to the new processes and conceptual dialogues that arose due to these social changes it is a critical shift from discussing the internet as a contained entity governing merely our digital interactions to saying something more about its ubiquitous presence and the reconfiguration of all culture by the internet this paper aims to examine the dimension of mediation in the postinternet condition through the postinternet art medium in an effort to produce a better understanding around the changing nature of life post internet and very importantly to encourage researchers at the intersections of sociotechnical and technocultural research to consider the ubiquitous medium of internet art as a rich and useful tool for their work in the posthuman glossary clark writes about the postinternet this rebirth of a condition defines a quantitative shift in the ontological treatment of digitalnondigital technological hybrids on both sides of the posthuman ambivalence this includes interleaving with and decentring difference through connections to previously out of reach global otherness on the one hand and the use and reproduction of dominant standardised distribution production platforms and protocols which redefine much of the space formerly known as offline on the other the concept of a condition aims to create an understanding of exploring the historical present and to provide a framework for exploring its elements which in the case of this paper is the dimension of mediation the main point of mediation in the postinternet condition has to do with viewing the mediated experience on the same level as primary experience mediation in the postinternet condition moves further than the digital cultural heritage or the physical as digital through digital reproduction processes in the postinternet condition the shift from analogue to digital is not a point of friction anymore while mediation through digital technologies does not rely on reality representation but rather on acceptance of mediated realities as reality postinternet mediatisation processes bring together the physical imagined virtual and the hybrid viewing the mediated experience on the same level as primary experience has been associated with the work of many postinternet artists like parker ito oliver laric and artie vierkant mediation postinternet is shaped by participatory cultures within network societies where sociocultural processes operate within an overabundance of information and contribute towards a constant process of creation distribution usage manipulation and integration of information in all its forms mediation in the postinternet context can be understood as a complex and hybrid process of understanding and articulating our being in and becoming with the technological world our emergence and ways of intraacting with it as well as the acts and processes of temporarily stabilising the world into media agents relations and networks a key concept discussed by kember and zylinska is that mediation entails recognising our locatedness within media as being always already mediated this allows for a metalevel of mediation where engagement with the world happens within conditions of mediation that can be measurable and identifiable but they can also be unmeasurable and nonidentifiable the unmeasurable and nonidentifiable aspects of mediation in the postinternet condition hint towards the unprecedented unexpected unformed and unruled products of mediation where the networks and infrastructures of icts exist together with an infinite production of both human and nonhumanproduced knowledge communication experience politics and culture human and nonhuman actors humans and machines networks algorithms and technologies cocreate conditions of life in a hybrid and liquid state in this mediated state the human and nonhuman exist in a state of mutualistic symbiotic intraaction meaning that human and nonhuman actors are attached by constantly exchanging and diffracting influencing and working inseparably to examine and understand this level of mediated life postinternet requires a view of the internet as more than its technical elements systems protocols and networks the various processes of mediation that involve icts have definitely a lot to do with their technical elements however their biological elements are equally important in producing and driving these processes of mediation together the biological and the technical elements are capable of generating new forms unprecedented connections and unexpected events within what zylinska calls living media and biomediations this shift from ideas of connected media and media life that examine a metaphysical living condition as a result of the connectivity of the object to the world via the medium to a living condition that both exists within and drives the mediatisation processes is a key element of how mediation in the postinternet condition could be approached and understood mediation postinternet can even be described as multidimensional and postinternet artworks can be understood as art in the postinternet condition instead of technologicallymediated art any aspect of sociocultural production affected by the internet can be considered as mediated based on its mediatisation processes like mediated sociality mediated entertainment and mediated consumerism three main areas of mediatisation are being discussed here as highlights and indicators of the hybrid and multifaceted character of mediation in the postinternet condition these are mediated publicness mediated self and mediated trust mediated publicness publicness is one of the aspects of life that has been discussed in the last two decades as an increasingly mediated process more specifically the mediation of publicness is linked to the rise of social media and how public engagement has been shaped by icts the link between publicness and technologies has been extensively examined from the lens of the public and the media communities have always used media like newspapers radio and television to create new publics and form new connections amongst actorsusers and the public to the extent they could people have always used media to create public identities for themselves others and groups the scale pervasiveness ubiquitousness and connectivity of the internet and more specifically of social media are what makes the level of widespread publicness postinternet unprecedented this increased level of mediated publicness depends on practices of appropriation of both internet technology and web content within the context of participatory cultures the sociocultural practices of mediated publicness are dependent on the appropriation of networked media tools icts and web content smartphones cameras editing applications and software are what people use to take photos and videos to document their lives or to simply create content for instagram facebook twitter and youtube social media are where people can post their content engage with the public consume content and participate in online social interactions platforms for social news aggregation and discussion and chat software like reddit discord and twitch are where people can engage with specialised topics and form niche yet global communities countless sites dedicated to online news and content aggregation like digg pocket and fark are where curation of the massive everyday social activity online along with community engagement and participation based on interests and topics takes place all of the above and much more enable activity by mediated connection to take place as part of a new form of mediated publicness internet artists have been using these mediated public spaces to directly connect with global audiences without necessarily targeting art audiences online performances through social media are a great example of how an art experience can be designed for mediated public spaces amalia ulmans scripted performances designed entirely for circulation in instagram and facebook excellences and perfections and privilege are notable examples of this practice both works are premised on appropriating and acting out the expectations of the social media audience by turning a mirror back onto the fantasies of this public in order to expose their effects on how women perceive themselves the performative nature of both facebook and instagram platforms where identities and experiences are carefully constructed and curated for public consumption and approval guide the nature of these online performances where artificial situations are presented as real these situations include plastic surgery and fake locations like cities and hotel rooms the red lines artwork by evan roth is a peertopeer network performance the red lines network connected users with servers in geographically specific locations to participate in the sharing and viewing of 82 individual pieces from the artists landscape video series over the course of two years 120000 people in 166 countries connected to the red lines network the work was commissioned via the arts organisation artangels open call for proposals to produce a major project that could be experienced anywhere in the world the artist has travelled to coastal sites around the world where internet cables emerge from the sea to record the works videos red lines investigates the physicality of the internet through a public performance that any viewer could stream at home but also become an active participant to the works network this is because of the red liness decentralised peertopeer network where a viewer becomes part of the network streaming from other viewers who simultaneously stream the feed from them anywhere in the world red lines is a network containing infrared videos of coastal landscapes that can be streamed to a smartphone tablet or computer by anyone anywhere by setting a device in your home or workplace to display this artwork you share a synchronized viewing experience with people around the world filmed in infrared the spectrum by which data is transmitted through fiber optic cables 82 slowly moving videos are stored on servers located in the same territories in which they were filmed when you view a network located video made in hong kong for example it activates the submarine cable route between hong kong and you you then become part of the peertopeer network which enables this work to be experienced by people around you mediated self the reality of the mediated selfa concept that is not new or born through the mediated processes of icts and digital mediabecomes extended in the postinternet condition as with appropriation or mediated publicness the mediated self moves further than the virtual imagebody represented as a proxy or a standin for a virtual world the self in a state of mediation is what becomes the state of the self postinternet earlier technologically mediated representations of the self like mirrors photographs and videos have allowed for new understandings of how the self can be seen by ourselves or others in different representational mediums and different times and spaces the number of interactions that ourselves can have online along with the abundance of spacetimes within which ourselves exists online and the ability to willingly or unwillingly controlarchivetracemanipulatecurate and exploit the image and activities of said selves is what allows the postinternet mediation of the self to operate within a previously impossible level of mediation the extent of the mediation of the self postinternet is constantly expanding and with it expand implications relating to privacy freedom and control the transformative possibilities of the self online whether that is in visual appearance behaviour or action allow for unlimited versions of the self at the same time the level of control or lack of control over these versions of the self allows for new levels of embodied identities the self as data the self as avatar the self as image are all extensions of the self contributing to new ways of seeing the self the self postinternet is mediated and extended and with it are our ways of seeing and understanding the self itself james bridles 2015 artwork citizen ex examines the concept of algorithmic citizenship the concept of algorithmic citizenship is based on the work of john cheneylippold first outlined in the 2011 journal paper a new algorithmic identity soft biopolitics and the modulation of control which discusses the capacity of computer algorithms to infer categories of identity upon users based largely on their websurfing activities bridles algorithmic citizenship is described as a new form of citizenship which is not assigned at birth or through complex legal documents but through data by downloading a browser extension you can see where on the web you really are and what that means as one moves around the web the citizen ex extension looks up the location of every website visit then by clicking the citizen ex icon on the browsers menu bar one can see a map showing where the website is and one can also see their algorithmic citizenship and how it changes over time with the websites they use citizen ex calculates your algorithmic citizenship based on where you go online every site you visit is counted as evidence of your affiliation to a particular place and added to your constantly revised algorithmic citizenship because the internet is everywhere you can go anywhere but because the internet is real this also has consequences like other computerised processes it can happen at the speed of light and it can happen over and over again constantly revising and recalculating it can split a single citizenship into an infinite number of subcitizenships and count and weight them over time to produce combinations of affiliations to different states 2007 the status project is a study of the construction of our official identities and creates what bunting describes as …an expert system for identity mutation the work explores how information supplied by the public in their interactions with organisations and institutions is logged the project draws on his direct encounters with specific database collection processes and the information he was obliged to supply in his life as a public citizen in order to access specific services this includes data collected from the internet and information found on governmental databases this data is then used to map and illustrate how we behave relate choose things travel and move around in social spaces the project surveys individuals on a local national and international level producing maps of influence and personal portraits for both comprehension and social mobility mediated trust trust in persons institutions and systems is to a considerable extent the outcome of mediated processes specifically communication of information which is inherently a mediated process is a determinate factor to how trust is built and developed as the internet has increasingly become the main space for communication circulation and retrieval of information a trust intermediary it has also presented important new developments on how trust is being determined and affected by the heterogeneity of online and digital media information is embedded in a flurry of heuristic cues such as likes shares and comments which may influence how trust indicators are taken up at the same time the platforms where information is being communicated and circulated are themselves objects that people can trust or distrust since the birth of the internet there has been a constant state of tension between digital freedoms of expression and association authoritarian restrictions on information and communication access and the development of internet framing policies and national and international web and internet public and private regulations this level of tension is telling of the importance of continuing to expand our understanding of how trust in persons institutions and systems is affected by internetrelated mediated processes acts and movements of critical practice and resistance like hacking building of free software and opensource communities digital resistance techniques and training sessions and circumvention devices and techniques are all indicators of the complex trustdistrust issues that keep emerging early internet art netart is a great example of how artworks were directed towards exposing and bypassing the economic juridical and technical obstacles restricting free data and information exchange and free development of software demonstrating who how and which interests determine net conditions of the time postinternet art has also been dealing with contemporary issues around control power trust and their processes of mediation subjects and themes associated with postinternet artworks are trust in technologies and platforms interpersonal trustauthenticity trust in systems and governance and trust in information some of the methods postinternet artists use to approach trust today are as follows identity play audience manipulation critical interventionshacktivism algorithmic play network mapping and social media propaganda benjamin grossers 2018 artwork safebook is a browser extension that makes facebook safe the artist asks given the harms that facebook has wrought on mental health privacy and democracy what would it take to make facebook safe is it possible to defuse facebooks amplification of anxiety division and disinformation while still allowing users to post a status leave a comment or confirm a friend with safebook the answer is yes the safebook browser extension is facebook without content where all images text video and audio on the site are hidden what is left behind are the empty boxes columns popups and dropdowns that allow for the like and react features the user can still post scroll through an empty news feed and do everything that they would normally do on facebook grosser asks with the content hidden can you still find your way around facebook if so what does this reveal about just how ingrained the sites interface has become and finally is complete removal of all content the only way a social media network can be safe maybe the only way to keep facebooka platform that has been criticised for being complicit in and a space for spreading hoaxes and misinformationfrom harming us is to hide everything twitter demetricator is used as a tool that allows users to think critically about social media it is up to the user to reflect on how visible metrics affect the way we behave and interact on social media visible metrics are designed to draw our attention they can influence and even guide the how what and when of our posts as users learn what works best in terms of approval and engagement by the users indeed its almost impossible to comprehend just how central metrics are to the twitter experience until you install demetricator only when i tried it did i realize that my eyes were instinctively flicking to a tweets retweet and favourite counters before i even processed the tweet itself only when i tried demetricator did i understand how much i relied on those signals to evaluate a tweetnot only its popularity or reach but its value conclusion both the level and nature of mediatisation processes have changed as a result of the social economic cultural and political developments in relation to the internet how the physical becomes digital through digital reproduction processes or how physical reality is being represented in digital space has been an important area of scholarship during the first wave of widespread internet use and adoption of digital technologies in postinternet times however mediation is considered a precondition for most areas of social activity analysing the complex and hybrid processes of mediation in the postinternet condition requires a broad examination of the myriad of intraactions between human and nonhuman actors which operate by constantly exchanging and diffracting influencing and working inseparably as mediation is an important dimension of the postinternet condition it is also a common theme in postinternet artworks the three main areas of mediatisation as observed by the processes of reviewing internet artworks and discourse around the postinternet are mediated publicness mediated self and mediated trust the artworks discussed in this section help illuminate the processes dynamics tensions and experiences of mediation in the postinternet condition performing for social media audiences expectations critically manipulating social media applications engaging internet users globally in peertopeer networks developing new methods that examine identity as defined by algorithmic processes and developing a platform that attempts to manipulate public opinion are all perfect examples of how important the role of mediation is for our understanding of the world and of ourselves and how vital it is to continue to explore and critically engage with its processes

this paper examines the dimension of mediation in the postinternet condition through the postinternet art medium in the postinternet condition human and nonhuman actors humans and machines networks algorithms and technologies cocreate conditions of life in a hybrid and liquid state of mediation the paper discusses three important areas of mediatisation as highlights and indicators of the hybrid and multifaceted character of mediation postinternet these are mediated publicness mediated self and mediated trust the artworks discussed in this paper help illuminate the dynamics tensions and experiences of contemporary mediation and act as examples of how important the role of mediation is in our understanding of the world and of ourselves in it and how vital it is to continue to explore and critically engage with its processes

background the population economy and social situation of china are facing new changes and challenges in order to improve the population structure and actively respond to the aging population china implemented a new threechild policy to allow per couple to have up to three children on may 31 2021 1 with the arrival of the threechild policy childrearing has become a focused problem especially for children aged 03 years chinese government emphasizes the care of children aged 03 years and issued childrearing policies including guidance on promoting the development of care services for infants and young children under 3 years 2 and the decision to optimize the family planning policy and promote longterm balanced population development 3 to promote the healthy growth and development of young children 03 years is a critical period for childrens physical and mental development 4 ensuring childrens development during this period provides a strong foundation for the future childrens early development requires nurturing care and childrearing can have a significant influence on childrens development 5 jeong et al 6 did a metaanalysis using 102 researches by november 5 2020 and found that parenting interventions for children during the first 3 years of life are effective for improving early child cognitive language motor socioemotional development and attachment and reduced behavior problems zhou et al 7 implemented a communitybased integrated and nurturing care intervention among 2745 childcaregiver pairs in four povertystricken counties and found that childcare intervention could significantly prevent developmental delay in children under 3 years in rural china for rearing children aged 03 years previous studies mostly focused on childrearing attitude knowledge and quality 8 9 10 there are few researches on childrearing barriers in china and lack of national surveys in 2009 it was reported that 306 of chinese households with children aged 03 years found childrearing to be much more difficult than before 11 recently zhang et al 12 conducted a crosssectional survey with a sample of 2229 parents of children aged 635 months and found that 875 of chinese parents reported experiencing childrearing difficulties and 315 of parents reported experiencing major difficulties they also found that family having financial problems and father not joining in childrearing might face high risk to major childrearing difficulties several foreign and domestic studies also showed that sociodemographic characteristics and environment such as parents education and family income seem to have influence on childrearing challenges and difficulties 111314 in this study we performed a national crosssectional survey on the barriers to rearing children aged 03 years in china hoping to provide scientific evidence for making childrearing policies and supporting measures help reduce childrearing barriers ensure the early physical and mental development of children and improve the quality of chinese population methods study design and study population a national anonymous crosssectional survey was conducted online in june 2021 using a random sampling method on the largest online survey platform in china wen juan xing a sample database covering over 26 million respondents was established by this online platform whose personal information was confirmed to ensure an authentic diverse and representative sample 15 a sample size of 4200 people was indicated to be sufficient to estimate the prevalence of 875 with 1 margin of error and 95 confidence level using the formula n z 2 α2 ×p d 2 16 the participants completed the questionnaires online by mobile phone a total of 5491 potentially eligible respondents were randomly selected and invited to participate in the survey after quality control and manual check procedures to exclude ineligible incomplete and invalid questionnaires the final sample consisted of 4406 respondents data collection a selfadministered questionnaire was designed to collect information from the participants including 12 questions about sociodemographic characteristics 4 questions about reproductive status 5 questions about fertility intentions and one question about childrearing barriers the primary outcome was the prevalence of barriers to rearing children aged 03 years which was defined as the proportion of respondents who selfreported childrearing barriers fertility intention refers to the unwillingness or willingness to have a second or third child the onlychild situation of parents includes parents neither of whom is only child parents one of whom is only child and parents both of whom are only child sociodemographic characteristics included gender ethnicity age residence educational level annual household income number of children province and occupation according to the economic development level the provinces and municipalities were divided into 3 regions including eastern central and western region 17 barriers to rearing children aged 03 years was investigated with the question what do you think is the biggest barrier to rearing 0 to 3yearold children we defined the respondents who chose the first five options as parents with childrearing barriers for the biggest barrier high time cost referred to the lack of time to raise children high childrearing cost referred to the heavy economic burden of rearing children high education cost referred to the great pressure to satisfy the education of young children physical factor referred to the factors related to personal health status statistical analysis we used proportion to describe categorical variables and calculated the prevalence of barriers to rearing children aged 03 years univariate logistic regression was used to estimate the crude odd ratio and its 95 confidence interval after controlling sociodemographic characteristics multivariate logistic regression was adopted to analyze the association between fertility intention onlychild situation of parents and childrearing barriers and then calculated the adjusted odd ratio and its 95 ci moreover we analyzed subgroups stratified by number of children twosided p values 005 were considered statistically significant all analyses were performed with r version 405 patient and public involvement patients and the public were not involved in the design and conduct of the study results sociodemographic characteristics and fertility intention among our study population of the 4406 chinese parents included in our study 579 were women 953 were the han nationality 655 were urban 709 had a college degree or above 621 had an annual household income of over 80000 cny 689 had one child 311 had at least two children 581 lived in the eastern region and 473 were employees 530 of the respondents were parents neither of whom is only child 626 intended to have a second child and 148 intended to have a third child prevalence of barriers to rearing children aged 03 years 947 of the 4406 respondents selfreported barriers to rearing children aged 03 years of which 393 reported high time cost 365 reported high childrearing cost 135 reported high education cost and 50 reported physical factors as the biggest barriers high time cost and high childrearing cost were also major barriers among respondents intended to have a second child and those intended to have a third child related sociodemographic factors of childrearing barriers women and people with college degree or above were associated with higher prevalence of childrearing barriers whereas farmers were associated with lower prevalence women and people having an annual household income of over 80000 cny were more likely to report high time cost as the biggest barrier people having at least 2 children tended to report high childrearing cost while people with an annual household income of over 120000 cny did not women and people aged 4049 years reported high education cost more often while people having an annual household income of over 80000 cny reported less often the association between fertility intention onlychild situation of parents and childrearing barriers multivariate logistic regression models showed that people who intended to have a second child and people who intended to have a third child were associated with less childrearing barriers people who intended to have a second child and parents one of whom is only child were more likely to report high time cost as the biggest barrier while people who intended to have a third child were less likely to report parents one of whom is only child were related to less reported high childrearing cost people who intended to have a third child and parents both of whom are only child were more likely to report physical factors while people who intended to have a second child were less likely to report in subgroup analysis the association between fertility intention and childrearing barriers were stable discussion in this study we conducted a national represented crosssectional study in 2021 right after the new threechild policy to estimate the prevalence of childrearing barriers and analyze related factors thereby helping make childrearing policies and supporting measures we found that 947 of 4406 chinese adults aged 1849 years who had children selfreported barriers to rearing children aged 03 years the biggest barrier included high time cost high childrearing cost and high education cost for related factors women and welleducated people were associated with higher prevalence of barriers while people who intended to have a second or third child were less likely to report childrearing barriers attention should be paid to childrearing barriers among children aged 03 years following the change of family planning policy the prevalence of childrearing barriers in our study was close to previous studies 1112 zhao et al found that 882 of chinese caregivers of children aged below 3 years reporting parenting difficulties in 2010 11 we found that women were more likely to report childrearing barriers than men consistent with previous researches 1920 although women traditionally play a significant role in family and childcare more and more women enter workforce nowadays previous studies showed that it is difficult for working women to balance childcare and career because of incomplete supporting system for them in china 21 additionally father involvement in childrens early upbringing is a key source of positive child developmental outcomes 22 23 24 however fathers involvement in parenting was less than mothers in chinese families 10 therefore childrearing policies and supporting measures should be improved to help women to juggling work and childcare and encourage fathers to participate in childrearing welleducated people reported childrearing barriers more often and this was consistent with previous study 13 the reason might be their more attention to childrearing and education more investment and busier work our results also showed that farmers selfreported barriers less often this be ascribed to their outdated childrearing concepts lack of scientific childrearing knowledge insufficient investment and lower parenting costs in rural areas 25 making them to feel easy to raise children aged 03 years a survey conducted in 1715 rural households in western china found that the average parenting knowledge score of sample caregivers is much lower than the expected average score and parental investments are poor in rural areas 8 therefore it is necessary to strengthen education of parenting knowledge and guide farmers to form scientific childrearing concepts notably parents one of whom is only child were more likely to report high time cost as the biggest barrier and parents both of whom are only child were more likely to report physical factors after onechild policy for 36 years and universal twochild policy for only 5 years in china 26 many onlychildren became parents and might face considerable childrearing barriers besides time cost economic cost physical factors and other hard barriers onlychild couples might face psychological and cultural barriers and need more time to adjust and accept 27 moreover onlychild couples tended to have more than one child 28 therefore targeted strategies are needed for onlychild parents to support their childrearing for the association between fertility intention and childrearing barriers people who intended to have a second child and people who intended to have a third child were less likely to report barriers this finding was similar to previous studies in the context of twochild policy 2930 a crosssectional study of 11991 chinese women on fertility intention in 2016 and 2017 indicated that economic health childrearing and educational barriers were associated with a lower intent to have a second child 30 conversely people with fertility intention might have positive attitude towards childrearing nevertheless fig 1 the biggest barrier to rearing children aged 03 years among people who intend to have a secondthird child because of their fertility potential sustained efforts to reduce their barriers to rearing children aged 03 years are required for high time cost our findings showed that people intended to have a second child were more likely to report high time cost as the biggest barrier while people intended to have a third child were less likely to report the potential reason is that people with sufficient time would consider having a third child with the development of society and the popularization of education chinese people of childbearing age are widely involved in social production busy working parents often leave their children to their grandparents to raise 3132 which might mitigate this problem but bring childrearing pressure to grandparents 33 moreover leftbehind children need more attention due to the detrimental influence of parental migration and poor rearing environment 34 35 36 therefore sufficient parental leave available and qualified childcare services and other supporting measures should be provided to reduce high time cost of rearing children aged 03 years table 3 the barriers to rearing children aged 03 years among our study population stratified by number of children aor adjusted odd ratio ci confidence interval cny chinese yuan the aor was calculated through the multivariable logistic regression controlling variables including ethnicity age region and the onlychild situation of parents indicates significant at pvalue 005 for high childrearing cost our study suggested that 365 of chinese parents of childbearing age reported high childrearing cost as the biggest barrier based on the data from china family panel studies in 2013 the average direct consumption expenditure of 0 to 5yearold children was 62726 chinese yuan 37 the financial burden of childrearing is also a substantial barrier to fertility intention liu et al 30 found that 477 of chinese women of childbearing age reported economic barrier as the main obstacle to having a second child in order to reduce economic cost of childrearing childbirth allowance for parents with a second or third child and strengthening price regulation of childcare products and services are expected number of children for high education cost we found that 135 of chinese adults aged 1849 years who had children reported high education cost as the biggest barrier consistent with the results of previous crosssectional surveys 30 nowadays chinese parents attached great importance to early education of children aged 03 years 38 however the proportion of young childrens enrollment in various childcare institutions is less than 5 in china far lower than 50 in some developed countries 39 additionally there exist many problems such as uneven quality of childcare services and shortage of teachers and professionals 40 therefore it is necessary to make relevant policies and measures to encourage the development of childcare and early education institutions and strengthen regulation for physical barriers our results indicated that people who intended to have a third child were more likely to report physical factors as the biggest barrier while people who intended to have a second child were less likely to report a crosssectional study among japanese mother showed that mothers aged 40 years or older had a high risk of facing difficulties with childrearing 41 people are younger and healthier when they have a second child thus downplaying physical factors in contrast people intended to have a third child are concerned about their health because they are older when they have a third child therefore following the threechild policy targeted childrearing policies and measures for older parents are needed the ongoing covid19 pandemic might bring about difficulties in childrearing 42 the united nations educational scientific and cultural organization estimates 138 billion children are out of school or child care 43 the economic impact of the pandemic increases the financial burden of rearing children aged 03 years 43 moreover the health risks and fear connected to covid19 influence parents levels of stress and consequently childrens wellbeing 44 therefore it is essential to make effective strategies to strengthen childrearing and protect a future for children during the covid19 pandemic strengths and limitations the main strength of our study is that it is the first to understand the barriers to rearing children aged 03 years and the association between fertility intention and childrearing barriers among chinese parents following the new threechild policy the estimated prevalence of barriers could provide scientific evidence for the need of making childrearing policies and supporting measures and the analysis of related factors could help formulate targeted policies and measures for people with different sociodemographic characteristics and fertility intention thereby reducing childrearing barriers and guaranteeing child health however there are some limitations first we collected data using online questionnaire so that people who were not internet users were not included in our study nevertheless there were 989 million internet users in china by december 2020 and 997 of them surf the internet by mobile phone 45 additionally internet use was more prevalent in people of childbearing age than in other age groups second our study was crosssectional and could not demonstrate causal association third because of lacking occupation option like immigrant workers in our questionnaire we could not measure the barriers among immigrant chinese who face more childrearing difficulties 46 last the coronavirus disease 2019 pandemic might have an impact on our results 42 conclusions in conclusion 947 of chinese people of childbearing age who had children selfreported barriers to rearing children aged 03 years the biggest barrier mainly included high time cost high childrearing cost and high education cost the people who intended to have a second child and people who intended to have a third child were less likely to report childrearing barriers full consideration should be given to the barriers of people with different sociodemographic characteristics and people with fertility intention thus making targeted childrearing policies and supporting measures to reduce the burden on people of childbearing age encourage suitable couples to have a second or third child and then cope with chinas aging population abbreviations cor crude odd ratio ci confidence interval aor adjusted odd ratio additional file 1 supplemental competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum 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background to further optimize birth policy china implemented a new threechild policy to allow per couple to have up to three children on may 31 2021a national crosssectional survey was conducted among 18 to 49yearold chinese parents who had at least one child in june 2021 we calculated the prevalence of selfreported childrearing barriers and used univariate logistic regression and multivariate logistic regression to analyze associated factors results 947 of the respondents selfreported barriers to rearing children aged 03 years and the biggest barrier included high time cost 393 high parenting cost 365 and high education cost 135 women aor 149 95 ci 113196 and people with college degree or above aor 346 95 ci 208 575 were associated with higher prevalence of childrearing barriers and people who intended to have a second child aor 058 95 ci 040 083 and people who intended to have a third child aor 05195 ci 037 071 were less likely to report childrearing barriers the biggest barrier was more likely to be high time cost for parents one of whom is only child aor121 95 ci 103 142 and physical factors for parents both of whom are only child aor 15695 ci 108 226 the prevalence of barriers to rearing children aged 03 years was high among chinese people of childbearing age who had children full consideration should be given to the barriers of people with different sociodemographic characteristics and people with fertility intention thus making targeted childrearing policies and supporting measures to reduce the burden on people of childbearing age encourage suitable couples to have a second or third child and then cope with chinas aging population

introduction purchasing virtual goods has become increasingly pervasive among the young generations virtual goods are nonphysical in nature and exist in the online platforms they are created in 1 that is they cannot be carried off to and used in another online platform this characteristic separates virtual goods from digital goods while virtual goods have existed as long as virtual worlds they did not receive attention before vw operators started to sell them to users with real money interestingly many of the current vws are targeted for users aged between 5 and 15 years who make the majority of over 14 billion registered vw users 2 the large user base has made the overall spending on virtual goods to reach 15 billion already in 2012 1 despite the economic potential the research on virtual goods purchasing behaviour in vws is still in its infancycompared to the traditional online shopping or that which occurs offline to contribute to virtual goods research we seek to fill three gaps in the current literature first prior literature on virtual goods has focused rather heavily on adult consumers albeit young people admittedly make a notable group of existing consumers for example young people have been underinvestigated in information systems research 3 with regard to the second gap we advance virtual goods research by building on user experience we believe this is of considerable importance since purchasing virtual goods requires engagement in online platforms where the goods are available to this end we employ cognitive absorption which is an established driver of technology use also in vws 4 5 notwithstanding its influence on purchasing behaviour has remained poorly understood third we center on social context while social context is demonstrated as critical for online platform success 6 studies on virtual goods fall short in examining its effect on purchasing behavior 7 in this paper we conceptualize social context to operate through perceived network size social presence and trustall of which we consider relevant for virtual goods exchange by filling these gaps we add on to three different research areas virtual goods purchasing behavior 7 8 9 young users use of information technology 3 and the relationship between virtual goods and platforms where they are exchanged 10 11 the paper is organized as follows it starts with a literature revive and provide a foundation for the research model the paper will then explicate the research model and hypotheses this is followed by the methods and results lastly it concludes with a discussion including implications limitations and suggestions for future research 2 research background and hypotheses prior literature on virtual purchasing behavior prior vw research has largely examined user adoption 12 13 14 including initial acceptance and postadoption use 4 15 16 17 18 19 purchasing behavior in turn has received less empirical research attention 20 the prior research on the topic has found purchasing in vws have being affected by the virtual environment 7 user motivation 1 8 and social influences 8 here we focus on two aspects that have drawn less attention in the vw namely user experience and social context they supplement each other as user experience stresses the experience obtained by an individual and social context the environment which is cocreated by individual users social context is also expected to influence the individuals behavior 21 given virtual goods purchasing behavior is fairly inseparable of vw use we believe social context and user experience fit in perfectly to our research goal the research model the user experience of vws can be characterized with three key aspects first vws employ avatars as a core of the navigation mechanisms and to represent the users second vws accommodate a multiuser 3d graphical environment that includes sounds and music third the user interface is highly dynamic because of a constant influx of new features and activities to sustain users interest thus the richness of stimuli that make the user absorbed in the inworld activities lie in the core of the vw user experience hence we employ the concept of cognitive absorption cognitive absorption consists of focused immersion intrinsic motivation perception of control temporal dissociation and curiosity we measure it as a multidimensional construct as it was originally developed 22 we also scrutinize how the social context can influence virtual purchasing behaviour the social context is essentially dependent on the number of users involved in the vw the social interaction and the value users derive from it is influenced by network externalities 19 this is articulated in metcalfes law that postulates that the value of a telecommunications network is proportional to the square of the number of connected users 23 for an individual user however the value of interactive digital technologies is more dependent upon the presence of relevant people ie the users personal network than the network size in general 19 24 from a sociological perspective this can be explained by the concept of homophily ie the tendency to bond and associate with individuals with whom one perceives similarity 25 prior evidence from computermediated communication shows that interaction that involves the use of it is likely to occur with key interpersonal relationships 26 thus network externalities stem particularly from the presence of ones key social network in the vw in addition to the presence of other users and an inworld social network the social atmosphere and the relationships between users represent important aspects of the social context for example people tend to communicate more when they perceive human warmth and psychological presence 27 as a result we examine the degree of human warmth and contact associated with the vw using the concept of social presence 28 trust is fundamental component of interpersonal relationships and an important predictor of online purchasing 29 hence we investigate the trust in other vw users as a predictor of virtual purchasing the constructs with their definitions and references are presented in table1 table 1 the research constructs and their definitions construct definition source perceived enjoyment the degree of enjoyment associated with using the vw 22 focused immersion the experience of total engagement where other attentional demands are in essence ignored 22 perception of control the users perception of being in charge of the interaction 22 temporal dissociation the inability to register the passage of time while engaged in interaction 22 30 curiosity the extent the experience arouses an individuals sensory and cognitive curiosity 22 perceived network size the perception of the degree to which important others are present in the vw 16 31 social presence the degree of human warmth associated with the vw 28 32 usertouser trust the belief in the other vw users honesty 29 the research model accommodating the user experience and social context is presented in figure 1 below fig 1 the research model hypotheses agarwal and karahanna 22 positioned cognitive absorption as a predictor of perceived usefulness and ease of use but did not examine its direct effect on behavioural intention cognitive absorption is an intrinsically motivating state 33 enjoyment being one of its dimensions 22 intrinsic motivation often captured with perceived enjoyment in turn has been found to predict the intention to adopt and use various forms of it particularly those of hedonic nature 34 35 prior vw research offers empirical support for the link between cognitive absorption and behavioural intention 4 5 as a result we assume that the purchase intention is influenced by cognitive absorption and put forward the following hypothesis h1 cognitive absorption has a positive effect on purchase intention due to network externalities the size of ones personal network inside the vw influences the amount of opportunities the user has for social interaction and communication furthermore a large social circle in an vw provides more opportunities to demonstrate status through virtual purchasing or when trading virtual items with other users prior research on online social networking 36 instant messaging 24 and vws 16 offers empirical evidence that the perceived size of users network predicts the usage intention social presence has been found to have a positive effect on loyalty in the online shopping context 37 furthermore previous vw research has shown a positive relationship between social presence and favourable attitudes 38 and user satisfaction 15 however the research has reported no relationship between social presence and behavioural intention 7 15 h3 social presence has a positive effect on purchase intention abundant research on ecommerce has verified a positive relationship between trust in the online merchant and users purchasing behaviour 39 however considerably fewer studies have examined to what extent the trust between users affects purchasing especially in an environment where the users are represented as avatars lu et al 40 reported a positive relationship between intentions to purchase from the website and membertomember trust h4 trust in other users of the vw has a positive effect on purchase intention social presence has been found to increase the number of messages exchanged in electronic communication 27 as vws are informationrich environments that are well capable of transmitting various nonverbal cues 15 we propose a positive relationship between social presence and trust in the other vw users this assertion is also in accordance with the ecommerce literature that has reported social presence to have a positive effect on trust 32 41 h5 social presence has a positive effect on trust in the other users of the vw empirical research data collection and measurement the data was collected through an online survey among the users of the finnish habbo hotel portal in cooperation with sulake corporation the finnish company that owns and operates habbo hotel the survey was opened 8928 times 3265 respondents proceeded to the final page and submitted the survey this yielded a response rate of 366 percent to further ensure the reliability of the results only fully completed questionnaires were included in the analysis as a result the final sample consisted of 1225 responses 608 per cent of the final sample was female to ensure the reliability of the measurement the survey items were adopted from prior literature with wording adjusted to match the vw context and the target audience the literature references of the measurement items were presented in table 2 the items were measured with a sevenpoint likert scale anchored from strongly disagree to strongly agree except perceived network size which was measured with semantic scale the constructs were modeled using reflective indicators data analysis the data was analysed using partial least squares with smartpls software 42 we began the analysis by testing the convergent and discriminant validity of the measurement model convergent validity was evaluated based on three criteria 43 firstly all indicator factor loadings should be significant and exceed 070 secondly composite reliabilities should exceed 080 thirdly average variance extracted by each construct should be greater than 05 appendix a illustrates that the data met the criteria for convergent validity with respect to discriminant validity the ave for each construct should exceed the squared correlation between that and any other construct 43 table 3 shows that discriminant validity was confirmed after having verified the validity and reliability of the measurement model we proceeded to testing the structural model according to agarwal karahanna cognitive absorption was modeled as a second order construct bootstrapping with 1000 subsamples was used to estimate the significance of the path coefficients the latent variable scores of its five constituting factors were used as an input to build the second order variable the r 2 of purchase intention was 427 per cent which indicates that the model as a whole exerts good predictive validity as the sample size was large instead of looking strictly the significance of the path coefficients we considered the value of 01 as a threshold to interpret that a variable exerts a substantial effect on its endogenous construct 44 based on this criterion all hypotheses were supported except h3 age gender and length of usage experience with the vw were included in the structural model as control variables none of the control variables exerted a significant influence on purchase intention figure 2 below summarizes the results from testing the structural model fig 2 results of the pls analysis discussion and conclusion the key finding of this study is that user experience captured through cognitive absorption and its first order constructs is the main driver of purchase intention while prior research provided empirical evidence of user experience in driving usage 45 our results show that it has effect on purchase intention that takes place beyond usage overall this finding implies that engaging user experience can drive vw operators sales and thus it is critical for vws success theoretical implications our results verify the importance of cognitive absorption as a component of the vw user experience and its value in predicting purchasing behaviour on a more theoretical level our conceptualization of cognitive absorption as a fivedimensional second order construct offers other researchers guidance how to capture the contextual characteristics of vws based on our findings virtual purchasing is substantially affected by the experiential aspects of vw usage indicating that the user experience is a stable predictor of virtual purchasing across context 7 perceived network size with regard to the social context our findings show that purchasing behaviour is influenced by the size of users inworld network and the trust experienced in other users of the vw this indicates that network externalities play a role in virtual world participation 19 network externalities can thus affect the hedonic value extracted from the vw participation by offering more invitations to inworld events and parties furthermore the status value 46 from possessing virtual items is likely to be dependent on the size of ones inworld social network albeit social presence did exert hardly a marginal effect on purchase intention it is a relative strong predictor of the trust between users while the trust in other users influenced purchase intention its role was not particularly salient we assume that rather than having a linear relationship with purchase intention trust may exert a threshold thus being a prerequisite for purchasing to take place implications for practice for vw operators and developers creating engaging experiences seems to be a way to reinforce inworld purchasing behaviour this may indicate that purchasing results from sustained participation in the vw and can thus represent a subsequent stage in the development of the customer relationship from this perspective operators should focus on developing the customer relationships rather than utilizing tactical marketing tools to promote inworld purchasing second the results offer certain evidence that a trusting and psychologically warm social environment encourages purchasing behaviour thus vws operators are advised to have mechanisms not only to protect users virtual property but to prevent aggressive behaviour and communication towards other users third we suggest operators should take a close look at how the presence and actions of other users within and beyond the vw affect users participation and purchasing decisions young people have been reported to follow fads and fashion and thus be more prone to bandwagon effect than older generations 47 this can partly explain the dynamics of the social setting and sometimes very short lifespans of trends in the vw for the young limitations and future research first due to our research context generalizability of the results is limited second we examined behavioural intention instead of actual behaviour third we used three constructs perceived network size social presence and trust in other users to examine the social context due to its conceptual breath social context is very difficult to condense into a set of variables we recommend further research to offer a richer understanding of the social context and structures behind the behavioural outcomes such as virtual purchasing for example future research could examine the interplay between the social context and purchasing behaviour 21 fourth in our conceptualization of trust we focused only on the trustworthiness ie the reliability of other users however prior research has highlighted the complex multifaceted nature of trust 29 moreover in the vw context the user may or may not trust in several entities such as the user community the company operating the service and the service as a whole thus research focusing particularly on the nature and dimensions of trust in the vw context would offer a better understanding of the social context of vws and at the same time uncover the role of the avatarcentric environment in the formation of trust finally we used only the cognitive absorption to empirically examine the key aspects of the vw user experience however from vws people do not necessary seek for immersion and intensive experiences but a relaxing place to spend time and socialise with other users in a casual manner hence further research could examine to what extent the vw participation is perceived relaxing or stressrelieving

millions of young people spend real money on virtual goods such as avatars or inworld currency yet limited empirical research has examined their shopping behaviour in virtual worlds this research delves into young consumers virtual goods purchasing behaviour and the relevance of social context and usage experience we assert that virtual goods purchasing behaviour is inseparable of the online platform in which it is taking place we employ the concept of cognitive absorption to capture the user experience and examine the social context with three variables the size of ones inworld network trust in the other users of the online platform and social presence we test our research model with data collected from 1225 virtual world users and use pls in the analysis the results show that virtual goods purchasing behaviour is predicted by cognitive absorption perceived size of ones inworld network as well as trust in the other users

i introduction over the last four decades social assistance programmes for the poor have undergone dramatic expansions in most developing and transition countries these programmes include a wide spectrum of cash and inkind support programmes for the needy including conditional cash transfers free healthcare for the poor food aid and public work programmes the world bank has facilitated and shaped this expansion through social assistance policy recommendations to national governments several scholars have illustrated that national governments have taken these recommendations into serious consideration in designing and redesigning welfare systems according to weaver forces not necessarily would have entailed ie those objectives that cannot be reduced to a mere reflection of structural dynamics more specifically political objectives refer to government concerns for the containment of social unrest protests waves popular political grievances in the broader sense and the mobilization of popular support needed during times of intraelite competition wartime and the mobilization of new blocs of supporters by new political leaders from outside established intraelite circles the latter may occur via populist political change as in the case of india thailand brazil turkey russia ukraine and south africa where governments appeal to the poor through populist policies facing opposition from the middle classes and the elites the existing literature on the expansion of social assistance programmes has predominantly focused on a wide array of structural factors that are considered by national governments including rising poverty unemployment deindustrialization and aging political motives of authorities have been mentioned in the literature however to a lesser extent there are a number of studies that look at political factors to explain the policies of the world bank specifically but there is still much space left for empirical evidence moreover these studies address different policy domains in which the wb operates but not welfare and poverty reduction ii politicisation and existing literature g concerns with political mobilization have accelerated as a consequence of the global rise of the poor as a key grassroots political group which has largely grown in capacity to threaten or strengthen existing local and global political and economic regimes during the last decades mike davis argues that the informal proletariat which consists of workers and the poor who are excluded from formal social security nets and live on precarious grounds has now become a new grassroots political agency as the source of political threat and support for both governments and the economic elite poverty of the informal proletariat usually interacts with existing ethnic racial and religious inequalitiesdifferences and this contributes to prevalent political polarizations as well there are many scholars providing arguments and evidence for the statement that social assistance policies serve to stabilize politics in the contemporary world harvard economist dani rodrik drew attention to the political dimension of growing social policy programmes rodrik argued that globalization created deeper class divisions between the rich and the poor that would be politically unstable he suggested that a reorientation from pensions to antipoverty programmes would address the political challenges of globalization the mobilizing capacity of terrorists and fuel civil and ethnic conflict the welfareterrorism nexus fits within the broader literature on securitization and the securitydevelopment nexus favourable social policy measures can assimilate oppositional movements by undermining substitute for economic security and equality and hence there has been a broader securitisation of policies after 911 so the question arises whether politicization and securitization of welfare policies by the wb can be attributed iii social welfare as a political tool and the world bank depoliticising rhetoric of social assistance in the postwar period up to the late 1970s welfare systems in many countries worldwide were based on employmentbased social security programs which since the 1980s have been gradually replaced by social assistance programmes targeting the poor the literature explaining the welfare systems in the postwar period ie during the socalled golden age of capitalism or embedded liberalism emphasized political factors and structural factors together including such political factors as the containment of unrest or mobilization of popular support and such structural factors as demographic changes or economic incentives according to ruggie embedded liberalism is the system in which economic and political elites pursued the double task of continuing the free markets economy on an international level and developing interventionist and welfare based policies domestically a modern welfare state was established in the western world to sustain fullemployment economic growth and social services under the auspices of the us hegemony over time social security came to be seen in the western world as a permanent feature of capitalism for its contribution to political stability and continuity the welfare state provided the means for political legitimacy necessary to contain the threat from grassroots groups most importantly the working class movements simply put the welfare state functioned to contain 1973olson 1982offe 1984foxpiven and richard cloward 1971 o c while the literature on the pre1980 welfare systems thus emphasized both structural and political factors most students of recent welfare systems transformations have solely emphasized structural factors such as aging labour informalization unemployment globalization deindustrialization the rise of poverty and the rise of the service sector this literature has thereby largely underexamined the possibility that contemporary welfare system changes have also been affected by political concerns of national and supranational institutions t w b and denies having political objectives in its policy recommendations the 1944 articles of agreement that established the workings of the bretton woods institutions un 1944 65 see also van houten 2007 6534 reasons for this nonpolitical character would be that it allows the bank to cooperate with different types of regimes and provide the bank with more authority and legitimacy in recommending policies to others a 2011 study by the independent evaluation g wb social assistance programmes in third world countries while poverty b reduction generally does not directly support such objectives and never gets involved in political matters however a number of studies have however found that there are clear references to w b t w b ies in a broader framework of politics and globalization as argued by barnett and finnemore w b processes t w b b making with the us remaining the most influential one donors impose their interests through direct appointment of the leadership cadres of the bank donating majority of the funds the threat of denying bank funds access to the national private capital markets in case bank declines donor g 1994 56 cited in weaver 2008 t b would thus be situated somewhere in between being an instrument of powerful states and having a bureaucratically driven autonomy giving it a form t b s has developed an internal culture consisting of ideologies norms values and power relations that create particular interests distinct from those of member governments however as noted by weaver since the mid1990s there has been a shift in the bank discourse to include greater emphasis on political factors as a result of the changing external u d c war tensions no longer shied away from these inherently political areas of development 2008 92 moreover having recognized the devastating effects of the crude neoliberalism of the 1980s the bank has modified its agendas to include policy of 1990s w thus the bank is a rationally organized bureaucratic structure whose bureaucracy has welldefined interests and objectives in order to attain these objectives and maximize bureaucratic interests the bank has to negotiate manners with member organizations which structurally leads the bank towards a conservative direction domestic and international political interests of donor and client governments are thus negotiated within the relatively autonomous structure of the bank and translated into politically driven policy recommendations to the extent that member states have tendencies to contain unrest and mobilize popular support the bank is drawn into recommending mechanisms to do so it is fairly possible for the bank to recommend social assistance for political containment or mobilization because the clients as political actors tend to internalize policy recommendations that would function politically at home in short politically useful recommendations might find customers more easily on the other hand due mainly to the encouragement of donor governments the bank also functions as an overseer of global political stability world bank donor states may have their longerterm security interests defended if one considers the objectives of stability which in turn should lead to less migration or threat social unrest is k and raube 2013 557 this is different than creating particular recipes for particular governments but generating blueprints for political stabilization through social assistance programs that can be modified and adapted to each case the bank in that sense is politically conscious and concerned for global grassroots political stability in addition to existing structural factors these political objectives have increasingly iv research and empirical findings the following section will systematically assess how the arguments raised in literature about welfare spending as means to political containment and mobilization may apply to the policy recommendations of the world bank as well t t whether social unrest w b s we will examine the extent to which the world bank social assistance policy recommendation documents include references to political concerns for containment of social unrest and mobilization of popular support we will also analyse how the references to these concerns have changed over time w b political objectives 1 nvivo 10 was used to code all relevant documents the following section will present the trends and patterns that were highlighted through the analysis subsequently the article will provide an analysis of the content of these social policy recommendation documents and show the ways in which the world bank has proposed social assistance as a political instrument trends over time the results show that the world bank has explicitly discussed social assistance as an instrument of political containment and mobilization in more than one quarter of all documents 116 out of 447 reports specifically 48 documents referred to welfare as a tool for political mobilization 57 documents for political containment and 11 to both containment and mobilization the time series analysis of the number of world bank documents that contain political references has furthermore shown two main trends 1 the number of documents that include references to political containment or mobilization has increased over time especially after the 2000s 2 in relative terms the percentage of documents with reference to political containment visàvis political mobilization has increased after the 1990s the world bank furthermore argues that in order to mitigate conflict countries need providing socioeconomic growth among all the significant regional religious and ethnic wb ø l b to the genocide and reducing poverty is critical also as a means to improve the political base by providing free public services or lucrative servicerelated jobs to their versal healthcare programme in thailand the socalled 30bath gold card system as an instrument that thai governing party used to win a f b new public work programmes have usually been introduced before elections such as in bangladesh india indonesia pakistan jamaica and the philippines in 2010 the world bank stated that the zambian government used the socalled fertiliser support progr t w b wb ieg another political objective of social protection programmes that is observed in these reforms which may otherwise not have been accepted by the society wbbarr 1995 3 see also wbbigio 1998 178 the world bank believed that political instability is considered a hindrance for policy implementation in the 1998 report f p b also can be the world bank in fact seems to apply social safety nets as a means to institute a ieg safety net can be installed at the same time as economic reform that is an n ieg 2011 66 thus resistance or political opposition against the reforms can be avoided and as such governments would prevent insecurity and instability to this end the reforms should be pushed through fast and have an extensive scope n helping win support in elections demonstrating government legitimacy to gain social ieg 2 unrest elections populist dissident employment turmoil political security threat strike demonstration contain conflict stability safety health target violen risk v discussion and conclusion 2 these strategies are not solely applied in policies towards developing countries also in the case of germany certain economic developments have deliberately been made socially acceptable through means of social security benefits declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article author biographies

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background in 1994 the new south african government declared the overall priority of eradicating poverty and removing inequities socioeconomic inequalities and differential access to services that are unfair or unjust 1 as a result the government created the reconstruction and development programme to reduce poverty and distribute income more evenly less spending was to go to the military and more was to be distributed on education housing and health including the building and upgrading of clinics and promises of free health care to children under six and pregnant mothers 2 the rdp however fell out of public view within two years and the ministry overseeing it was abolished 3 it was criticized by some as a shortsighted programme of basic needs fulfilment 4 in 1996 to help meet the goals of the rdp and respond to neoliberal influences the government adopted the growth employment redistribution macroeconomic policy gear intended to reduce the role of the state and increase corporate and private investment 56 gear was publicly proposed as a way to provide a fast growing economy create jobs redistribute income and hasten universal access to basic needs 7 consistent with a focus on decentralization the national provincial and local governments adopted local economic development strategies which aimed to reduce poverty and increase employment through local initiatives and solutions 8 led encourages communities to take control to stimulate economic growth through communitybased initiatives and local skills resulting in increased opportunities community empowerment and self reliance 9 one of the policies adopted along with led was the creation of spatial development initiatives in 1997 by the south african department of trade and industry intended to promote and encourage private investment and development in areas that were considered to have the greatest potential for growth the sdis focussed on short term interventions designed to attract private sector investment to stimulate growth of locally owned small medium and microenterprises and empower local communities 10 they identified and sought to address bottlenecks to investment such as inadequate infrastructure 11 development was concentrated in relatively small areas rather than thinly spread across larger regions or provinces 5 the sdis expected to benefit rural communities through increased employment improvement of local infrastructure and income from leasing out lands 12 since 1994 there have been some successes nationally as a result of the national and local development strategies these include new health clinics schools housing and improved water facilities 2 yet there are also reports that many south africans have become disillusioned at the lack of progress particularly with regards to standard of living and employment for example unemployment rates rose from 19 in 1996 to 29 in 2001 13 economic growth rates have been modest at best and south africa is often seen as one of the most unequal societies with regards to distribution of income 14 some authors have described a dual economy the first economy containing the industrial mining and agricultural sectors that produce wealth while the second economy is characterised by poverty and underdevelopment 15 16 17 concerns exist around health care as well many south africans criticize the governments handling of the hiv aids epidemic 18 one of the leading causes of life expectancy estimates declining by ten years between 1996 and 2002 19 furthermore public spending is rarely optimised towards the poor 2021 the wealthiest provinces receive most health care expenditure and since 1999 there has been increasing emphasis on privatized health care which the poorer regions cannot afford 22 this leaves the most vulnerable less likely or unable to access health services when they need them leading to higher risk of poor health increasing the burden of future health costs and reducing their ability to seek employment or farm their own lands 2324 the eastern cape is one of nine provinces in south africa and is located along its south eastern shore it was formed in 1994 with the new government encompassing the previously transkei and ciskei xhosa homelands it is one of the poorest provinces in the country and by 2001 only onefifth of the population was employed 25 it has two large cities port elizabeth and east london but much of the region is rural and relies on subsistence farming the province is home to the wild coast region located along its north eastern coast after years of labour migration under the apartheid system by 1994 the wild coast population was predominantly female and unemployed at that time the wild coast had little access to clean water or public service infrastructure unemployment was higher than the national average and much like the province as a whole nearly threequarters of the wild coast population lived in poverty 4 the region also faces many health threats including hivaids and tuberculosis 26 the wild coast sdi started in 1997 with a particular focus on tourism and smme development agriculture and forestry were other sectors that were identified to stimulate growth with private companies partnering with communities 12 such initiatives expected to create economic opportunities for local populations particularly women the sdi identified four coastal high potential anchor areas as the focus for public and private investment mkambati port st johns coffee bay and dwesacwebe sdi planners felt that intensive investment in these four areas would spill out and spur economic development in the rest of the wild coast region in partnership with the eastern cape socioeconomic consultative council ciet assessed the wild coast sdi over several years while coverage of basic needs was not an explicit goal of the sdi early feedback from communitybased evaluation of the sdi showed that unless these were met the initiative had little chance of success a 1997 baseline study showed that people in the region were unaware of what they could do to improve their socioeconomic conditions there were high levels of unemployment and lack of food security a low proportion of households obtained their water from protected sources such as taps there was a substantial degree of corruption in the public services and little knowledge of the sdi project itself 27 followup surveys in 2000 and 2004 showed little evidence of increased economic opportunities 2829 the wild coast sdi was terminated since the 2004 evaluation responsibility for development of the region moved from the dti to the department of environmental affairs and tourism newer initiatives in the area have included the eu communitybased tourism initiative the controversial n2 toll road the establishment of the pondoland national park and a new wild coast development project it remains unclear how these new initiatives intend to decrease poverty and improve health in the region as they seem poised to repeat the shortcomings of the sdi an additional 2007 followup survey of the same communities provided an opportunity to examine the inequities detected in the original 1997 baseline and how such inequities affect access to health care methods the methods relied on standard ciet social audit protocols 3031 we stratified the last stage random sample of twenty communities by anchornonanchor status geographic location proximity to infrastructure and road accessibility the 2000 2004 and 2007 followup surveys returned to the sites of the 1997 baseline data collection instruments across the different cycles included household questionnaires and community profiles we additionally shared and discussed preliminary findings with the participating communities through gender stratified focus groups we translated all instruments into isixhosa and then nonmembers of the research team translated them back into english to ensure questions remained true to their intended meaning we piloted the instruments extensively before implementing them in the field to refine the instruments test for clarity and ensure proper translation the cietinternational ethical review board conducted and granted ethical clearance fieldworkers recorded and stored household data without any identifying fields ensuring confidentiality of the respondents we maintained confidentiality of the sample community identities as much as possible especially with regard to the nonanchor areas the exact sample sites were not included in any reporting data entry and analysis relied on public domain software epiinfo 32 and open source analysis and geomatics software cietmap 33 we adjusted indicators to account for the effect of uneven sampling and report weighted results we examined associations between factors in bivariate and then multivariate analysis using the mantel haenszel procedure 34 multivariate models took into account potential household inequities such as nonanchor status household crowding access to protected sources of water roof construction main food item purchased and perception of community empowerment individual level models additionally accounted for age sex education and income earning opportunities for access to health services we made separate models for men and women and limited these to those aged 1865 in order to account for income earning opportunities we adjusted for clustering using a method produced by gilles lamothe based on a variance estimator to weight the mantel haenszel odds ratio for clustercorrelated data described elsewhere 35 we describe associations using the odds ratio indicating where this is adjusted by stratification accompanied by the cluster adjusted 95 confidence interval averages are accompanied by a measurement of the standard error and the total number we derived measurements of trend using the mantelhaenszel extension 36 some indicators were not comparable or collected in 1997 and for these trends compare 2000 to 2007 we imputed ten additional datasets using the amelia ii program for missing data 37 to test how missing data would affect the final models these tests showed little effect on the final models so we report the original results results socioeconomic indicators household characteristics in 2007 we collected data from 2401 households respondents provided information about 8496 individuals among these 57 were female a nearly identical proportion to previous years average household size in 2007 was 37 people the same as in 2004 but lower than in 1997 onethird of households were made of mud with grass thatch roofs a significant reduction from previous years community empowerment hearing about and having a say in development when asked in 2007 what development projects respondents had heard about in their area only onequarter of household respondents could name something only one respondent mentioned the sdi by name when asked about development projects in 2007 among those who had heard of any development projects only one half felt they had a say in it sources of water just over half of households in 2007 got their water from a relatively protected source such as a tank or tap households made of mud and grass and households who bought basics as their main food item were less likely to have protected sources of water there has been a significant and steady increase in households having access to protected sources of water since the baseline from 20 in 1997 to 52 in 2007 the increase is consistent across different household types for example both among those with tin roofs and among those with grass roofs yet inequities remain between the two food in 2007 85 of households purchased basics such as maize as their main food item the proportion purchasing basics was lower than in previous years despite the objective of the sdi to generate small and medium economic activity only 7 owned a business in 2007 those from larger households and men were less likely to own their own business in 2007 the proportion who owned a business was nearly identical to the proportions from previous years household loans and credit in 2007 some 16 of households had loans this is the same proportion as in 1997 and 2004 but much lower than in 2000 there has been a significant increase of households reporting emergencies as the purpose of their loans from 4 in 1997 less than 1 in 2000 and 2004 to 13 in 2007 when asked about the source of their loan 56 claimed they got their loan from a loan shark a source which has seen a dramatic and consistent increase since the baseline access to health services accessed in the last year access to health services by female residents increased each year among increasing age groups a lower proportion of male residents of working age accessed health services than in the two other age groups in each year additionally a lower proportion of those 1865 accessed health care in 2007 than in 2000 among those aged 66 higher proportions of men accessed health services since 2000 for both male and female residents aged 1865 those from less crowded households were more likely to have accessed health services in the last year those from households without loans were less likely to have accessed health services in the last year type of health service used there was an increase in the use of government services and a corresponding decrease in use of private services and hospitals particularly among women those with an income from wages or a business and those from houses with tin roofs were less likely to have visited a government or a traditional health services among female residents aged 1865 those with an income earning opportunity those from houses with tin roofs and those who purchased nonbasics as their main food item were less likely to have visited a government or traditional health service and women from anchor areas were more likely to have visited a government or a traditional health service than those from nonanchor areas choice of health service the most common reasons cited for choosing government health clinics were proximity cost and feeling there was no other choice the most common reasons for choosing private clinics were good service good medication feeling there is no other choice and referrals reasons for choosing government and private health services were nearly identical for male and female residents among male residents aged 1865 years those with an income earning opportunity were more than twice as likely to choose the health institution on their last visit due to better service better medication or referrals than those without an income earning opportunity we found the same for female residents aged 1865 but only among those who lived in houses that did not receive any income from migrant workers attention needed some 8 of users of government clinics attended for prevention reasons like immunisation while 2 of users of private clinics attended for prevention reasons a much lower proportion of male than female residents attended a health institution for prevention reasonsand only 5642 men in 2007 attended for prevention reasons among female residents aged 1865 those with some formal education were nearly eight times more likely to have accessed a government health service for prevention reasons than those with no formal education and those who lived in households that received income from migrant workers were less likely to have accessed government health service for prevention reasons than those who lived in households that had not received income from migrant workers waiting times users of government facilities reported longer waiting times than users of private clinics and female users overall reported longer waiting times than did male users in government facilities however in 2007 female users of private clinics reported lower average waiting times than men among male users of government clinics those from households without loans were twice as likely to report waiting less than one hour for service than those from households with loans this was similar for female users as well however additionally among female users of government clinics those with an income earning opportunity those from less crowded households and those whose main food item was not basics were less likely to have waited less than an hour for service payments at government clinics payments at government clinics have decreased significantly overall since 2000 for both male and female health service users only 2 of users of government clinics in 2007 claimed they paid something for their service on their last visit fewer than in 2000 and 2004 we found no evidence of a difference by sex age group or other socioeconomic characteristics in the rare report of having made a payment in 2007 discussion the wild coast has seen development improvements since 1997 including increased access to protected sources of water and a marginal increase in employment pronounced inequitiessuch as differential access to health care based on education and income were still evident in 2007 water since the baseline in 1997 water supply from protected sources increased from 20 to 50 in 2007 yet the proportion with access to protected sources in the wild coast region is lower than the provincial average and lower still than the national average 38 this still leaves half of the population of the region without a protected source making them susceptible to waterrelated illnesses such as diarrhoea and cholera reported improvements in access to water supplies in the eastern cape overall are offset by reports of poor water quality particularly in rural areas 3940 and it is possible that those with protected sources are not much better off than those without as access to clean and safe water directly impacts on health and income potential community and district capacities for ongoing and consistent monitoring and testing must be implemented alongside improved water infrastructure developments priority must also be given to ensuring water provision and quality in the wild coast increases to meet provincial and national standards income and employment the sdi aimed to increase employment and to promote entrepreneurship there has been no increase in the number of respondents considering owning their own business or of those who actually do own a business employment levels among adults increased gradually from 15 in 2000 to 20 in 2007 but this still leaves a majority without work as with water employment rates within the region are still below the provincial and national rates 41 leaving the wild coast region largely in the same economic shape as before the initiative importantly the most vulnerable are less likely to have worked for wages leaving them with little chance of improving their standard of living loan sharks have prospered as the main source of household loans increasing numbers of loans are to respond to household emergencies few are for starting businesses or creating income opportunities access to health services fewer male than female residents accessed health services and among those who did very few did so for preventive reasons lower rates of mens access may be explained by womens increased interaction with the health service through antenatal care yet other studies have found that men also tend to wait until they see signs of illness before seeking help or attention 3542 striking differences in health care access exist between the most and least vulnerable within the region women with some formal education were nearly eight times more likely to access health services for prevention reasons in comparison with those with no formal education for both male and female residents income was strongly related to type of health clinic visited and the reason for doing so consistent with results found in kwazulunatal 43 those with less income were more likely to visit government services reporting determinants of cost and distance users of private clinics sought out better service and medication lower food security and poorer house construction was also associated with women visiting government not private health services each of the male and female focus groups discussed a lack of satisfaction with government clinics stressing poor service and a lack of privacy as key concerns additionally medication was reportedly either missing or expired and several focus groups stated that patients were given panado regardless of their ailment average waiting times were also consistently lower for users of private clinics than for users of government clinics despite this the proportion using government clinics increased payments at government health clinics for free services were nearly nonexistent by 2007 an indication that corruption in the form of unofficial payments is no longer an issue this is promising as it frees up household resources for other needs focus groups still complain about favouritism among the nurses and doctors at the clinics and removing user fees for service does not help those who need medicine that is unavailable although unique as a detailed followup of health care and development in the wild coast there are some limitations to this study the cross sectional design only allows us to report associations and limits what we can conclude about causality for example when we state that those from households with unprotected sources of water were less likely to have worked for wages in the previous month we cannot attribute causality in one direction or another secondly we can report with some confidence on trends over time but we are unable to provide individual linkages through the years as one might through a longitudinal study that follows up with the same individuals in each year conclusion the governments economic and development initiatives since 1994 have failed in their shortterm goals in the wild coast region particularly with regards to employment and health policies such as the rdp and gear set out to improve quality of life redistribute wealth in a more equitable manner and increase economic activity in the most vulnerable areas yet much of the wild coast region was still without clean water in 2007 and the majority were unemployed much of the economic growth in the country as a whole since democracy has taken place in the larger urban centres with smaller towns and rural areas falling further behind 44 led strategies aimed to stimulate growth locally and empower communities but there is little evidence of this happening in the wild coast consistent with evidence nationally that suggests led successes have been modest at best and primarily located in larger well resourced cities 8 the wild coast sdi sought to increase economic activity and foster the growth of smmes yet there is no evidence of an increase in locally owned businesses or even the consideration of ownership furthermore development initiatives seem to have failed in increasing access and improving health services even though these were identified early on in the process as crucial for their success by 2007 residents still complained of poor service and a lack of medications in government health clinics and there are still socioeconomic inequities in terms of access particularly for preventative reasons one might argue that development takes time and that the full effects of the initiatives have not yet been felt although a decade of repeated and consistent measurement make this unlikely the wild coast region still falls well below provincial and national standards in key areas such as access to clean water and employment inequities in access to health services leave the most vulnerable in a continued negative cycle as poor health impacts negatively on income generating opportunities and increase the burden of health costs for households that are already struggling to survive authors contributions sm contributed to instrument design conducted data analysis and drafted the manuscript na designed the study developed the methodology and contributed to the analysis and the drafting of the manuscript both authors have approved the final manuscript competing interests the authors declare that they have no competing interests published 21 december 2011

background after election in 1994 the south african government implemented national and regional programmes such as the wild coast spatial development initiative sdi to provoke economic growth and to decrease inequities ciet measured development in the wild coast region across four linked crosssectional surveys 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 the 2007 survey was an opportunity to look at inequities since the original 1997 baseline and how such inequities affect access to health care methods the 2000 2004 and 2007 followup surveys revisited the communities of the 1997 baseline householdlevel multivariate analysis looked at development indicators and access to health in the context of inequities such as household crowding access to protected sources of water house roof construction main food item purchased and perception of community empowerment individual multivariate models accounted for age sex education and income earning opportunities results overall access to protected sources of water increased since the baseline from 20 in 1997 to 50 in 2007 yet households made of mud and grass and households who bought basics as their main food item were still less likely to have protected sources of water the most vulnerable such as those with less education and less water and food security were also less likely to have worked for wages leaving them with little chance of improving their standard of living less education or 059 95 ci 037094 less water security or 067 95 ci 048093 less food security or 043 95 ci 029064 people with less income were more likely to visit government services among men or 028 95 ci 013059 among women or 033 95 ci 020054 reporting decision factors of cost and distance users of private clinics sought out better service and medication lower food security and poorer house construction was also associated with women visiting government rather than private health services women with some formal education were nearly eight times more likely than women with no education to access health services for prevention rather than curative reasons or 765 while there have been some improvements the wild coast region still falls well below provincial and national standards in key areas such as access to clean water and employment despite years of governmentled investment inequities remain prominent particularly around access to health services

introduction the effect of peer passengers on teenage drivers crash risk has received considerable research and attention the majority of states in the united states limit the number of passengers in the vehicle during the first few months a teenage driver is licensed to drive independently these policies are supported by epidemiological and observational studies that suggest the presence of peer passengers increases fatal crash risk and risky driving behavior particularly if those peers are young males however research suggests the detrimental effect of the presence of peer passengers may not hold true under all conditions for example simulator studies have found peer passengers increased some but not all risky driving behaviors and the presence of peer passengers may improve reaction times for teenage drivers this indicates there may be specific circumstances where peer passengers increase risk and others where they promote safer driving depending on the circumstances teen drivers perceptions of their peer passengers influence represents a potentially valuable source of understanding of the conditions under which peer passengers increase crash risk or promote safer driving a previous selfreported survey study found that teen drivers did not perceive the presence of peer passengers to increase their crash risk unless they created distractions or encourage dangerous behaviors few studies have used qualitative research methods to examine teen drivers perceptions of their peer passengers presence in the vehicle and their potential contribution to crash risk the purpose of this study was to examine teen drivers perceptions of their peer passengers using semistructured interviews with questions focused on distraction and social influences methods results themes regarding peer passengers the report of themes that emerged from the interviews regarding young drivers perceptions of peer passengers will be structured around the two organizing topics of distraction and mechanisms of social influence included are themes that were expressed by many of the participants as well as themes that were relevant but expressed by fewer participants furthermore for several themes multiple viewpoints were expressed often in contrast with one another reflecting diversity in the perceptions of young drivers these findings are described below distraction drivers responded to multiple questions about how having passengers affected their level of distraction and concentration when asked directly almost all drivers acknowledged that passengers were a distraction however most drivers described that distraction as a little or not much some perceived the risk but also suggested they were able to manage it they affected it but… i dont think it was a big distraction …they really wouldnt distract me and even if they would try … id be watching the road so…my first awareness would be the road a smaller subset of drivers described having passengers as very distracting notably when asked about the effect of having multiple versus a single passenger the majority of drivers recognized that multiple passengers detrimentally affected their driving and provided vivid descriptions of the distraction that having multiple passengers can pose participants described losing control of the invehicle environment due to increased talking and movement in the vehicle using statements like messing around… in the backseat punching each other ridiculously loud definitely more hectic than a drive by myself and mayhem this example is typical as a group they male passengers were very distracting and often they would mess around with each other poke at the cameras a lot especially in the beginning and they would do it together… it was very distracting…compared with one i could pretty much control one i really cant control a group talking was the most commonly described way that passengers distracted the driver talking distracted drivers in several ways such as drawing their attention to the topic being discussed or requiring drivers to concentrate on the conversation as described by this male driver some noted that turning ones head to look at a passenger who was speaking required the driver to take their eyes off the road id make eye contact in the rear view mirror … you do it too long and you look back on the road and youre like oh shoot got a little close or fast or something… loud noise and loud music were also frequently mentioned particularly in the context of groups of passengers several drivers mentioned physically active behavior such as horseplay or dance parties the following quotes from two participants are examples of how this was described just be obnoxious guy stuff… be loud and have the window rolled down and have to have the radio on … my friends are very partial to dance parties in my car so we had a lot of thosethose are pretty distracting…i wasnt as focused … additionally one infrequent but notably dangerous distraction was when a passenger directly interfered with the vehicle controls some were minor such as turning on or off the windshield wipers or hazard lights but two drivers described a passenger who grabbed the steering wheel drivers were not asked how they responded to these distractions but several offered their strategies for managing their driving with peer passengers one strategy was to put more effort into focusing on their driving when they felt themselves being distracted as evidenced in the following quotes for some this was a response to being a new driver or a concern regarding consequences of a lapse of attention i was … just so afraid as a new driver on the road … i didnt want to screw up so i just focused and try not to let anything change … i would just focus more so on the road because i would have to or else something bad could happen… some responded to passenger behavior by managing the invehicle environment including requesting passengers to be quiet and turning down the music as one driver said it felt like being a parent referring to his efforts to get a group of passengers to settle down other drivers noted that they simply ignored their passengers and concentrated on their driving most indicated that as their driving skill and confidence improved their ability to cope with the distraction also improved here is an example of how they handled distractions in response to traffic if it got to be tight traffic id be shut up for a second let me drive so it affected it a little bit but i think i was pretty good at handling the distraction interestingly several drivers regarded having a passenger as a responsibility for some this was framed as them worry ing more about others safety than their own for example one male driver explained he drove more risky when alone because my life is my life but if somebody else is in the car its their life that im taking into account as well as indicated in the quote below having more passengers in the car exacerbated this sentiment when i have more people in the car … sometimes hits me… oh my gosh i gotta pay attention i cant get involved in what theyre talking about i need to pay attention i dont want to be responsible for them social influence in addition to the overt distractions that peer passengers posed when asked about how passengers affected their driving the majority of drivers described at least one form of social influence from their peer passengers this included direct comments about driving and indirect pressure in the form of social norms and unspoken expectations from their passengers for example one female described how a male passenger encouraged her to drive over a median i was with a friend who kind of encouraged it which was probably the more dangerous thing … oh just go over the median cause we wanted to go left but we couldnt in contrast a male driver described how his girlfriend discouraged his fast cornering my girlfriend did say i took corners too fast so i havent taken corners so fast one driver described the negative influence of passengers on his concentration and his driving behavior suggesting distraction and social influence can cooccur participant they act like idiots its terrible they affect my concentration a whole lot interviewer would you say it would be a negative or positive way participant most certainly negative … i can admit this they get me acting more stupid too participants also described several forms of indirect pressure from the passengers in the vehicle some male drivers described driving more safely with female passengers while being less concerned with the safety of their male passengers as one driver explained guys dont really care about bad driving… or at least my friends the passengers that i had another form of indirect pressure stemmed from drivers perceptions of their passengers unspoken expectations or from knowledge of their passengers driving behavior drivers were not asked how their driving behavior was affected but participants mentioned the specific behaviors that they would change in the presence of passengers i drove faster mainly cause they always drove faster in the case of having a more experienced driver as a passenger one driver stated i would probably be a tiny bit more daring more likely to sit at a stop sign and wait for a very large gap if im by myself versus if i have a passenger in the car … and more daring because they know what theyre doing and you dont as much when drivers had knowledge of their passengers driving behavior these influenced their driving when those passengers were in the vehicle for example i had a friend who is kind of reckless the first year of his driving and it made me a little reckless well depending on the person that was in there it made me already know how i should drive with them in there thats how i would drive… either fast or slow… several participants described the diminishing effects of different forms of social influence over time one male participant described a crash as a formative experience leading to a lower susceptibility to influence from peer passengers when they were in the car i would sometimes act a little more dumb participant laughs … i would go for the impression thing until i wrecked … and then id slow down before that id have the radio louder id take turns tootoo fast drive a little bit faster especially on that trip where i wrecked i was driving a lot faster than i should have a common theme that several drivers described was that they considered their driving as a performance at times this was in direct response to passengers comments about driving but at other times it was due to the desire to appear skilled and competent in the presence of peers for both male and female drivers these perceptions were heightened in the presence of male passengers if i was inwith another male in the car id probably pay more attention to what i was doing and …how i was performing here are two more examples now im not as distracted when males are in my car but at first i would say … it was intimidating to have a male passenger even though theyd never driven before cause you know males know how to drive i would try and drive a little bit better … we were all getting our license and it was kind of a competition for who was a more skilled driver and who was better we didnt say any of that …so i dont think that i overly sped or anything like that… i just tried to be more skilled in what i was doing like when i was merging on to the highway id just make it seem like it was really normal and i had done it a lot cause i wanted to look more experienced than them when carrying peer passengers some teens reported that their driving was influenced by the need to appear laidback this may have resulted in their being less vigilant while driving or taking risks such as rolling through a stop sign to seem more in control for example i was more carefree with female passengers like with my friends… i felt i was the cool one in the bunch who could drive already and take everyone everywhere … i was the same kind of carefree and maybe didnt pay attention as much as i did when i was by myself a related point raised by some drivers was the desire to appear attractive to passengers of the opposite sex while driving as exemplified by one female driver who stated that she tried to look more pretty… more graceful when driving with male passengers whom she stared while driving discussion the purpose of this study was to examine teen drivers perceptions of their peer passengers using interviews from a sample of newly licensed teenage drivers and guided by a grounded theory approach to data analysis we found that teenage drivers were aware of the potential sources of risk that their peer passengers pose some participants articulated descriptions of the specific mechanisms of influence and detrimental effects on driving performance demonstrating an awareness of the risks that peer passengers can pose in contrast other teens did not perceive the presence of peer passengers as having an influence on their own driving behavior whether or not they described peers as distracting brown and colleagues describes four elements being involved in peer influence for teenagers an event activation of peer influence a response and generation of an outcome several participants described the operation of these steps in relation to their peer passengers specifically during events of driving the presence of passengers would exert some influence and participants would respond often by driving in a riskier way to look skilled or attractive and meet their passengers unspoken or observed expectations notably the influence was not uniformly to drive in a riskier way with some participants describing safer driving in response to passenger expectations this suggests social influences can operate indirectly through norms which can be transmitted through modeling and verbal and nonverbal actions a recent experimental simulator study reported increased risky driving among young male drivers exposed to young male passengers with considerable variability depending on the type of the passenger present eg risk accepting or riskaverse the consistency of evidence regarding social influences on driving behavior from studies using differing methods strengthens the conclusion that social influences are operating on driving behavior in ways similar to wellknown pathways found in other areas of adolescent risk behavior such as alcohol use and smoking teen drivers described distraction and social influence as two potentially reinforcing forms of influence from peer passengers our findings suggest that future experimental study designs examine the potential interaction of these sources of crash risk another promising avenue of examination is teens description of driving as a performance and their desire to appear skilled competent cool and attractive while driving in the presence of their passengers this may lead them to engage in risky driving maneuvers to demonstrate mastery or skill that may also increase crash risk reframing social 10 norms about skill and competence to be focused on minimizing crash risk may present a potential avenue for intervention limitations the participants in this study may represent a unique sample of teenage drivers they were recruited to participate in a naturalistic driving study where driving behavior was recorded continuously for 18 months completed periodic surveys about their driving behavior and participated in two test track driving assessments participants may have had a heightened awareness of their own driving behavior relative to other teens while participants were not provided with any feedback on their driving during the course of the study volunteering to be subjects and participating in this research may have primed them to be more aware of safety concerns and crash risk participants descriptions of their driving behavior may be influenced by the presence of laws that restrict behaviors during the first 12 months of licensure all study participants were subject to the single peer passenger restriction of the state of virginia for newly licensed teens while the interview questions did not ask participants to describe the timing of behaviors some response bias may exist that is participants may have been less willing to report behaviors that were illegal during the interview furthermore the interview protocol was intended to elicit responses for specific circumstances and behaviors such as distraction caused by peers at times the interviewer probed participants and reinforced their statements that related to risk and safety while these instances were rare they may have affected the participants responses despite these limitations the findings of this study represent a unique and valuable source of insight into teen drivers perceptions of their peer passengers and the findings could be used to inform the experimental study design measurement development and safety interventions

backgroundthe presence of peer passengers increases teenage drivers fatal crash risk distraction and social influence are the two main factors that have been associated with increased risk teen drivers perceptions of their peer passengers on these factors could inform our understanding of the conditions under which peer passengers increase crash risk or promote safer

d eimplementing lowvalue care is a major challenge within healthcare systems around the world 1 the perpetuated use of healthcare services that provide little or no benefit to patients or which may cause harm represents wasteful consumption of healthcare resources 2 since the launch of the choosing wisely campaign in 2012 there has been an exponential increase in research identifying hundreds of lowvalue practices across all areas of healthcare 3 4 5 although many lowvalue practices have been identified as candidates for deimplementation their use persists because the process of changing engrained clinical behaviour is complex while we have established theories models and frameworks to guide the process of implementing highvalue care into practice less is known about the process of deimplementing lowvalue care studies have begun to further unravel the complex interplay between processes and determinants of deimplementation and implementation nevertheless despite advancements in our understanding of deimplementation lowvalue care remains a major burden within healthcare systems throughout the world prior to the coronavirus disease 2019 pandemic reducing lowvalue care was increasingly recognized as a priority for healthcare system improvement now owing to the many negative health system impacts of covid19 reducing lowvalue care should be an even greater priority 67 ensuring that healthcare providers are delivering highvalue care will help mitigate the resource and financial constraints that will impact healthcare systems postpandemic 8 in verkerk and colleagues recent study key factors that promote lowvalue care views of experts from the united states canada and the netherlands 9 the authors aimed to explore the factors that promote ongoing use of practices identified as lowvalue this commentary will review the article by verkerk et al highlight key findings and offer further consideration for how their findings may be interpreted and applied to future initiatives to reduce lowvalue care verkerk et al interviewed 18 experts from canada the united states and denmark preexisting frameworks describing drivers of poor medical care and determinants of healthcare professional practice were used to guide interviews and elicit factors that promote lowvalue care this enabled the authors to fill a gap within the literature and potentially identify social and systemlevel factors that are often overlooked yet at a macrolevel are potentially very influential 10 key factors promoting use of lowvalue care that emerged from the interviews included social factors system factors and knowledge factors the identification and description of these factors are a meaningful addition to the body of literature describing determinants of lowvalue care 1112 and offer potential strategies to reduce its overuse generalizability of many of the key factors promoting lowvalue care likely depends on context for example one of the social factors promoting lowvalue care identified in the study by verkerk et al was public culture and the tendency to believe that more is more this suggests that patients may value the receipt of tests and treatments because it makes them feel like something is being done to help them and understanding this clinicians may decide to provide tests or treatments when the clinical indication may be weak or absent patient education materials such as those from the choosing wisely campaign have been shown to increase patients awareness of lowvalue care and encourage them to initiate conversations about the value of their care with their physicians 13 the importance of patient perceptions likely varies across clinical contexts diagnostic imaging for lowrisk low back pain is an example of a lowvalue practice where patients expectations or preferences have been shown to significantly influence utilization 14 healthcare providers have reported that more patient education and additional time to explain their rationale to a patient would help them reduce lowvalue imaging for low back pain 15 targeting patient expectations through implementation of an intervention within the patientclinician interaction in primary care may provide an opportunity for the patient to express their preferences and engage in a discussion about the merits of imaging a national intervention in australia applied this approach to the patientclinician interaction regarding imaging for lowback pain in their study patientspecific educational tools and cliniciantargeted decisionsupport tools were implemented to assist with decision making regarding imaging for lowback pain 16 they found that this intervention reduced primary care ordering of imaging by nearly 11 over the study period similar results have been achieved with interventions targeting the patientclinician interaction in other primary care contexts such as with antibiotic prescribing for upper respiratory tract infections and diagnostic imaging for lowrisk head injuries 17 in contrast to primary care where decisions regarding use of lowvalue tests or treatments are commonly made during the patientclinician interaction acute care and in particular the intensive care unit is a care environment where some of the decisions regarding care required to save life or limb may be less influenced by public culture for example several studies suggest that for most patients admitted to adult icus a hemoglobin target of 7 gdl is sufficient and transfusion to higher hemoglobin levels that more closely resemble normal values is associated with worse outcomes 18 red blood cell transfusion when the hemoglobin is 7 gdl or higher is for most patients lowvalue care owing to their severe illness icu patients are not aware that their hemoglobin level may be lower than normal whereas the clinicians are and thus best positioned to make decisions regarding the merits of transfusion in this case an intervention that targeted patients or their family members would be less impactful than one focusing more heavily on clinicians their medical knowledge and the strong medical culture that more care and normalization of physiology is better the more care is better culture and the ability of clinicians to adapt established medical practice patterns in response to new evidence are major barriers to reducing use of lowvalue care that likely transcend all areas of medicine it is hard for clinicians to unlearn patterns of practice that have emerged from years of medical training and experience 19 20 21 a recent qualitative evidence synthesis indicates that clinician knowledge is a commonly reported determinant of lowvalue care 12 yet it is less clear how this should be addressed clinicians engage with multiple sources of evidence within a medical culture with established norms whilst also subject to their own cognitive biases all of these elements may contribute to how they interact with and apply their medical knowledge surrounding lowvalue care 22 clinicians are also faced with patients whose complexity frequently exceeds that of those examined in clinical trials and therefore have difficulty applying evidence to the clinical contexts they encounter additional work is required to further explore with clinicians their own experiences interacting with new potentially contradictory evidence and the decision to deimplement care that may no longer be considered high value in addition to social and knowledge factors the system in which care is delivered has been shown to influence the delivery of lowvalue care for example a study examining vitamin d screening in the united states and canada found modest reductions in lowvalue screening following the release of choosing wisely recommendations 23 however when a new payment policy eliminating reimbursement for the screening was introduced in ontario canada the rate of screening was reduced by 93 23 here an intervention addressing systemlevel factors was needed in addition to the choosing wisely campaign which targets knowledge and social factors differences in the structure of healthcare systems suggests that context specific interventions may need to be considered a systematic review of interventions to reduce lowvalue care identified the importance of systemlevel strategies that aimed to reduce demand of lowvalue care and supply of lowvalue care 24 research suggests that effective interventions that reduce lowvalue care are more commonly multicomponent interventions that address both systemlevel factors and social and knowledge factors 24 the factors identified by verkerk et al complement those cited within the current lowvalue care and deimplementation literature two recent evidence syntheses of determinants of lowvalue care suggest patient and provider characteristics to be the most cited determinants of lowvalue care 1112 other factors outside the patientprovider dynamic like the systemlevel factors identified by verkerk et al appear to be less commonly reported in the literature but as demonstrated by verkerks findings this does not dismiss their impact on lowvalue care verkerks study is an important reminder that no single determinant is responsible for the challenges associated with reducing lowvalue care social knowledge and systemlevel factors are driving lowvalue care in an interconnected manner when designing deimplementation interventions these social knowledge and system factors should be evaluated to understand what the predominant driver of use of the specific lowvalue practice is and what might work best to reduce its use as highlighted in this commentary these factors are likely going to look different depending on the target lowvalue practice care setting and health system in conclusion the study by verkerk et al highlights key social knowledge and system factors that promote lowvalue care and underscores the complexity of the challenge of deimplementation understanding how these key factors vary with contextual factors such as the specific lowvalue practice and clinical setting is an important consideration in the design of deimplementation interventions it is essential that we engage all relevant stakeholders including clinicians and patients as we continue to build the body of evidence describing determinants of lowvalue care pursue initiatives to reduce lowvalue care and advance the science of deimplementation ethical issues not applicable competing interests authors declare that they have no competing interests authors affiliations 1 faculty of medicine university of ottawa ottawa on canada 2 school of health administration faculty of health dalhousie university halifax ns canada 3 department of critical care medicine university of calgary and alberta health services calgary ab canada 4 department of community health sciences university of calgary calgary ab canada 5 obrien institute for public health university of calgary calgary ab canada

lowvalue care contributes to poor quality of care and wasteful spending in healthcare systems in verkerk and colleagues recent qualitative study interviews with lowvalue care experts from canada the united states and the netherlands identified a broad range of nationally relevant social system and knowledge factors that promote ongoing use of lowvalue care these factors highlight the complexity of the problem that is persistent use of lowvalue care and how it is heavily influenced by public and medical culture as well as healthcare system features this commentary discusses how these findings integrate within current lowvalue care and deimplementation literature and uses specific lowvalue care examples to highlight the importance of considering context culture and clinical setting when considering how to apply these factors to future deimplementation initiatives

introduction the severe acute respiratory syndrome coronavirus 2 pandemic has brought about unprecedented challenges worldwide in an attempt to deter the spread of the virus and disease associated with the virus many countries implemented social and physical distancing restrictions that led to the closure of work places schools and recreational facilities 1 the impact of covid19 restrictions on physical activity levels in adults has been mixed due to research studies reporting decreased exercise engagement 2 3 4 the maintenance of pa levels 5 or even increased exercise practice 56 however among children these closures have had primarily a negative impact on 24h activity behaviors 1 including decreased pa increased sedentary behavior and poor sleep habits in the sedentary profiles in children 7 8 9 these behaviors are independently and collectively associated with poor physical and mental health outcomes 10 the purpose of this commentary is to extend the discourse on the importance of 24ab by focusing on youth wheelchair users where ywu can be defined as youth aged 517 years who are disabled as a result of musculoskeletal neurological cognitive or other types of dysfunction and use a wheelchair as their main source of mobility 11 specifically children 2021 8 690 2 of 6 we discuss the importance of chronic disease prevention provide a brief overview of 24ab and outline some of the lessons that can be learned from the covid19 pandemic we have focused on ywu due to the high likelihood of their 24ab being impacted by the covid19 social restrictions the high risk of developing severe illness and complications following a covid19 infection due to underlying health conditions and comorbidities 1213 and the potential for improved mental and physical health outcomes with decreased sb increased pa andor improved sleep habits impact of covid19 restrictions on physical and mental health those with preexisting chronic diseases including cardiometabolic diseases such as obesity type ii diabetes and hypertension are at heightened risk for severe complications and death following covid19 infection 14 the ywu population is largely characterized by preexisting conditions 15 not least because some type of preexisting condition may have preempted and ultimately necessitated wheelchair use these preexisting conditions place ywu at greater risk for covid19related complications 1617 in addition wheelchair use creates a situation in which the child is more susceptible to negative 24ab all of which are linked to chronic diseases that can further exacerbate susceptibility to covid19related complications 18 19 20 as an example consider a ywu who has a spinal cord injury whose risk for covid19related complications may be increased both as a result of autonomic dysfunction associated with the spinal cord lesion as well as the negative impacts on cardiometabolic health related to physical inactivity and sb the increased risk of poor health outcomes among ywu either directly or indirectly related to covid19 highlights the need for focused and effective preventive health measures in this population 18 physicians alliedhealth practitioners mental health professionals as well as parents and teachers should be aware of the increased susceptibility to covid19 related complications faced by ywu 9 and work collaboratively and creatively to ameliorate health risks through the promotion of positive lifestyle behaviors 21 fortunately 24ab are modifiable and can and should be targeted in ywu as a means to maintain health and reduce risk of complications for covid19 andor future variantspandemics 22 24h movement behaviors with respect to 24ab the most established guidelines are available for pa followed by sleep however there is sufficient evidence to strongly associate each 24ab with chronic disease outcomes for example meeting pa guidelines is extremely important to improve physical and mental health as well as preventing many chronic diseases such as hypertension or diabetes for youth at least 60 min of moderate to high intensity physical activity is recommended per day 2324 sufficient sleep duration and quality are also critical in supporting mental health immune function and attention span 2526 therefore 911 h of uninterrupted sleep is recommended for youth per night 23 lastly sb is an independent risk factor for cardiometabolic diseases in adults 27 and likely youth 10 sedentary behavior has been defined as any waking behavior in a seated or reclining posture 28 however due to the lack of available evidence regarding sb and health outcomes in wheelchair users the most recent world health organization guidelines concluded that there is no reason to believe that recommendations to reduce sb would be any different for wheelchair users 29 the who recommends reducing sb and others recommend 2 h of screen time per day specifically for youth 233031 activity behaviors including pa sleep and sb interact with one another across a 24h day therefore time spent engaging in one activity behavior should not be considered independently from the other behaviors time spent engaging in one activity behavior influences the physiological processes involved in the other behaviors for example increasing pa may lead to a reduction in sb or reducing tv time may result in a child going to bed earlier or improving their sleep quality 3233 it is extremely important for parents or guardians to establish a routine that promotes positive 24ab in order to achieve the recommended guidelines for increasing pa reducing sb and promoting good sleep duration and quality challenges moving forward and lessons learned infection with the covid19 virus and the imposed social restrictions will likely have lasting health impacts on ywu 14 at present many of the longterm health impacts cannot be predicted additionally it is unclear what types of specialized healthcare these youth will require or whether there are enough properly trained medical experts to provide the necessary acute and chronic specialized medical care while we cannot control all of the negative longterm implications of covid19 there is reason to believe that positive 24ab can be beneficial to health outcomes 33 additionally we are now in a position to reflect on events surrounding the covid19 pandemic specifically in the remainder of this section we will use a socioecological model to provide perspective on which lessons we can learn from and make use of moving forward the sem posits that the ability to motivate or educate an individual to change their behavior is likely to be restricted if their sociocultural and physical environments do not enable and support the behavior 33 specifically the sem allows us to contextualize the multiple levels of influence on behavior including intraindividual interindividual physicalenvironment and policy levels the policy level is beyond the scope of this short commentary the remainder of this section will focus on the intraindividual interindividual physicalenvironment levels children 2021 8 x for peer review 3 of 6 influences the physiological processes involved in the other behaviors for example increasing pa may lead to a reduction in sb or reducing tv time may result in a child going to bed earlier or improving their sleep quality 3233 it is extremely important for parents or guardians to establish a routine that promotes positive 24ab in order to achieve the recommended guidelines for increasing pa reducing sb and promoting good sleep duration and quality challenges moving forward and lessons learned infection with the covid19 virus and the imposed social restrictions will likely have lasting health impacts on ywu 14 at present many of the longterm health impacts cannot be predicted additionally it is unclear what types of specialized healthcare these youth will require or whether there are enough properly trained medical experts to provide the necessary acute and chronic specialized medical care while we cannot control all of the negative longterm implications of covid19 there is reason to believe that positive 24ab can be beneficial to health outcomes 33 additionally we are now in a position to reflect on events surrounding the covid19 pandemic specifically in the remainder of this section we will use a socioecological model to provide perspective on which lessons we can learn from and make use of moving forward the sem posits that the ability to motivate or educate an individual to change their behavior is likely to be restricted if their sociocultural and physical environments do not enable and support the behavior 33 specifically the sem allows us to contextualize the multiple levels of influence on behavior including intraindividual interindividual physicalenvironment and policy levels the policy level is beyond the scope of this short commentary the remainder of this section will focus on the intraindividual interindividual physicalenvironment levels the intraindividual level includes factors such as selfefficacy and activity enjoyment the covid19 pandemic has led many of us to become more selfsufficient and to realize that we can do more with lessincluding engaging in pa and breakingup sb within our homes 34 this heightened selfreliance can be channeled to raise selfefficacy the intraindividual level includes factors such as selfefficacy and activity enjoyment the covid19 pandemic has led many of us to become more selfsufficient and to realize that we can do more with lessincluding engaging in pa and breakingup sb within our homes 34 this heightened selfreliance can be channeled to raise selfefficacy towards positive 24ab 28 simple techniques include the use of goal setting selfmonitoring and selfmanagement 35 this could include pa tracking via smartphone apps setting and monitoring fixed bedtime and waketimes and getting timed reminders to breakup children 2021 8 690 4 of 6 sedentary behaviors 30 simple yet enjoyable activities that can be engaged in within the home include breakingup sedentary behavior with light pa or participating in modified yoga available via the internet of relevance to the interindividual level of the sem ywu can participate in activities while engaging with others to combat isolation during the covid19 pandemic many people have learned to interact using various virtual platforms the use of such platforms can continue postcovid to for example challenge family or friends to sb interruption challenges or to participate in pa classes 36 for example individuals within support groups could challenge one another to engage musculature for at least one minute every hour or by reminding one another to breakup a sedentary bout with resistance band exercises additionally positive 24ab habits could be a family affair including encouraging parents to restrict nighttime access to screened devices and replace the screen time with story time lastly the physical environmentlevel can be used to contextualize barriers to engaging in positive 24ab while covid19related social restrictions have been viewed negatively with respect to our health and wellbeing many individuals have adapted their home environments to improve their quality of life 37 while physical therapy gyms leisure centers and other facilities are beginning to operate on a normal schedule the adaptations made during the pandemic need not be reversed as opposed to physical infrastructure around the home including paths greenways and public transportation barriers within the home are relatively easy to reduce 38 modifications could include installing grabbars to provide opportunities to breakup sb or more simply placing resistance bandsother equipment around the home to make it easier to replace sb with pa additionally to improve sleepwake cycles the home environment could be modified to ensure children are positioned throughout the day to enhance exposure to sunlight and timers can be set ensure children go outside at regular intervals conclusions challenges faced by ywu include the greater risk of developing severe illness and complications following a covid19 infection and the inability to fully predict the longterm health impacts of covid19 to the pandemic however we can take a moment to reflect and take away some important lessons gleaned during the pandemic era for example among the general ablebodied population we know that positive 24ab improve chronic disease outcomes and in doing so decreases the risk of covid19 infection complications we have no reason to believe the same is not true for ywu using the sem to provide context we can take something positive away from this blight on our history by reflecting on the adaptions we made to improve our quality of life during the pandemic to model positive and longterm 24ab data availability statement not applicable

preventative measures taken worldwide to decrease the transmission of covid19 have had a tremendous impact on youth following social restrictions youth with and without physical disabilities are engaging in less physical activity more increased sedentary behavior and poor sleep habits specifically youth wheelchair users ywu are likely disproportionately affected by covid19 and have a higher risk of contraction due to underlying comorbidities while we cannot control all of the negative longterm implications of covid19 for ywu participation in positive 24h activity behaviors can decrease chronic disease risk and the likelihood of longterm complications resulting from infection this commentary is to extend the discourse on the importance of 24h activity behaviors by focusing on ywu specifically we discuss the importance of chronic disease prevention provide a brief overview of 24h activity behaviors and outline some of the lessons that can be learned from the covid19 pandemic

introduction in belgium and western europe new hiv diagnoses have been declining for the last 10 years 12 men who have sex with men are still at highest risk for hiv acquisition in belgium more than half of new hiv infections were being diagnosed in this group in 2017 1 to further reduce the high number of hiv infections among msm primary prevention needs to be strengthened preexposure prophylaxis the use of antiretroviral treatment as prevention has shown to be highly efficacious in reducing hiv infection risk if used correctly 34 given this efficacy 4 preprelated research has increasingly focused on how to implement this novel biomedical prevention tool in europe an increasing yet limited number of countries are now providing prep through national healthcare systems including france norway belgium portugal luxembourg scotland and germany 5 however delivery and uptake may need to be upscaled and the implementation periods might have been too short to affect the overall course of the hiv epidemic across europe 6 of 15 developing effective strategies for ensuring optimal prep uptake by populations at risk of hiv acquisition is an important implementation challenge ideally such strategies should be based on active engagement of populations at risk while also exploring prep use by individuals who are at lesser risk use of prep beyond the margins of clinical eligibility criteria may be costly 7 8 9 and may result in unnecessary exposures to potential sideeffects another concern expressed on communitylevel has been prevention optimism ie the belief that it is safe to engage in condomless sex because other men are perceived to take prep 10 on the individual level increased engagement in condomless anal sex considered as risk compensation may lead to more sexually transmitted infection among msm 1112 willingness to take prep has frequently been used as a measure of acceptability and as a predictor of its uptake 13 the construct willingness as part of a broader acceptability assessment has been investigated in other hivrelated health promotion areas such as voluntary counseling and testing 14 and circumcision 15 examples outside the hiv field are prevention programs for cardiometabolic diseases 16 or mental health interventions 17 investigating this concept can contribute to better an understanding of how to disseminate theoretically promising public health interventions on a broader scale translating efficacy into effectiveness willingness is believed to shape the pathway from behavioral intention to actual behavior and it may partially predict actual behavior 18 the perceived level of efficacy and barriers such as potential health consequences and social stigma are then typically presented as what may explain disparities between willingness and its actual uptake 18 studies conducted in high income countries showed prep acceptability rates among msm between 40 and 60 19 factors associated with willingness were younger age having high hiv risk behavior with casual sex partners many partners 20 21 22 23 and being aware of own hiv risk for instance in australia 23 england 24 and germany 25 willingness was associated with previous postexposure prophylaxis use in australia and england 2324 a study conducted in the united states found that men at highest risk were most willing but least likely to have access to prep 18 msm who reported to be unwilling to take prep on the other hand expressed concerns about sideeffects nonefficacy lack of information medical mistrust and costs 26 27 28 prep guidelines have issued eligibility criteria to identify individuals who qualify for prep based on known hiv risk factors 2930 to ensure that prep is prescribed in a targeted way 31 in belgium as in many western countries prep eligibility criteria for prescription and reimbursement issued by the belgian federal office of health include msm with risky sexual behavior people who inject drugs and share needles sex workers other people that may be exposed to greater hiv risk and partners of hiv positive people whose viral load is detectable 32 a recent belgian prep demonstration project showed that msm at highest risk for hiv acquisition could be reached using similar screening criteria 33 by november 2018 nine months after implementation of the belgian prescription and reimbursement policy 1352 prep users predominantly msm were reported by the specialized hiv treatment centers qualified for prep delivery 3435 the willingness to take prep in the future so far has not been assessed against formal eligibility criteria a better understanding of this relationship and its associated factors can inform tailored prep promotion and support strategies to optimize prep uptake the aim of this study was to explore hypothetical willingness to take prep among msm and to assess it against the formal prep eligibility criteria more specifically we aimed to assess differences in terms of sociodemographic knowledgerelated attitudinal and behavioral factors between msm who are eligible and willing to use prep and those who display incongruences between their eligibility and willingness box 1 preexposure prophylaxis eligibility criteria in belgium criteria for men who have sex with men that permit reimbursement of prep condomless anal intercourse with at least two different partners in the last six months diagnosed with multiple sexually transmitted diseases in the last year taken multiple pep treatments in the last 12 months used psychoactive substances while involved in sexual activities general prep eligibility criteria independently from sexuality people who inject drugs sex workers individuals that are being exposed to unprotected sex and a high risk of hiv partners of hivpositive patients who has a detectable viral load methods study design a crosssectional study was conducted among a convenience sample of belgian msm using an online questionnaire study population and recruitment the online questionnaire was promoted via social and sexual networking applications additionally it was disseminated via social media of msm communitybased organizations in belgium it was online from 21st november 2016 to 27th february 2017 ie before prep was available for prescription and reimbursement inclusion criteria in this study were msm or transgender aged 16 years and above selfreporting to be hiv negative or unknown serostatus and living in belgium or having a belgian citizenship questionnaire and variables measured we developed a questionnaire via sosci 36 the questionnaire was intentionally kept short and included skip logics and filter options for nonapplicable questions to limit the time needed to complete it questions about sociodemographics sexual behavior hiv risk and protective behaviors were similar to those used in other prep research ie the belgian prep demonstration project beprepared 3337 to inquire about prep awareness knowledge and acceptability we adapted questions from similar research among healthcare providers 3839 it was available in dutch french and english to reduce potential language barriers and was piloted for feasibility and userfriendliness within the research team we measured willingness to use prep using the following statement if prep was available in belgium what is the probability that you would use prep answering options were given on a fivepoint likert scale ranging from certainly not rather not no opinion rather yes to certainly yes answers rather yes and certainly yes indicated being willing to use prep any other answer denoted the absence of such willingness eligibility criteria were measured with questions assessing the relevant sexual and preventive behaviors as defined by the belgian criteria 32 to calculate eligibility we focused on criteria specific for msm the questionnaire included questions on preventive and sexual behavior asking about hiv test recency pep and prep use use of psychoactive drugs during sexual activity number of anal sexual partners in the last six months and anticipated cai in the next three months sociodemographic items collected information on age sexuality nationality place of residence education and relationship status five items measured participants attitudes towards prep through fivepoint likert scales ranging from 2 totally disagree to 2 totally agree for the current analysis the scales were dichotomized where 2 and 1 denote agree whereas 2 1 and 0 denoted an absence of agreement with the respective attitudinal statements cronbachs alpha for these five items was 068 hence we did not treat these items as one single scale prep awareness was examined through a dichotomous yes or no question asking whether participants had ever heard of prep participants also had to selfestimate their knowledge about prep on a fourpoint scale from very bad to very good for the current analysis the selfratings very bad and rather bad were merged into the category little knowledge and rather good and very good into good knowledge selfperceived risk to acquire hiv was also measured through a fivepoint likert scale ranging from very little risk to very high risk again the middle category was added to the category implying absence of perceived risk statistical analysis in this analysis only completed questionnaires of participants matching the inclusion criteria for msm were included we analyzed cleaned data using ibm spss versions 220 and 250 after forming four groups of participants according to their willingness and eligibility factors associated with either of the four groups were examined we used a chisquare test to examine the relationship between eligibility and willingness and chisquare or fishers exact tests to determine the relationships between the four groups and potentially associated factors statistical significance was set at p 005 ethics we obtained ethical approval for the study through the institutional review board of the institute for tropical medicine antwerp 1140 16 before filling in the questionnaire participants were informed about the study the procedures and voluntary nature of study participation by clicking through participants consented to participate results description of study sample we received 1444 completed questionnaires participants sociodemographic background characteristics are displayed in table 1 participants median age was 365 years with a minimum of 16 years and a maximum of 77 years almost all participants were male except for four femaletomale transgender participants and for one persons gender was missing participants were predominantly belgian living in belgium and highly educated almost half of the participants lived in metropolitan areas ie 298 in the brussels capital region and 144 in the antwerp region in total 443 of the participants were eligible for prep the criteria most often applied were reporting cai with at least two different partners and having used psychoactive substances while engaging in sexual activities most participants were willing to use prep in the future 840 of the eligible ones and 580 of the illegible who were not eligible these results will be discussed in more detail below when looking at the congruence between the subgroups results description of study sample we received 1444 completed questionnaires participants sociodemographic background characteristics are displayed in table 1 sexual and preventive behavior most participants were sexually attracted to men 76 participants were also attracted to women in the last 12 months the median numbers of men with whom they had sex were seven with whom they had anal intercourse five and with whom they had cai was one about 398 reported that they had not engaged in any cai with sexual partners during the last year sex under the influence of psychoactive drugs in the last six months was reported by 253 almost sixty percent reported having had their latest hiv test in the previous six months pep was used by 82 in the last year 75 had used prep before about one fifth perceived themselves at a high risk of acquiring an hiv infection and 442 were in a steady relationship at the time of the survey prep awareness knowledge and attitudes a great majority of the participants reported having been aware about prep about 552 of the participants rated their prep knowledge as good or very good participants attitudes towards prep were generally positive a vast majority perceived prep as a good extra prevention tool and agreed with the statement that its a good thing that hiv negative people can protect themselves with prep only 156 felt that prep was unnecessary due to better alternatives about one third of participants expected that prep users will receive negative remarks from others prep eligibility and willingness participants who were eligible for prep were significantly more likely to be willing to take prep among those who were eligible 160 were unwilling or unsure to use prep in the future among participants where were not eligible 58 were willing to take prep overall willingness was significantly associated with higher prep awareness better prep knowledge more risky sexual behavior and the relationship status single no significant differences were found between the four groups in terms of other sociodemographic background characteristics eligible participants factors associated with their willingness to take prep participants who were eligible for prep but not willing to use it were significantly more likely to be in a steady relationship to not have tested for hiv in the last six months and to have had fewer male partners for anal sex in the last 12 months when compared with eligible and willing participants eg 88 of eligible unwilling participants reported to have had cai with more than five partners compared with 289 among eligible willing participants eligible unwilling participants were also less likely to perceive themselves at high risk for hiv in terms of awarenessrelated knowledgerelated and attitudinal factors the following differences were found eligible but unwilling participants were less likely to be aware of prep and to consider their prep knowledge to be good when compared with willing participants eligible and unwilling participants were also significantly less likely to have a positive attitude towards prep although they did not significantly differ in their opinion towards the use condoms to prevent other stis while on prep a selfestimated knowledge about prep very good and good versus bad and very bad b totally agree and agree versus don know or unsure disagree and totally disagree and c pvalue for chi 2 or fisher exact test for association between willingness and characteristic within eligible or ineligible groups ineligible participants factors associated with their willingness to take prep participants who were willing to use prep but ineligible to do so according to the belgian criteria were more likely to be single to have tested for hiv in the last six months to perceive themselves at higher risk of getting an hiv infection and had a higher number of male partners for anal sex when compared with those ineligible and unwilling a substantial proportion in both groups anticipated that they may have cai in the next three months willing participants were less likely to find it important to still use condoms when being on prep compared with unwilling ineligible participants willing msm were also more aware of prep and were more likely to indicate that their prep knowledge was good when compared with ineligible unwilling participants discussion in this online survey among belgian msm we aimed to explore the hypothetical willingness to take prep and to assess it against the formal prep eligibility criteria about 443 of the participants were eligible for prep according to the belgian eligibility criteria more than two third were willing to start prep once it became available in belgium more than half of those were also eligible we also found that a small proportion of those eligible were unwilling to take prep and that more than half of those ineligible at the time of the survey were willing to take prep in the future among eligible participants those unwilling to take prep reported relative lower levels of cai and were more often in a steady relationship this may have contributed to their lower individual risk perception they also had lower awareness and knowledge of prep and reported less positive attitudes towards this prevention method than their willing counterparts among ineligible participants a distinct group of msm willing to take prep emerged in spite of not formally qualifying for prep prescription single men perceiving themselves at risk for hiv acquisition with relative high number of male partners for anal sex while their attitudes were more favorable towards prep they were less likely to anticipate prep related stigma than their unwilling counterparts and anticipated to have cai in the future the study provides new information regarding prep uptake within a framework of formal eligibility criteria which may be useful for other western countries facing similar situations our findings point to a high congruence between prep eligibility and hypothetical willingness to use prep most eligible msm in our study were also willing to take prep which is in line with demonstration studies showing that those coming forward for prep are highly likely to be at risk for hiv 2021 23 24 25 39 however about 40 of participants showed incongruence between formal riskcriteria and their hypothetical willingness a recent australian prospective cohort study showed that 698 of gay and bisexual men who met the eligibility criteria had not yet commenced prep 40 this is higher compared to our study where only 16 of those eligible were unwilling on the contrary more than half of ineligible participants were also hypothetically willing to use prep in the future the two incongruent groups are important for hiv prevention and sexual health promotion since they require different approaches in sexual health promotion the first group albeit small in numbers are the ones eligible yet unwilling to take it this group may be concerning given that eligibility criteria are based on factors known to be associated with high risk for hiv acquisition the high proportion of participants in this group who had sex while using psychoactive drugs in the six months prior to the survey and the high proportion of participants having had cai with at least two male partners in the last 12 months demonstrates that they are indeed at risk for hiv our data suggest that they might be unwilling to take prep due to an inadequate risk perception and a less positive attitude towards prep only 10 of this group perceived themselves to be at high risk for hiv acquisition this is in line with the lower proportion of participants that have recently tested for hiv in this group when compared with willing eligible participants overall this may reflect misconceptions about the levels of risk required to advise prep use 40 eligible and unwilling msm were also more likely to indicate that prep users will receive negative comments potentially indicating an anticipated stigmatization of prep such anticipated social discrediting of prep may function as barrier in accessing prep 41 42 43 44 45 the results suggest that this group and their sexpartners are at substantial risk for hiv acquisition but are less likely to selfidentify as being at risk and are less interested in measures such as prep future interventions should take into account that eligible unwilling msm are harder to reach because they may be less likely to come forward themselves for hiv testing counselling and other sexual health promotion services resulting in less opportunities for prep promotion 46 47 48 modifying hiv risk perceptions through educational interventions could be a promising strategy to promote prep among those who could benefit from it 49 also when improving knowledge about prep addressing potential negative associations is warranted factors related to attitudinal constructs are potentially modifiable as are stigmatizing attitudes and this should be considered in future interventions the second incongruent group concerns msm ineligible for prep who were willing to take it as the reported willingness is hypothetical this finding does not necessarily mean that this group will come forward for prep despite being ineligible however these results do suggest that we have to be aware that there will be potential prep use outside of the narrow margins of clinical criteria in australia it was found that consistent condom use had dropped on a community level to a similar extent that prep was taken up 50 the group we identified as ineligible but willing to take prep may be most prone for contributing to such a communitylevel risk compensation effect however a decreasing trend of condom use was already existing prior to the introduction of prep 5152 with parallel increases of stis 12 prep is recommended for those at highest risk of hiv infection 53 but little is known about the extent of msm starting with prep with the intention of using less condoms or engaging in other high risk sexual activities in our sample a majority was convinced that it is important to keep using condoms while taking prep which is a promising finding however we suggest further research is needed to explore to what extent prep remains to be perceived as an additional tool or becoming a condom substitute within the msm community to develop information strategies accordingly ineligible and willing participants were more likely to perceive themselves at higher risk for hiv and to have tested for hiv in the last six months when compared with those unwilling hence it is not surprising that they were also more likely to be aware of prep and to selfrate their prep knowledge as good the question remains whether this ineligible group is willing to take prep in the future should they be in need or whether they are actually would be willing to take prep despite being at low risk to feel better protected against hiv given their recent testing such contact with the health care system provides an opportunity for counseling and helping in deciding whether or not prep use would be appropriate in contrast to our findings it was recently observed that msm in england selfevaluated their risk of acquiring hiv appropriately which lead the authors to recommend prep for everyone perceiving themselves at risk resulting in broader eligibility criteria 54 the high contextuality and fluctuation of sexual behavior over time 55 justifies positioning prep as a positive sexual health promotion and wellness framing tool potentially avoiding preprelated stigma 56 in addition such branding and rollout would avoid the ethical dilemma arising when denying someone prep coming forward for this prevention tool because of currently insufficient risk behavior 57 the question should perhaps not be on what comes first reduced condom use and hence being or becoming eligible or the intention to use prep it would be unwise to deny such efficacious hiv prevention tool instead we argue that the challenge lies in promoting condom use concomitantly within a combination prevention approach based on our data we suggest that efforts need to be strengthened to promote prep as prevention method for msm who are eligible for prep simultaneously measures to endorse condoms for the prevention of stis among prep users as well as a general means for effective sexual health promotion among all msm as stipulated by existing guidelines 5859 is equally important limitations eligibility for prep should not be considered a static condition because sexuality may quickly change over time in accordance with individual behavior risky contexts and situations leading to seasons of risk 60 the concept of hypothetical willingness should be understood in this perspective however this study is the first to examine the proportion of msm being eligible for prep and their willingness in an online sample in belgium we were able to obtain a relatively large nationwide convenience sample of 1444 participants it may not be representative for msm in belgium and we cannot make inferences to the entire msm population the use of sexual networking applications for recruiting participants may have led to a selection bias ie participants with high levels of sexual activity seeking sex partners on the internet or with a particular interest in prep we kept the questionnaire intentionally short so that a maximum number of participants would complete the questionnaire although this did not allow us to obtain indepth insights on topics such as their intentions regarding future sexual behavior and condom use given the likelihood of multicollinearity of several independent variables the findings pertain to a set of covariates that are jointly related to the outcome of hypothetical willingness to use prep conclusions in spite of the above limitations we conclude that most msm in this study were hypothetically willing to take prep in the future in particular those who were eligible according to formal prep criteria recommendations to increase prep uptake among those eligible but unwilling to take it we recommend strategies that modify hiv risk and address potential misconceptions about prep we also recommend further research to explore to what extent condom use is being replaced by prep on a community level and how condoms can be promoted alongside prep for prep to work optimally on a population level its promotion should be embedded in a comprehensive combination prevention strategy tailoring information and prevention needs and including destigmatization of prep at the community level author contributions jb developed the data analysis plan conducted the formal data analysis and wrote the first and subsequent drafts of the paper tr was involved in the conceptualization of the study development of the questionnaire funding acquisition supervised the data analysis and was involved in the writing of the paper bv was involved in the conceptualization of the study and the writing of the paper ml was involved in the conceptualization of the study and the writing of the paper cn was involved in the conceptualization of the study development of the questionnaire and supervised the writing of the paper including reviewing and editing funding this research was funded by gilead sciences benelux funding year 2016

men who have sex with men msm are at high risk for acquiring hiv in belgium this study explores msms hypothetical willingness to use preexposure prophylaxis prep assesses it against formal prep eligibility criteria and identifies factors associated with incongruence between eligibility and willingness we used data from an online survey of n 1444 selfreported hivnegative msm participants were recruited through social media of msm organizations and dating apps univariate analysis described prep willingness and eligibility bivariate analyses examined how specific covariates sociodemographic knowledgerelated and attitudinal and behavioral factors were associated with eligibility and willingness about 44 were eligible for prep and about 70 were willing to use it those who were eligible were significantly more likely be willing to take prep p 0001 two incongruent groups emerged 16 of eligible participants were unwilling and 58 of ineligible participants were willing to use prep factors associated with this incongruence were sexual risk behavior hiv risk perception partner status prep knowledge and attitudinal factors because the two groups differ in terms of profiles it is important to tailor hiv prevention and sexual health promotion to their needs among those at risk but not willing to take prep misconceptions about prep and adequate risk perception should be addressed

introduction in the context of population ageing care stands alongside the other great challenges such as climate change that we must face at the global level and in our own lives many countries rely heavily on care provided by unpaid family members or friends yet amid increasing debates around balancing the work ethic with the care ethic there is currently something of an impasse concerning unpaid care and employment the need for care is rising and governments are keen to support the provision of unpaid care to meet this need at the same time partly to reduce the publicly funded costs of pensions governments are extending working lives and encouraging older workers to continue in employment however older people of working age are those who are most likely to provide unpaid care which is often incompatible with employment particularly when provided for long hours in this context helping carers to combine caring responsibilities with paid work is becoming a key policy objective in many countries in england over the last two decades there has been an emphasis in government policy on enabling people to combine unpaid care and employment 2008hmg 1999 the coalition governments carers strategy has four priority areas one of which is enabling those with caring responsibilities to fulfil their educational and employment potential the emphasis in policy relating to unpaid care and employment in england as in other countries has primarily been on flexible working as part of a worklife balance agenda in britain the work and families act 2006 gave employees who care for adults the right to request flexible working arrangements and from june 2014 the implementation of the children and families act 2014 extended this right to all employees however as well as an emphasis on flexible working there is now an emphasis on replacement care to support work and care in england the term replacement care was initially used in government policy around carers and employment in the 2008 carers strategy which included a commitment to fund replacement care for those who are participating in approved training in order to help carers to reenter the labour market in the coalition governments carers strategy there is a new emphasis on developing social care markets partly to meet carers needs for replacement care to enable them to continue to work the current emphasis on replacement care goes further than previous policy because it implies ongoing support for working carers rather than temporary support to help carers to reenter the labour market the care act 2014 stated that carers assessments must consider whether the carer wants to work and introduced a new duty on local authorities to provide support to meet carers needs explanatory notes make it clear that a carers need for support may be met by providing support directly to the caredfor person for example by providing replacement care the notes also make it clear that replacement care refers to paid support and services for the caredfor person stating that carers will not be charged for care and support provided to the adult needing care the emphasis on replacement care in government policy is an important development because it represents a marked change from previous government policies on carers in england previous uk governments had rejected any notion of replacing or substituting unpaid care with paid services in terms of the conceptualisation of carers in the service system an emphasis on replacement care is consistent with a superseded carer model as such it involves recognition of the dual focus of caring acknowledging that caring takes place in a relationship and that policy should therefore focus on both the disabled or older person and the carer recognition of the need to provide better services for disabled and older people as a means of supporting or replacing carers is consistent with key approaches to policy around disability and caring including disability rights and feminist approaches however it is important to note that the coalition government sees replacement care as taking the form of services that would be provided through social care markets and is therefore consistent with a neoliberal approach to care provision a joint report by the government and employers emphasises ways in which people can be supported to combine work and care and the market for care and support services can be stimulated to grow to encompass their needs a position recently restated in the governments carers strategy national action plan despite the new emphasis on replacement care in england little is known about its effectiveness as a means of supporting carers in employment in this country lilly and colleagues in their systematic review of the international literature on unpaid care and employment identify the relationship between the use of paid homecare services and unpaid caregiver employment as needing further international analysis they could identify only four papers on this issue in the period covered by their review all from the united states two further studies one carried out in the united states and one crossnationally have also been reported recently the existing international literature on the effectiveness of paid services as a means of supporting unpaid carers in employment is inconclusive two of the studies from the united states show a positive relationship between the use of paid homecare services by the carerecipient and carers employment rates moreover a study carried out for the organisation for economic cooperation and development found that countries with more extensive formal homecare provision such as the scandinavian countries tend to have higher employment rates for midlife women than countries with limited or average formal homecare provision such as the uk however two of the studies from the united states show no relationship between the use of paid services and carers labour force participation rates further one of the studies from the united states suggests that there is a negative relationship between the use of formal services by the carerecipient and carers employment rates the study shows that carers of people who use formal services are more likely to reduce their labour market hours than carers of people who do not receive services suggesting that higher levels of both types of care may reflect the carerecipients increasing care needs not only is the existing international literature on the effectiveness of paid services as a means of supporting working carers inconclusive but it is also the case that none of the studies relates specifically to england where a policy advocating replacement care to enable carers to work is being proposed research carried out in other countries is not necessarily applicable to england because of differences in labour market conditions community care arrangements and financing mechanisms for health and social care however there appear to have been no previous peerreviewed studies on the effectiveness of services to support carers in employment in england there are studies showing that access to services by working carers is low and that employed carers would like more service support but this is not in itself evidence that the provision of such support would be effective in supporting carers employment there are also smallsample qualitative studies providing examples of paid services that enable carers to work but there have been no previous studies of the effectiveness of services in supporting working carers using largescale survey data there is therefore a gap in the evidence relating to the effectiveness of paid services as a means of supporting working carers in england the aim of the present paper is to contribute towards filling this gap by utilising largescale survey data to examine how far paid care services for the caredfor person are effective in supporting carers employment in england and if so which services are most effective the paper also aims to explore the implications of the results for the current policy emphasis in england on replacement care for working carers data and methods in order to examine the effectiveness of paid services in supporting working carers the analysis examines the association between the use of paid social care services by the caredfor person and the employment rates of unpaid carers controlling for covariates an association between use of services by the caredfor person and carers employment may not in itself indicate a causal connection however a positive association between paid services for the caredfor person and carers employment rates can be regarded as a necessary condition if services for the caredfor person are effective in supporting carers employment if the analysis finds no association between use of services by the caredfor person and carers employment it is unlikely that services would be effective in supporting carers employment the analysis uses the 200910 personal social services survey of adult carers in england 2010a the survey includes questions on both the employment of the carer and the services received by the caredfor person moreover the survey has a very large sample size comprising approximately 35000 carers excluding the tenyearly census for england and wales the 200910 pss sace was at the time it was collected the largest survey of carers ever carried out in england the 200910 pss sace was administered through local authorities and was designed for adult carers in contact either directly or via the person they cared for with social services the 200910 pss sace was the first national survey of carers in contact with councils from 2012 the pss sace is being conducted biennially and is compulsory for cassrs but in 200910 participation in the survey was voluntary and 90 out of 152 cassrs participated although not all councils participated the health and social care information centre regards the survey as representative of cassrs in england in the survey carers are defined as people who look after a family member partner or friend in need of support or services because of their age physical or learning disability or illness including mental illness questions about unpaid care provision relate to the main caredfor person 1 the eligible population in the pss sace is defined as carers aged eighteen and over caring for an adult aged eighteen and over where the carer has been assessed or reviewed by social services during the previous year and in some cassrs carers identified from the records of service users an eligible population of 175600 carers was identified and 87800 were randomly selected and sent a postal questionnaire a total of 35165 carers then responded giving a response rate of approximately 40 per cent carers in the survey are more likely to care for longer hours than carers nationally however as explained below it is with carers who provide long hours of care that this paper is concerned as already indicated the survey asks the carer about both the services received by the person they look after and their own employment the question on service receipt asks whether the carerecipient has used a range of services in the last twelve months including care home personal assistant home carehome help day centreday activities lunch club and mealsonwheels the analysis of services in this paper combines day centre day activities and lunch club into one service home carehome help refers primarily to help with personal care the service described as care home refers to either shortterm breaks or permanent residence in a care home but for reasons explained later it seems likely that care home use in the survey primarily refers to shortterm breaks personal assistants are people employed by individuals with care needs who are often in receipt of personal budgets mealsonwheels are meals delivered to individuals at home services are classified according to whether they are used on their own or in combination with other services the employment variable utilised here measures the labour force participation rate that is whether or not the respondent is employed including selfemployed although the distinction between fulltime and parttime employment is also important the focus of much of the international literature on caring and employment is on labour force participation per se and this is clearly of importance in its own right the analysis focuses on working age carers aged between eighteen and state pension age which at the time the data were collected was sixty for women and sixtyfive for men because relationships around unpaid care and employment vary greatly by gender it is customary to examine men and women separately wherever possible and this practice is observed here the analysis focuses on intense carers providing unpaid care for ten or more hours a week because previous research suggests that it is at this threshold that unpaid care has a negative effect on employment in england and carers employment is at risk the analysis begins by describing the characteristics of unpaid carers and the receipt of paid services by the people cared for in the pss sace the analysis then looks at bivariate associations in order to identify patterns that appear to be occurring in the data before adjustment for relevant covariates the bivariate analysis initially compares the employment rates of carers where the carerecipient does and does not use paid services the bivariate analysis then looks at the employment rates of women and men carers by a range of variables that may affect provision of unpaid care and employment multivariate logistic regression analysis is then undertaken with the dependent variables being whether or not the carer is in employment in all the analyses presented here a level of 005 is used as the criterion to determine significance all analyses are performed using the stata 121 software package characteristics of unpaid carers and service receipt by caredfor people in pss sace of the approximately 35000 carers in the 200910 pss sace approximately 10500 are of working age providing intense care for ten or more hours a week not all were asked questions on service receipt andor employment because councils could choose whether to include these questions the sample size of intense carers under state pension age answering questions on both services and employment is 6304 respondents the characteristics of these intense working age carers are similar to the characteristics of all intense working age carers in the sample and for both the overall employment rates are between 46 and 47 per cent for women and 38 per cent for men the higher employment rate for women carers in the sample probably reflects the higher percentage of women carers who work parttime since parttime work is more compatible than fulltime work with unpaid care provision table 2 shows the distribution of unpaid carers in the survey according to the use of services by the person they care for in the table carers who look after someone who receives at least one paid service are distinguished from those who look after someone who receives no services the types of services received are further disaggregated into a number of mutually exclusive categories use of one service only use of combinations of two services only and use of combinations of three services only the most frequently occurring combinations of services are included 2 with the remaining combinations categorised as other combinations of paid services services are categorised in this way in order to examine the independent effects of each individual service as well as the main combinations of services table 2 shows that although the pss sace is a survey of carers in contact with local authorities not everyone looked after by carers receives paid services of the 4106 women carers in the sample 29 per cent are looking after someone who does not receive any services while this is true of 675 of the 2198 men among carers looking after someone who receives a paid service the majority look after someone receiving only one service the most frequently received being either home care or day care with fewer people receiving help from a personal assistant care home or mealsonwheels of those caring for someone who receives more than one service most receive two services some services are more likely to be received in combination with another service than on their own in particular care home and mealsonwheels are both more likely to be received in combination with home care than on their own use of a care home is particularly likely to be combined with other services including day care as well as home care and this suggests that the service users are not permanently resident in care homes where all these services would be provided therefore use of a care home in the survey is likely to refer primarily to shortterm breaks employment rates of unpaid carers by caredfor peoples use of paid services the analysis now explores whether the employment rates of unpaid carers vary according to the receipt of paid services by the caredfor person table 3 shows the employment rates of carers who provide unpaid care for ten or more hours a week employment rates are shown both where the carerecipient receives paid services and where they do not the table shows that in initial bivariate analysis women and men providing intense unpaid care seem more likely to be in employment if the carerecipient receives at least one paid service than if the carerecipient does not receive any services 3 the employment rate of women providing intense unpaid care for someone who does not receive a paid service is 373 per cent but is 503 per cent where the caredfor person receives at least one service the equivalent figures for men are 289 per cent and 424 per cent respectively moreover the employment rates of women and men caring for someone who receives any individual service or combination of services are always higher than the employment rates of those whose carerecipient does not receive any services employment rates of carers by characteristics of carers caredfor people and caring as already indicated as well as the receipt of paid services by the caredfor person the employment rates of unpaid carers may be associated with other variables these include the carers age health ethnicity and region of residence the health of the carerecipient whether or not he or she lives with the carer and the hours of unpaid care provided by the carer previous british studies suggest that the employment rates of carers are likely to be higher among people aged in their thirties and forties who are in good health who live in the south east or east of england who care for someone with relatively low disability or who does not coreside with them or who provide fewer hours of care ethnicity is also important as there is variation in the extent to which people from different ethnic backgrounds provide intense care in the analysis presented here the age variable distinguishes those aged eighteen to thirtyfour thirtyfive to fortynine and fifty to state pension age carer health is measured in terms of presence or absence of illness or disability the ethnicity variable distinguishes those with and without a black and minority ethnic background region of residence distinguishes nine english regions the indicator for health of the care recipients distinguishes those with and without a condition that affects them mentally given evidence that caring for someone who is affected mentally is more demanding for carers the locus of care variable distinguishes caredfor people who do and do not live with the carer the intensity of care variable distinguishes care provided for ten to nineteen twenty to thirtyfour thirtyfive to fortynine fifty to ninetynine and a hundred or more hours per week table 4 shows the employment status of women and men of working age who provide unpaid care for ten or more hours a week in the 200910 pss sace by a range of characteristics most of the results are as expected from the literature employment rates of carers appear to be higher if they are in their thirties and forties rather than if they are nearing retirement although women carers in the younger agegroups also have comparatively low employment rates employment rates of carers also seem higher where carers do not have an illness or disability where the carerecipient is not coresident with the carer and where fewer hours of unpaid care are provided the employment rates of women carers vary significantly by region with the south east appearing to have the highest rates although employment rates of men providing care are not significantly different by region in addition the survey suggests that women carers from black and minority ethnic backgrounds seem less likely to be in employment than those who are not from bme backgrounds although the reverse seems true for men in the bivariate analysis shown in table 4 there effectiveness of paid services in supporting working carers 579 is one relationship that seems unexpected from the literature the employment rates of carers do not seem to vary significantly according to the health of the carerecipient measured here by whether the person cared for has a mental health problem relationship between employment rates of unpaid carers and carerecipients use of paid services controlling for covariates the associations between the employment rates of unpaid carers and carerecipients use of services are tested further using multivariate analysis controlling for a range of covariates the dependent variable is the employment status of women or men providing unpaid care for ten or more hours a week four models are reported two each for women and men carers the first two models include receipt of at least one service while the second two models include receipt of individually identified services and combinations of services each model initially includes carer age health ethnicity and region of residence whether or not the carer lives with the carerecipient whether or not the carerecipient has a mental health problem and the intensity of caring all of these latter variables are initially included irrespective of whether they are significant in bivariate analysis since their associations with employment status may vary when other factors are taken into account the odds ratio for each variable is estimated along with the significance level and 95 per cent confidence intervals for each model we compared the fit of the full model with all covariates included and the final model including only significant covariates in each case the final model has a better fit than the full model and is reported here table 5 shows the results of the logistic regression analysis to determine the factors associated with the employment status of women providing intense unpaid care including the use of at least one paid service by the caredfor person in the model controlling for covariates there is a significant association between the employment rate of women carers and the use of at least one paid service by the caredfor person women who provide unpaid care for ten or more hours a week have significantly higher odds of being in employment if the person they care for receives at least one paid service compared with if they receive no services controlling for covariates 4 other factors significantly associated with being in employment for women carers are their age health region of residence hours of care provided and coresidence with the carerecipient midlife women and those in their fifties are more likely to be in employment than younger women although this effect tends to be less marked for women nearing retirement women are also significantly more likely to be in employment if they do not themselves have an illnessdisability if they live in the south east of england and if they care for relatively few hours a week in addition a somewhat surprising result is that coresident carers are more likely to be in employment than extraresident carers factors that are not associated with women carers employment status are the ethnicity of the carer and whether the caredfor person has a mental health problem table 6 shows the results of the multivariate analysis to determine the factors associated with the employment status of men providing intense unpaid care including the use of at least one paid service by the caredfor person there is a significant association between the employment rate of men providing care and the use by the caredfor person of at least one service men who provide unpaid effectiveness of paid services in supporting working carers 581 care for ten or more hours a week have significantly higher odds of being in employment if the person they care for receives at least one paid service compared with if they receive no services controlling for covariates other factors significantly associated with being in employment for men who provide unpaid care are their health and hours of care provided men who do not have an illnessdisability and who care for relatively few hours are significantly more likely to be in employment factors that are not associated with the employment status of men providing care are their age and ethnicity the region of residence of the carer whether the caredfor person has a mental health problem and whether the carerecipient is coresident with the carer relationship between employment rates of unpaid carers and carerecipients use of individual services and combinations of services controlling for covariates multivariate analysis is used to look at the associations between the employment rates of unpaid carers and the carerecipients use of individual services and combinations of services as before the dependent variable is the employment rate of women or men providing unpaid care for ten or more hours a week tables 7 and8 show respectively the results for women and men carers the models control for other factors including the characteristics of the carer the caredfor person and the nature of the care provided with the patterns of significance of these other factors being similar to those in the previous models tables 7 and8 show that carerecipients use of home care only and use of a personal assistant only are significantly associated with the employment rates of both women and men carers women and men who are providing unpaid care for ten or more hours a week have significantly higher odds of being in employment if the person they care for receives home care compared with if they receive no services similarly women and men who are providing intense unpaid care have significantly higher odds of being in employment if the person they care for receives help from a personal assistant compared with if they receive no services carerecipients use of day care only and mealsonwheels only are also significantly associated with women carers employment carerecipients use of a care home only is not significantly associated with the employment rates of either women or men carers but use of this service is significantly associated with carers employment when combined with other services carerecipients use of a care home when combined with home care is significantly associated with the employment of men carers while carerecipients use of a care home is significantly associated with women carers employment when combined with day care or both home care and day care in addition although carerecipients use of neither day care nor mealsonwheels on their own are significantly associated with the employment rates of men carers each service is significantly associated with the employment of men providing care when combined with home care discussion and conclusions this study suggests that there is a positive association between the employment rates of unpaid carers in england and receipt of paid services by the person they care for the analysis has focused on carers whose employment is at risk which consistent with previous research is defined here as those providing care for ten or more hours a week using largescale survey data the 200910 pss sace the study finds that where the caredfor person receives at least one paid service women and men providing unpaid care for ten or more hours a week are more likely to be in employment than if the caredfor person does not receive any services a positive association between carers employment and receipt of paid services is a necessary condition if services for the caredfor person are effective in supporting carers employment therefore our results give some support to the hypothesis that services for the caredfor person are effective in supporting carers employment carers employment in england is associated with receipt by the caredfor person of some services more than others the study finds that use by the carerecipient of home care only or help from a personal assistant only are both positively associated with the employment rates of women and men carers while carerecipients use of day care and mealsonwheels are associated with women carers employment gender differences in the association between paid services and carers employment may be associated with the greater likelihood of women carers working parttime since a service like day care which tends not to be utilised by the carerecipient every day may be more helpful to parttime than fulltime workers in addition the study finds that use by the carerecipient of a care home only is not significantly associated with the employment rates of carers although this service is associated with carers employment when combined with other services one reason for the difference in the association between carers employment and carerecipients use of this particular service may again be the frequency with which the service is provided the study has suggested that use of a care home is likely to refer primarily to shortterm breaks a service that tends to be provided for a limited number of weeks a year whereas to facilitate employment services that are provided regularly during the working week are likely to be needed the results show that a number of factors in addition to the caredfor persons receipt of paid services are positively associated with carers employment including good health on the part of carers and providing fewer hours of care as well as for women carers being in midlife or older and living in the south east these results are broadly consistent with other studies in britain one result that is somewhat surprising is the finding that controlling for other variables women providing coresident care are more likely to be in employment than those providing care to someone in another household whereas the existing literature suggests that the employment rates of carers are higher when care is provided to someone who does not coreside with them closer examination of our results shows that coresident women carers are more likely to be in employment than those providing extraresident care when they care for thirtyfive to fortynine hours a week this finding may be associated with the effect of the receipt of carers allowance since this benefit is only paid to carers providing care for at least thirtyfive hours a week and receipt of carers allowance can limit carers employment opportunities while interactions with other benefits could mean this differentially affects extraresident carers this could not however be explored further because information on carers allowance was not included in the dataset used here other factors such as the health of the carerecipient have also been shown elsewhere to affect carers employment but were not significant in the multivariate analysis reported here this may be because the variable used here to indicate the carerecipients health did not sufficiently distinguish between those with severe and relatively minor problems and this represents a limitation of the analysis however the key implication of our multivariate analysis is that the employment status of women and men providing long hours of unpaid care is likely to be associated not just with factors like their health and hours of care provision but also with the use of paid services by the person they care for the results presented here have important implications for social policy the findings support the policies of recent governments in england of emphasising replacement care as a means of supporting unpaid carers employment this is because the results show that paid services for the caredfor person are associated with higher employment rates among unpaid carers a key policy implication is therefore that if a policy objective is to support people to combine unpaid care and employment then there needs to be greater access to paid services for disabled and older people who are looked after by unpaid carers more widely our findings support disability rights and feminist approaches to policy which have argued for better services for disabled and older people as a means of supporting carers and of bringing together the interests of both carers and the people they care for however our results also raise two important issues around recent government policies emphasising replacement care in england first the evidence raises questions about the use of the term replacement care there is no evidence from this study that unpaid carers are replaced by paid services for the person they care for the unpaid carer is still providing care even when paid services are provided to the person they look after this suggests that paid services for the carerecipients are better described as complementing or supplementing the care provided by unpaid carers use of this latter terminology would be more consistent with the international literature on substitution between formal and informal care which suggests that paid domiciliary services provided to disabled and older people living in their own homes do not tend to replace the care provided by unpaid carers 5 what this suggests is that a new term is needed for replacement care in the meantime it is advisable to use the term in inverted commas as in this paper the second issue around a policy of replacement care as currently described in english government policy documents relates to the emphasis on the market to meet the needs of unpaid carers and the people they look after the evidence from this study relates to unpaid care for adults for whom most unpaid care in england is provided with regard to care for adults the costs of replacement care are likely to fall to the carerecipient typically a disabled or older person who may lack the resources to purchase care on the market it is therefore likely that more publicly funded replacement care is also needed it is not clear that government policy would be so keen to advocate replacement care if this was publicly funded as the feminist literature on unpaid care policy has long recognised the major disadvantage of increasing publicly funded services to disabled and older people with carers is the cost yet public investment in services could lead to savings in public expenditure it has been estimated that the public expenditure costs of carers leaving employment in england are more than a billion pounds a year based on the costs of carers allowance and lost tax revenues on forgone incomes therefore greater public investment in replacement care to support carers in employment could represent good value for money further research examining the policy of replacement care is now needed first there is a need for evidence around the costs of providing publicly funded replacement care and whether these would be offset by public expenditure savings in other words there is a need for evidence not just about the effectiveness of replacement care as a means of supporting working carers but about its costeffectiveness second this paper has used crosssectional data the 200910 pss sace to examine the association between paid services for the carerecipient and carers employment but in order to examine causation longitudinal analysis would be preferable in particular it has not been possible to show conclusively here whether it is services for the caredfor person that enable carers to remain in employment or whether employed carers are better able to purchase services for the carerecipient the international evidence suggests that it is more often the carerecipient rather than the carer who makes payments for formal care suggesting that it is services that enable carers to work but longitudinal data would help to establish the direction of causal influence in england third there is a need for more informative data on the health of the carerecipient the dataset used here did not contain detailed information on the health of the carerecipient and specifically did not allow for those with severe problems to be distinguished from those with relatively minor problems in addition the data used here did not allow for an examination of the potential impact of new technology on carers employment many of these issues are now being pursued by the authors in further research on replacement care as a means of supporting working carers nevertheless what this study has shown is that there is already some evidence to support a policy of replacement care and that this type of policy may be central to resolving the current impasse around unpaid care and employment notes 1 the main caredfor person is the person that the carer spends most time helping if carers spend an equal time caring for two or more people they are asked to answer in relation to the person who lives with them if carers live with two or more people that they spend an equal amount of time caring for they are asked to choose one person as the main person they care for 2 combinations of two paid services are included if the underlying sample size of carers is at least thirty the two most frequently used combinations of three paid services are included the analysis includes each service used on its own but where sample numbers are small as in the case of mealsonwheels figures in tables are shown in square parentheses published online by cambridge university press 588 linda pickard derek king nicola brimblecombe and martin knapp 3 bivariate tabulations do not constitute a platform for identifying associations results adjusted for covariates are reported later in the paper 4 this can be approximately interpreted to mean that controlling for other factors women carers have 57 per cent higher odds of being in employment if the person they care for receives at least one paid service compared with if they receive no services 5 where substitution between formal and informal care does take place the evidence suggests that it occurs when the disabled or older person is in permanent residential care rather than in their own home

this paper explores the effectiveness of paid services in supporting unpaid carers employment in england there is currently a new emphasis in england on replacement care or paid services for the caredfor person as a means of supporting working carers the international evidence on the effectiveness of paid services as a means of supporting carers employment is inconclusive and does not relate specifically to england the study reported here explores this issue using the 200910 personal social services survey of adult carers in england the study finds a positive association between carers employment and receipt of paid services by the caredfor person controlling for covariates it therefore gives support to the hypothesis that services for the caredfor person are effective in supporting carers employment use of home care and a personal assistant are associated on their own with the employment of both men and women carers while use of day care and mealsonwheels are associated specifically with womens employment use of shortterm breaks are associated with carers employment when combined with other services the paper supports the emphasis in english social policy on paid services as a means of supporting working carers but questions the use of the term replacement care and the emphasis on the market

introduction a ccording to the who 1 obesity is defined as an abnormal excess in body fat which represents a health risk it is a major risk factor for many noncommunicable diseases 15 which incur high health costs 6 and increased mortality it is estimated that in 2016 13 of adults worldwide suffered from obesity 1 many epidemiological studies show that the prevalence of obesity has clearly increased in recent decades 7 8 9 10 11 12 13 14 15 16 17 18 19 since 1975 the rate has nearly tripled globally 1 trend prognoses indicate that obesity will also further increase in the future 2021 however obesity is largely preventable 1 first of all however the identification of major risk groups is necessary allowing specific support for target groups at the individual and societal levels for this reason it is necessary to investigate this serious public health problem within the wider framework of the general population longitudinal data on rates of obese subjects collected over several decades allow a precise assessment of trends in obesity 22 the authors found only a few current longterm studies for obesity in european countries which were extensive enough to provide reliable estimates to be made for the prevalence of obesity in subgroups of adults 822 in austria the latest trend analysis for obesity in the general adult population was investigated for the time span of 197307 during that time the prevalence clearly increased and higher rates were consistently observed among more women than men the ageadjusted prevalence of obesity was 145 for the whole austrian population in 2007 22 in 2014 the most recent representative health survey was conducted in austria which allows researchers to obtain information on the further development of obesity on the national level therefore the aim of this study was to analyse the most current obesity trends for austrian adults according to their sex age and educational status studies reported that the social gradient of subjects should be considered when investigating obesity 1819 22 23 24 socioeconomic health inequalities should be addressed from a gender perspective since the effects of socioeconomic status differ between women and men 24 another objective of our study was to present the magnitude of inequality related to obesity among educational groups for women and men during the study period for each survey a random sample was drawn from the national population register for the sake of representation the sample was stratified by the 32 administrative districts in austria microcensus data and data from athis 2007 were collected in standardized facetoface interviews with persons aged 15 years or older interviews were held in private homes or longterm care facilities by trained interviewers in 2014 computerassisted telephone interviews were conducted with the participants and this data was combined with data collected using individual questionnaires the data were weighted using age sex and regionspecific weights to ensure the representativeness of the sample 25 the data analysis was limited to data for adults aged 20 years since the athiss concerned only entire age bands therefore data from subjects younger than 20 years of age were excluded in all surveys in cases of missing data regarding sex and body mass index data were excluded cases with implausible bmi values were also removed from the database the proportion of individuals included in the analysis was 647 methods data source and sampling variables in all six surveys demographic socioeconomic and health data were collected via an interviewer questionnaire individuals selfreported their body height and body weight to identify obesity the bmi was calculated participants with a bmi 30 were categorized as obese 1 four age groups were formed according to the who 26 age group codelist 2034 years 3554 years 5574 years and 75 years the age groups were chosen so that the distribution of participants within the groups is similar educational status was measured as the highest educational level reached and then categorized as primary school or vocational school secondary school with general qualification for university entrance university or college of higher education in germanspeaking countries this is a frequently occurring categorization of the educational level 342227 the international standard classification of education 28 would allow a more precise categorization of educational groups and better international comparability however such data are lacking that comparability for educational status over the entire study period would not have been possible analyses for educational status are presented only for the period of 198314 since the educational level was not assessed in the first survey correcting for selfreporting bias based on results of a preliminary study in which the validity of selfreported body weight and height was investigated data correction factors for bmi were applied 26 correction factors for bmi were only applied to data for individuals 45 years and older because deviations between selfreported and measured data on bmi only increased in those subjects data analysis all statistical analyses were conducted using ibm õ spss õ statistics 250 selected and comparable variables were entered into a common database the crude and agestandardized prevalence values were calculated using the who european standard population for direct standardization binary logistic regression analyses were conducted for the whole study period using the dichotomous variable obesity as a dependent variable and the survey period as a predictor age was integrated as a correction variable with the youngest age group forming a reference category to quantify trends in the prevalence of obesity the percentages of absolute change were assessed the aetiologic fraction a ratio measure was calculated and represented the subgroup with the greatest relative risk for obesity the af denotes the percentage portion of the disease risk to calculate the ac and af the prevalence values for the first and last years were used as estimated using binary logistic regression models the ac was defined as plpf and the af as pl 29 the exact formulas are described as follows ac ¼ 1 1 þ exp½àðb0 þ b ã t þ à 1ð1 þ exp½àb0þ af ¼ ðrr à 1þrr rr ¼ relative risk 1 þ exp½àðb0þ 1 þ exp½àðb0 þ b ã t þ b ¼ regression coefficient b0 ¼ intercept t ¼ time period in years the magnitude of inequalities for obesity between educational groups was measured by calculating the relative index of inequality 30 the rii describes the percentage of the predicted rate for the lowest level in the hierarchy with relation to the predicted rate for the highest level in the hierarchy the variable educational level was transformed into the variable fractional rank when ranking the sample by educational level in doing so the population at each educational level was allocated a modified rigid score which was based on the midpoint of the range in the cumulative spread of the population a binary logistic regression with the dichotomous variable obesity and the predictor fractional rank was performed to obtain the exponentiation of the regression coefficient representing the rii à1 ã100 statistical tests were twosided and a p 005 was considered as statistically significant pearsons 2 test was carried out to analyse the statistical significance of the data during the survey period ethical concerns participation was voluntary verbal informed consent was obtained from all subjects witnessed and formally recorded for every survey this study was approved by the ethics committee of the medical university of graz results in 2014 the crude prevalence for obesity was 168 and the agestandardized prevalence for obesity was 158 in the general adult population stratified by sex the prevalence was only higher for men than for women in the latest survey subjects aged 5574 years old showed the highest rates during the period investigated with more men being affected the lowest prevalence of obese subjects was observed among the youngest age group with higher prevalence seen for male adults in the latest survey regarding the educational level the prevalence of obesity was highest among subjects with the lowest educational level the differences in the rates of obesity between individuals middle and high levels of education were low with somewhat lower values seen for participants with a high educational level the rii consistently showed higher values for women than for men for men the rii showed a rising trend during the study period with similar values obtained in the last two surveys in figure 1 the crude and agestandardized prevalence rates observed during the study period are illustrated separately for women and men the lowest obesity proportion was estimated in 1983 up until 1991 the prevalence of obesity strongly increased from 2007 to 14 the values stabilized for women while the prevalence for obesity continued to rise for men calculated trends for the prevalence of obesity are presented for the period of 198314 due to the increase in the obesity prevalence in 1983 in the whole population an ac of 20 for obesity prevalence between 1983 and 14 was found the ac for the prevalence of obesity was higher among men than women a larger af means a greater dynamic which was observed for men the strongest increase in obesity prevalence was noted among the oldest women men between 55 and 74 years and those with a low educational level results for the ac among women with a high educational level showed the lowest increase the af was highest among the youngest participants who were women with a middle educational level and men with a low educational level to identify interactions between age and educational level two educational groups were grouped into four age groups to gain a more precise outcome subjects with a middle educational level were allocated to the group with a high educational level because the obesity prevalence between individuals with middle and high levels of education was similar during the study period and to obtain comparably large groups men aged 75 years and older with a high or middle educational status had the highest ac among the women the oldest age group with a low level of education had the highest increase in the prevalence of obesity the af was highest for men in the oldest age group with a high or middle educational level discussion obesity decreased less strongly between 1973 and 1983 among the different subgroups in austria but an increase was observed for both sexes between 1983 and 2007 and a peak occurred between 1991 and 2007 from 2007 to 2014 the prevalence did not significantly change for women but increased for men in 2014 we observed the highest prevalence of obesity in older age groups with the highest rate seen in men aged 5574 years subjects with a low educational level also showed the highest obesity prevalence with somewhat higher rates seen for men with low levels of education than for women a high ac in obesity prevalence was found for the oldest women for men aged 5574 years and for subjects with a low level of education only a small increase in obesity prevalence was found among highly educated women the most prominent ac in the prevalence of obesity between 1983 and 2014 was observed for men in the oldest the analysis refers to the period from 1983 to 2014 a b is the regression coefficient b ac is the absolute change in obesity prevalence during the study period computed from logistic regression c af is the aetiologic fractions of obesity prevalence during the study period computed from logistic regression age group with high or middle levels of education while the lowest ac was found for the youngest women with a high educational level the youngest and oldest men with highmiddle educational status showed the greatest afs the magnitude of educational inequalities related to obesity was higher among women than men comparison with the literature among austrian adults the agestandardized prevalence for obesity was 158 in 2014 compared with the results of european studies carried out in germany 13 switzerland 11 norway 14 and poland 16 our estimated prevalence of obesity is low populationbased studies for european countries 23 or worldwide 1217 also reported higher rates for obesity for most developed countries it was observed that the percentages varied widely from country to country with highest prevalence seen in northeastern european countries and lowest prevalence in western and southern european countries and especially mediterranean countries 1523 extremely high obesity prevalence has been reported from the usa 181931 in 2016 the prevalence of obesity was 399 for us adults 31 this result is more than twice as high as that obtained in our study a strong increase in the prevalence of obesity has been reported from 1990 in other countries on as in our study 781417 in the usa a similarly striking increase in obesity was cited 10 years earlier 3132 high obesity rates are mainly attributed to a reduction in physical activity and to the increased production of lowcost and energydense foods 1 these factors seem to be the universal consequences of industrial development and improved living conditions 33 the strong increase in obesity prevalence observed in austria might be due to the higher living standard achieved in the early 1990s and on 22 it is interesting that for the first time the prevalence for obesity is higher among men than women in austria studies have shown that women usually have higher obesity rates 12 13 14 18 more recent studies and also a future prognosis however cite higher prevalence for men than for women in europe 162023 in england it is estimated that about 50 of women and 60 of men will be obese by 2050 20 poland shows similar trends as austria in 2005 the prevalence for obesity was higher in women in poland while in 2014 the rates were higher for men the proportions of obesity in men have also been growing more rapidly in the last decades 2234 the european male aging study concluded that weight and bmi are especially rising among men in countries that are undergoing socioeconomic and political transitions 15 it seems that public health strategies in the past were better received by women than by men further reasons for these trends could be that women paid more attention to maintaining a healthy diet and exercised more because social norms have increased womens awareness of their appearance 22 we assume that this is especially true for highly educated women in austria and thus they still had the lowest obesity prevalence and showed the lowest increase in obesity prevalence this may be the reason that the prevalence of obesity remained stable among women during recent surveys but increased among men in austria between 2007 and 14 regarding age we observed the highest obesity prevalence among subjects aged 5574 years old this outcome is in accordance with that of similar studies 10161923 gallus et al 23 reported that european adults aged 65 years and older showed the highest obesity prevalence in our study men aged 5574 years old showed the highest prevalence among all age groups for obesity and a high ac for obesity this differed from former trend estimations for obesity in austria 22 it was also noticeable that women aged 75 years and older suffered more often from obesity than men in the same age group and that the oldest women showed a higher increase in obesity prevalence during the study period compared with men in the same age group a higher number of obese older subjects represent a major problem for austria because obesity among older subjects is associated with higher care needs and correspondingly more resources are needed in the health care practice 35 our outcomes confirm that adults with the highest educational level have the lowest prevalence of obesity in highincome countries 23 36 37 38 the increase in the prevalence of obesity was also lowest among highly educated subjects compared with those with middle or low educational level as seen in other studies the inverse relationship between the educational level and obesity was observed to be more pronounced for women 2336 the educationbased rii was still higher for women than for men which is in accordance with results cited in former publications 2436 devaux and sassi 36 investigated social inequality and obesity in different countries the greatest educational inequality related to obesity was found in france sweden austria spain and italy in our study the educational inequality related to obesity tended to increase in men although this has stabilized since 2007 the increase in the prevalence of obesity among austrian adults has led to an increase in relative inequalities in men however in general the results of the rii were quite variable in our study this can be attributed to the fact that the proportion of subjects with a high educational level was low especially among the women the oldest men with high and middle educational levels showed the highest increase in the prevalence of obesity compared with all other investigated subgroups this outcome was unexpected and not in accordance with the results of the former trend analyses for obesity in austria 22 therefore it should be investigated more thoroughly in the future men aged 5574 years old with a low educational level also showed a high ac reasons for this result could be that retired men with a low educational level had professions in the past in which they had to work hard and were more physically active during their retirement these people gained weight because their level of physical activity decreased while the energy flow remained the same this result more strongly affects men in austria limitations one limitation of the study was that no measured data were available however we tried to compensate for this by correcting the selfreported bmi 39 another limitation was that the socioeconomic status was only represented by the educational level as other variables that could be used to measure socioeconomic status eg income were not available for most surveys investigating different income groups could have resulted in more stable values for the rii furthermore data for educational status were only available from 1983 and onwards it would have also been interesting to investigate other sociodemographic determinants of obesity personal interviews were held in the first five surveys while in the last survey was conducted via telephone which may influence the comparability of the results because of the different ways of collecting from the sample however the computerassisted telephone interviews and facetoface interviews had similar measurement properties 40 implications and conclusions regular monitoring of obesity makes it possible to control vulnerable groups monitoring the obesity prevalence is also essential to study the effectiveness of healthpromoting policies at national and local levels this study showed that it is important to examine trends in subpopulations to determine risk groups for obesity subjects aged 55 years and older with a low educational level and men in the oldest age group with middle or high educational level represented the greatest risk group for obesity in austria longterm preventive strategies to control obesity epidemic should be address middleaged individuals before they become obese this is important because a high obesity prevalence in a nation with an aging population threatens to overload the resources of the health systems in the future it will also be necessary to conduct research in austria on caring for obese subjects furthermore there is need for prospective populationbased studies that are designed to investigate cultural determinants and lifestyle factors related to weight change this could be beneficial for the assessment of causality and to construct effective prevention strategies for austria due to the differences in the obesity prevalence and trends observed between the sexes public health strategies should be developed that adopt a gender perspective the promotion of physical activity for subjects with a low socioeconomic status especially for men was found to prevent obesity and reduce health inequalities 24 the reduction in material inequality would be an important contribution in the fight against obesity as well 41 and in general to narrow social class inequalities in health care subjects need to have an access to a healthy lifestyle through sustained implementation of evidenceand populationbased strategies that make regular physical activity and healthy nutrition available and affordable for example by taxing highcaloric soft drinks 1 public health advocates should lobby for better nutritional standards for meal consumption before obesity prevalence becomes even more acute our findings could help guide the development of effective health and social policies and programmes aimed at reducing the burden of obesity in austria introduction o ver the last decades a worldwide increase in the prevalence of childhood and adult overweight and obesity has emerged posing a major global health challenge 1 especially childhood obesity is of great concern because it is a predictor of adult obesity 2 and also because it is associated with psychological and physical problems such as high blood pressure type 2 diabetes and high cholesterol 3 in major cities of the netherlands the trend of increasing overweight and obesity rates has recently been shown to level off and even decline in certain groups however between ethnic groups in the netherlands the prevalence of overweight and obesity still differs considerably with dutch children showing the lowest prevalence of overweight including obesity and turkish children the highest 4 parental socioeconomic status was repeatedly found to be negatively associated with the presence of overweight and obesity in children 56 in the netherlands children from nonwestern ethnic groups generally have a low ses 7 this raises the question if overweight and obesity can be explained by ses alone or that ethnicity influences overweight and obesity prevalence independently of ses a dutch study of overweight and obesity in dutch turkish and moroccan adults showed that individual ses alone did not eliminate the differences between the ethnic groups however conflicts of interest none declared key points a trend analyses over four decades for the prevalence of obesity was made showing a constant increase in obesity among men who show higher prevalence rates than women for the first time subjects aged 5574 years old with a low educational level and men aged 75 years and older with a highmiddle educational level are at the greatest risk for becoming obese in austria public health strategies should be developed from a gender perspective due to differences in the prevalence and trends in obesity and educational inequalities related to obesity

background the examination of obesity trends is important to plan public health interventions specific to targetgroups we investigated longterm trends of obesity for the austrian adult population between 1973 and 2014 according to their sex age and education and the magnitude of educationalinequalities methods data were derived from six national representative crosssectional interview surveys n 194 030 data correction factors for selfreported body mass index bmi were applied obesity was defined as bmi 30 kgm 2 absolute changes acs and aetiologic fractions afs were calculated to identify trends in the obesity prevalence to measure the extent of social inequality the relative index of inequality was computed based on educational levels results in 2014 the ageadjusted prevalence of obesity was 146 95 ci 140153 for women and 168 95 ci 161179 for men obesity was most prevalent among subjects aged 5574 years and those with low educational status the ac in the obesity prevalence during the study period was highest for men aged 75 years and older with highmiddle educational levels 162 and also high for subjects aged 55 years and older with low educational levels the greatest dynamics for obesity were observed among the oldest men with highmiddle educational levels educational inequalities for obesity were higher among women but only increased among men conclusions since 1973 the prevalence for obesity was observed to be higher for men than women in austria for the first time men showed the greatest increase in prevalence and risk for obesity during the study period further studies are needed to determine the drivers behind these trends

study question what are the factors that influence elective egg freezers disposition decisions towards their surplus frozen oocytes summary answer achieving motherhood or dealing with grief if motherhood was not achieved the complexities of donating to others and a lack of information and professional advice what is known already most women who undergo eef do not use their oocytes consequently there is an abundant but unquantified number of women with surplus oocytes in storage globally many women are deciding about the disposition of their surplus oocytes due to storage limits in countries such as australia belgium finland and taiwan however no studies have examined the factors that influence eef oocyte disposition decisions research exploring factors relevant to embryo disposition and planned oocyte donation may not be relevant consequently women are making the challenging and stressful decision regarding the fate of their oocytes with limited research available to support them study design size duration thirtyone structured interviews took place in australia between october 2021 and march 2022 recruitment was via facebook newsletters and emails from universities and professional organizations emails to eligible patients from an ivf clinic and snowballing a reflexive thematic approach was planned data collection and analysis occurred concurrently recruitment occurred until the process of analysis did not identify any new themes and saturation have been reached participantsmaterials setting methods eligible participants were interviewed and included women who had previously made a disposition decision were currently deciding or who not yet considered the decision interviews took place on recorded teleconference were transcribed verbatim and anonymised transcripts were iteratively coded via nvivo and analysed and themes developed inductively the researcher reflected on their subjectivity with coauthors to ensure accuracy and clarity of data interpretation main results and the role of chance six interrelated themes were identified related to the decisionmaking process decisions are dynamic triggers for the final decision achieving or not achieving motherhood conceptualisation of oocytes the impacts of egg donation on others and external factors affecting the final disposition outcome all women reported a type of trigger event for making a final decision women who achieved motherhood were more open to donating their oocytes to others wanting to share the joy of motherhood but were concerned about the implications for their child and also felt responsibility for potential donor children women who did not achieve motherhood were less likely to donate to others due to the grief of not becoming a mother often feeling alone misunderstood and unsupported reclaiming oocytes and closure ceremonies helped some women process their grief donating to research was viewed as an altruistic option as oocytes would not be wasted and did not have the complication of a genetically linked child decisions were often made based on misinformation and a lack of knowledge of the available disposition options and their consequences with few women seeking professional advice on their decision limitations reasons for caution most participants had not considered the decision and their stated intentions may not reflect their final decision women who had previously made disposition decisions were difficult to recruit despite comprehensive study advertising other limitations were the use of convenience sampling and conduct of interviews via teleconference wider implications of the findings due to a lack of understanding of the disposition options their impacts and women not seeking professional advice decision support is suggested counselling should occur at least at the beginning and end of the process address disposition options impacts grief and gaining support from others what is known already men have an important role to play in the decisionmaking process regarding family building however research on this topic has historically focused on women furthermore existing research focuses primarily on data from highincome countries with limited perspectives from men from lowand middleincome countries this study aimed to explore the factors influencing mens attitudes and behaviours regarding family building decisions across low middle and highincome countries study design size duration a systematic review was conducted via a search on pubmed psych info and web of science databases using the following keyword combinations fertility and intention or desire or pregnancy and childbearing or family building or reproductive decision making and attitudes or motivations or desires or behaviours and parenthood or fatherhood or men study designs were either qualitative quantitative or mixedmethods participantsmaterials setting methods studies were included if they examined mens attitudes and behaviours regarding family building decisions involved only male participants or male and female participants if the results for male participants were reported separately male participants undergoing fertility treatment participants with or without children or homosexual participants were included studies from any country published between years 20102022 and in english language only were included main results and the role of chance a comprehensive search yielded 1745 articles with studies being excluded if they involved female participants only results were aggregated for studies including male and female participants and studies involving participants undergoing surrogacy or adoption as a result 22 studies were included in this review from the 22 included studies 2 main themes were derived personal and social factors the personal theme consisted of factors at the individual level related to finance education health age sexuality masculinity knowledge and other personal factors the social theme related to wider issues including social pressure social support and marital status across included studies the most common personal factor influencing mens attitudes and behaviours regarding family building decisions was financial issues that is being financially stablesecure the most common social factor across included studies was discovered to be support that is receiving support from family society and workplace half of the included studies reported the stability of mens relationship with their partner as a factor that influences their intention for fatherhood interestingly masculinity was a recurring theme with men reporting fatherhood as being an expression of masculinity and a way to fulfil their masculine roles and identity within their family society and community limitations reasons for caution of the 22 studies included in this review 8 of the studies involved young participants of ages 25 years thus results obtained from these studies were not representative of the attitudes and behaviours of all adult men regarding family building decisions wider implications of the findings this is the first review to include studies of men from a combination of low middleand highincome countries understanding mens attitudes and behaviours regarding family building decisions can help raise and promote fertility awareness among men thereby helping men achieve their desired reproductive intentions trial registration number not applicable summary answer spanish and us egg donors differ in their desire for anonymity awareness of consumer ancestry testing and the implications of ancestry testing for maintaining anonymity what is known already in the literature many have expressed concern that without the promise of anonymity people would be unwilling to donate eggs and sperm a related concern is that the rise in consumer ancestry testing will mean the end of anonymous donation and therefore contribute to a reduction in donors study design size duration this is a mixedmethods study drawing upon surveys and interviews with oocyte donors in the united states and spain the study was conducted between the years of 2018 and 2022 and included participants from multiple fertility clinics throughout spain and the united states participantsmaterials setting methods this is a multisited study participants include current and former compensated oocyte donors who completed an online redcap survey text boxes were provided in the survey so the participant could elaborate where appropriate a subset of donors in each location agreed to participate in a semistructured openended interview with one of the investigators interviews were conducted in person or over zoom in the participants language of choice main results and the role of chance of 341 us respondents nearly twothirds preferred that open or known donation rather than anonymous of the spanish respondents 38 stated they would prefer nonanonymous donation 50 were unsure and 11 stated they would not want nonanonymous donation both groups 178 us and 57 spain equally expressed a desire to someday meet the people born from their eggs or would be open to contact to share medical information of the us donors only 17 expressed a desire for no future contact with the people born from their donations while 9 of the spanish donors expressed desire for no future contact us donors were almost unanimously aware of the existence of consumer ancestry testing and 66 had attempted to use such tests to either find their donorconceived offspring or make themselves available to be found among 111 spanish respondents 24 were not aware that consumer ancestry testing exists or that it could be used to find them but 57 expressed a desire to be found if it were to become more widely used in spain findings indicate that egg donors in both locations are mostly open to the idea of nonanonymous donation limitations reasons for caution study limitations include a potential bias in the survey sample as it is possible that people who participate in research might be more open than those who do not we attempted to ameliorate this possibility by recruiting participants from a wide range of clinics practices and other sources wider implications of the findings findings indicate that concerns surrounding the impact of consumer ancestry testing and the loss of anonymity for donors are overestimated while there are cultural differences surrounding donation in the us and spain assumptions surrounding oocyte donors desires for anonymity are not wellaligned with donor sentiments in either location trial registration number not applicable abstract citation id dead093900 p566 is the seminal oxidative stress the mirror of psychological stress perceived by infertile men study question to assess the association between anxiety and depression scores and the levels of oxidative stress in seminal plasma of tunisian infertile men summary answer depression in hypofertile men is associated to higher levels of catalase in seminal plasma and thus to oxidative stress what is known already within the last decades the knowledge concerning the link between psychological and oxidative stress in infertile men has been surging in a limited number of studies aiming to elucidate the psychological aspect of male infertility data related to increased incidence of depression and anxiety have been reported it has also been reported that anxiety and depression may trigger the production of reactive free oxygen radicals leading to disruption of the balance between free radicals and antioxidants semen properties study design size duration this was a crosssectional study performed in the laboratory of cytogenetics and reproductive biology of fattouma bourguiba university teaching hospital a total of 282 patients were assessed for levels of anxiety and depression and evaluated for i456

european countries a thematic analysis was performed using atlasti software the study used purposive sampling technique in order to capture heterogeneity of young participants gender age residence marital statusrelationship sexual orientation education and religion main results and the role of chance young adults perceive infertility as a topic that is not discussed very much in public the individuals affected by it tend to keep it private reluctant to discuss it within their social environment which contributes to the taboo of infertility and may limit access to mar techniques despite this many individuals male and female face infertility problems including data n these countries in all four countries young people agree that infertility imposes great pressure on both males and females in certain countries religion affects the use of mar techniques whereas lgbt people are faced with stigmatization while using mar techniques young interviewees reported general knowledge about mar treatments and specifically certain techniques they are familiar with such as in vitro fertilization or artificial insemination in addition surrogacy was a process that many participants were familiar with however all young interviewed participants claim that more information about mar is needed and they are not confident about where they should search for it limitations reasons for caution this study is first of its kind in the mar research body and its results are useful for policymakers dealing with in fertility however information provided by the young participants in these 4 countries would serve as an overview of gaps and concerns about mar techniques wider implications of the findings the results of this study are used to develop national guidelines aimed for policy makers and mar clinics to improve information about infertility among young people

more symptoms of depression are more likely to seek inpatient treatment for emotional disturbances and report more suicide attempts than their heterosexual peers homeless gb young people often lead highly chaotic and dysfunctional lives and are similarly isolated from school and community networks where they might find supportive adults and peers outside of their family these young adults may suffer from exposure to high levels of family disorganization ineffective parenting and intolerable levels of maltreatment problems at home such as interfamily conflict poor communication dysfunctional relationships and physicalsexual abuse or neglect are predictive of runaway episodes and symptoms of anxiety and depression these problems may stem from or be exacerbated by conflict related to sexual identity ryan and colleagues found that sexual identity conflict was the primary cause of gb young people leaving or being ejected from their home and that family rejection on the basis of sexual identity was strongly associated with a number of negative health outcomes including a sixfold increase in depression family rejection and social stigma can also result in internalized homophobia which can contribute to increased depression and anxiety among gb individuals gb young people who experience family rejection on the basis of sexual identity are more than three times as likely to use illegal drugs compared to those not experiencing rejection moreover homeless gb young adults reporting family rejection during adolescence are over eight times more likely to report suicide attempts and six times more likely to report high levels of depression than peers with a strong family support system for homeless gb young adults compounded stressors of being homeless and a part of a sexual minority may produce emotional distress and an overwhelming sense of alienation from the mainstream society among gb youth and young adults the link between depression alcohol and drug dependency is well established alcohol and other substance dependence is higher among gb young adults than among their heterosexual counterparts in fact homeless gb youth and young adults are also more likely to use hard drugs such as amphetamines than their heterosexual peers in this study the comprehensive health seeking and coping paradigm served as the theoretical framework this framework which originated from the stress and coping model and the health seeking paradigm and has been applied to investigations focusing on understanding hiv hepatitis and tb risk and protective behaviors and health outcomes among homeless and impoverished adults identifying predictors of depressive symptoms will provide valuable information to those engaged in disease prevention and intervention efforts the chscp is composed of a number of variables that guide data collection these include sociodemographic factors situational and personal factors cognitive and social resources and coping responses situational factors that might be relevant to predictors of depressive symptoms among gb young adults include age and education situational factors include length of time homeless personal factors for this paper incorporate the perception of pain and health status and internalized homophobia social factors may include social support while cognitive factors may include internalized homophobia and knowledge of hivaids and hepatitis coping responses include use of drugs and alcohol given the increased vulnerability to depression among homeless and gb young adults it is important to explore correlates of depressed mood among those who experience the compound stigma of being homeless and gay or bisexual guided by the chscp this paper describes the sociodemographic personal cognitive social and coping response correlates of depressed mood in a sample of homeless male gb young adults in hollywood california methods design baseline data were collected as part of a randomized clinical trial focused on assessing 267 stimulantusing gay and bisexual young men who were randomized into one of two programs designed to reduce stimulant use the human subjects protection committees for the university of california los angeles and the friends research institute a community dropin site for gb adults approved this study sample and setting the sample consisted of 267 methamphetamine cocaine and crackusing gb young adults who frequented a community site in hollywood california eligibility criteria included a homelessness b gay or bisexual identity c age 1846 d stimulant use within the last three months and e no selfreported participation in drug treatment in the previous 30 days urine testing was used to validate recent stimulant use at screening if the urine test was negative hair analysis was conducted that could detect stimulant use within the previous 3 months a homeless person was defined as any individual who spent the previous night in a public or private shelter or on the streets in total 564 men were screened of which 267 met the eligibility criteria and were enrolled into the study the 297 individuals who were not enrolled were rejected on the basis of negative hair test result reported not to be gay or bisexual over the age limit no stimulant use in the last three months were not homeless and were in drug therapy for last 30 days procedure participants enrolled as part of a clinical trial designed to reduce stimulant use and promote hepatitishiv prevention the research staff was trained extensively prior to the onset of the study by the principal investigator coinvestigators and project director potential participants were a communitybased sample recruited by current or former participants inservice presentations at communitybased organizations that serve the targeted population or by responding to a flyer distributed in the community the research staff reviewed the informed consent form in a private location with potential participants who were interested in the study and administered a short screening assessment to confirm eligibility the screener took approximately two minutes to complete and assessed demographic characteristics homeless status and substance use and dependency using the tcu drug screener eligible participants were asked to provide a blood sample to be tested for hepatitis a virus hepatitis b virus and hepatitis c virus the participants were asked to return after two days to receive their hepatitis test results from the study nurse after a second informed consent for the full study was reviewed and signed once data on hbv status was collected and data relating to age race was entered a computerized randomization table assigned enrolled participants into one of two treatment arms baseline assessment was administered by the research staff participants were compensated 10 to complete the brief screening questionnaire and 20 to complete the baseline assessment measures sociodemographic informationa structured questionnaire was used to collect sociodemographic information including age birthdate ethnicity education employment relationship status and history of homelessness health statusa selfreported oneitem measure was used to measure health status which asked about general health ranging from excellent to poor and dichotomized as fair poor vs goodexcellent and bodily pain in the previous 4 months dichotomized as severe very severe vs nonevery mildmildmoderate social supporta 6item scale used in the rand medical outcomes study was used to measure social support the items elicit information about how often respondents had friends family or partners available to provide them love and affection help with chores etc on a 5point likert scale ranging from none of the time to all of the time the instrument has demonstrated high convergent and discriminant validity and internal consistency the cronbachs alpha for this sample population was 88 participants were considered as having received no social support if they answered none of the time for all 6 social support items social support was thus dichotomized as none versus any as no social support was a significant factor for depressed mood in the preliminary analysis hepatitis b knowledgea modified 17item instrument was used in a prior hepatitis b study to measure knowledge of and attitudes toward hepatitis b items were measured on a fivepoint scale ranging from definitely true dont know cronbachs reliability coefficient for the instrument in this population was 81 for the knowledge subscale and 92 for the attitude subscale hivaids knowledgea modified 21item centers for disease control scale was used to measure knowledge of and attitudes toward hivaids range was 021 modifications to the cdc instrument have been detailed elsewhere internal consistency reliability for the overall hiv knowledge and attitude scale was 86 in this homeless population drug use and related problemsthe addiction severity index a standardized clinical interview that assessed the clients selfreported substance use the author reveals excellent interrater and testretest reliability as well as discriminate and concurrent validity selfreport of substance use utilized a 30day report a slightly modified version of the asi has been used by reback et al with similar populations sexual behaviorthe behavioral questionnaire amphetamine was used to assess substance use in relation to sexual behavior this scale has been validated with methamphetamineusing populations and assesses specific sexual behaviors alone and accompanying substance use both with primary and other partners relating to unprotected anal insertive sex and receptive anal sex as well as number of sexual partners over the previous 30 days the bqa has excellent overall reliability of 92 in addition participants were asked if current or past sexual partners had injected drugs traded sex for money or drugs and had sex while incarcerated internalized homophobiaherek attitudes toward gay men scale was used to assess internalized homophobia the 5item assessment was used to assess responses to questions on feelings about being a man who has sex with a man answers were scored on a 5point likert scale from disagree strongly to agree strongly the questions were summarized to yield a scale score of 1 to 25 with higher scores indicating a higher degree of internalized homophobia and lower scores indicating greater acceptance of gay men a man was considered to have a high level of internalized homophobia if his summary score was over 15 which indicated that on average he agreed or agreed strongly with the five internalized homophobia questions depressed mooda short form version of the center for epidemiologic studiesdepression scale was used to assess depressed mood a term used to replace depressive symptoms in this study the short form cesd is a 10item scale that measures depressive symptoms on a 4point continuum the cesd has wellestablished reliability and validity scores on the cesd range from 030 with higher scores indicating greater depressive symptomatology internal consistency reliability for this scale was 82 in this homeless population for purposes of this study depressed mood was defined as having a cesd score of at least 10 on this 10item cesd scale this cutpoint of 10 has been used to identify persons in need of psychiatric evaluation for depression in previous work data analysis summary statistics were performed to present to describe participants demographic and clinical characteristics as well as other independent variables due to the large number of variables we collected from the survey model selection technique was applied to study the possible predictors of depression among the homeless gay men chisquare and paired ttests were carried out to examine the bivariate correlates of depression stepwise multiple logistic regression analysis was then used to create a model of depression including variables such as medical visit hiv knowledge education general health status body pain homeless status homophobia and social support which were associated with depression at the 015 level in the preliminary analyses this justification was based on the fact that frequently two variables that are not significantly associated based on zeroorder correlations will be significantly associated when another variable is controlled while allowing the 15 allowed important correlates to be viewed stepwise techniques used in the final model to reduce chance of spurious result covariates that were significant at the 005 level were retained in the final model multicollinearity was assessed and model fit was examined with the hosmerlemeshow test all statistical analyses were conducted using sas version 91 results sociodemographic characteristics this gb young adult male population reported an average age of about 34 years and was infrequently employed the majority of the participants was white and reported being homeless for the entirety of the previous four months approximately one in every five of the participants met the criterion for internalized homophobia almost twothirds of the participants reported a lifetime history of injecting recreational drugs of these approximately onethird reported injecting heroin other opiates or pain relieving drugs approximately twothirds reported that they had been given information about hepatitis prior to participating in the study just under over half of the participants were infected with hbv 29 were infected with hcv and 17 were infected with hiv coinfection rates between hiv and hcv were also high at 6 few participants reported having no social support depressed mood was commonly reported in this population the level of hiv knowledge was moderate whereas hbv knowledge was lower in general onefourth or fewer respondents reported good to excellent health and a mean of 12 visits for medical problems within the previous four months associations with depressed mood table 2 reports unadjusted correlates of depressed mood age employment partner status and number of children were not found to be significantly associated with symptoms of depression hivhbvhcv status and injection of recreational drugs were also not associated with depression symptoms however fewer visits to health care providers and being less knowledgeable about hiv were important correlates internalized homophobia was a significant correlate as well in addition not having graduated from high school and not having social support also correlated with symptoms of depression additional significant correlates of depressed mood included fairpoor health status having severevery severe bodily pain and having ever injected heroin opiates or painkillers in terms of environmental and psychosocial factors having been homeless all the time for the previous four months was positively correlated with depressed mood multivariate results the adjusted odds of reporting clinically relevant symptoms of depression were almost 11 times greater for persons who reported no social support and almost six times greater for those who reported severe or very severe body pain being homeless all the time in the previous 4 months was positively associated with high depressive mood scores also those who reported fairpoor health status and those whose responses indicated high levels of internalized homophobia were more likely also to report high levels of depressed mood in addition those who had ever injected of heroin opiates or painkiller were about 2 times more likely to report significant depression complaints than those who did not inject discussion findings from this study revealed that gb homeless young adult men who lacked social support were more likely to report high levels of depressed mood and among those who reported elevated levels of internalized homophobia they were also more likely to report high levels of depressed mood further participants who reported a history of injecting heroin opiates or painkillers and those homeless in the previous four months were more likely to have high levels of depressed mood understanding the correlates of depressed mood among gb young adult men who are homeless can help service providers design more targeted treatment plans and provide more appropriate referrals to ancillary services a negative impact of lack of social support on the emotional state of individuals has been found previously as absence of social support has been associated with more depressive symptoms among homeless young adults gb youth and among other populations at high risk for poor mental health such as methadonemaintained adults and parolees in a recent qualitative study hudson et al found that homeless young adults craved support from family friends and homeless peers and were constantly subjected to rejection and discrimination from passersby and law enforcement it is very likely that the homeless gb young adults in this study had experienced similar social isolation combined with social stigma and perhaps this is magnified when internalized homophobia is taken into account despite increasing mainstream exposure to homosexuality gb young adults particularly when homeless find themselves alone and unable to share feelings when subjected to social taunts and attacks thus by understanding the importance of social support in relation to depression healthcare and service providers may need to consider avenues where social interaction can occur among gb young people such as group education activities while the participants were not asked directly about the social stigma prejudice and discrimination often associated with minority sexual orientation we did find that reports of high levels of internalized homophobia corresponded with other negative psychosocial complaints this is consistent similar findings from a report of older urban very poor msm in los angeles we believe there is a link between depressed mood and internalized homophobia among gb young men as having higher levels of anxiety and depression feeling downhearted and blue and having high levels of nervousness may lead gb men to have negative attitudes towards their own homosexuality family and societal stigma may also contribute to depression in gb men which could lead to internalized homophobia study findings add to the literature specific to gb homeless populations that are active stimulant users while further research needs to be done with this specific subgroup other researchers have found elevated rates of depression symptoms and diagnoses in gb people implications again exist for service providers to maintain gbfriendly dropin sites where young populations can gather and socialize and have the freedom to express themselves without concern about stigma or acceptance findings demonstrated that gb young homeless men who reported injecting heroin opiates or pain killers were more likely to report experiencing a depressed mood in previous work with a similar population 75 met the beck depression inventory criteria for mood disorder and 33 met criteria for major depressive disorder however amphetamine methamphetamine injection was significantly associated with depression rather than opiod injection the relationship between injecting opiods and depression has also been identified in other populations such as needle exchange clients and older adults injection use often reflects an advanced state of drug dependency which may be more emotionally distressing among gb young adults furthermore the fact that homelessness was associated with depression is not surprising as homelessness represents a state characterized by a confluence of stressors homeless gb young adults may well fear for their safety not know where their next meal is coming from and be exposed to the elements clearly they are also more vulnerable to violence and victimization simply by being more visible in another study with homeless young adults mental health issues were the most commonly reported health concern and some young homeless adults reported using illegal drugs as an attempt to alleviate the symptoms of feeling depressed or hearing voices while a longitudinal study is required to assess the causation of comorbid conditions other studies have highlighted the link between depression alcohol and drug dependency and the fact that adolescents with substance abuse and comorbid psychiatric disorders have poorer drug treatment outcomes than youths with only substance abuse disorders therefore ongoing investigation of causes of depression and its identification and treatment can be also considered a tool in the prevention of continued drug and alcohol addiction and dependence an equally important relationship was identified between the health status of the young homeless gb young adults in this study and depressed mood as such depressed mood was associated with having experienced severe body pain within the previous four months and was inversely associated with good to excellent health status this association between severe bodily pain and depressed mood is novel as no other studies have found this relationship this finding helps to advance the understanding of the link between health status and in particular pain experienced and level of depressed mood our findings also suggest that participants who wanted to get treatment for mental health were less likely to report having a depressed mood healthcare providers who work with a population who suffer from numerous and often severe physical and mental health problems are a vital link in providing services and treating these health issues to improve the health outcomes of those most vulnerable access to care for this population is often challenging acting as a link or facilitator to more intensive social and health resources is critical traditional barriers to care faced by these young adults include concerns regarding confidentiality the cost of services lack of insurance lack of transportation cultural issues including homophobia spiritual and discrimination distrust of healthcare providers feeling embarrassed to ask for healthcare and distrust of social workers and police another study found a marked difference in the amount of respect and consideration homeless people receive from health care delivery systems in comparison to the general population an inequity that has been found to result in homeless persons being less likely to seek health care limitations while this study reported unique findings relative to the mental health of gb young adults this study had several limitations first the participants were exclusively homeless gb young men so our ability to generalize to gb older men or to women is limited second all study participants were selected from an area surrounding the research site whether these participants differ from those further from this site or in other cities is unknown moreover most of the data are selfreported and a clinical screener for depression was not used finally it was not possible to assess the direction of influence between mental health and substance use thus longitudinal studies are needed to examine such influences conclusions this study is one of the first to assess the impact of severe body pain and depressed mood among gb homeless young adults these findings advance our understanding of the link between pain experienced and experiencing a depressed mood moreover the desire of many participants to access mental health treatment and the relationship to lower odds of depressed mood provides useful information for practice and the provision of services for these vulnerable young adults future investigations will be critical to prospectively assess the impact of identifying and providing services for stimulantusing homeless gb young adults who report high depressed mood in terms of both ongoing mental health and substance use issues table 2 bivariate correlates for depressed mood depressed

homeless gay and bisexual gb men are at risk for reporting suicide attempts and have high risk of depressed mood defined as elevated level of depressive symptoms this study describes baseline sociodemographic cognitive psychosocial and healthand drugrelated correlates of depressed mood in 267 stimulantusing homeless gb young men who entered a study designed to reduce drug use gb men without social support were 11 times more likely to be experience depressed mood than their counterparts who had support while persons who reported severe body pain were almost 6 times more likely to report depressed mood than those without pain other factors that increased risk of depressed mood included being homeless in the last four months injecting drugs reporting poor or fair health status and high levels of internalized homophobia this study is one of the first to draw a link between pain experienced and depressed mood in homeless young gb men understanding the correlates of depressed mood among homeless gb young men can help service providers design more targeted treatment plans and more appropriate referrals to ancillary care serviceshomeless gay and bisexual young men depressed mood stimulantusing elevated levels of mental disorders and suicidality have been found in studies among gay and bisexual gb men in an extensive review and metaanalysis of publications on mental disorders suicide and deliberate selfharm behaviors among gb men king and colleagues 2008 found that gb men had over a twofold increase in suicide attempts compared to a heterosexual men and were at significantly higher risk for depression and anxiety disorders suicidal ideation substance misuse and deliberate selfharm than their heterosexual peers these trends are important to note however among the younger gb subpopulation other challenges may be significant the transition from adolescence to adulthood is a difficult time for many young people in particular for gb youth and young adults physical mental and social developmental changes compounded by the emergence of a sexual identity which deviates from the heterosexual norm saewyc et al

introduction the coronavirus disease has become a global health concern the world health organization characterized covid19 as a pandemic on march 11 2020 1 as of november 13 2020 the number of global confirmed cases and deaths has risen to over 52657000 and 1291000 respectively in japan more than 113600 infections and 1800 deaths were confirmed 2 effective antivirals and vaccines are currently being developed and effective therapeutic solutions have not been ultimately approved 34 therefore protecting citizens from new infections and health care institutions from using up capacities has become extremely important for all the countries many governments conducted lockdowns and interruption of citizens economicsocial activities during rapid infection increases these countermeasures were remarkable while their effectiveness depended on the knowledge attitudes and preventative practices toward covid19 among citizens according to kap theory and previous experiences 56 meanwhile countermeasures dramatically converted citizens lifestyles and daily behaviors and thus change in the mental health wellbeing and psychological impacts related to covid19 have also been highlighted and investigated 78 for example a largescale international survey to analyze citizens mental wellbeing at the onset of the covid19 pandemic 9 and a largescale international survey to evaluate the students wellbeing have been conducted 1011 in japan the government issued several foundational policies for preventing and controlling covid19 including an emergency declaration for tokyo kanagawa saitama chiba osaka hyogo and fukuoka on april 8 2020 and later for the whole country until may 25 2020 12 although the emergency declaration was significant to control the rapid increase of covid19 infections it can not last long due to socioeconomic losses after lifting of declaration increases in covid19 infections started including those in the young generation 13 at the onset of covid19 a survey on japanese citizens behavioral changes and preparedness against covid19 conducted by muto et al revealed that being younger was among the factors associated with reluctance to follow prevention measures 14 owing to the explanation and awareness that older individuals are at a highest risk of becoming severely ill or passing away 1516 there is a possibility that the young japanese generation has not paid enough attention to covid19 although later research stated that covid19 does not spare young people 1718 there is still a risk that the young generation will not undertake precaution measures as necessary moreover young asymptomatic cases have the possibility of spreading viruses to the highrisk population therefore the young japanese generations kap that influence the compliance with countermeasures should be evaluated japans 2019 universityjunior college entrance rate was 581 19 suggesting that university students account for most young individuals university students have higher economic independence higher autonomy and are less dependent on parents than high school students or those with a lower level of education 20 high school students or those with a lower level of education are more likely to follow their parents lead and further obey the government countermeasures in contrast intelligent university students can judge their surroundings and exhibit behaviors based on their judgment especially those who live separately from their families meanwhile university students engage in vigorous activities such as academic activities sports clubs and parttime jobs and for this reason they have more opportunities to get in contact with others these aspects increase the importance of analyzing the university students kap in japan as reported from other countries 2122 knowing the states of kap toward covid19 among university students and further analyzing the kap factors can play vital roles in planning and confirming the countermeasures for the young generation in the covid19 prevention so far to the best of our knowledge there is a survey that investigated japanese university students awareness and actions toward covid19 23 but the knowledge of covid19 and factors influencing kap have not been evaluated yet previous surveys on kap and wellbeing in other countries showed that citizens and university students had related high levels of knowledge about covid19 and displayed positive attitudes and lowrisk practices differences in gender age education level and major fields of studiesbackgrounds affect the levels of knowledge the practices such as appropriated hygiene and social distancing behaviors and sometimes psychological health 521 24 25 26 27 whether these factors affect japanese university students kap toward covid19 has not been studied moreover because most studies only focus on practice not much is known what affects the extent of knowledge and attitude this information should be paramount in improving university students knowledge and attitudes besides the factors listed above psychological factors are also assumed to be crucial to university students behaviors and practices university students are independent of their families forming their own identities 28 they are very concerned about how they present themselves and how people see them in an emergency such is the covid19 pandemic in which behaviors are strictly restrained ones behavior is more frequent based on the viewpoints of their own and others selfconsciousness 29 is considered to significantly influence young peoples behavior as a factor determining their behavior another critical factor is personality it can be assumed that the extroverted nature of actively interacting with others determines university students range of action this study conducted an online survey to evaluate kap toward covid19 among university students in japan meanwhile we attempted to examine kaps differences related to the factors such as gender education level nationality residence responders major and their psychological characteristics and the relationship between kap and these factors materials and methods study design participants and data collection this crosssectional study administered an anonymous survey using a questionnaire constructed using google forms participants inclusion criteria were universitycollegejunior college students who lived in japan and could read and understand japanese or english due to the emergency and particular period we adopted a convenience sampling we distributed our online survey form together with a quick response code via direct deliberation in laboratories online lectures and lecture homepages university club mailing lists and social networks the answer procedures the voluntary nature of participation and anonymity declaration within the explanation of informed consent were presented on the questionnaires top page responders answered the questionnaire via their internet surroundings data were collected from may 22 to july 16 2020 crossing the emergency declaration lift at 8 weeks which is the earliest time after receiving an ethical review approval questionnaire design we designed a questionnaire so as to have seven categories demographic information knowledge about covid19 and virology approach and frequency of obtaining information and comprehension level social behaviors and actions personalpsychological aspects change in awareness before and after the declaration of emergency and concerns about online lectures the questionnaire was designed in japanese with an english translation demographic information included gender respondents majors or science subjects grade age nationality residence and so forth awareness included two questions asking whether there was a change in awareness before and after the emergency declaration and the percentage of change psychological aspects were designed based on two instruments extroversion from a short form of the japanese bigfive scale 30 and publicprivate selfconsciousness scales from the selfconsciousness scale for japanese 31 knowledge information behavior and lecture were selfdesigned as 6point likert scales according to several questionnaires for infectious diseases 32 33 34 data preprocessing typos were corrected different terminology for the same nationality or residences were unified inconsistent responses were corrected in an interpretable direction for example when the selfdefense change was answered as increased but its percentage was answered with 0 we corrected the answer to no change to align the positive with the desired direction and provide a concise view we exchange responses to reverse questions using the largest scale 1original value scales for each category were validated using factor analysis and variables for the following analyses were generated the number of factors was decided by wayne velicers minimum average partial criterion or bayesian information criterion if the number of factors was not 1 the promax rotation was conducted questions with the magnitude of loadings 04 were removed variables were created from the subscale scores obtained from the mean of the questions within factors finally 10 continuous variables indicating psychological aspects and kap with acceptable internal consistencies were obtained for the following subgroup comparisons based on the response time recorded we created a binary variable response time several variables were organized into binary variables major subject is selected vs nonbiobackgrounds others education level nationality and residence psychological aspects were also converted into binary values as high or low data analysis descriptive statistics to directly evaluate kap toward covid19 among university students in japan the responses to the questions were aggregated and the extent and magnitude of kap were confirmed subgroup comparisons to examine responses to what questions are different caused by the factors we carried out subgroup comparisons subgroup comparisons for all the questions were conducted to determine if there were any differences in responding to questions within subgroups the normality and homoscedasticity of data were tested by the shapirowilk and ftests if data were nonnormally distributed and homoscedastic differences were tested using the mannwhitney method brunnermunzel method was used to test the significance between two groups of nonnormal but heteroscedastic data the bonferroni method was adopted for multiple comparisons the subgroups were those generated in data preprocessing logistic regression logistic regression models were constructed to evaluate whether the previously reported important variables from other countries surveys and psychology aspects mentioned above influence kap toward covid19 among japanese university students kap outcomes were generated from factor analysis and in logistic regression models were used as binary outcomes here we created binarization of basic knowledge advanced knowledge info acquisition info explanation info anxiety selfrestraint and preventative action as outcomes for the former four outcomes explanatory variables used are response time gender major subject education level nationality residence and psychological aspects for the last two outcomes indicating the actions continuous variables of basic knowledge advanced knowledge info acquisition info explanation info anxiety and selfrestraint were further added as we also want to confirm whether the knowledge and attitude to information influence the practices multiple linear regression multiple linear regression models were constructed to further confirm the factors of practices further the outcomes were set to be binary in the above logistic regression while in mlr the outcomes were used as continuous values therefore the mlr models were quantitative the mlr models for selfrestraint and preventative action were constructed the explanatory variables used were the same as above determinant factors were decided when akaikes information criterion reached a minimum data were first normalized and the variance inflation factor was also calculated to confirm multicollinearity the regression models predictive power was assessed by the mean r 2 which is calculated from fivefold cross validation by repeating 50 times a significant level of 01 was adopted software and package versions all the analyses were conducted using r rstudio mephas web 35 and r packages psych coin stats lawstat glm lm bestglm car and caret ethics the ethics committee of waseda university and the graduate school of pharmaceutical sciences of osaka university approved this study informed consent was obtained from each participant on the first page of the questionnaire results demographic characteristics a total of 362 participants were included in the analyses after one participants response was removed due to the invalidate residence input the age of the participants was 208 ± 35 years students whose majors were biology related accounted for 329 undergraduate students for 790 japanese students 837 and participants from capital region residence 354 overall results showed that respondents were inclined toward safety and good health the overall results showed that the respondents were inclined toward safety and good health proportions of responses larger than the theoretical median of 35 varied from 246 to 100 the highest response score was to i know its important to avoid enclosed spaces crowded areas and close situations no response was less than the theoretical median suggesting a deep understanding of the japanese governments advisement of 3cs 36 high scores were also obtained in the knowledge or awareness of the infectious routes vital signs the severity of the virus preventative measures additionally 685 of respondents showed a positive attitude toward early drug administration differences detected among subgroups the significant differences among subgroups were extracted late response time showed significant lower medians in the questions related to the tension toward covid19 suggesting that with time although the basic knowledge has increased tension has been eased for gender differences females showed conservativesafer attitudes than males in the stance to close bars and go to university compared to nonbiobackgrounds biobackgrounds showed a higher level of advanced knowledge as expected surprisingly nonbiobackgrounds showed a higher score on the opinion i think that i can naturally heal without medical care such as hospitalization even the novel coronavirus infects me suggesting a safer consideration on the covid19 infection similarly for education level students at the graduate level or above had significantly higher advanced knowledge stronger willingness to accept anxious news and slightly higher satisfaction about online lectures and assignments in terms of nationality japanese students knew more basic knowledge and were more sensitive to the emergency declaration in contrast international students knew more advanced knowledge and had a stronger willingness to accept anxious news and correct information explanations when considering the residence students living in the capital region showed stronger selfrestraint and acted more safely than others from the psychological aspects more active information collection was detected in the high extroversion and the high private selfconsciousness groups factors influencing university students knowledge levels logistic regressions were conducted to explore the determinant factors on high basic knowledge and advanced knowledge for basic knowledge gender major subject education level nationality residence extroversion and private selfconsciousness were significant determinant factors the odds of japanese students gaining basic knowledge was 333 times greater than others which strongly implies that japanese students gained more basic knowledge than international students the odds ratios of extroversion and private selfconsciousness were also 1 suggesting that extroverts and individuals with high private selfconsciousness were likely to possess more basic knowledge than others the ors of gender major subject education and residence were 1 suggesting that females with biobackgrounds at the level of graduate or above and in the capital region could positively influence the acquisition of basic knowledge for advanced knowledge except for response time all the explanatory variables were significant biobackgrounds living in the capital region low public selfconsciousness and high private selfconsciousness strongly positively influence the acquisition of advanced knowledge factors influencing university students attitudes the university students attitudes to covid19 were assessed considering the frequency and activities of information acquisition the correct explanation of the information and willingness to collect anxiety information for the frequency and activity of information acquisition only psychology aspects showed significance and were positively associated with the outcome the determinant factors for the correct explanation of the information were female residence public selfconsciousness and private selfconsciousness incorrect explanations may affect students protection and further increase their infection risk for the willingness to collect anxiety information response time nationality and extroversion are significant international students and low extroversion are more likely to receive information regardless of whether it can make people anxious notably the or was 056 suggesting that more students were willing to receive anxious news and countermeasures with time passing factors influencing university students preventative practices and behaviors preventative practices and behaviors included selfrestraint and preventative action two logistic regression models for these behavior terms were constructed using the variables mentioned above and variables of knowledge and information as explanatory variables for the selfrestraint response time gender residence extroversion info explanation and info anxiety there was statistical significance female living in capital region and low extroversion show a relatively safer selfrestraint the selfrestraint is attenuated compared to early responses moreover we found that information explanation positively and the anxiety of information negatively affected the selfrestraint for the preventative action residence private selfconsciousness basic knowledge info acquisition and info anxiety were significant we also applied mlr when treating selfrestraint and selfaction as continuous values after variable selection using aic important variables remained the predictive abilities for the models were 045 and 034 respectively nested crossvalidation revealed similar predictive abilities the selfrestraint model revealed that correct information explanation and japanese nationality were associated with strong selfrestraint on the other hand male nonbiobackgrounds living in the noncapital region high advanced knowledge and unwillingness to receive anxious information and extroversion negatively influenced the selfrestraint the model for preventative action was constructed using less explanatory variables the coefficients of private selfconsciousness basic knowledge and variables about information were positive and that of residence in the noncapital region were negative the results generally consist of logistic regressions students living in the capital region having more basic knowledge frequently inquiring information correctly explaining information and with high private selfconsciousness tend to act more safely discussion university students in japan exhibited a relatively high level of basic knowledge and awareness university students in japan belong to a representative group of the young generation the outbreak of unprecedented covid19 pandemic directly impedes their daily lives and activities compared to the employees and other adult populations university students exhibit less financial independence but have more free time and broader activities meanwhile university days are the most crucial period in forming ones selfwill and university students are much more likely to act on their selfjudgment than other students to control the spread of infections governments provided guidelines and countermeasures and kap influences adherence to them since university students belong to a separate population according to the aspects above we first evaluated their kap toward covid19 overall we found a high level of basic knowledge on covid19 and control measures among university students in japan for example with regard to the question about avoiding enclosed spaces crowded areas and close situations 36 all the responses were no less than the theoretical median and the frequency of handwashing and maskwearing no less than the theoretical median were both 964 indicating university students clearly understand the importance of avoiding the overlapping three cs and the basic protective methods these results were in line with the previous survey result in february according to which approximately 838 of japanese citizens always or sometimes conducted hand hygiene 37 these results could be a possible reason for effective control of the infection in the early period after the emergency was declared several similar surveys from other countries also showed high levels of university students kap toward covid19 our results agree with these previous surveys and compensate for the lack of japanese data for example considering the view on maskwearing approximately 521 of jordans university students 21 and 980 of chinese university students 5 wore a facemask when leaving home according to their responses from march and january respectively and 869 of indonesian undergraduate students wore masks frequently when in a crowded place 22 according to their responses collected in april and may our results showed that the rate of frequent maskwearing in japanese students was 964 which is still relatively high compared with the global results although it has not been proven a commentary published in april hypothesized that japanese culture which is inherently suited for social distancing and face mask use prevents viral spread 38 this may be the reason why our results were relatively high students with high education levels and biobackgrounds were found to have more advanced knowledge about viruses vaccines and drug targets interestingly international students were prone to having more advanced knowledge while japanese students more basic knowledge for some basic knowledge such as diarrhea and taste disorders being symptoms of covid19 japanese and international students showed slight differences indicating that the route of obtaining basic knowledge may be different therefore particular education information about japans countermeasures for international students may be necessary other kap studies in global did not separate knowledge into basic and advanced therefore our results provide novel information moreover we found that females had more basic knowledge and explained the information more correctly than males which agrees with previous studies in other countries showing that females have higher knowledge about covid19 and a proper attitude 3940 students living in the capital region conduct themselves with strong selfrestraint and safe preventative action however there is a decrease in selfrestraint over time the behaviors of students were evaluated using selfrestraint and preventative action for all the models the residence was a significant factor and students living in the capital region exhibited safer behaviors when compared to other regions until now infections have been most extensive in tokyo enhancing the awareness of capital region residents therefore behaviors took a safer direction a survey targeting indonesian undergraduate students showed that rural students showed significantly higher kap than those living in cities which seems to be in disagreement with the current results however we compared the capital region and others in japan and the severity of the infection situation was different making students living in the capital region higher kap toward covid19 one noteworthy observation was that the logistical regressions and mlr showed the response time to be significant for selfrestraint indicating a decrease in selfrestraint over time psychological aspects influence students behaviors behavior patterns of individuals differ depending on their personality extroversion and introversion have been terms widely used and they depend on how people direct their energy that is externally or internally 41 extroverts tend to be more interested in the outside world and the decisionmaking process of things they follow the environment when it comes to directions and common sense recommended by others from the perspective of sociality extroverts are more active social adapt faster and are active when working with others their thinking patterns are realistic execution first and centered on others therefore it can be said that an extrovert is highly othercentered and environmentdependent and he or she can correctly recognize and make a judgment on the surrounding situation during the covid19 pandemic it has been presumed that extroverts can actively learn and absorb new knowledge but may require synchronized actions owing to the emphasized relationships with others the aforementioned results of university students support this hypothesis the higher the score of extroversion the higher the coronavirus knowledge and the more selfdefense measures implemented however there was a high tendency to go out with others therefore the character of extroversion has the useful side of knowledge acquisition and selfdefense and the opposite effect of not strictly following the stayathome order a recent report on a psychological and behavioral survey on covid19 in japan revealed that extroverts scored highly for infection prevention behavior and maskwearing behavior 42 which was consistent with the findings above another aspect to note is that peoples behaviors are influenced by how they pay attention to themselves that is selfconsciousness 29 private selfconsciousness is a measure of individual differences considering the extent to which they pay attention to those aspects of themselves that are not directly observed by others such as inner feelings emotions and moods when selfconsciousness is high people monitor themselves act in harmony with their own will and values and provide planning in their lives to achieve their goals this refers to the socalled spirit of selfdenial or severity for oneself conversely public selfconsciousness shows individual differences in the degree to which they pay attention to the aspects of themselves that others can observe such as clothes and hairstyles or their behavior toward others they refrain from selfcentered behavior that may be criticized by the group or use expectations of others and norms of the field as their behavioral standards their appearance varies depending on the situation 43 the results of this study point to the behavioral tendencies of selfconsciousness concretely to cope with infection a person high in private selfconsciousness does not easily neglect the infectious disease and positively acquires knowledge about it more importantly they take strict selfprotection measures on the contrary although people who are high in public selfconsciousness are interested in the spread of infectious diseases it cannot be said that they place importance on the risk of infectious diseases in addition similar to highly extroverted people it can be said that they tend to violate the stayathome order when invited by others because they focus on how others see them education of students per the critical factors of behaviors may provide benefits this survey was designed and conducted to evaluate the kap on covid19 among university students in japan and investigate determinant factors meanwhile through this quantitative evidence suggestions about reasonable control of the spread of infections among university students and the entire society including university managers expert teams and policymakers are expected via the aforementioned analyses the following can be concluded from the aspects of imposing stricter selfrestraint andor acting more safely 1 living in the capital region is associated with higher kap 2 being female is associated with higher kap 3 japanese students exhibit slightly stronger selfrestraint than international students 4 basic knowledge is more important compared to advance knowledge frequent information acquisition correct explanations of the information and willingness to receive anxious information are essential 6 extroversion is positive to safer preventative action but negative to selfrestraint 7 those with high private selfconsciousness act more safely but high public selfconsciousness influences strict selfrestraint negatively 8 the strength of selfrestraint decreases over time the ongoing covid19 pandemic has substantial impacts on peoples lives accompanied by economic damage financial support was provided by governments to individual households or small companies to make living easier and maintain social sustainability during the selfrestraint or lockdowns within the social surroundings and university measures to covid19 campus life lifestyle behaviors and economic status have dramatically changed for university students accompanying other changes in their mental health and wellbeing 11 these points are incredible when considering university students for example the ministry of education culture sports sciences and technology in japan created a series of financial support measures for university students including emergency student support 44 instead of focusing on university students mental health and wellbeing this study focused on their frequent activities assuming that there was a possibility that young university students may exhibit low adherence to selfrestraint and protective action contrary to our initial expectations university students in japan generally showed a high kap level however when we search the factors that influence kap we obtained the findings described above therefore we suggest that universities media and the government should consider these aspects of university students devising publicity and education measures to achieve a more significant education effect for example it is particularly beneficial and vital to educate or inform those who are less careful of the current situation or those who are not cautious enough comparisons with the kap covid dashboard from johns hopkins university and a recent report on the comparison of knowledge precaution practice and depression among students in south korea china and japan our data in this report come from the survey completed on july 16 2020 while we are revising this paper similarly a group from johns hopkins university conducted a global kap covid survey in july 2020 and published a dashboard online 45 although the kap covid dashboard focused on the whole population and no psychological factors were analyzed which is different from the current study it provides results for each country and subgroups making it possible to compare the results indirectly the kap dashboard implied that a high percentage of individuals with a college education or above showed high selfreported prevention behaviors in japan these results are similar to our findings from the japanese university students survey described previously and illustrated in fig 1 furthermore the dashboard shows that individuals with a college degree or above have better knowledge than the other groups when it comes to three or more symptoms of covid19 and no treatment or vaccine at the time of the survey these results also agree with our findings that university students possess a high level of knowledge our results further showed that basic and advanced knowledge levels varied in gender major subjects education levels nationality residence extroversion and selfconsciousness from logistic and multiple linear regressions moreover the dashboard showed that 70 of individuals with college education or above accepted vaccines according to our results 685 of collegeuniversity students were willing to use newly developed drugs therefore despite the different population target groups our results agree with results from the kap covid dashboard from johns hopkins university suggesting a high reliability a paper on the comparisons of knowledge precaution practice and depression of students from south korea china and japan has been reported more recently 46 the main difference between this report and the present study is that our study focused on kap factors while the other study explored the depression symptoms if we only focus on kap the previous report indicates that in all three countries students showed good knowledge and high levels of covid19 awareness and the japanese group performed better than the other two considering hand hygiene they also clarified that females tended to have a higher level of preventative measures than males 46 these results are in line with our findings discussed above strength limitations and future work the strength of this study is in its target groupthe japanese universitycollege students when we launched the study to the best of our knowledge no other studies had been reported to investigate the kap toward covid19 among this target group we conducted this survey to provide evidence meanwhile unlike other kap studies we analyzed the determinant factors including psychological factors for not only the practices of selfrestraint and preventative actions but also for the knowledge and the attitudes toward information the factors of knowledge and attitudes toward information have not been analyzed in other studies understanding determining factors can help us improve kap among university students during the covid19 pandemic this study has certain limitations it mainly adopts a convenience sampling method which is a nonrandom and nonprobability selection recruitment bias may have occurred sampling error could not be calculated as well as the response rate and the anonymity of participants to each other may have been violated the samples were limited in number and they exhibited imbalances in the subgroups thus the results may not sufficiently represent the whole population of japanese university students more importantly with regard to response bias due to spontaneity only students with high awareness responses to the questionnaire may provide results with favorable evaluations and these selfreported responses may not be the same for the whole population furthermore this study is cross sectional and the results are timedependent as the covid19 situation is changing rapidly the kap among university students is also changing the results reported here represent the situation during the survey period additionally the responses obtained before the emergency declaration lifting are far fewer than those obtained after the lifting making it impossible to analyze behaviors due to the emergency declaration lifting therefore this should be considered when discussing the results as this study can only show the related determining factors further studies are required to clarify causal relationships between the aforementioned factors and the behaviorsactions by controlling baseline information moreover because this survey is cross sectional to examine the timedependent kap changes and factors longitudinal studies are also necessary conclusion japanese university students have been inclined toward safety and good health preservation during the covid19 crisis gender major subjects education levels nationality residence private selfconsciousness and extroversion have all been associated with knowledge and plos one attitudes toward covid19 capital regions high levels of basic knowledge high information acquisition and correct information explanations have all contributed positively to preventative action noncapital regions male gender nonbiobackgrounds high public selfconsciousness high levels of advanced knowledge incorrect information explanations and high extroversion have all contributed negatively to selfrestraint moreover selfrestraint has decreased with time the understanding of these factors and trends may help university managers experts and policymakers in planning countermeasures that would control the future spread of covid19 among university students and japanese society all relevant data are within the manuscript and its supporting information files supporting information s1 data

the coronavirus disease covid19 pandemic has greatly altered peoples daily lives and it continues spreading as a crucial concern globally knowledge attitudes and practices kap toward covid19 are related to individuals adherence to government measures this study evaluated kap toward covid19 among university students in japan between may 22 and july 16 2020 via an online questionnaire and it further investigated the associated determining kap factors among the eligible respondents n 362 528 were female 790 were undergraduate students 329 were students whose major university subjects were biologyrelated 354 were from the capital region and 837 were japanese the overall kap of university students in japan was high all respondents 100 showed they possessed knowledge on avoiding enclosed spaces crowded areas and close situations most respondents showed a moderate or higher frequency of washing their hands or wearing masks both at 964 in addition 685 of respondents showed a positive attitude toward early drug administration in the logistic regressions gender major subjects education level nationality residence and psychological factors private selfconsciousness and extroversion were associated with knowledge or attitudes toward covd19 p 005 in the logistic and multiple linear regressions capital regions high basic knowledge high information acquisition correct information explanations contributed positively to preventative action p 005 noncapital regions male gender nonbiobackgrounds high public selfconsciousness high advanced knowledge incorrect information explanations and high extroversion contributed negatively to selfrestraint p 005 moreover selfrestraint was decreasing over time these findings clarify the japanese university students kap and the related factors in the early period of the covid19 pandemic and they may help university managers experts and policymakers control the future spread of covid19 and other emerging infections

introduction public health and health equality are essential for human development health is both a medical and social issue compounded by structural economic and environmental factors if these factors are compromised vulnerabilities can create health inequalities and human disasters low socioeconomic status is associated with poor birth outcomes infectious diseases chronic conditions and life expectancy which result from disparities that include poor access to health care financial constraints environmental differences differential access to information geographic locality and behavioral factors economic instability is associated with worse health outcomes forcing individuals to prioritize other issues such as rent and utility bills over food and health needs some key barriers to obtaining food include reduced access to supermarkets with healthier food options as well as difficulty accessing federal nutrition assistance programs and food from food banks or pantries due to lack of these nearby lack of transportation to get to them and complicated and timeconsuming application process to access federal assistance informational barriers like the lack of awareness or understanding about available food and housing resources also may contribute to low utilization in addition the stigma associated with participation in public assistance programs may affect access as well food security is access by all people at all times to enough food for an active healthy life food insecurity exists whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain p 1560 food insecurity is a risk factor for all types of malnutrition food deficiencies excess or imbalance of energy as well as under and over nutrition like being overweight or obese due to insufficient intake and overconsumption of highcalorielownutrientdense foods food insecurity is more prevalent in urban areas immigrant communities and among racialethnic groups which are tied to lack to equity of resources leading to poor health outcomes that during periods of economic downturn tend to increase in addition systemic inequities drive food and nutrition insecurity differences between racial and ethnic groups highlight a lack of equity that may lead to health disparities among foodinsecure populations housing security is defined as availability of and access to stable safe adequate and affordable housing and neighborhoods regardless of gender race ethnicity or sexual orientation p 99 housing insecurity is a lack of access to safe affordable and quality housing and it includes homelessness housing instability poor housing conditions and low household or neighborhood safety housing insecurity is a determinant of multiple highrisk behaviors and poor health outcomes among adults and it also contributes to several low health outcomes among children in the united states approximately one in 10 college students is homeless and 45 live in an unsafe environment with a wide range of challenges related to housing affordability and stability the relationship between education and health at both individual and regional levels is salient in the united states accessibility to colleges and universities has increased in the past 50 years resulting in demographic composition changes with more lowincome firstgeneration racial and ethnic minority students enrolled than ever before nationally the demographic characteristics of university students are shifting and it is becoming more common for students to have children and work fulltime while enrolled as fulltime students food insecure students are also more likely than food secure students to experience housing insecurity gain weight while attending college partake in unhealthy diets with higher sugar and fat content and experience psychological distress among higher education students basic needs insecuritywhich includes food and housing insecuritycontributes to poor academic and health outcomes food and housing security is a basic need and if students needs are not met then they will be unable to engage in higherlevel learning basic needs insecurity among college and university students is associated with several negative health outcomes including decreased cognition and sleep quality increased rates of certain chronic diseases higher body mass index higher odds of stress and depression more emergency room visits and hospitalizations and higher mortality rates a study by college and university food bank alliance revealed that 30 of college students in the us are food insecure and 56 of these students are employed 75 receive financial aid and 43 participate in some type of campus meal plan in addition 36 are housing insecure a number that increases to 51 for community college students and 14 of students are homeless the growing cost of campus tuition health care books transportation and living expenses have resulted in students having to decide between paying for bills or securing food forcing some students to leave college without obtaining degrees with financial concerns as the primary cause the covid19 pandemic exacerbated the financial challenges for many us households higher unemployment due to lockdowns and social distancing measures resulted in new or worsening economic barriers to basic needs security in addition public transportation was disrupted due to social distancing requirements presenting a physical barrier to obtaining food for millions of americans while young people are less vulnerable to severe illness from covid19 their education work and social lives have been interrupted by the pandemic these interruptions have important consequences for public health including an increase in anxiety and depressive symptoms and increased risk of psychiatric diagnosis beyond mental health the combination of covid19 and food insecurity was found to promote gut anomalies which could have acute or longterm health implications for infections and chronic conditions importance of university response to fs and hs it is critical to improve our understanding of the impact of the covid19 pandemic on food and housing security among higher education students by measuring changes in basic needs security for this population we can prepare for the likely public health and social consequences in the short and medium term furthermore by identifying the key factors that are associated with food and housing security we can more effectively direct limited resources to the students who are most in need and improve student academic outcomes in the long run in this article we analyze fs and hs among higher education students the paper focuses on variables of importance that contribute to food and housing security to highlight some of the differences that coincided with the covid19 pandemic in conclusion we make recommendations for other institutions experiencing similar effects of the pandemic on student food and housing security materials and methods procedure in 2019 and 2020 online surveys were administered to students via a university platform to collect analyze and translate data in real time author and coauthors prepared the study protocol and instrument which was piloted in the focused population by a trained interviewer and student feedback from the pilot survey helped inform the final version of the survey questions using a customer relationship management program survey invitations were sent to all students at the hsi in fall 2019 and fall 2020 the student population over the age of 18 enrolled at the university in 2019 was 25177 and in 2020 was 24879 four emails were sent by crm including the initial invitation and three reminders in both years participants who voluntarily accepted to be in the study consented electronically and completed the survey online the survey contained 3036 questions took approximately 10 min to complete was anonymous and was open for at least 16 days each year participants had the option to enter a raffle for four 75dollar electronic gift cards a total of 6484 participantswho met the inclusion criteria of being at least 18 years old and enrolled at the university at the time of studycompleted the survey in 2019 and 12536 participants completed the survey in 2020 measures both surveys contained questions that provide key measures of food security housing security and potential determinants of these outcomes among survey respondents to measure fs authors used the validated survey questions and scoring procedures from the sixitem short form of the us department of agriculture household food security survey module the usda survey questions ask about different aspects of household food security in the past 12 months and each response option corresponds to a score the responses to the sixitem usda survey were scored summed and categorized using the validated food security status groups reported in bickel et al the resulting three categories of fs are very low fs low fs and high or marginal fs to measure hs two survey questions were adaptedusing input from college students in the target populationfrom the los angeles community college district survey of student basic needs the two hs measures were most suitable for the population of interest given the characteristics of their sample and our community the first hs survey question was in the past 12 months have you had a permanent address a yes response indicates higher hs whereas a no response indicates lower hs the second hs question was have you had to spend a night in any of the following hotel or motel home or room of a friend or acquaintance home or room of a family member shelter transitional living center public spaces like library abandoned buildings or a car higher frequency responses indicate lower hs whereas lower frequency responses indicate higher hs for measures of potential determinants of fs and hs the survey asked questions on income education employment age gender raceethnicity transportation and living situation for the survey question on gender respondents were asked to indicate their preferred pronouns some of the standard questions were taken or adapted from the los angeles community college district survey of student basic needs to meet our community characteristics the study was irb approved as exempt in september 2019 and amended and approved in 2020 and it was launched by the universitys dean of students office data cleaning and validation all identifying information from the survey data was removed to protect confidentiality of participants as well as responses with fully missing data a missing value analysis was conducted for the remaining data in order to detect any further missing answers or patterns of missingness however data was deleted since missingness was not random but exhibited strong patterns following this analysis the observations that did not have levels recorded for food and housing security were deleted from the data this results in a reduction in data as shown in figure 1 consort diagram following this preprocessing stage the data was readied for analysis by matching 28 variables common to both surveys some minor editing of variable levels was conducted in order to match results of the surveys this was minor and inconsequential in each case except for household income where each year was aggregated to two levels since the levels provided as choices did not match with higher granularity finally the usda categories for food security were programmatically created using the six measures included in each years survey these categories were validated by the usda and are used for reporting out food security results statistical analysis descriptive statistics of the variables to both years were tested for association with the usda food security outcomes and the housing security outcomes when the factor was continuous a simple f test from an anova model was used to detect any difference in the means when the data were categorical exact fisher tests with simulated pvalues were used to test for association these tests results were summarized with pvalues in the analysis following the statistical tests data visualizations were utilized to probe important factors that differ across the years when a factor was deemed significant in 2020 but not 2019 we summarized this outcome using an appropriate visualization to understand the nature of the shift all analyses were conducted in r and made use of the ggplot2 and summary packages results initial analysis implies that food security increased from 2019 to 2020 and there is some evidence that housing securityas measured by a permanent addressincreased as well the housing security results are mixed because a higher percentage of respondents reported experiencing a lack of any address in 2020 the housing and food security results are complex and due to a variety of factors some of which may be temporary in nature we explore the factors below and we return to these findings in the discussion to investigate the intersectionality of food and housing security across 2019 and 2020 regarding gender ethnicity age food security results according to the survey results several variables have a different relationship with food security across survey years in table 2 there is a change in the employment status across the 2019 and 2020 cohort and its association with food security 04 pvalue 0001 figure 2 illustrates the change in employment status across the 2 years note that the level no was not an option in 2019 and hence excluded additionally the location of employment differs in association across the years 0001 pvalue 02 figure 3 illustrates this change in association finally also regarding employment the level of employment is also different across years 03 pvalue 0001 as demonatrated in figure 4 in general for the variables about employment status there were more parttime employed students and fewer students working on campus during the pandemic than before moreover the association between this and being food secure was associated with employment variables regarding variables focused on student characteristics there was an association now between academic level and food security that did not exist prior to the pandemic more senior and junior students were having issues with food security relative to other academic levels the number of dependents also was no longer associated with food security 0002 pvalue 06 this was indicated particularly by less impact by number of dependents finally other students characteristics were associated with food security across both data collections housing security results the survey results also demonstrate changes in relationships between some key variables and housing security across survey years significant with the exception of enrollment regarding housing security there was a slight difference in association for employment status and housing security 003 pvalue 008 this indicates that more fulltime students were housing secure during the pandemic as depicted in figure 7 ethnicity also indicates a decrease in hispaniclatino students during the pandemic who have permanent housing as shown in figure 8 0001 pvalue 013 other variables were and remain to be associated with housing security across 2019 and 2020 discussion the results suggest that food security and one dimension of housing securitypossessing a permanent addressimproved among university students in the 2019 and 2020 samples specifically levels of high or marginal food security increased from 44 in 2019 to 55 in 2020 levels of very low food security decreased from 32 in 2019 to 23 in 2020 and possessing a permanent address increased from 89 in 2019 to 95 in 2020 in contrast for the second measure of housing security there was an increase in the percentage of students who reported that at least sometimes they lacked any address despite the pandemics upheaval of academic economic and social structures our findings demonstrate that fewer students at this hsi experienced very low food security and low housing security during the first year of the pandemic we are unable to determine why food and housing security improved among university students during the pandemic but social assistance interventionsincluding the expanded efforts by the government community organizations and the universitymay have played a key role it also is important to note that the percentage of students in the sample who lived off campus with family increased from 70 in 2019 to 80 in 2020 which could account for some of the increase in food security below we highlight some key factors that are associated with student food and housing security across 4 employment status and other related employment variables were altered during the pandemic nationally many who had worked fulltime reduced their employment to parttime status or no employment this change in employment status along with a halting on payment plans for student loans and the financial assistance provided by the cares act may have affected the changes in association with food and housing security the results figure hours worked per week and food security suggest that educational and higher education institutions need to shift to providing more employment opportunities to students on campus when possible and consider that many students are still struggling to adjust to the end of cares funding and will need additional income generating opportunities it is important to emphasize that the student population at an hsi is not monolithic key differences in food and housing security exist across subgroups for example regarding housing security it is evident that hispanic students experienced a decreased access to permanent housing prepandemic 84 of hispanic students had access to permanent housing and during the pandemic it decreased to 77 this presents an opportunity for higher education and educational institutions to address this change by providing support services centered on locating affordable housing on and off campus considering this evidence it is recommended that educational institutions be flexible and responsive regarding needs for affordable and accessible housing and university leaders may want to target information campaigns to vulnerable student groups overall the article has some important strengths food and housing security is assessed among students at an hsi students so the results fill a key gap in our understanding of food and housing security in higher education in addition the article presents food and housing security data both before and during the pandemic by assessing food and housing security in two different time periods the article improves our understanding of how food and housing security changed after the start of the pandemic furthermore the study has high survey response rates the high response rates by students may be due to the use of a trusted online survey platform and convenient email distribution methods previous studies often have low percentages of hispanic recommendations along with other forms of social assistance university interventions can play an important role in addressing basic needs and inequities among hsi higher education students given the biopsychosocialeconomic factors and stressors associated with the covid19 pandemic it is imperative to provide students with continued financial psychological and support services to mitigate the mediumand longterm effects of the pandemic government tuition and relief support programs are needed to help students in their education to provide nutrition and housing to struggling students and to improve the quality of life of the community tailored interventions are needed to address stigma associated with accessing psychological counseling food and housing support services and to meet students cultural and linguistic realities to assist with student retention and academic success it is key to reduce barriers such as chronic hunger and sustained risk of unstable housing food distribution centers on campus are key environments to assist students in acquiring enough nutrientdense food to overcome dietary limitations and reduce health disparities it is important to orient students on public assistance and other campus and community resources to increase fs and hs including the existence and eligibility of the supplemental nutrition assistance program special supplemental nutrition for women infants and children medicaid childrens health insurance program and local food banks and hunger relief centers in the informational campaigns a special emphasis should be placed on reaching vulnerable student subgroups including those who work are head of household have children receive health and human services and have limited or no transportation instructors can provide information on assistance resources in the course syllabus programdepartment web pages and social media pages the establishment and promotion of campusbased programs and services through noquestionsasked food distribution and assistance venues for students is necessary it also is essential to develop and implement food housing and financial security tools for higher education students so that the university can provide programming on campus to promote a secure campus environment with visual appeal a comprehensive safety net and culturally and linguistically responsive services based on the study results and the reviewed literature we conclude that it is important to bring access and excellence university shifted to provide a range of financial assistance and support services pantry was one of the few sites that remained operational due to the essential service it provided campus pantry adapted its model to seek donations through social media and a digital platform where donors could browse purchase and send nonperishable items delivered directly to campus additional investments in the pantry by the university to help meet growing student needs and expanded its efforts by providing grocery store gift cards and donating additional holiday gift baskets to ensure that students had sufficient food during long holidays in addition the foster homeless and adopted resources program provided financial and other support services for students with severe housing insecurity pantries with perishable frozen and nonperishable items of high nutritional value with online and pick up options open an integrated eligibility office to enroll in snap and other public benefits offer nutrition and health promotion education through professionals to orient on nutrients and meal preparation collaborate up with campus food services food banks and communitybased organizations to bring hot meal kitchen services to campus inform of external food distribution centers and housing assistance sites generate and disseminate directories of housing food transportation health and human services online and hard copies identify and participate in health fairs and community events to promote food and housing security post event announcements on the online and bulletin boards campus venues and student health centers reduce stigma surrounding use support services ensure that course syllabus includes resource links to food housing transportation and other support services and encourage faculty to promote access offer regular tours to faculty staff and student advisors of the university food pantry and foster homeless and adopted resources and promote access motivate faculty staff and students to visit the support services on campus to demystify and mitigate stigma secure grants financial or inkind support from private and public donors and funders to increase the food banks nutritious options and make campus food services affordable to students rename campus food pantry based on student input to make to more inclusive conduct ongoing food and housing security assessments to inform campus leadership on way to address social and political determinants create opportunities for communityengaged scholarship engage faculty staff and students in the development and implementation of a food and housing security strategy designate student ambassadors or advisors in campus colleges and schools to promote food housing and transportation security institutionalize support services generate policies to secure and expand nutritional food services and improve access to affordable housing transportation and health services develop a food housing and financial security toolkit to guide programming on campus ensure adequate space equipment and personnel for food storage and distribution include the food pantry and student support services in university interactive maps and expand h of operation evenings and weekends to meet the needs of working students study limitations the study contains some key limitations the crosssectional study design limits our ability to make causal inferences regarding key factors and food and housing security also the selfreported instrument relies primarily on subjective responses from students which may be biased furthermore foodand housinginsecure students may be less likely to respond to a survey which will overestimate food and housing security levels despite these limitations the findings from this study have several important implications for research practice and policy conclusion the current study contributes to the literature on food and housing security in higher education by focusing on college studentsboth before and during a pandemicat an hsi higher education plays an important role in the generation of social capital mobility and health to ensure that university students thrive academically succeed socially and ultimately graduate it is necessary to ensure that education institutions secure food and housing assistance for marginalized and vulnerable populations designing programs and policies with input from students is essential if we want to increase the utilization of assistance and prevent hunger and homelessness being responsive to changes in food or housing security also is crucial and requires concerted work to achieve multidisciplinary and collaborative work is required to mitigate food insecurity on campus advance health and academic outcomes improve the oncampus food and housing environments and provide subsidized food options to facilitate equitable access to food these efforts require guidance from health professionals including nutritionists to assist students with meal preparation and budgeting skills ensuring equitable access to healthy food and affordable housing on campus is essential future research can evaluate the use and effectiveness of campus resources in improving food and housing security of university students the challenges of the pandemic create an opportunity for universities to strengthen food and housing security among students economic and health crises do not guarantee increased levels of basic needs insecurity instead higher education institutions can shift to a new more comprehensive model of food and housing assistance the model shift will improve student basic needs security and academic outcomes increase opportunities for higher education and upward social mobility and create stronger and more successful communities 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 human participants were reviewed and approved by university of texas at el paso the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

university students occupy a socially marginal position and therefore are often underserved by academic and service institutions this article analyzes food and housing security among students at the university of texas at el paso a hispanicserving institution located in the usmexico border region findings of a sample of n university students are presented in the first crosssectional twoyear food and housing security study on campus administered via platform campus labs baseline the first sample in consisted of n students representing of student enrollment total enrollment and the second sample in was n representing of student enrollment total enrollment to measure food security the sixitem short form of the us department of agriculture usda household food security survey module was used to document housing security we created questions informed by student input in this study survey results are reported and tests are conducted to assess the relationships between various student characteristics and food and housing security student characteristics significantly impacting food and housing security are probed further using data visualizations and subpopulation analysis with a focus on analyzing factors impacted by the covidpandemic results indicate that employment status consistent employment status hours per week academic level number of dependents and gender are all factors associated with food security during the pandemic but not prior to the pandemic other factors including college a liation ethnicityrace having any dependents and being head of household living alone mode of campus transportation and mode of the transportation household income and age all were associated with food security in both academic years using these results a critical analysis of past interventions addressing food and housing security is presented with a focus on frontiers in public health frontiersinorg wagler et al fpubh changes made during the pandemic recommendations are made for further datadriven interventions and future steps

introduction sexual minorities experience pervasive health disparities associated with stigma discrimination and violence 1 2 3 4 chronic stress stemming from these social contexts of stigma discrimination and violence contributes to health inequities 35 for example a national us study reported that lesbian gay and bisexual persons had higher risk for the onset of posttraumatic stress disorder than heterosexuals in part due to lgb persons elevated exposure to interpersonal violence 6 lesbian bisexual and queer women experience sexual violence at similar eg adult sexual assault or higher rates than heterosexual women 7 8 9 10 11 12 13 14 there is an urgent need to better understand the interplay between sexual violence health outcomes individual social and structural factors among lbq women sexual violence among sexual minority women although study findings highlight that lbq women experience health disparities and are particularly vulnerable to certain types of violence there is a dearth of lbq populationspecific information about types and correlates of sexual assault 68 a recent systematic review by rothman et al 14 explored prevalence rates for various types of sexual assault victimization including lifetime sexual assault childhood sexual assault asa intimate partner sexual assault and hate crimerelated assault and concluded that these types of violence were elevated for lgb populations for example although estimates from the united states indicate 1117 of women have experienced lsa 1516 systematic review results reported lesbian and bisexual women had prevalence rates of lsa from 16 to 85 14 the wide variance was in part attributed to study design with populationbased studies reporting lower rates of sexual violence in comparison with convenience samples as well as widely varying sampling methods and definitions of sexual assault and sexual orientation 14 friedman et als 9 metaanalysis indicated that female sexual minorities were 15 times more likely to have experienced csa than female heterosexuals although lb women were more likely than gaybisexual men to report csa asa lsa and ipsa lb women remain greatly underrepresented in sexual violence research in comparison with gb men 14 few studies assess the gender or sexual orientation of perpetrators of sexual violence among lb women and this is also true for ipsa studies where there is a knowledge gap regarding whether perpetrators were same or oppositesex partners 14 social and structural contexts of health among sexual minority women systematic reviews and populationbased studies highlight elevated risks for mental health issues among sexual minority women social ecological approaches explore the complex associations between health disparities and social and structural environments 1718 health outcomes are shaped by individual social and structural level factors 18 for example numerous studies indicate higher rates of depression among sexual minority women in comparison with heterosexual women 13 19 20 21 sexual stigmaa structural factorhas been associated with these higher rates of depression 3 and psychological distress 22 sexual stigma refers to social and institutional processes of devaluation of sexual minority identities communities and samesex relationships 23 forms of stigma include perceived or feltnormative stigma that refers to awareness of negative societal attitudes and fear of discrimination and enacted stigma such as overt acts of discrimination and violence 2324 internalized homophobia refers to individuals acceptance of negative beliefs views and feelings toward the stigmatized group and oneself 2324 experiences of sexual violence may also be correlated with depression 13 and ptsd 625 among lesbians internalized homophobia was associated with ptsd among gay male 26 and lesbian 27 sexual assault survivors among heterosexual women sexual violence appears to be consistently correlated with alcohol abuse yet the pattern with lbq women appears to be different for instance one study found that among lbq women csabut not asawas positively associated with alcohol abuse 10 limited research has examined physical and sexual health correlates of lsa among sexual minority women childhood sexual abuse was associated with functional pain in a us based cohort study of sexual minority youth 28 functional pain refers to pain without a diagnosed pathology such as headaches abdominal and pelvic pain 28 another study reported that a history of csa was associated with the likelihood to engage in sexual risk behaviors in adolescence and adulthood thus contributing to hiv and sexually transmitted infections risk among mostly heterosexual c h logie et al young women 29 sexual abuse was also correlated with hiv risk behaviors among lb students in a us and canadian cohort study 30 response strategies to sexual violence among sexual minority women sexual minority and heterosexual women tend to have passive response strategies following incidences of sexual violence they either do nothing or only tell someone they trust as opposed to authorities that can intervene 831 however some researchers argue that sexual minority women are better at coping with violence as a result of managing the stigma of being a sexual minority and subsequently developing stronger support networks 7 although the literature indicates that lbq women do access certain support services there are barriers to access for lbq women concerns regarding stigma and discrimination may result in lbq women choosing not to disclose their sexual orientation to healthcare providers 3233 the experiences of lbq women accessing care may also differ based on sexual identity for instance bisexual and mostly heterosexual women may feel uncomfortable accessing services for lesbians 30 similarly lesbians may feel uncomfortable accessing services that are perceived to be for heterosexual women 731 study goals and objectives we aimed to address two important gaps in the literature in this study first scant research has explored the impact of lsa among sexual minority women 14 sexual violence research with lbq women has predominately focused on prevalence rather than the impact of such violence on various dimensions of womens lives including sexual and mental health outcomes 7 second most studies among sexual minority women have not explicitly measured the associations between lsa and structural factors such as sexual stigma and barriers to health care the social ecological approach of understanding individual social and structural factors associated with lsa among sexual minority women therefore warrants further exploration our study was informed by the social ecological framework the objective of this study was to contribute to understanding regarding associations between experiences of lsa and health outcomes individual factors social factors and structural factors among sexual minority women in toronto canada methods study design and population we conducted a structured crosssectional internetbased survey with sexual minority women in toronto canada in december 2011 inclusion criteria for survey participants were adults aged 18 and over capable of providing online informed consent who selfidentified as a women a sexual minority andor a women who has sex with women including lesbian gay bisexual queer other and residing in the greater toronto area we hired 10 peer research assistants defined as someone who identifies as a sexual minority women to facilitate participant recruitment pras represented diverse ages ethnicities and sexualities data collection we used modified peerdriven recruitment where each pra recruited a prespecified number of participants as well as convenience sampling whereby participants could invite additional participants recruitment was primarily undertaken by pras through word of mouth and emails to social networks lgbtq agencies and ethnocultural agencies there was an email that briefly outlined the study purpose and inclusion criteria that included a direct link to the survey this email was distributed by pras and agencies we used a selfadministered survey that participants completed online in a location of their choosing the survey took 60 min to complete we aimed to recruit 425 participants the recommended sample size for logistic regression correlates of sexual assault among sexual minority women is 406 as calculated using g power 31 research ethics board approval was obtained from womens college hospital at the university of toronto we designed a survey to collect information on sociodemographic variables health outcomes individual social and structural factors we pilottested the survey with a focus group of sexual minority community representatives to acquire feedback to enhance clarity and content validity no identifying information was collected participants had the option to choose to include their email address to receive a 20 gift card as honorarium for survey completion email addresses were erased after the gift card was sent at the end of the survey participants were provided with a list of community and online resources for sexual minority women and health and supportive services measures we report measures used and cronbachs alpha coefficients from the current analyses the survey included 105 items measures were chosen based on conceptual relevance for the social ecological framework established reliability and validity in the north american context and where possible among lgbq persons and shortened scales where possible to reduce participant burden we summed scale items to calculate total scores for sexual stigma depression safer sex practices resilient coping subscale and total scores were calculated for social support the intervals for the measures were one unit lifetime sexual assault we used a single dichotomous item in your life have you ever experienced forced sex to assess if participants had a history of lsa health outcomes participants selfreported if they had ever been diagnosed with an sti selfreporting of hivsti history was effective in a previous study with lbq women in the united states 34 the twoitem patient health questionnaire2 was used to assess depression symptoms 35 cronbachs a ¼ 089 participants rated their health using single global selfrated health response recommended by the world health organization 36 sociodemographic variables we collected the following sociodemographic information age annual personal income sexual orientation ethnoracial identity and highest level of education individual factors resilient coping was measured using the brief resilient coping scale 37 cronbachs a ¼ 069 selfesteem was measured using the singleitem selfesteem scale that has participants respond the statement i have high selfesteem on a fivepoint likert scale 38 substance use was assessed using an eightpoint likert scale singleitem measure regarding frequency of drug and alcohol use in the past 3 months social factors safer sex practices were measured using the safer sexual behaviors among lesbian women scale 39 cronbachs a ¼ 070 the social support measure was based on the multidimensional scale of perceived social support 40 that includes subscales to assess support from family friends and a significant other structural factors the sexual stigma measure was based on the homophobia scale 5 that includes subscales to examine both perceived and enacted stigma participants responded to questions asking if they had ever received an hiv test and an sti test participants also responded to questions asking if they had ever experienced the following barriers to accessing health care cost travel cost medications and belief that their hcp was not comfortable with their sexual orientation data analysis we conducted descriptive analyses to calculate frequencies means and standard deviations for each variable data analyses were conducted using ibm spss 20 cronbachs alpha was conducted to assess scale reliability for each scale we conducted logistic regression analyses based on the social ecological framework to examine sexual violence and its association with health outcomes individual social and structural factors multivariate logistic regression analyses were conducted to determine correlates of having experienced sexual assault in ones lifetime we first conducted unadjusted logistic regression analyses followed by analyses that controlled for sociodemographic variables we also present relative risks for significant variables to illustrate the probability of the outcome for those who have a history of lsa in comparison with those with no lsa results study population there were 439 women who participated in the survey 415 completed the item on lsa and were included in the analyses sociodemographic and health characteristics of participants are described in table i the mean participant age was 3144 and the median annual income was 29 00000 most participants identified as queer followed by lesbian bisexual gay and other almost half of participants reported having experienced sexual assault onefifth of participants reported ever being diagnosed with an sti correlates of having experienced sexual violence logistic regression results are presented in table ii discussion this studys examination of correlates of experiences of lsa among lbq women revealed deleterious health outcomes associated with lsa including exacerbated risk for depression sti and lower selfrated health our findings that individual social and structural factors were associated with lsa support the utility of the social ecological framework to understanding lbq womens experiences of sexual violence a social ecological conceptual framework that incorporates these multilevel domains associated with lsa among lbq women is illustrated in fig 1 we categorized multilevelstructural social individualfactors and health outcomes correlates of sexual assault among sexual minority women united states 14 our findings that lsa was associated with reported higher mean frequencies of depressive symptoms and prevalence of sti and lower mean frequencies of selfrated health and selfesteem corroborate previous research the negative effects of sexual assault are well documented and include ptsd in up to 50 of sexual assault survivors and concurrent depression 6132141 our findings that lsa was correlated with lower selfrated health align with roberts et al 28 us based cohort study findings with sexual minority youth that reported associations between functional pain and csa 28 indeed our study found associations between lsa and higher sti rates supported by previous research with samples of predominately heterosexual 4243 and sexual minority 29 women we found lower selfesteem was associated with lsa selfesteem has been associated with csa 44 similar to another study with lesbians we found no significant association between substance use and sexual violence 10 despite the disproportionate rates of sexual violence experienced by sexual minority women in comparison with heterosexual women we found no other studies that explicitly measured associations between lsa and perceived or enacted sexual stigma our findings that lsa was correlated with higher reported mean frequencies of overall perceived and enacted sexual stigma suggests that sexual violence may be associated with experiences perceptions and subsequent expectations of homophobia and discrimination the belief that ones hcp was uncomfortable with their sexual orientation is another example of a structural barrier experienced by lbq women with a history of lsa this finding is corroborated by research that highlights heterosexism in womens sexual health care 4546 fear of discrimination from disclosing sexual orientation to hcp 3233 and discomfort utilizing services not tailored for their sexual orientation 72931 other barriers emerged for participants who experienced lsamedication costseven when controlling for income and education this suggests that factors such as sexual stigma and fear of discrimination may enhance perception of other barriers to healthcare access despite these barriers those with a history of lsa did in fact access sti testing more frequently than those without a history of lsa we are not aware of research that has explored this phenomenon other research however suggests that coping with stigma and discrimination has resulted in utilization of services by lbq women for example some authors have suggested that as a result of having had to cope with sexual stigma lbq women tend to access therapy at a higher rate than heterosexual women 71013 lbq women who have experienced lsa may therefore be more accustomed to accessing healthcare services and this may also be viewed as a strategy of resilience those with a history of lsa reported lower mean frequencies of overall social support and social support from family this could be associated with sexual stigma from family members due to their sexual minority identity 4748 lower levels of family social support could also be associated with a history of csa especially if the perpetrator was a family member or close to the family family support is often compromised with divided loyalties or outright disbelief when the accused perpetrator is a family relation or friend 49 structural factors social factors individual factors health outcomes fig 1 social ecological approach to understanding correlates of lsa experienced by sexual minority women in toronto canada c h logie et al participants with a history of lsa were more likely to identify as queer than lesbian there is very little understanding of the interplay between lsa and sexual orientation previous studies with young women reported higher rates of csa 29 and lsa 30 among women who identified as mostly heterosexual or bisexual 938 in comparison with those identifying as heterosexual austin et als 29 thoughtful discussion regarding possible reasons for sexual orientation differences in rates of sexual assault include response bias sexual identity formation and different risk factors first a woman identifying as queera fluid sexual orientation that moves beyond the dichotomies of lesbian heterosexual 50 may be more willing to report sexual violence than other women as they may feel less stigma about having forced sex with men second depending on when sexual assault occurred it could influence sexual identity formation 29 for example adopting a queer identity rather than a lesbian one could be more congruent with a history of lsa third persons identifying as lesbian may have more positive group identity and social support than those with other sexual minority identities such as mostly heterosexual 28 and this strong group identity and support may reduce vulnerability to abuse by parents adults and youth 5152 the interplay between sexual orientation and lsa warrants further attention the study design has several limitations first the nonprobability sample limits the generalizability of findings the sample was recruited by diverse pras but oversampled white lbq women our sample included approximately onethird visible minorities while almost onehalf47 of persons in the city of toronto are visible minorities 53 our sample also had higher education levelswith almost 65 holding a bachelors degree or higherthan the general population of toronto where 33 hold a bachelor degree 54 the online survey method may have contributed to oversampling lbq women with access to internet and computerwritten literacy meyer and wilson 55 discussed a digital divide in the united states where persons with internet access were more likely to be white the online survey method and sampling strategy may therefore have introduced selection bias second because of the crosssectional survey design we could not assess causation therefore a longitudinal design could be more conducive to understanding the relationships between sexual violence mental and sexual health outcomes and sexual stigma as we did not measure ptsd it is possible that higher rates of depression were associated with ptsd stemming from sexual assault in addition we did not measure internalized homophobiathis could have enhanced our understanding of sexual stigma correlates of lsa third we only had one sexual violence occurrence question limiting understanding of age and frequency for which sexual violence occurred gender of perpetrator and the number of perpetrators we did not explore whether sexual violence occurred within a relationship or differentiate between the types of sexual violence fourth our measure of resilient coping may not have adequately captured the complexity of resilience the ability to cope with multiple risks or access to multiple resources 5657 fifth we used a single item question regarding substance use that did not differentiate between alcohol and other substances precluding an indepth understanding of this phenomenon among participants given these limitations further research could engage more diverse samples of lbq womenperhaps using both on offline methods explore additional resilience and substance use measures and include more detailed questions regarding types and perpetrators of sexual violence despite these limitations our study has several strengths first this study contributes to theoretical development by exploring health outcomes and individual social and structural factors associated with lsa among lbq women our findings support the utilization of a social ecological approach to better contextualize sexual violence and its impacts among lbq women second to our knowledge this is the first study to demonstrate associations between enacted and perceived sexual stigma with lsa among lbq women third this study highlighted the importance of understanding barriers to correlates of sexual assault among sexual minority women accessing health care and the need for training hcp to demonstrate traumainformed lgbtq affirmative practice enhanced understanding of correlates of lsa among lbq women can inform the development of multilevel interventions to promote health and reduce stigma and violence our findings suggest that lbq women who have experienced lsa have unique health needs as they may be particularly vulnerable to sexual stigma depression sti and report lower selfesteem and selfrated health these myriad health challenges require a syndemics approach that targets the interaction between these risk factors to allay the health impacts of lsa 9 on a microlevel interventions could focus on counseling to build strategies to cope with experiences of sexual violence as well as address selfesteem internalized sexual stigma depression and sti prevention 929 mesolevel interventions could foster peer support and solidarity and address family issues to illustrate support groups for survivors of lsa could address the particular needs of lbq women who may have less social support from family due to sexual stigma on a macrolevel interventions could focus on enhanced competence among providers across a range of systemseducational mental and sexual health social servicesto better support sexual minorities and provide referrals to lgbtq community resources 930 clinicians should practice from a traumainformed approach that screens all patients for a history of sexual assault 1430 for example as lbq women who have experienced lsa may be more likely to offer sti testing sexual health clinics could screen patients for a history of sexual violence and provide resources for support and counseling practice competence must involve an understanding of the fluidity and multiplicity of sexual identities such as queer that are not captured in standard categorizations of lesbian bisexual gay or heterosexual identities 2829 programming should also promote empowerment and engage youth and others in advocacy 9 communitybased approaches and interventions to challenge sexual stigmaand sexual violenceare urgently needed 14 putting into practice strategies that concomitantly build coping address depression and sti risk challenge sexual stigma within community norms and healthcare practice and reduce violence can promote health and wellbeing among sexual minority women conflict of interest statement none declared

stigma discrimination and violence contribute to health disparities among sexual minorities lesbian bisexual and queer lbq women experience sexual violence at similar or higher rates than heterosexual women most research with lbq women however has focused on measuring prevalence of sexual violence rather than its association with health outcomes individual social and structural factors we conducted a crosssectional online survey with lbq women in toronto canada multivariate logistic regression analyses were conducted to assess correlates of lifetime sexual assault lsa almost half 42 of participants n ¼ 415 reported experiences of lsa participants identifying as queer were more likely to have experienced lsa than those identifying as lesbian when controlling for sociodemographic characteristics experiencing lsa was associated with higher rates of depression sexually transmitted infections stis receiving an sti test belief that healthcare providers were not comfortable with their lbq sexual orientation and sexual stigma overall perceived and enacted a history of sexual violence was associated with lower selfrated health overall social support family social support and selfesteem this research highlights the salience of a social ecological framework to inform interventions for health promotion among lbq women and to challenge sexual stigma and sexual violence

raceethnicity related stressors stressors that are a function of the cultural background and the context of the individual that are unique to being a member of a racialethnic minority group can make racialethnic minority young adults susceptible to tobacco and marijuana use for example perceived racialethnic discrimination is a type of racialethnic stress that has been linked to increased smoking and higher odds of lifetime marijuana use the national conference on tobacco and health disparities highlighted a need for researchers to examine the social and cultural context of tobacco use among racialethnic groups past research has also stressed the problematic perspective of viewing tobacco or marijuana use as an isolated problem rather than being viewed as a part of a larger more complicated picture that includes social and cultural components additionally health promotion researchers note that culturally specific interventions are important in addressing smokingrelated health disparities culturally specific interventions refer to the degree to which ethnicity attitudinal and behavioral norms shared beliefs history and environment are integrated into the intervention for example the pathways to freedom is a smoking cessation guide developed for african americans that incorporates known smoking patterns of african americans religious quotes pictures of african americans and emphasizes family and community definitions of culture vary but for the context of this paper we focus on raceethnicity and the shared characteristics within these groups whichcomprise religion language and nationality the historical experiences of different racialethnic groups create unique physiological and social characteristics that can include lifestyle and value systems past research examining cultural variables has primarily focused on racialethnic minority individuals in relation to the dominant culture or mainstream us culture however an individual can also experience stress emanating from tensions within their own racialethnic groupthis phenomenon known as intragroup marginalizationrefers to the perceived interpersonal distancing by members of ones racialethnicgroup when the individual diverges from racialethnicnorms deviating from racialethnicnorms can create a backlash whereby group members reject or distance themselves from the individual the interpersonal distancing occurring from intragroup marginalization can be viewed as a social sanction placed on the individual and can take the form of teasing and criticism intragroup marginalization is based on social identity theory suggesting that group members marginalize ingroup members when they do not conform to group standards in order to maintain the uniqueness and stability of the group group members displaying behaviors or attitudes that conflict with group norms can be perceived as threatening the distinctiveness of the group and can then be marginalized in order to preserve the groups distinctiveness intragroup marginalization may be experienced by any racialethnic group additionally family friends and other racialethnic members in the community can all impose group norms and engage in the process of intragroup marginalization limited research suggests intragroup marginalization may lead to higher levels of acculturative stress or stress associated with adapting to a new culture and increased alcohol use among young adults past research while not directly investigating intragroup marginalization has made potential links betweenfamilial and peer stresswith tobacco and marijuana use foster and spencer suggest thatmarijuana and other drug use may underlie a deeper need for connection in the absence of close familial connections for marginalized young adults or young adults that have been rejected by their families these young adults may be seeking opportunitiesto connect and create a sense of belongingand marijuana use can play a common and significant social role in building supportive and caring relationships researchers further contend that investigation is needed to better understand how culture impacts these young adultsdrug use currently intragroup marginalization is measured using the intragroup marginalization inventory which is comprised of three separate scales measuring perceived intragroup marginalization from the heritage culture family friends and other members of the individuals ethnic group the inventory is comprised of 42items rated on a 7point likert scale the scale items were developed so that the scale could be tailored to any ethnic group while the scale is comprehensive the length of the survey can make it difficult for researchers to distribute the entire inventory with many opting to use only one scale in their research in practice this has limited studies of intragroup marginalization to focus either onfamily members or friends rather than examining both due to the length of the survey the feasibility of using the measure in largescale studies or with large sample sizeshas been limited most studies using the inventory havelimitedsample sizes focused on one racialethnic group greater sample sizes allow for segmentation of the data across demographic characteristics reduce the margin of error and provide the statistical power to conduct more advanced analysesin addition some items may have less applicability for certain groups such as items related to linguistic expectations lastly the inventory was developed and validated with a college population and hasnotbeen validated with noncollege populations tobacco and marijuana use are problematic for all young adults and intragroup marginalization may be an important factor in understandingtobacco and marijuana disparities in this population as a wholeyetwithout an efficient means to assess intragroup marginalization this important construct will continue to remain absent within health disparities research current study limited research addresses whether shared cultural values or feelings of marginalization may help explain high rates of tobacco and marijuana use among young adults the purpose of this study is to provide a psychometrically sound abbreviated measure of intragroup marginalization such a measure would have great utility when survey length is of concernand the survey needs to be distributed across diverse racialethnic groups this study tests and validates an abbreviated measure of the intragroup marginalization inventory which we refer to as the imi6 the imi6 consists of six items that measure perceived intragroup marginalization from the heritage culture family and friends the items of the imi6 are hypothesized to have content validity as items were taken directly from the existing scale which has already been found to have content validity and were selected in consultation with the survey developer and by the primary author whoseresearch focuses on racialethnic minority issues and intragroup marginalization in specific we hypothesize that the imi6 also has construct validity whichwe establish in this study through exploratory factor analyses in addition to testing the feasibility of using this abbreviated measure a primary aim of this study was to apply the imi6and examine relationships between intragroup marginalization and tobacco and marijuana use we hypothesize that participants reporting more experiences of intragroup marginalization would be more likely to use cigarettes ecigarettes cigars blunts hookahs and marijuana method item selection the original intragroup marginalization inventory consists of three scales family friend and ethnic group the scales have a common factor structure and while there are slight differences in items and factor names they fall into five general factors homeostatic pressure linguistic expectations and accusations of assimilation accusations of differentiation and discrepant values the imi6 consists of six items that measure perceived intragroup marginalization from the heritage culture family and friends the original scale developer provided consultation during item selection ultimately reviewing and approving the final six items items were selected based on the researchersand developers experience with the survey as well as those items that had the greatest applicability to a diverse pool of respondents and were broad enough to remain appropriate for different racialethnic groups items from the accusations of assimilation and linguistic expectations factors were not included as they contained items that were tailored to specific racialethnic groups items from the homeostatic pressure were similar to items from the accusations of differentiation factor however items from the homeostatic pressure focusedsolely on the individuals behavior while items from the accusations of differentiation included items assessing both behaviorand appearance the selected items were taken from the discrepant values factor and the accusation of differentiation factor of the full inventory two items were taken from the discrepant values factor assessing whether family and friends have the same hopes and dreams as the respondent four items were taken from the accusation differentiation factor assessing whether family and friends accuse the respondent of not really being a member of ones ethnic group because she does not look like and act like members of the group responses were rated on a 7point likert scale ranging from never does not apply to extremely often items 3 and 6 were reverse coded so that higher numbersrepresentgreaterexperiences of intragroup marginalization items were piloted with 45 young adults from the san francisco bay area participants were recruited from local bars on a thursday friday and saturday evening to be interviewed that same weekend and received a 75 incentive if they participated in a onehour focus group completed the pilot questionnaire and engaged in an interview with project staff to share feedback about the questionnaireindividuals reviewed the item clarity and representation of their experiences no items were altered and participant feedback suggested that the selected items accurately captured participant experiences participants and procedure samplethis study used data we collected in 2014 as part of the san francisco bay area young adult health survey a probabilistic multimode household survey of 1826 year old young adults stratified by raceethnicity the study was conducted in alameda and san francisco counties in california we identified potential respondent households using address lists from marketing systems group in which there was an approximately 3040 chance that an eligible young adult resided at a selected address we used 20092013 american community survey and 2010 decennial census data in a multistage sampling design to identify census block groups and then census blocks in which at least 15 of residents were latino or nonhispanic black adults in the eligible age range ultimately we randomly selected 61 blocks then households within these blocks then young adults within eligible households we oversampled these blocks because young nonwhite urban adults are among the most difficult populations to survey and we wished to ensure appropriate population representation we surveyed in three stages and utilized four modes of contact in the first stage we conducted a series of three mailings with sample 1 households respondents returned paper questionnaires or completed surveys online using qualtrics in the second stage we telephonedthose who did not respond to mail and lastly we performed facetoface interviews with a random selection of the remaining nonresponders from sample 1 as well as all of the households identified in sample 2 potential sample 2 respondents did not participate in the mail or telephone phases of the survey each of these households was visited in person the final sample consisted of 1363 young adult participants for a response rate of approximately 30 with race sex and age distributions closely reflecting those of the young adult population overall in the two counties surveyed ethnicityrace was measured using items from the census bureaus american community survey instrument with participants first asked to identify if there were hispanic latino or spanish origin and then to select their race from 14 categories raceethnicity was then collapsed into mutually exclusive categories including hispanic nonhispanic white nonhispanic black nonhispanic asianpacific islander and mixed race those who selected more than one raceethnic category were categorized as mixed racewe constructed individual sample and poststratification adjustment weights during data reduction measures outcomeswe evaluated associations between intragroup marginalization and current use of cigarettes cigars blunts hookah ecigarettes and marijuana each outcome measure was dichotomized and set equal to 1 if a respondent reported using the product in question at least once in the past 30 days main explanatory variables covariates age in years since birth was measured continuously sex was measured dichotomously with male set equal to 1 and female to 0 and maternal education was set equal to 1 if the respondents mother had completed at least a bachelors degree and 0 otherwise raceethnicity was measured as an indicator variable with mutually exclusive categories including hispanic nonhispanic black nonhispanic asianpacific islander and mixed race we restricted our analysis to young adults in these categories excluding nonhispanic white as the intragroup marginalization inventory has only been used and validated among nonwhite populations previously and endorsement of intragroup marginalization was not expected among this population the resulting number of observations was 1058 or 78 of the total sample statistical analysis to examine the items in the abbreviated measure we conducted an exploratory factor analysisdue to the exploratory nature of our analysis we chose to conduct an efa rather than confirmatory factor analysis cfa is useful to extract latent factors from a set of items based on an a priori theory this requires a strong empirical or conceptual foundation and a prespecification of the number of factors pattern of factor loadings as we are using these items in a relatively innovative fashion we wanted to determine without specifying a structure how the items were relatedwe conducted an efa using an oblique geomin rotation in mplusefa methods typically follow rules of thumb with factor loading cutoff criteria rangingfrom 30 to 55 to establish a solid factor loading coefficient we used a cutoff value of 55 in this studythe number of factors retained was based on eigenvalues 1 internal consistency was examined by computing cronbachs α for theentire measure and each subscale second we fit multinomial logistic regression models using sas surveylogistic to account for the complex survey design this was repeated with six dichotomous outcomes in two steps1 unadjusted analysis and 2 controlling for race ethnicity age sex and mothers highest education results sample information weighted percentages and standard error of percent are presented in table 2 approximately onethird of the sample retained for analysis was latino 40 was nonhispanic asianpacific islander 15 was nonhispanic black and the remaining 10 reported being of two or more racesclose to half of all participants endorsed feeling marginalized by friends because they did not look or act like members of their racialethnic group approximately a quarter of participants endorsed feeling marginalized by family members because they did not look or act like members of their racialethnic group most participants reported having similar hopes and dreams as their friends and family exploratory factor analysis and internal consistency the efa indicated two factors as show in table 3 every item loaded above 060 on at least one factor factor 1 might be described as looking or acting like your ethnic group and was composed of items friends and peers in my ethnic group tell me i am not really a member of my ethnic group because i dont look like my ethnic groupfriends and peers in my ethnic group tell me i am not really a member of my ethnic group because i dont act like my ethnic groupfamily members tell me i am not really a member of my ethnic group because i dont look like my ethnic group and family members tell me i am not really a member of my ethnic group because i dont act like my ethnic groupfactor 2 appears to represent hopes and dreams and was composed of the two items friends and peers in my ethnic group have the same hopes and dreams as me and my family has the same hopes and dreams as methe cronbachs α for the entire imi6 was 066 cronbachs αs were computed for each subscale and found to be factor 1 81 and factor 2 071 mean imi factor scores by raceethnicity are presented in table 4 a regression analysis was conducted to determine mean differences in imi factor sores by raceethnicity a significant difference in means scores was found by raceethnicity for factor 1 f 2002 p 001 r 2 004 latinos had greater mean scores for factor 1 than nonhispanic blacks t443 p 01 and nonhispanic asianpacific islander t 381 p 01 mixed race individuals had greatermean scores for factor 1 than nonhispanic blacks t 500 p 01 and nonhispanic asianpacific islander t 299 p 05 no significant difference in means scores was found by raceethnicity for factor 2 f 181 p022 r 2 0005 imidiscriminant validity nonhispanic whites were not expected to report intragroup marginalization and not included in the factor and regression analyses as the full inventory has only been used and validated among nonwhite populations todemonstrate the discriminant validity of the measure two ttests were conducted nonhispanic whites were compared to the rest of the sample on the two factors nonhispanic whites experienced significantly lower scores on discrimination for both factor 1 and factor 2 326 vs 371 p 0001 imi6in unadjusted logistic regressions results varied by outcome such that no significant relationship was found between the two factors and cigarette use ecigarette use orblunt use however factor 1 was related to hookah marijuana and cigar use higher scores on factor 1 were related to higher odds of hookah use and marijuana use but lower odds of cigar use factor 2 was related to lower odds of hookah use imi6 in multinomial logistic regressions when controlling for raceethnicity age sex and mothers education the results were consistent with the unadjusted models except that factor 1 and 2 were no longer associated with hookah use no significant relationships were found for cigarettes ecigarettes or blunts when adjusting for covariates factor 1 and 2 were no longer associated with hookah use however the associations with marijuana and cigar use were robustfactor 1 was associated with increased odds of marijuana use and lower odds of using cigars discussion results support the use of an abbreviated measure of intragroup marginalization the imi6 was found to be psychometrically sound and representative of the full construct of intragroup marginalization as theorized by castillo and colleagues two factors emerged from the abbreviated scale the first factor encompassed items related to belonging and membership capturing whether individuals felt marginalized due to deviations in their physical appearance or behaviors the second factor encompassed whether the individual shared similar hopes and dreamsas their families and friends thesefactors reflected similarly identified factors from the validation study of the full inventory scales suggesting good agreement between the original measure and the abbreviated version examining racialethnicdifferences in mean scores across factors demonstrated significant differences in factor 1 latinos and mixed race young adults experienced greater intragroup marginalization related to not looking or acting like members of their racialethnic group compared to nonhispanic blacks and asian americans pacific islanders the full intragroup marginalization inventory was developed with a diverse sample and past research has explored intragroup marginalization with african americans asian americans and latinos however specific racialethnic differences have not been examined latinos may be particularly susceptible to intragroup marginalization given the heterogeneity among latinos in terms of national origin physical appearance political ideology immigration status and class status in particular latinos can encompass different racial groups which can contribute to differences in appearance one of the concepts captured in factor 1 physical appearance can limit the extent to which people are accepted as belonging to a certain racialethnic group which is also especially relevant for multiracial individuals whose physical appearance may not align with any specific ethnicracial group additionally multiracial individuals describe feeling marginalized from peers rooted in having different appearance culture andor beliefs than their peers explaining the higher rates of intragroup marginalization observed in this study research examining young adult tobacco and marijuana use often relies on college samples thereby neglecting individuals in this age group that may be at greater risk of substance use the intragroup marginalization inventory which may have particular utility with young adults who are negotiating the stresses of transitioning to adulthood was also developed and tested with a collegeonly sample this study validates an abbreviated version of the imi the imi6 which was developed to capture tensions experienced within racialethnic groupswe tested the imi6in a large representative household sample of raciallyethnically diverse young adults in the san francisco bay area in order to better understand the impact of cultural stressors on tobacco and marijuana use among young adults in general when controlling for demographic characteristics factor 1 was associated with greater marijuana use participants who felt that they did not look or act like members of their racialethnic group demonstrated increased oddsof marijuana use young adults who feel marginalized by family members or friends may seek to find a way to belong and connect with other young adults and marijuana use may be a way to find belonging within a group this parallels research which suggests that the decision to engage in marijuana use comes from an internal need for emotional connection and friendship and as an opportunity to connect and create a sense of belonging other research has identified marijuana as a more acceptable substance viewed as superior and safer than other substances marijuana may be the substance of choice to build connection with others and combat feelings of intragroup marginalization if marijuana use is perceived as a means for social connection it mayhelp to explain the findings between factor 1 and cigar use when controlling for demographic characteristics participants who felt as though they did not look or act like members of their racialethnic group haddecreased odds of cigar use cigarswere the least frequently used product within the sample retained for analysisnational averages parallel this trend with current cigar use having lower prevalence than to cigarettes and marijuana for young adults if marginalized young adults seek to connect with others via substance use cigar use may not be the best mechanism by which to connect with others and therefore they may be less likely to use cigars the combination of low rates of use and potential lack of opportunity to build social connection may help explain the decreased odds of cigar use this finding is unexpected and further research is needed to better understand the relationship between intragroup marginalization and cigar use similarly cigarette ecigarette blunt use and hookah use had lower rates compared to marijuana use while unexpected cigarette ecigarette and blunt use were not associated with experiences of intragroup marginalizationthis may be due in part to the lower rates of use it is worth noting that blunt use was examined independently although it is often associated with marijuana use and in this sample most blunt users also reported concurrent marijuana use additionally the use of these substances may be less tied to social use and therefore their use may not be linked to developing ways of belonging past research has differentiated between social smoking and smoking alone studies have suggested that young adults not in college may be less likely to be social smokers and social smoking may not be prevalent across racialethnic groups this study did not differentiate between social smoking and smoking alone and may be another important factor to better understand the role of intragroup marginalization and tobacco use intragroup marginalization was associated with higher hookah use however when controlling for raceethnicity this association was no longer significant due to racialethnic differences while hookah use has been noted as a means for socializing and is often smoked ina group setting this may be population specific hookah use is common in middle eastern countries and has strong cultural underpinnings middle eastern young adults experiencing intragroup marginalization may use hookah as a means to connect and fit in within their cultural group furthermore african americans have been found to have lower rates of use compared to other ethnicracial groups additional research may be needed to further investigate differential impacts of intragroup marginalization on hookah use ethnicracial group factor 1 captures the challenges young adults face when they feel they do not fit in with members of their ethnicracial group young adults experiencing this may desire to find ways to gain membership and connection with others while factor 1 focuses on difficulties in belonging and membership factor 2 centered on shared values and dreams feeling marginalized due to a lack of similar hopes and dreams was not associated with tobacco or marijuana use this finding supports the theory that young adults use these substances as a means of building belonging and connection while having dissimilar hopes and dreams may be stressful it may not necessarily indicate one does have any connection to others given these findings the scale may be able to be further abbreviated by dropping factor 2 particular when examining tobacco and marijuana use future research may be needed to further investigate impacts of factor 2 on other health outcomes despite the strengths of this research there are important limitations to notethis study focused on young adults in the san francisco bay area and findings may be not be generalizable to all young adults however by using populationbased sampling we were able to obtain a representative sample which past research has noted the difficulty in reaching urban young adults this study also utilized a crosssectional design preventing any potential inference concerning causality tobacco and marijuana use were measured using selfreport data and use was not biochemically verified while past research has demonstrated the reliability and validity of selfreported smoking in anonymous surveys with young adults this validation has not extended to noncigarette tobacco productsthis may be a potential area for future research this study examined intragroup marginalization among mixed race young adults a populationoften overlooked in intragroup marginalization studies mixed race participants were not required to identify which group served as the primary source of intragroup marginalization however it is possible that different cultural norms around tobacco and marijuana use could influence whether intragroup marginalization impacted behavior oyserman and colleagues have demonstrated the identitybased motivation ofhealth behaviors with racial ethnic minorities more likely to identify unhealthy behaviors with their group additional research may be needed with mixed race individuals to better understand how different groups may impact the relationships between intragroup marginalization and tobacco use a final limitation is that we did not directly assess reasons or motivations for use future qualitative research is needed to explicitly examine motivations for use as a result of experiences of intragroup marginalization this study provides the first quantitative examination of intragroup marginalization with tobacco and marijuana use results respond to recent calls to better understand motivations for young adult marijuana use with findings demonstrating an association between intragroup marginalization and increased marijuana usethese findings are especially relevant given the changing climate regarding the legalization of marijuana with california just recently voting to legalize marijuana results reaffirm existing arguments that drug policy must attend to the social and cultural contexts of use additionally findings respond to existing calls in the literature to better understand how culture impacts use past intervention research has highlighted the importance of attending to peer smoking behavior and norms providing further support for the need to attend to social dynamics when addressing young adult tobacco and marijuana use additional research is needed to further investigate the relationship between intragroup marginalization and marijuana use which can help in the tailoring and development of targeted health education programs mean differences of imi factor scores by raceethncity

tobacco and marijuana use among us young adults is a top public health concern and racial ethnic minorities may be at particular risk past research examining cultural variables has focused on the individual in relation to the mainstream us culture however an individual can also experience withingroup stress or intragroup marginalization we used the 2014 san francisco bay area young adult health survey to validate an abbreviated measure of intragroup marginalization and identify associations between intragroup marginalization and tobacco and marijuana use among ethnic minority young adults n1058 exploratory factor analysis was conducted to identify factors within the abbreviated scale and logistic regressions were conducted to examine relationships between intragroup marginalization and tobacco and marijuana use two factors emerged from the abbreviated scale the first factor encompassed items related to belonging and membership capturing if individuals experienced marginalization due to not fitting in because of physical appearance or behavior the second factor encompassed whether individuals shared similar hopes and dreams to their friends and family members factor 1 membership was associated with increased odds of marijuana use or 134 p 05 and lower odds of using cigars or 079 p 05 controlling for sociodemographic factors results suggest that young adults may use marijuana as a means to build connection and belonging to cope with feeling marginalized health education programs focused on ethnic minority young adults are needed to help them effectively cope with intragroup marginalization without resorting to marijuana useethnic minority young adults intragroup marginalization tobacco marijuana tobacco and marijuana use among us young adults is a top public health concern chen jacobson 2012 young adults use both substances at higher rates than any other age group

introduction to cope with the ongoing threat of infectious disease it is common for governments to implement public health guidelines aimed at preventing or limiting community spread of a pathogen many of which focus on health protective behaviors although adherence to such guidelines is expected to have both societal and individual benefits evidence suggests that sizable subsets of the population fail to adhere to recommended health protective behaviors during pandemics thus it is imperative to identify factors that relate to lower adherence to recommended health protective behaviors in the context of pandemics that substance use is motivated by desires to increase social affiliation individuals may be more willing to violate social distancing recommendations to meet these needs substance use may also reduce risk perceptions of disease thereby reducing motivation to adhere to social distancing recommendations finally many substances have a disinhibiting effect that may interfere with decision making and increase the likelihood of noncompliance with social distancing and other health protective behaviors notably one factor that may account for reduced adherence to social distancing recommendations among individuals using substances during this pandemic is low selfefficacy for adhering to these recommendations defined as beliefs in ones own ability to engage in a particular behavior selfefficacy is theorized to play a key role in the initiation of and engagement in subsequent behaviors and has been identified as a primary factor influencing engagement in protective health behaviors within prominent models of health behavior thus consistent with these theories perceptions of ones ability to adhere to social distancing recommendations would be expected to influence both actual and intended engagement in these behaviors with regard to the relation of substance use to selfefficacy for adhering to social distancing recommendations studies have consistently shown that greater substance use frequency is associated with lower selfefficacy in general and for specific health protective behaviors substance use would also be expected to decrease selfefficacy for adhering to social distancing recommendations in particular specifically the need for facetoface interactions to obtain certain substances as well as heightened urges to use substances in social contexts may decrease expectations that one is capable of adherence to social distancing likewise repeated experiences with violating social distancing recommendations due to the disinhibiting effects of substances would also be expected to reduce selfefficacy for social distancing thus this study examined the explanatory role of social distancing selfefficacy in the relation of substance use frequency to adherence to social distancing recommendations and social distancing intentions during the early stages of the covid19 pandemic to this end we examined the prospective relations of substance use frequency at the initial assessment to both adherence to social distancing recommendations onemonth later and intentions to adhere to these recommendations in the following two weeks as well as the role of social distancing selfefficacy in these relations we hypothesized that baseline substance use frequency would be negatively associated with social distancing selfefficacy adherence to social distancing recommendations and social distancing intentions onemonth later in addition we hypothesized that social distancing selfefficacy would account for significant variance in the relations of baseline substance use frequency to both social distancing behaviors and intentions onemonth later method measures substance use frequency the drug use questionnaire was used to assess baseline substance use frequency at the initial assessment participants indicated the frequency with which they used 12 substances during the past month on a 5point likerttype scale the duq demonstrates good construct and convergent validity items were summed to create a total score of baseline substance use frequency social distancing selfefficacy social distancing selfefficacy at onemonth followup was assessed via a 3item measure created for this study participants were asked to rate three items assessing their perceived ability to follow us social distancing recommendations on a 5point likerttype scale items were summed to create a total score of social distancing selfefficacy adherence to social distancing recommendations adherence to social distancing recommendations at onemonth followup was assessed using a 5item selfreport measure created for this study and derived from the theory of planned behavior participants were asked to report on engagement in recommended social distancing behaviors over the past two weeks on a 5point likerttype scale items were summed to create an overall index of adherence to social distancing recommendations at followup intentions to adhere to social distancing recommendations in the future intentions to adhere to social distancing recommendations in the two weeks after the onemonth followup were assessed via a 5item measure created for this study and derived from the theory of planned behavior participants were asked to report their intentions to engage in the aforementioned recommended social distancing behaviors over the next two weeks on a 5point likerttype scale items were summed to create a total score representing social distancing intentions clinical covariates the depression anxiety stress scales21 was used to assess symptoms of depression and anxiety at the initial assessment participants rate items on a 4point likerttype scale the dass21 has adequate reliability and convergent and discriminant validity procedures all procedures received approval from the universitys institutional review board to ensure the study was not being completed by a bot participants responded to a completely automatic public turing test to tell computers and humans apart prior to providing informed consent initial data were collected in blocks of nine participants at a time and all data including attention check items and geolocations were examined by researchers before compensation was provided participants who failed one or more attention check items were removed from the study those whose data were considered valid were compensated 300 onemonth following completion of the initial assessment participants were contacted via cloudresearch to complete the followup assessment of the 500 participants who completed the initial assessment 77 completed the followup participants who failed two or more attention check items were removed from the study the rest were compensated 300 in addition two participants were excluded for invalid data and four were excluded for extensive missing data on the measures of interest resulting in a final sample size of 377 results preliminary analyses descriptive statistics for and correlations among all variables of interest are presented in table 1 the most frequently reported substances at the initial assessment were alcohol followed by marijuana prescription sedatives and prescription opioids with 44 of participants reporting regular use of alcohol and 133 reporting regular use of marijuana to identify covariates for primary analyses we examined associations of relevant demographic and clinical characteristics to the outcome variables given significant associations of age sex and depression and anxiety symptoms to adherence to social distancing recommendations at followup these variables were included as covariates in this model consistent with hypotheses baseline substance use frequency was significantly negatively associated with social distancing selfefficacy and adherence to social distancing recommendations at the onemonth followup however it was not significantly associated with intentions to adhere to social distancing recommendations at followup additionally social distancing selfefficacy was significantly positively associated with both adherence to social distancing recommendations and intentions to adhere to social distancing recommendations primary analyses next we examined the indirect relations of baseline substance use frequency to both adherence to social distancing recommendations and social distancing intentions at 1 3 onemonth followup through social distancing selfefficacy using the process macro for spss indirect relations were evaluated using biascorrected 95 confidence intervals based on 5000 bootstrap samples providing partial support for study hypotheses results revealed a significant direct relation between baseline substance use frequency and adherence to social distancing recommendations one month later consistent with hypotheses results revealed significant indirect relations of greater baseline substance use frequency to both lower adherence to social distancing recommendations and lower social distancing intentions at the onemonth followup through lower social distancing selfefficacy discussion to extend extant research on the factors associated with nonadherence to recommended health protective behaviors during pandemics this study aimed to examine the prospective relations of substance use frequency to both adherence to social distancing recommendations and future social distancing intentions onemonth later during the early stages of the covid19 pandemic in the us as well as the explanatory role of social distancing selfefficacy in these relations consistent with study hypotheses results revealed a significant direct relation of baseline substance use frequency to lower adherence to social distancing recommendations onemonth later this finding provides support for the premise that substance use may increase noncompliance with social distancing recommendations during the covid19 pandemic and is consistent with past research suggesting that frequent substance use is associated with poor adherence to protective behaviors in other contexts notably however and contrary to predictions substance use frequency did not have a significant direct relation to intentions to engage in social distancing behaviors in the weeks following the onemonth followup thus findings suggest that substance use may interfere with adherence to social distancing recommendations despite intentions to engage in such behaviors this discrepant pattern of findings may capture the difficulties complying to social distancing recommendations posed by substance use which may prompt engagement in risky behaviors that go against ones selfinterest for the purpose of obtaining or using substances with regard to the theorized role of social distancing selfefficacy in the relations between substance use frequency and both adherence to social distancing and social distancing intentions results provided support for study hypotheses revealing significant indirect relations of greater substance study identify substance use as one factor that may negatively influence adherence to social distancing during the covid19 pandemic via lower social distancing selfefficacy as the covid19 pandemic remains an ongoing public health crisis and evidence suggests the increased likelihood of future pandemics of this kind identifying promising targets for interventions aimed at increasing engagement in health protective behaviors in the context of pandemics is critical results of this study highlight the potential utility of interventions targeting substance use and social distancing selfefficacy use frequency to lower levels of both social distancing behaviors and intentions onemonth later through lower social distancing selfefficacy these findings are consistent with recent research highlighting the role of selfefficacy in both social distancing behaviors and intentions during the covid19 pandemic and extend this research to a substance use context several limitations of this study warrant consideration first the generalizability of our findings to more severe substance use or the use of illicit substances like heroin or cocaine remains unclear another limitation is the exclusive reliance on selfreport questionnaire data which may be influenced by social desirability biases or recall difficulties future research should incorporate other assessment methods to further clarify the nature of the relation of substance use and social distancing during this pandemic further although our use of a prospective design facilitates examination of the associations of baseline substance use frequency to both adherence to social distancing recommendations and social distancing intentions onemonth later we were not able to examine the interrelations of substance use social distancing selfefficacy and social distancing behaviors and intentions over time likewise we cannot speak to the temporal relations among these factors and whether social distancing selfefficacy predicts social distancing behaviors or intentions research incorporating the repeated assessment of these factors over more extended time periods is needed to clarify the precise interrelations among these factors over time including their likely reciprocal influences future research should also examine adherence to other health protective behaviors such as maskwearing and vaccinations beyond the risks associated with substance use in general substance use in the context of a pandemic may be particularly risky insofar as it interferes with adherence to recommended health protective behaviors results of this data availability data for this study is available upon reasonable request to drs matthew t tull or dr kim l gratz authors contributions all authors contributed to the study conception and design material preparation and data collection was performed by all authors data analysis was performed by kayla scamaldo kim gratz and matthew tull the first draft of the manuscript was written by kayla scamaldo and kim gratz all authors commented on previous versions of the manuscript all authors read and approved the final manuscript conflicts of interestcompeting interests the authors have no competing interests to declare that are relevant to the content of this article ethics approval all procedures performed in this study were in accordance with ethical standards of the institutional research committee and with the 19634 helsinki declaration and its later amendments or comparable ethical standards the study was approved by the university of toledo institutional review board consent to participate informed consent was obtained from all individual participants included in this study consent for publication not applicable publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations springer nature or its licensor holds exclusive rights to this article under a publishing agreement with the author or other rightsholder author selfarchiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law

the covid19 pandemic provides an ideal context for exploring this question specifically the unprecedented worldwide spread and impact of covid19 prompted the implementation of extraordinary social distancing interventions and highlighted the public health importance of widespread adherence to these guidelines yet given that individuals vary considerably in their adherence to social distancing recommendations coroiu et al 2020 making the identification of factors that may increase risk for nonadherence to these recommendations of utmost importance one factor that warrants attention in this regard is substance use consistent with evidence that substance use increases during periods of disease outbreaks eg lee et al 2018 increases in substance use were observed during the early stages of the covid19 pandemic grossman et al 2020 taylor et al 2021 in addition to the health risks associated with substance use in general obtaining and using drugs in the context of a pandemic may confer unique risks for contracting and transmitting the virus by interfering with social distancing for example some substances can only be obtained through facetoface interactions necessitating social contact moreover to the extent

introduction in april 2011 media reported that mothers had a mysterious disease at asan medical center in seoul south korea 1 six women were hospitalized in the respiratory intensive care unit before and after childbirth the symptoms were respiratory failure and pulmonary fibrosis 2 the patients were not from one area but from all over korea the korea center for disease control and prevention commissioned an epidemiological investigation to determine the cause of these unique symptoms the results showed that the humidifier disinfectant a biocide used by adding to the water in the humidifier was causing these diseases 12 according to the cdc humidifier disinfectants are absorbed into the body through the nose mouth and skin during respiration which has a deleterious effect on lung disease 2 approximately 998 million humidifier disinfectant products were sold from 1994 to 2011 these were distributed to unspecified people 3 the chemicals in the humidifier disinfectant were poly hexamethylene guanidine phosphate oligo 2 ethoxy ethyl guanidine chloride cholromethylisothiazolinone and methylisothiazolinone among others among them products containing cmitmit the most toxic chemicals have been sold since 1994 4 diseases caused by toxic chemicals take a long time to show if the toxic chemicals have caused actual health damage as they involve many variables such as the incubation period 5 it is difficult to accurately count the number of survivors of humidifier disinfectant damage as of september 2021 the government reported that the number of persons who claimed damage was 7540 including 1713 deaths 6 the humidifier disinfectants accumulate in the body damage lung cells and ultimately lead to widespread health impairments pulmonary fibrosis asthma and dyspnea are the main symptoms 7 in addition acute bronchitis pneumonia rhinitis interstitial pneumonia nonspecific otitis media chronic sinusitis chronic obstructive pulmonary disease acute sinusitis and acute bronchiolitis have been reported 8 in a study on mice it is reported that lung damage caused by repeated exposure to phmgp does not recover from structural changes caused by pulmonary dysfunction and pathology even after a long recovery period this suggests that the damage caused by humidifier disinfectants may also have longterm effects on survivors therefore plans to help survivors recover need to be considered in a longterm context 9 in addition to physical health the damage caused by humidifier disinfectant adversely affects mental health problems as for the mental health problems that occurred after exposure depression and helplessness were reported by 575 of individuals guilt and selfblame by 551 anxiety and tension by 543 suicidal thoughts by 276 and suicide attempts by 11 this indicates that survivors suicide attempts are 45 times higher than the general population 8 the deterioration of physical health impacts the survivor whereas mental health problems impact both the survivor and hisher significant others 10 moreover studies have shown that sociodemographic social and environmental factors should be considered in the psychological factors of victims of social disasters such as social support sociality and community cohesion 11 12 13 this indicates that the psychological pain of survivors should be understood from a sociodemographic perspective humidifier disinfectants can be classified as a social disaster and it is closely related to japans exposure to radiation in fukushima in that it had many random victims not only physically but also psychologically 14 studies argue that the mental and physical health of survivors are much more serious than those of the general group and require special attention 610 it is necessary to explore more clearly which variables are specifically related to survivors psychological difficulties this study aimed to examine the psychological health of humidifier disinfectant survivors and the general population next we examined the sociodemographic variables influencing survivors psychological symptoms specifically this study attempts to explore survivors psychological symptoms by gender economic status educational level and social variables such as the number of friends this study can serve as preliminary research to identify important variables when designing intervention strategies to improve survivors mental health issues method dependent variables psychological symptoms to measure the psychological symptoms the asr the adult version of the achenbach system of empirically based assessment 15 was used in this study along with mmpi2 asr is one of the most used personality assessments to measure psychological symptoms in south korea the asr was validated in korean and the convergent validity concurrent validity and discriminant validity of the korean version were confirmed 16 the psychological symptoms scale consists of eight syndrome subscales and is rated on a 3point likerttype scale the eight syndrome subscales are as follows anxiousdepressed withdrawn somatic complaints thought problems attention problems aggressive behavior rulebreaking behavior and intrusive the combination of anxiousdepressed withdrawn and somatic complaints is termed internalizing problems and the combination of aggressive behavior rulebreaking behavior and intrusive is termed externalizing problems anxiousdepressed subscale measures the feelings of being emotionally depressed overly worried and anxious and the sample items are i worry about my future and i cry a lot the withdrawn subscale evaluates withdrawal passive attitude and showing no interest in surrounding people i dont get along with other people and my social relations with the opposite sex are poor are the sample items the sample items of the somatic complaints subscale which assesses various physical symptoms despite no clear medical cause are i feel dizzy or lightheaded and i feel tired without good reason the thought problems subscale estimates unrealistic and bizarre thoughts and behaviors such as excessive repetition of certain actions and thoughts and seeing phenomena or hearing sounds that do not exist the sample items are i cant get my mind off certain thoughts and i hear sounds or voices that other people think arent there the attention problems subscale measures inattentive or hyperactive behavior and difficulty in making plans the sample items are i have trouble concentrating or paying attention for long and i daydream a lot the aggressive behavior subscale evaluates verbally or physically destructive behavior and hostile attitudes with i argue a lot and i blame others for my problems being examples of the items in the subscale the rulebreaking behavior subscale assesses impulsive engagement in problematic behaviors that do not follow rules or violate social norms at work or in society and i damage or destroy my things and i break rules at work or elsewhere are the sample items sample items of the intrusive subscale that estimate behavior that bothers or disturbs others are i brag and i try to get a lot of attention the internal consistency of the subscales ranged from 070 to 092 in this study independent variables four variables were utilized as independent variables gender educational level family economic status and number of friends gender was coded into two categories educational level was measured by one item asking about educational level and was coded into three categories family economic status was assessed by one item compared to the economic level of all households in korea which of the following would you say you belong to this single question was coded into three categories number of friends was measured by one item how many friends do you have besides family this single question was coded into two categories covariate variable because age is a continuous variable we included age as a covariate according to a previous study age is related to psychological symptoms younger adults scored significantly higher than older adults on anxiousdepressed somatic complaints attention problems aggressive behavior and intrusive 17 data analysis oneway multivariate analysis of covariance was conducted to compare dependent variables between the general and survivor groups moreover cohens d was calculated to determine the effect size for differences between the general and survivor groups effect sizes are considered small if d 02 medium if d 05 and large if d 08 18 then a series of twoway mancova was conducted to determine the main and interaction effects of independent variables on dependent variables the independent variables were gender educational level family economic status and number of friends the dependent variables were anxiousdepressed withdrawn somatic complaints thought problems attention problems aggressive behavior rulebreaking behavior and intrusive the covariate variable was age as eight dependent variables were conceptually related to each other the mancova which controlled correlations among dependent variables was suitable for the analysis results a oneway mancova with group as the independent variable age as the covariate and psychological symptoms as dependent variables was performed to compare the psychological symptoms of the general and survivor groups moreover cohens d was calculated to determine the effect size for differences between the two groups the covariate of age 7967 p 0001 η 2 0125 was statistically significant moreover a significant main effect for the group 28574 p 0001 η 2 0339 was found main effects were found for seven psychological symptoms anxiousdepressed f 152301 p 0001 withdrawn f 143436 p 0001 somatic complaints f 120920 p 0001 thought problems f 80489 p 0001 attention problems f 56567 p 0001 aggressive behavior f 86133 p 0001 and rulebreaking behavior f 9383 p 001 the results revealed that the survivor group displayed higher anxiousdepressed symptoms withdrawn symptoms somatic complaints thought problems attention problems aggressive behavior and rulebreaking behavior than the general group group differences in anxiousdepressed withdrawn somatic complaints thought problems and aggressive behavior indicated a large effect size next a series of twoway mancova were conducted separately with age as the covariate first the twoway interaction effect of group × gender was tested the covariate of age 8005 p 0001 η 2 0126 was statistically significant moreover a significant main effect was found for group 26002 p 0001 η 2 0319 and gender 3641 p 0001 η 2 0062 specifically main effects for gender were observed for somatic complaints f 5699 p 005 and rulebreaking behavior f 4451 p 005 female participants displayed more somatic complaints than male participants on the other hand male participants showed more rulebreaking behavior than female participants however the twoway interaction effect of group × gender was statistically insignificant 1309 p 0237 η 2 0023 second the twoway interaction effect of group × educational level was tested the covariate of age 7399 p 0001 η 2 0118 was statistically significant a significant main effect for group 17427 p 0001 η 2 0240 was found however the main effect for educational level 1033 p 0418 η 2 0018 and the twoway interaction effect of group × educational level 1615 p 0059 η 2 0028 were statistically insignificant third the twoway interaction effect of group × family economic status was tested the covariate of age 7837 p 0001 η 2 0124 was statistically significant a significant main effect of group 28546 p 0001 η 2 0341 and family economic status 3559 p 0001 η 2 0061 was observed moreover a significant twoway interaction effect of group × family economic status was found 2304 p 001 η 2 0040 specifically interaction effects were observed for five psychological symptoms anxiousdepressed f 4615 p 005 withdrawn f 10407 p 0001 thought problems f 7869 p 0001 attention problems f 7740 p 0001 and rulebreaking behavior f 5003 p 001 although the general groups psychological symptoms decreased as the family economic status increased the survivor groups psychological symptoms showed a different tendency in other words the upper family economic status group had the highest mean value for psychological symptoms followed by the lower and the middle groups fourth the twoway interaction effect of group × number of friends was tested the covariate of age 8428 p 0001 η 2 0132 was statistically significant a significant main effect for group 26403 p 0001 η 2 0322 and number of friends 9049 p 0001 η 2 0140 was observed in addition a significant twoway interaction effect of group × number of friends was found 2243 p 005 η 2 0039 the effects of twoway interaction were found on six psychological symptoms anxiousdepressed f 7069 p 001 withdrawn f 14408 p 0001 somatic complaints f 4785 p 005 thought problems f 5326 p 005 attention problems f 6389 p 005 and aggressive behavior f 9527 p 001 compared to the general group which showed a slight decrease in psychological symptoms with an increase in the number of friends the survivor group showed a prominent decrease in psychological symptoms as the number of friends increased discussion the first purpose of this study was to compare the psychological symptoms of humidifier disinfectant survivors and general groups to examine these differences a oneway mancova was performed the survivor group showed higher scores on seven psychological symptoms than the general group anxiousdepressed withdrawn somatic complaints thought problems attention problems aggressive behavior and rulebreaking behavior consistent with previous studies 19 that suggested that social disasters have a serious impact on the mental health of survivors the mean differences in scores between humidifier disinfectant disaster survivors and general groups in this study indicated that survivors experienced severe psychological difficulties it was also revealed that the greater the damage and the closer the relationship with the survivor the more severe the psychological trauma of the survivors as for the social aspect of survivors the findings of a metaanalysis study 20 showed that multilevel social support from the microsystem mesosystem and macrosystem need to be implemented to help survivors recovery therefore this study explored the effects of sociodemographic variables such as gender educational level family economic status and number of friends on psychological symptoms a series of twoway mancovas was conducted to determine the main and interaction effects of four demographic variables by groups on psychological symptoms among the four demographic variables the results indicated that educational level had no main effect on participants psychological symptoms studies have found mixed results regarding educational levels and psychological symptoms some studies reported that low educational level was related to increased behavioral problems 21 but other studies found that educational level was not related to behavioral problems 22 the findings of this study are consistent with the findings of latter studies that is the educational level of both humidifier survivors and the general group did not influence psychological symptoms we also examined the relationship between psychological symptoms family economic status and number of friends as factors of social resources family economic status and number of friends had significant main and interaction effects on psychological symptoms interestingly the interaction effects of family economic status and the two groups were also found for five psychological symptoms being anxiousdepressed withdrawn thought problems attention problems and rulebreaking behavior the psychological symptoms of the survivor group that were divided according to family economic status level showed a vshaped pattern while those of the general group showed a decreasing pattern as the family economic status level increased consistent with many prior studies that lower levels of family economic status was associated with higher levels of psychological symptoms 2324 our findings also show that individuals with lower family economic status have more severe psychological symptoms next survivors with high economic status have more severe psychological symptoms than those in other groups the results of the higher family economic status group imply that social comparison may contribute to psychological symptoms the results of the higher family economic status group could be explained by the theory of the big fish little pond effect herbert and john emphasized the importance of the frame of reference with the bflpe model according to the model individuals compare their own selfconcept with their peers and individuals have higher selfconcept when they are in a less capable group than in a more capable group even though they perform equally 25 although the bflpe model was originally intended to explain academic achievement it can be expanded and used to explain the psychological status experienced subjectively by individuals who compare relative satisfaction with those around them because survivors with a high economic status have more severe psychological symptoms than other groups it is important that psychologists and other such professionals focus on individuals subjective psychological damage rather than objectively measured ones the results provide implications for considering the subjective frame of reference for survivors by designing differential psychological interventions next there were significant main and interaction effects of the number of friends and two groups on six psychological symptoms anxiousdepressed withdrawn somatic complaints thought problems attention problems and aggressive behavior our results found that the level of psychological symptoms in both groups reporting that the number of friends being four or more was significantly healthier than the group with three or fewer friends the effects of the number of friends on psychological symptoms were more prominent in survivors than in the general groups that is friends support was more helpful for the psychological health of survivors than general groups consistent with previous studies 26 social relationships contributed to the psychological symptoms of survivors according to a metaanalysis study examining factors influencing posttraumatic stress response after a disaster social relationships were found to be beneficial in posttraumatic stress response in social disasters but not in natural disasters studies 2728 have reported that disaster survivors can improve their quality of life and return to their daily lives if they receive social support based on the research results it can be seen that formal and informal social support should be provided for the recovery of disaster survivors this study had some limitations first the sample of humidifier disinfectant survivors was relatively small although the sample was a representative group of humidifier disinfectant survivors the results should be cautiously interpreted therefore future studies should use larger samples second due to the small number of survivors analysis of various dimensions of variables such as dividing the number of friends more specifically into three groups was limited future studies are needed to diversify dimension of variables third the current findings are limited to data from one selfreported psychological assessment previous studies have shown that a survivors quality of life is affected by factors such as demographic characteristics physical health psychological characteristics and social support in an integrated way to expand the knowledge of survivors psychological status it is necessary to analyze their relationship with psychological health and additional data such as physical status diagnosed disease amount of damage compensation and degree of damage to the family member fourth the results are obtained from crosssectional data and it is necessary to analyze the psychological health of survivors longitudinally in the future despite these limitations the results of this study highlight survivors ability to recover the findings of this study are expected to provide information on psychological symptoms and aid in the provision of counseling for better outcomes in survivors of humidifier disinfectant disasters additionally to recover and improve survivors quality of life it is believed that a comprehensive support system is needed in consideration of psychological health as well as economic and environmental aspects data availability statement the data presented in this study are available on request from the corresponding author

this study aimed to compare the psychological symptoms of humidifier disinfectant survivors to the general population and explore sociodemographic factors influencing survivors psychological symptoms a oneway multivariate analysis of covariance mancova and a series of twoway mancova were conducted with a sample of 228 humidifier disinfectant survivors and 228 controls the results demonstrated that the survivor group displayed higher anxiousdepressed symptoms withdrawn symptoms somatic complaints thought problems attention problems aggressive behavior and rulebreaking behavior than the general group moreover among the sociodemographic factors the twoway interaction effects of group × family economic status and group × number of friends were found to be statistically significant the limitations and implications of this study are discussed

introduction the majority of people with dementia live at home with support from their family members if a partner is present he or she is usually the person who fulfills the role of primary informal caregiver 1 family caregiving plays an increasingly vital role in care for people with dementia in european countries like the netherlands since policies encourage people to call on their own social network in the first place supported by home and communitybased services in order to delay institutionalization 23 providing family care can be a serious burden for caregivers and can negatively affect their psychological and physical health especially among informal caregivers of persons with dementia 145 for instance caregivers of people with dementia show higher rates of depression anxiety sleeping disorders and physical morbidity including cardiovascular disease and lower immunity than noncaregivers for example 6 7 8 9 furthermore studies indicate that healthcare use is higher among family caregivers of persons with dementia compared to noncaregivers 610 the health of family caregivers is one of the most important predictors of institutionalization of the person with dementia 11 a majority of persons with dementia and their family caregivers prefer care at home 12 and institutionalized care increases healthcare expenses 13 it is therefore important to offer timely support to avoid deterioration of health in family caregivers and to enable them to maintain the care for their partner relative or friend with dementia as long as possible currently there is limited insight into the occurrence of health problems and changes in healthcare utilization in different stages of the care trajectory while information about this is essential in order to offer timely support to family caregivers furthermore studies of health problems in family caregivers have mainly focused on psychological health outcomes as opposed to physical health outcomes and have used relatively small and selective study samples without a comparison group there is a lack of evidence from large representative populationbased studies regarding the most prevalent psychosocial and physical health problems of partners caring for a person with dementia and including a matching comparison group 14 the aim of the current study is to provide insight into the prevalence of a wide range of psychosocial and physical health problems in cohabiting partners of persons with dementia that occur during the dementia care trajectory in addition this study aims to provide information on the frequency of contacts with the general practitioner during the dementia care trajectory the research questions for this study are 1 which health problems are most prevalent among partners of people with dementia in the year prior to the dementia diagnosis and in the 3 years after the dementia diagnosis and to what extent do these differ from health problems in comparable partners of persons without dementia does the prevalence of these health problems change over time 2 how often do partners of people with dementia contact their gp in the year prior to the diagnosis of dementia and in the 3 years after the diagnosis does this frequency differ from that in comparable partners and does it change over time based on the previous systematic reviews we expected • psychological health problems including for example depression anxiety and sleeping disorders to be more prevalent in partners of people with dementia than in the comparison partners • cardiovascular problems and immunity problems to be more prevalent in partners of people with dementia than in the comparison partners • the gp contact rate to be higher than for the comparison partners materials and methods data from national administrative databases were linked with electronic health record data from gps the data covered the year before and the 3 years following the dementia diagnosis this time frame was chosen since dutch data on dementia care trajectories have revealed that institutionalization in a longterm care facility often takes place approximately 35 years after the diagnosis is recorded in general practice 15 data sources ehr data from gps routinely recorded ehr data of gps participating in the nivel primary care database were used to retrieve data on psychosocial and physical health problems the nivel pcd collects pseudonymized ehr data on approximately 17 million individuals which are routinely recorded by a nationally representative network of gp practices spread throughout the netherlands 16 this includes data on diagnoses prescriptions number of consultations and referrals of all the patients who are registered with the participating gp practices diagnoses made by a specialist from a hospital or a memory clinic are also recorded by gps international classification of primary care coding is used to code contact diagnoses 17 and grouped into disease episodes 18 gps receive support in coding and feedback on the quality of recording 1920 in the netherlands the gp acts as the gatekeeper to specialist care and is therefore usually the first healthcare provider people contact in the case of health problems virtually all dutch residents are registered with a general practice administrative data data on sociodemographic characteristics the date of death and the date of institutionalization were derived from administrative data sources made available for research by statistics netherlands statistics netherlands is the governmental institution that is responsible for the processing of statistical population data in the netherlands sociodemographic characteristics and date of death originated from the municipal personal records database covering all persons residing in the netherlands the date of permanent institutionalization was derived from administrative data for the dutch national longterm care insurance scheme covering all institutionalizations of all dutch adults study population partners of persons with dementia partners of persons born in 1965 or before with a recorded dementia diagnosis between 2008 and 2015 were identified in the ehr data partners were included based on the following criteria living at the same household address living together with ≤5 persons at the same address and having an age difference with the person with dementia ≤20 years living together with more than 5 persons at the same address could imply that the person lives in a residential care home and these cases were therefore excluded if the age difference is 20 years it is more likely that the person in question is not the partner of the person with dementia therefore these cases were excluded households with more than 1 person with dementia were also excluded heide i van der heins m verheij r hout hjp van francke a joling k prevalence of health problems and healthcare use in partners of people with dementia longitudinal analysis with routinely recorded health and administrative data gerontoloy 2021 this is a nivel certified post print more info at nivelnl comparison group for every person with a recorded dementia diagnosis an independent researcher identified if available a maximum of 4 comparison persons without a recorded dementia diagnosis from the same general practice in the same age category of the same sex and living with a partner a maximum of 4 comparison persons was identified because a large comparison group increases the reliability of the findings the partners of these comparison persons were included as comparison partners in the current study neither the comparison persons nor their partners were diagnosed with dementia during the study period both were usually registered with the same general practice outcomes psychosocial and physical health problems the prevalence of psychosocial and physical health problems was operationalized as a morbidity or symptom as recorded in the partners or comparison partners ehr during a specific year gps can use a total of 685 different icpc codes to record diagnoses that are clustered into 17 icpc chapters reflecting different systems of the human body in this study we used 16 icpc chapters as health indicators if significant differences were found in the prevalence of specific icpc chapters between the partners and comparison partners further analyses were conducted to examine whether there were differences between the samples at the icpc level within that specific chapter frequency of gp contacts the frequency of gp contacts in each year was obtained from the ehrs contacts included medical consultations at the gps practice home visits and telephone consultations sociodemographics characteristics the following sociodemographic characteristics of the persons with dementia and their partners and of the comparison persons and comparison partners were described age gender and migrant status the migrant status was categorized as a western background or as a nonwestern migration background frailty a frailty index was created for the persons with dementia and the comparison persons in order to obtain an impression of their health condition the frailty index was created by screening the gps ehrs for 35 predefined relevant health deficits including icpc codes of diseases and symptoms and one deficit polypharmacy 21 the proportion of deficits present in an individual resulted in the frailty index score in accordance with prior studies people were classified into nonfrail prefrail and frail 22 23 24 date of death and date of institutionalization the date of death and date of institutionalization of the persons with dementia and their partners and of the comparison persons and comparison partners were determined to describe the proportion of persons who moved to a longterm care facility or died during the study period heide i van der heins m verheij r hout hjp van francke a joling k prevalence of health problems and healthcare use in partners of people with dementia longitudinal analysis with routinely recorded health and administrative data gerontoloy 2021 this is a nivel certified post print more info at nivelnl data linkage the gp data were pseudonymized at the source and linked to the administrative data at statistics netherlands after being securely transferred by a trusted third party 16 pseudonyms were based on the citizen service number or on a combination of date of birth gender and postal code the pseudonymized data were made accessible to the researchers through a secured remote access facility provided by statistics netherlands under strict privacy conditions statistical analysis descriptive statistics were calculated to describe the sample characteristics χ 2 and independent t tests were used to determine differences between sample characteristics the prevalence of the 16 icpc chapters and the frequency of gp contacts were calculated and described per year for both partners and comparison partners to examine whether the prevalence of health problems and the number of gp contacts differed significantly between the partners and comparison partners and to examine whether the prevalence of health problems increased or decreased over time generalized estimating equation models were fitted gee models take into account the correlation of different measures within subjects for each of the 16 icpc chapters a gee model for binary response variables was fitted with the measurement year partner group and the interaction term measurement year partner group as predictors if a significant difference was found between partners and comparison partners in the prevalence of icpc chapters gee models were fitted for all specific health problems that fell within those overarching icpc chapters only significant differences in specific health problems that occurred in at least 5 of the partners were considered relevant and only these differences are therefore reported in addition a gee model for count response variables was fitted to estimate changes over time in the number of gp contacts this model also had the measurement year partner group and measurement year partner group as predictors all analyses were based on study subjects who were registered at a gp practice for at least one entire followup year all analyses were conducted in spss version 15 figure 1 table 1 results sample characteristics figure 1 shows the inclusion of partners and comparison partners per year a total of 1711 partners and 6201 comparison partners were included in the analyses the mean number of followup years was 23 years in both groups the partners as well as the persons with dementia were slightly but significantly older than the comparison partners and the comparison persons without dementia the partners had a mean age of 75 and the comparison partners a mean age of 74 in both groups almost all of the partners were of western origin a significantly higher proportion of the partners of the persons with dementia cared for a frail person than the comparison partners and a significantly higher proportion of the persons with dementia moved to a longterm care facility or died during the study period than the comparison persons heide i van der heins m verheij r hout hjp van francke a joling k prevalence of health problems and healthcare use in partners of people with dementia longitudinal analysis with routinely recorded health and administrative data 3 show that musculoskeletal problems were most prevalent across the years in both the partner and the comparison partner group differences between partners and comparison partners were found for the following health problems • social problems were more prevalent in partners than in comparison partners the prevalence of social problems increased over time in both the partner and comparison partner group • within the social problems chapter we found problems with the illness of the partner to be more prevalent in partners than in comparison partners and in the prevalence of urological problems gp contacts in partners and comparison partners in the year before and the 3 years after diagnosis it was found that partners had more gp contacts than comparison partners across the years p 001 partners had 910 contacts per year throughout the study period whereas comparison partners had 78 contacts per year see figures 4 and5 in addition the number of gp contacts increased over time in the partner group but not in the comparison partner group discussion reflection on main findings this study provided insight into the most prevalent psychosocial and physical health problems among persons taking care of their partner with dementia during the year before the dementia diagnosis was recorded in the gps electronic medical records and the 3 years after the diagnosis these health problems were compared to the health problems of a matched comparison group we found musculoskeletal problems to be the most prevalent type of health problem across all years in both partners and comparison partners which is in line with international research that suggests that musculoskeletal problems are one of the most prevalent health problems in older people 25 musculoskeletal problems were more prevalent overall in partners than in comparison heide i van der heins m verheij r hout hjp van francke a joling k prevalence of health problems and healthcare use in partners of people with dementia longitudinal analysis with routinely recorded health and administrative data gerontoloy 2021 this is a nivel certified post print more info at nivelnl 7 partners which could be related to the provision of family care but might also be related to differences in for instance the socioeconomic position of the partners and comparison partners we expected that psychological health problems including depression anxiety and sleeping disorders would be more prevalent in partners than in comparison partners after the diagnosis of dementia this hypothesis was partly confirmed as an increase in the prevalence of psychological problems and specifically sleeping problems over time was found in the partner group and not in the comparison partner group figure 3 figure 4 figure 5 besides sleeping problems no other specific psychological health problems such as depression were significantly more prevalent in partners than in comparison partners during the year before and the 3 years after the diagnosis in contrast a comparable dutch study showed that spouses of persons with dementia were 4 times more likely to be diagnosed with depression than spouses of persons without dementia 7 in this study a cohort of spouses was followed for 6 years but not specifically immediately after the diagnosis it could be that depression in spouses only manifests several years after the diagnosis and our followup time was too short to detect this another explanation for not finding a higher prevalence of psychological problems might be that gps are more likely to label depressive feelings or other psychological problems in partners of persons with dementia as problems with the illness of the partner which we found to be more prevalent in partners than in comparison partners we also expected that cardiovascular problems and problems related to immunity would be more prevalent in partners than in comparison partners after the diagnosis of dementia as described in the study of brodaty and colleagues 6 no significant differences were found with respect to cardiovascular problems between partners and comparison partners but we did find an increase of respiratory problems in partners over the years that was not found in the comparison partners the increase in respiratory problems may be related to immunity problems 6 although this could not be investigated in the current study third we expected that partners of persons with dementia would visit their gp more often after the diagnosis than comparison partners in accordance with previous research 610 it was found that during the entire study period partners visited their gp more often than comparison partners with a peak in the third year after the diagnosis since the formal diagnosis of dementia is often given after the disease has been manifest for a while it is likely that partners already struggle in dealing with dementia before this formal diagnosis and therefore may visit their gp more often this possible explanation is supported by the finding that during the year before the diagnosis partners visited their gp more frequently for problems with the illness of the person they were living with than comparison partners the increase in the number of gp contacts over the years in partners which was not seen in the comparison partners seems to confirm that caring for a partner with dementia becomes increasingly demanding over the course of time and may affect the health of the informal caregiver this assumption is also supported by the finding that compared to earlier years the third year after the diagnosis shows more health problems that are more prevalent in partners than in comparison partners in addition we found that social problems reflecting problems with the disease and loss or death of the person with dementia were 3 to 5 times more prevalent in partners than in comparison partners in the year before the dementia diagnosis and in the 3 years after the diagnosis the prevalence of social problems was lowest before the diagnosis and showed a peak during the first year after the diagnosis which gradually decreased in the following years this pattern could be due to the fact that after the diagnosis partners face many uncertainties and contact their gp in need of heide i van der heins m verheij r hout hjp van francke a joling k prevalence of health problems and healthcare use in partners of people with dementia longitudinal analysis with routinely recorded health and administrative data gerontoloy 2021 this is a nivel certified post print more info at nivelnl support as the disease progresses over the years it could be that informal caregivers are somewhat more prepared for the future or are receiving support by then nevertheless given the high prevalence of problems with the disease or loss of the person with dementia in partners compared to comparison partners over the years partners seem to be in need of advice or support in relation to the condition of their partner earlier survey research already highlighted this need among family caregivers at all stages of dementia 26 strengths and limitations an important strength of this study is that a large group of partners of persons with dementia was followed during several years of the care trajectory and a wide range of psychosocial and health problems were examined using routine registration data in addition we were able to include a large group of comparison partners with a long followup period as well because of the gatekeeping healthcare system in the netherlands in combination with the comprehensive use of ehrs with guidelines for proper ehr keeping 19 and the possibility of record linkage with pseudonymized data it was possible to use existing data to identify and followup partners of people with dementia without increasing the administrative burden for health professionals a limitation of this study is that dementia is likely to be underrecorded in dutch primary care there seems to be a reluctance to record dementia in ehrs if it is not yet officially confirmed by a medical specialist this means that it is possible that some of the partners and comparison partners as well as the partners of the comparison partners might have had dementia but were not yet diagnosed as such a second limitation is that in theory a few cohabiting children might have been included in the partner group however since cohabiting partners were selected based on the criterion that the age difference with the person with dementia should be ≤20 years and teenage pregnancies are rare in the netherlands this number would the negligibly low and would therefore not have affected the outcomes of our study conclusion the findings of the current study imply that having a cohabiting partner with dementia has consequences for the caregivers physical and psychosocial health this is reflected by a higher prevalence of musculoskeletal problems respiratory problems psychological problems and especially social problems as well as an increase in gp contacts over the course of multiple years prior to and following the diagnosis of dementia in practice this means that the increase in the number of people with dementia will be accompanied by an increased appeal to gps by partners of people with dementia given the finding that partners often visit the gp for problems with the disease of the person with dementia timely referral to for instance a case manager dementia for support is important support for partners seems needed throughout the disease trajectory starting in the first year after or even before the diagnosis of their relative this could contribute to the prevention of overburdening in partners of which the specific health problems and the increase in gp contacts as found in this study might be relevant indicators statement of ethics this study has been approved by the ethics committee of the vu university medical center and is in accordance with the governance code of nivel pcd under number nzr00315063 patients were informed by their gp about the use of their pseudonymized health data and could object data were processed in accordance with national and eu regulations and guidelines the use of ehrs for research purposes is allowed under certain conditions when these conditions are fulfilled neither obtaining informed consent from patients nor approval by a medical ethics committee is obligatory heide i van der heins m verheij r hout hjp van francke a joling for this type of observational studies containing no directly identifiable data conflict of interest statement the authors have no conflicts of interest to declare

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introduction the usa ranks first among highincome countries for the number of gun deaths and gun injuries per capita with 39740 people killed by guns in 2018 2020 the costs of gun violence for survivors are profound and include a higher likelihood of suffering from ptsd perpetrating violence carrying guns and experiencing subsequent reinjury or death than those who experience other forms of injury however gun violence is likely to have an important underappreciated impact on community members who hear about or witness gun violence the impact of gun violence on mothers is particularly understudied this gap in the literature is important because mothers mental health and wellbeing have important spillover effects for their children and partners examining the determinants of mothers mental health therefore offers important insights into how to improve mothers wellbeing as well as the wellbeing of her family in this study we examined whether witnessing gun violence in ones community has associations with mothers symptoms of depression probabilities of meeting depression criteria and reports of parental aggravation in doing so we point to important externalities associated with the uss gun violence epidemic background community violence and wellbeing prior research illustrates that individuals who are exposed to local violence have greater risks of experiencing mental health concerns including anxiety ptsd and depression the latter of which is the focus of this study these associations hold for those who are victimized by violence and for those who are indirectly exposed to violence by witnessing or hearing about it in their communities local violence can also exacerbate risk factors for depression by preventing individuals from going outside and socializing thereby corresponding to physical inactivity social isolation and lower social cohesion among neighbors low social cohesion has even been found to exacerbate the relationship between violence exposure and adverse mental health outcomes additionally neighborhoods with a greater prevalence of gun violence tend to be more socioeconomically disadvantaged racially segregated and have lower access to healthcare resources as such local violence can have direct and indirect impacts on community members mental health and may exacerbate socioeconomic and racial disparities in health and wellbeing while prior research has made important strides in highlighting the impacts of local violence on individuals mental health this research has largely not examined the relationship between gun violence in ones community and individuals risks of depression instead existing studies have largely focused on crime rates or cumulative measures of violence exposure that combine exposure to gun violence with other forms of violence such as stabbings muggings and physical fights this is an important gap in the literature because gun violence is far more likely to lead to the death or injury of victims and bystanders than other types of violence such as stabbings or physical fights and as such may be especially traumatizing for witnesses indeed residents of violent neighborhoods report fears that they or their loved ones will be the victims of gun violence victimization with a gun is also associated with significantly greater mental health distress than victimization with other weapons furthermore gun use is associated with and enables other forms of violence such as gang violence and suicide gun violence may therefore have an especially comprehensive association with local occurrences of crime injury and death and thereby have important enduring associations with depression and wellbeing among community members moreover much of the prior literature has examined the impact of local violence on children adolescents and victims and perpetrators few studies have examined the impact of local violence on mothers however maternal depression is important for mothers wellbeing for the wellbeing of her family members and for familial dynamics for example maternal depression is associated with aggravation in parenting harsher parenting practices negative attachment between parents and children and impaired family functioning including lower quality relationships between parents and worse familial problemsolving given these relationships it is perhaps unsurprising that prior research has found that maternal depression is associated with childrens behavioral problems risks of depression and attachment styles in the short and long term examining the determinants of maternal depression is therefore important for understanding the wellbeing of mothers and their families the few studies that have examined these associations for adult womens outcomes have largely been smaller scale focusing on specific areas or subsets of mothers such as those recovering from substance use disorders an important exception to this is a study by huang et al that examined the association between health outcomes and a dichotomous measure indicating whether mothers witnessed or were victimized by any type of violence including shootings attacks with other forms of weapons and being hit the authors found that exposure to violence 2 years prior was associated with health problems substance abuse and depression while that study made very important contributions to the literature on the effects of violence exposure on individuals health it did not separately examine exposure to community violence from victimization and did not focus on the association of gun violence with mothers outcomes it also explored the associations over a relatively limited 2year time frame it is therefore unclear the extent to which community gun violence specifically is associated with depression among mothers this study in this study we help fill these gaps in the literature by focusing on exposure to gun violence specifically and mothers symptoms and diagnoses of depression for a large sample of mothers across 20 us cities we used longitudinal fragile families and child wellbeing study data and examined whether witnessing gun violence in ones local community was associated with mothers symptoms of depression using three different depression outcome measures we also examined whether witnessing gun violence was directly and indirectly associated with parental aggravation our findings highlight the externalities associated with gun violence and contribute to the literature on the social factors that shape parenting practices and childrens outcomes further because gun violence disproportionately impacts underresourced communities and communities of color our findings are important for understanding socioeconomic and racial disparities in wellbeing data and methods the ffcws is a longitudinal survey that followed 4898 children born in 1998 and their parents at the childs birth and at ages 1 3 5 9 and 15 the ffcws randomly selected 20 us cities with populations of 200000 or more and selected hospitals within those cities 1 the ffcws oversampled unmarried lowincome parents and is therefore not nationally representative however because individuals with lower socioeconomic statuses are more likely to be exposed to gun violence the ffcws captures a sample that is disproportionately affected by gun violence and so is of special interest to this study we used data from waves 36 when children were 315 years old because these were the years for which we had information on mothers exposure to violence in their communities we studied approximately 4587 mothers for whom we had valid responses to the depression measures in at least two survey waves we did not include fathers because fathers were asked a more limited set of questions than mothers in most years missing values on the covariates were imputed using chained equations and imputing the dataset 10 times using stata 16s chained command the only pattern we observed in our missing data was that individuals who were missing data on neighborhood poverty rates were more likely to be missing information on countylevel crime rates the ffcws data are largely publicly available though we also used restricted access data on the characteristics of respondents census tracts and counties of residence to help account for characteristics of the residential environment this research project was approved by the institutional review board of the human subject division at the university of washington depression the ffcws measured depression using the composite international diagnostic interviewshort form the cidisf has been used in numerous epidemiological and research studies and the questions that comprise it are consistent with those included in the diagnostic and statistical manual of mental disordersfourth edition the cidisf included 15 questions related to whether respondents had feelings of depression or anhedonia for a period of at least 2 weeks during the prior 12 months these 15 questions included all those used for diagnosing major depression with the cidi they did not include questions from the full cidi questionnaire that are not necessary for diagnosing depression including respondents level of contact with healthcare providers and the recency of their symptoms respondents were first asked if they had felt depressed andor unable to enjoy things for a period of at least 2 weeks since the prior interview and if those feelings lasted most of the day every day during that 2week period those who agreed that they had feelings of depression or anehedonia most of the day every day for a 2week period were then asked 15 subsequent questions about their depressive symptoms these questions concerned whether respondents experienced a loss of interest tiredness weight changes sleep problems trouble concentrating feelings of worthlessness and thoughts about death and the frequency of those symptoms respondents who reported at least 3 symptoms of depression most of the day during that period met the conservative threshold for diagnosing depression ffcws created a dichotomous variable indicating whether respondents met the conservative depression criteria with those who meet the conservative depression criteria receiving a value of 1 and those who did not meet the conservative depression criteria receiving a value of 0 respondents who reported at least 3 symptoms of depression half of the day met the liberal depression criteria and were scored a 1 in a dichotomous indicator variable more information on these scales is provided in ffcwss public data guide in this study we examined depression in three ways we examined the probabilities that respondents met the liberal and conservative thresholds for depression and we constructed a continuous measure of depression symptoms the third outcome was developed by standardizing the component measures to have a mean of 0 and standard deviation of 1 and summing the results from the 15 cidisf questions into a standardized scale using stata 16s alpha command it was important to standardize each measure because our cidisf questions had varying scales some of the cidisf questions were dichotomous while others concerned the frequency of symptoms and were ordinal standardizing each measure addressed the different scales of these questions those who had no symptoms of depression were given a score of 0 this index had an alpha score of 09808 indicating it is highly reliable exposure to gun violence mothers exposure to gun violence was measured with a dichotomous variable representing whether mothers reported that they saw someone else get shot 1 or more times in the past year in their community mothers were told to only respond about shootings they had seen in their local community or neighborhood and to not include shootings they witnessed in their home or on tv mothers were asked this question in waves 36 covariates in our regressions we included a lagged outcome variable representing mothers symptoms or diagnoses of depression in the previous wave to account for preexisting mental illness we also accounted for the mothers raceethnicity as well as the mothers educational attainment and employment status logged household income and whether the household was in poverty2 these latter measures helped account for the households socioeconomic status which as noted above is important for mothers risk of depression and exposure to violence we controlled for the number of children in the household whether the mother was married or cohabiting and whether she was cohabiting with the father of the focal child additionally we included state fixed effects the logged violent crime rate in the county and the percentage of individuals in the respondents neighborhood who were below poverty level these contextual variables helped address prior findings that structural disadvantage in ones neighborhood is associated with individuals risks of depression and exposure to violence finally we included a control variable representing the length between survey years to account for the shorter temporal distance between earlier survey waves and the longer distance between later survey waves statistical analyses to examine the relationship between exposure to gun violence and mothers depression outcomes we first used linear and logistic regression models and included our lagged outcome variable as a covariate our depression outcome scale was continuous we used linear regression models for this outcome and included the dichotomous variable representing whether mothers witnessed a shooting as our predictor variable for the two dichotomous depression outcomes logistic regression models were used as with the linear regression model the dichotomous indicator for whether mothers witnessed a shooting was included as a predictor we performed bivariable analyses and multivariable analyses with the full suite of covariates robust standard errors were calculated at the individual level we then examined whether our results were robust when we used withinperson fixedeffects models by examining whether witnessing gun violence was associated with a change in depression within individuals these models parceled out unobserved timeinvariant heterogeneity and were thus less susceptible to omitted variable bias only timevarying covariates were included in these models and the lagged outcome variable was excluded because the fe models measured change in the outcome the disadvantage of these models is that they remove all observations for which there is no variation in the outcome leading to a loss of power and an inability to examine those who had never experienced depression as such it is valuable to examine the lagged outcome and fe models in tandem to provide a comprehensive insight into the relationship between exposure to gun violence and mothers depression and to guard against the limitations of each model all analyses were conducted in stata 16 supplementary analyses as noted above maternal depression is likely to have spillover effects for family members wellbeing to more directly examine this possibility we conducted a supplementary analysis using parental aggravation as an outcome parental aggravation was measured by the ffcws with the following questions being a parent is harder than i thought it would be i feel trapped by my responsibilities as a parent i find that taking care of my child is much more work than pleasure and i often feel tired worn out or exhausted from raising a family we dichotomized the responses to these questions and summed and averaged them to create a scale measure of parental aggravation this scale is wellsupported and has been validated in the literature on family functioning for this analysis we used structural equation models which allowed us to examine whether witnessing a shooting had a direct relationship with parental aggravation as well as an indirect relationship through maternal depression we expected to observe both direct and indirect relationships given that maternal depression is associated with harsher parenting practices solely examining the direct relationship between witnessing a shooting and parental aggravation could therefore underestimate gun violence exposures impact on parenting we included the full suite of covariates that had been used for our depression outcomes as well as a measure for child gender the continuous measure for maternal depression3 and a scale measure for child behavior problems as all may be associated with parenting aggravation the behavior problem measure was constructed from the child behavior checklist a list of 34 survey questions on childrens behavior problems that parents were asked in each survey wave of the ffcws we summed the 34 questions into a standardized scale with a mean of 0 and standard deviation of 1 because multiple imputation does not support sem in stata we used the original nonimputed dataset results descriptive statistics for the lagged outcomes models we observe about 12846 mother interviews in our analytic sample of which 744 reported witnessing a shooting in any survey year because the fe models relied on withinperson change they dropped observations for which we did not observe changes in the depression outcomes as such fewer mothers are observed in our fe analytic samples particularly for our conservative depression criteria outcome nevertheless we observed 3547 mother interviews in our fe samples for the conservative depression criteria our most restrictive criteria of those mothers 259 had witnessed a shooting in the past year we first examined the descriptive characteristics for our lagged outcome and fe analytic samples on average those who witnessed shootings were more likely to be persons of color and socioeconomically disadvantaged specifically the descriptive statistics for our lagged outcome sample indicated that mothers who witnessed shootings were more likely to be black in poverty and have less than a high school degree mothers who witnessed shootings were also less likely to have a college degree and be married or cohabiting further those who witnessed a shooting had lower household incomes and lived in more disadvantaged neighborhoods and counties on average mothers in the fe analytic sample displayed similar aggregate patterns indicatively our descriptive statistics indicated that mothers who witnessed shootings were more likely to meet conservative and liberal criteria for depression and have higher depression scores than mothers who did not witness shootings mothers are also about 34 percentage points more likely to meet liberal or conservative depression criteria in prior waves than mothers who did not witness shootings though mothers who witnessed shootings also exhibited greater changes in their depression scores and meeting criteria across waves than mothers who did not witness shootings similar disparities were observed in the descriptive statistics for our fe samples though we also observed that mothers in our fe samples were more likely than mothers in our lagged outcome samples to meet criteria for depression regardless of whether they had witnessed a shooting this is unsurprising given that the fe models relied on mothers who exhibited changes in depression criteria nevertheless mothers who witnessed shootings in our fe sample underwent larger increases in depression scores and the proportion meeting depression criteria across waves than mothers who did not witness shootings as such our descriptive statistics provide suggestive evidence that witnessing a shooting is associated with higher probabilities of meeting depression criteria regression models in both our bivariable and multivariable lagged outcome models witnessing a shooting was associated with significantly greater symptoms of depression and a significantly higher likelihood of meeting criteria for depression based on the conservative and liberal cidisf definitions these results held in both the bivariable and multivariable models though prior diagnoses of depression and individuals socioeconomic and marital statuses explained modest portions of those relationships in the fully specified multivariable models witnessing a shooting is associated with an increase in depression scores of 214 of a standard deviation and is associated with a 583 and 578 increase in the odds of meeting the liberal and conservative criteria for depression respectively the fe models largely confirmed the conclusions from the lagged outcome models specifically those who witnessed a shooting experienced a significant increase in their depression scores and exhibited an approximately 325392 increase in the odds of meeting both the conservative and liberal criteria for depression we did not observe any subgroup differences in these relationships by race ethnicity or socioeconomic status supplementary analyses in supplementary analyses we examined the direct and indirect relationships between witnessing a shooting maternal depression and parental aggravation using sem we found that witnessing a shooting had a direct and significant association with parental aggravation as well as an indirect relationship through maternal depression cumulatively witnessing a shooting was associated with a 15 standard deviation increase in parental aggravation scores approximately 90 of that association was the result of the direct relationship between witnessing a shooting and parental aggravation and an additional 10 resulted from the indirect relationship between witnessing a shooting maternal depression and parental aggravation thus witnessing a shooting may impact parenting a sample characteristics are for the samples utilized in the lagged outcome and fixed effects models for conservative depression criteria sample characteristics are substantively very similar for the other outcomes utilized for the lagged outcome models b pcg primary caregiver c hh household outcomes directly and indirectly by increasing mothers risk of depression we found substantively the same relationships using lagged outcome and fe models with our multiple imputation samples though neither model clearly highlights the direct and indirect relationships between these measures we therefore focused on the sem models here discussion in this study we found that 5873 of lowincome mothers in urban areas witnessed shootings in their local communities a meaningful proportion for these mothers witnessing gun violence in their community was associated with significantly high school degree some college college whether the mother is employed logged total household income whether the family is in poverty whether the mother is married or cohabiting whether the mother is married or cohabiting with the father of her child the number of children in the household state fixed effects the logged violent crime rate in the county the poverty rate of the census tract and the length between survey waves b all fixed effects multivariable models are adjusted for timevarying covariates including whether the mother is employed logged total household income whether the family is in poverty whether the mother is married or cohabiting whether the mother is married or cohabiting with the father of her child the number of children in the household the logged violent crime rate in the county the poverty rate of the census tract and the length between survey waves c dc depression criteria mothers highest level of education less than high schoolref high school degree some college college whether the mother is employed logged total household income whether the family is in poverty whether the mother is married or cohabiting whether the mother is married or cohabiting with the father of her child the number of children in the household state fixed effects the logged violent crime rate in the county the poverty rate of the census tract and the length between survey waves child behavior problems child gender and the continuous maternal depression scale b the indirect pathway modeled between witnessing a shooting and maternal depression included raceethnicity mothers highest level of education less than high schoolref high school degree some college college whether the mother is employed logged total household income whether the family is in poverty whether the mother is married or cohabiting whether the mother is married or cohabiting with the father of her child the number of children in the household state fixed effects the logged violent crime rate in the county the poverty rate of the census tract and the length between survey waves more symptoms of depression and with meeting conservative and liberal criteria for depression in fact witnessing a shooting was associated with a roughly 3258 increase in the odds of having depression depending on the model and depression criteria used these are highly meaningful increases and these relationships held after accounting for numerous characteristics of the mother her household and residential context that might shape the relationship between witnessing a shooting and depression we also find that witnessing a shooting has a direct association with parenting aggravation as well as an indirect association through maternal depression reinforcing that these relationships are likely to have spillover consequences for family members wellbeing these findings are important for scholars and policymakers our focus on community gun violence is a contribution to the literature on violence and mental health which has largely focused on victimization andor broader measures of community violence and has not specifically focused on gun violence ours is among the few studies to observe these associations for mothers rather than children adolescents victims or perpetrators the findings observed in this study therefore contribute to the literatures on mental health gun violence and parent outcomes moreover while resources are frequently directed toward the victims of gun violence our findings demonstrate the importance of providing resources for coping with trauma on a wider communitylevel basis this is especially important because women exposed to local violence are more likely than unexposed women to experience other forms of violent victimization and less likely to have access to healthcare resources similarly black latinx and lowincome mothers are disproportionately exposed to gun violence and less likely to have access to healthcare resources and mental health facilities latinx and especially black mothers are also more likely to experience additional stressors such as incarceration or the incarceration of a loved one poverty and discrimination while black and latinx women are less likely than white women to report depression our findings suggest that gun violence occurs in tandem with numerous stressors that are likely to take a toll on mothers mental health these relationships could in turn exacerbate racial and socioeconomic disparities in wellbeing our findings therefore indicate that mothers exposed to gun violence are likely to be an important underserved group of individuals who are vulnerable to depression further we demonstrate that the costs of gun violence are underestimated unless the effect of gun violence on community members is accounted for these effects include the direct effects of gun violence on witnesses and its indirect effects on the loved ones of witnesses who may be impacted if their kith or kin experience depression as a result of their exposure we document that one spillover effect may be an increase in parental aggravation which is associated with lower quality parentchild relationships and child behavior problems because lowincome children are more likely to be exposed to violence and live in singleparent families and families with greater parenting stress exposure to gun violence may exacerbate disparities in child wellbeing as noted above maternal depression is also associated with family functioning across a wide number of dimensions not explored here our findings are therefore important for illustrating that an important feature of residential contexts local occurrences of gun violence shapes the outcomes of mothers and their families additionally our findings demonstrate the importance of improving individuals access to healthcare resources and mental health facilities in areas that are exposed to gun violence developing support groups that are targeted to community members who live in areas affected by gun violence may be especially useful providing targeted supports to parents to help manage the stresses of parenting may also help ameliorate the association between local violence mental health and parenting outcomes these supports could include mental health counseling as well as access to lowcost highquality childcare and afterschool resources that help ease the stress of parenting in a neighborhood that may be higher risk for children and family members finally the presence of local community groups devoted to reducing violence is associated with decreases in local crime rates empowering communities through such local groups may not only help alleviate gun violence but could be beneficial for mental health as well limitations these findings are subject to limitations first we were only able to observe mothers across 4 waves of the ffcws during this time period mothers were surveyed when their children were 3 5 9 and 15 as such it would be valuable to have more waves of data at smaller more regular intervals in order to better isolate the relationship between witnessing a shooting and mothers symptoms of depression and to ensure that we capture the correct time ordering of witnessing gun violence and experiencing depression moreover having fewer survey waves tends to lead to conservative estimates using fe models our ability to perform both lagged outcome and fe models helped account for the limitations of each method and the survey design nevertheless these limitations are important to consider when interpreting the results especially regarding potential omitted timevarying characteristics and experiences that occurred between survey waves indeed it is possible that some of our respondents witnessed gun violence between survey waves as a result our comparison sample may include individuals who witnessed gun violence and who are suffering negative mental health outcomes as a result if this is the case our estimates may be conservative this possibility is reinforced by prior research showing that children exposed to violence tend to be exposed multiple times with these multiple exposures corresponding to progressively worse mental health outcomes as such results of this observational study should be interpreted as associational rather than causal additionally in our lagged outcome models we would ideally include fixed effects at a finer geographic level of aggregation than states to better account for neighborhoodand citylevel variation however too few individuals in the ffcws shared census tracts to use fixed effects at this level and city identifiers were not available in every year our ability to include measures of county and neighborhood characteristics helps ameliorate some of this concern finally the ffcws focuses on larger urban areas and lowincome families our results cannot therefore be generalized to the broader population conclusion this study provides important insights into the relationship between community gun violence and mothers risk of depression demonstrating that witnessing gun violence in ones community is associated with significant and meaningful increases in mothers symptoms of depression the probability that they meet the criteria for diagnosable depression and their reports of parenting aggravation these associations demonstrate the importance of providing local mental health and community resources for those who are exposed to violence and who may experience longlasting trauma as a result compliance with ethical standards conflict of interest the authors declare that they have no conflict of interest ethics approval this study was deemed minimal risk and was approved by the university of washington institutional review board consent to participate the study relied on precollected data and involved no contact with participants on the part of the research team informed consent was obtained from all individuals who participated in the study by the fragile families and child wellbeing study at baseline and at all subsequent waves publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

gun violence is a uniquely prevalent issue in the usa that disproportionately affects disadvantaged families already at risk of health disparities despite the traumatic nature of witnessing gun violence we have little knowledge of whether exposure to local gun violence is associated with higher risks of depression among mothers whose symptoms of depression are likely to have spillover effects for kin we examined the association between exposure to gun violence in mothers neighborhoods and their experiences of depression using longitudinal fragile families and child wellbeing study data n 4587 in tandem with lagged outcome and fixed effect models we find that mothers who witness at least one shooting in their neighborhoods or local communities exhibit more symptoms of depression and are 3260 more likely to meet criteria for depression than mothers who do not witness a shooting we also find that witnessing a shooting is associated with increases in parental aggravation which is partially mediated by maternal depression given this and other previously documented spillover effects of mothers mental health on children and family members these findings have important implications for mothers wellbeing and their kin further we observe substantial racial and socioeconomic disparities in exposure to gun violence suggesting that gun violence may heighten health disparities and drawing attention to the importance of providing mental health resources in communities that are most affected by gun violence

introduction w ellbeing is viewed as the state of peoples life conditions and some researchers have examined community wellbeing by using individual attributes such as satisfaction happiness quality of life individual efficacyagency andor social support wellbeing measurements have progressed to encompass broader dimensions such as social and environmental aspects and human rights it is now widely accepted that wellbeing is a multidimensional concept that encompasses all aspects of human life sustainability theories increasingly incorporate utilitarian concepts of wellbeing demanding the development of destinations that provide more advantages to a higher number of people within the constraints of available resources the overall welfare of a community necessitates that together these various components work well and maintain a healthy balance community wellbeing is a combination of social economic environmental cultural and political conditions identified by individuals and their communities as crucial for them to flourish and fulfill their potential cummins found that the satisfaction associated with the community wellbeing domain occurs when people satisfied with education neighborhood service facilities social life and social relations community satisfaction makes a significant and positive contribution to community members perceptions of their quality of life many factors can directly or indirectly affect community wellbeing equally one aspect of community wellbeing can impact another for instance there is a wellestablished link between economic wellbeing and health living environment and psychological needs as well as community satisfaction and attachment to an area finally community members with a high level of place attachment are more likely to engage in local volunteer work and collaborate with them and influence the the positive change in the community in the wider context human wellbeing is when individuals able to cope with psychological social and physical challenges the definition of human wellbeing is complex and subjective from different perspectives in the context of the local community wellbeing will be achieved if they have good satisfaction with the dimensions of the environment economy life and social relation services and facilities education neighborhood and culture which is in line with some previous studies authority intervention is considered a mediating variable in this study current administration and political power determine the wellbeing of the local population via socioeconomic indicators and infrastructure while also taking into account their satisfaction with economic social and environmental dimensions for example if the local community is satisfied with these dimensions then they would realize the importance of sufficient funds in the effort towards conservation so that they could also enjoy the benefits of a healthy ecosystem such as fresh air adequate income good mental and physical health and a healthy source of food the locals scientific and indigenous knowledge of conservation also contributes to a strong sense of physical and spiritual connection to a place with rich natural and cultural attributes while locals with low ecocentrism and limited conservation knowledge are more likely to engage in economic activities that disregard sustainability the local community in gmnp is frequently dissatisfied with the local government in regards to land ownership and logging activities that threaten their traditional way of life this relates back to the notion that human rights are a necessity that safeguards dignity and equality which is emphasized at the global level although there are initiatives by the government in improving their standard of living however to what extent do they want to accept such initiatives in improving their wellbeing thus human development which describes a process of enlarging peoples freedoms and opportunities and improving their wellbeing can also be challenged in this light the importance of empathy rises to the forefront as the primary focus for empowering communities to construct resilience in the face of crises and healing things that drive a wedge between them communication between the local community and the state government which leads to understanding and support towards biodiversity conservation efforts at gmnp needs to be further refined in terms of its effectiveness thus the groundlevel issues of the locals need to be addressed so that their wellbeing can be sustained and become the key to the effective biodiversity framework for gunung mulu national park therefore in this study we aimed to explore the community wellbeing dimensions in terms of environment economics and social aspects as well as authority intervention based on the perspective of the local community and professionals with an emphasis on the current issues in gmnp conceptual framework the conceptual framework was developed based on the relevant literature reviews on community wellbeing aspects that have been described previously figure 1 shows the conceptual framework built in the study which covers the environment economics and social aspects with an authority intervention and covid19 pandemic as a mediator the pandemic has affected the social community by forced them to isolate and disturbed the economy of society it also caused a major changes toward environmental with the increase of domestic waste thus this study has to consider the pandemic covid19 as one of the mediators other than authority intervention in the wellbeing methods research area gmnp is a national park located in marudi division sarawak malaysia which is one of the unesco world heritage site unesco has clarified the whs is the name given to locations on earth that have exceptional importance to humanity as a whole and to be preserved for current and future generations to enjoy and appreciate to date 1007 natural and cultural places inscribed on the list such as taj mahal india grand canyon pyramids in egypt etc this designation of whs for gmnp is particularly beneficial for insitu biodiversity conservation where greater awareness on its status could lead to the rise of level of preservation of its valuable properties with the status the areas under the whs will be aided with financial and expert advice from the whs committee to ensure its sustainability of the sites the given status also had improved community wellbeing in gmnp by allowing people to work together in enhancing their economic and cultural development especially through heritage tourism this gmnp area covers about 52864 hectares of the mountainous part of northern sarawak it is separate from other developing areas which lies between the headwaters of the tutuh river and the medalam river a tributary of the limbang river its location along the bruneisabahsarawaknorth kalimantan transboundary landscape is one of the six priority landscapes in the protected areas of borneo gmnp and nearby villages such as sungai melinau village batu bungan village long iman village and long terawan village are inhabited by the majority of penan and berawan communities which are indigenous to the park the local community of sungai melinau village from berawan community is the most engaged in tourism services such as homestay and transportation in mulu other local communities mostly work as farmers or fishermen for their livelihood the number of tourist arrivals to gmnp in 2019 is 21022 and it is higher than in 2015 which was 18632 the trend shows that the number of international tourists is almost double that of domestic tourists however since the pandemic hit in 2020 and 2021 the data is not available for disclosure by the sarawak forestry corporation due to the tourism industrys progress being too slow research technique this study employed a mixedmethods approach particularly a concurrent nested design that is more appropriate by considering the time constraints and comfort of the respondents during data collection this design gives priority to one of the methods and guides the study while another is fig 1 the conceptual framework used in the study the community wellbeing is dependent on its members satisfaction with respect to environmental economic and social factors as well as mediators such as authority intervention and the covid19 pandemic embedded which aims at one of the methods ie quantitative or qualitative method and guides to address a different question than the dominant one or to seek information from different levels the quantitative measures were triangulated with key informants narratives which allowed for a greater understanding of the meaning of the quantitative findings mixed methods that combine qualitative and quantitative data provide a convenient method of everyday problemsolving based on miri resident district office a total population of mulu subdistrict is 4696 using sample formula by kothari with an acceptable error of 10 at the 95 confidence level we consider to interview 99 respondents with the limitation of movement due to covid19 pandemic obtaining a sample size with a 5 to 10 margin of error seems impossible because of low number willingness to participate and fear of having contact with researchers kothari also emphasized that the selection of a research design for a sample size must be realistic taking into account the budget and time constraints and it is best to minimize sampling error as much as possible thus the likert scale questionnaire was disseminated to only 99 local communities in april 2021 through convenience sampling the sample size is appropriate with an acceptable error of 10 at the 95 confidence level the local community involved are those who live in the settlement areas around gmnp including kampung batu bungan kampung long iman and kampung long terawan the respondents were to be from local communities who are more than 18 years old and live at the study site for more than 5 years for the qualitative approach personal interviews with twelve key informants were conducted using snowball sampling they were identified as key informants due to their firsthand knowledge and active involvement in the community their narratives provide a qualitative aspect that has meaning significance and rich understanding the number of key informants is acceptable for the qualitative approach as its nature requires a small sample size according to hammarberg et al a large sample size is not recommended because it will possibly cause excessive data issues that will affect the depth of the scope for rigorous analysis the key informant voices help to achieve data saturation external validity andor information redundancy this techniques of data collection are aligned with stated in lietz and zayas in increasing the trustworthiness of qualitative research this qualitative longitudinal research method was chosen for this study because it is suitable for pandemic or disasterrelated studies in which unique and rapidly changing environments necessitate more comprehensive descriptions of human condition furthermore we also employed the reflexivity method of writing memos or field notes throughout data collection in order to comprehend the significance of each interview and observation session as suggested by to ensure the quality of our qualitative study table 1 presented to show the characteristics of twelve key informants interviewed in different sessions data analysis the descriptive data which includes sociodemographic and respondents community wellbeing were analyzed using the ibm statistical package for social sciences while the key informants narratives were themed deductively using atlasti version 8 software the themes highlighted the environment economics and social aspects which play a crucial role in the community wellbeing in gmnp results and discussion sociodemographic table 2 shows the demographic background of the respondents approximately 606 of respondents are male while the remaining 394 are female the majority of respondents are orang ulu the penan and berawan ethnic who are indigenous to gmnp most of them have received at least secondary education and are employed and engaged in tourism services such as accommodation and transportation in mulu their income in the tourism sector was less than myr2500 per month considered the lowincome group in malaysia locals perspectives on wellbeing table 3 shows the mean analysis of community wellbeing based on the respondents perspectives in the context of this study community wellbeing is assessed through their satisfaction with the dimensions of wellbeing in terms of the environment economy and social perspective the average respondent is very satisfied with the environmental and social aspects of this gmnp however it was noted that they showed a moderate level of satisfaction with services and facilities although both the environment and social variables on average show good satisfaction among the respondents they are not satisfied with the current monthly income due to the covid19 pandemic which is quite limited the wellbeing of the community in table 3 is based on the respondents perspective according to ibrahim et al the locals perception of elements related to wellbeing that are affected by governance is important and needs to be taken into account towards sustainability in general efforts to improve this ability need to happen at the macro level which is the existence and ability of an organization to provide sufficient investment to empower individuals toward a sustainable community consequently twelve key informants clarify the element of wellbeing through the environmental social and economic dimensions environmental dimension the mean analysis in table 4 shows that the respondents state that biodiversity issues as a whole are small in the area this includes water pollution extinction of animals and plants degradation of wetlands solid waste and wildlife threats this is contradictory to the narratives given by key informants including k1 in this study who stated that these issues are something that needs to be paid attention to in gmnp and the surrounding area regarding wildlife conservation and waste management it also gives a reflection that the local community has less awareness about biodiversity problems that occur in their area the imagined environmental futures of communities illuminate significant issues within the existing relationships between themselves and their physical surroundings locals consider it a less significant matter but it needs to be taken seriously water pollution tourism sector does not affect water pollution in gmnp however the attitude of a few parties who lack of environmental awareness contribute to the water pollution for instance private oil palm companies are reportedly conducting logging operations in the vicinity of gmnp resulting in cloudiness of the river water in the region particularly downstream of the river this issue seems to be beyond the peoples control because it involves local companies and authorities based on observations water pollution involving toxic waste does not occur but the cloudiness that has occurred in the downstream river side is due to the sedimentation of logging activities nearby the settlements you see how cloudy the river water is now in the early 1970s the tutoh river was still clear and beautiful we used to drink river water directly the logging companies are no longer operating in their area but the cloudy river water remains probably due to domestic waste into the river by a few local communities solid waste the issue of solid waste in the gmnp and its surounded arises as a result of several factors requiring attention from the facilicities management poor solid waste management including the lack of facilities to treat it will lead locals to dispose of trash in open spaces such as rivers there is no formal waste management system here the locals have to manage their own waste in the past we used to propose a landfill and the site was selected after a meeting with relevant stakeholders for many years the population is increasing the rubbish is increasing i have experienced it myself in a longhouse where the people just throw the rubbish into the river that floats down the population growth in mulu with the lack of services that are normally handled by the council is the garbage disposal there is no proper sewage everything will be thrown onto the ground and eventually end up in the river thats why the river is polluted its a major concern we dont have any policies on how to deal with the area that is outside the park but nearby for example okay you cant cut this people just cut it which means it can impact the microclimate and a lot of things local peoples are more inclined to throw wastes into the river since long time if this continues it will degrade the water quality and directly harmful to the aquatic life next the garbage suspended in the river will affect the scenic view of tourists during river cruising for visiting recreation area in gmnp such as long iman and camp 5 in the past the locals usually threw leftover foods into the river because it was organic that situation is acceptable but now the current generation is throwing away plastic that wont rot garbage is dumped randomly into the melinau river there is a lot of plastic in the trees i burn garbage if its a can i dig a hole to plant it in there are a few irresponsible people who throw garbage into the river perhaps when there are no people in the river at night as locals who are custodians of this whs unesco site they suppose to have a better ecocentric attitude compared to visitors however based on k5 k6 and k9 the visitors are very disciplined ie instead of randomly discarding trash they pick it up from the side of the road and place it into the trash can provided at their accomodation this may be due to the influence from the attitudes brought by ecocentric vistors to gmnp such visitors can influence locals to havebetter attitudes toward nature conservation the national park and marriot hotel have also worked together to run a community service program by emphasizing conservationrelated environmental awareness education for the local population regularly including river cleaning since 2006 to promote conservation activities it is essential to have a welldeveloped communityspecific activity system including manpower budget community awareness and consensus information normally we try to organize things in a day we divide them into different sections of the river penans from batu bungan village will clean between here and their settlement while sungai melinau villagers will clean up to kuala melinau because of the spread of houses in between they will take the bigger section because the community is bigger then we send a boat to assist the community as well everybody will bring their garbage here and we will count and monitor how much is collected each time we have this communal work at the same time running the awareness mainly focuses on trying to convince people not to dump rubbish into the river which is the best way to deal with it it is quite hard when some people change their practices but some ignore the advice they still dump it some villagers go by boat and dump it in the tutoh river it seems like the practice is still there but there have been some positive changes where the rubbish is not as bad as it was previously even though income and the number of people have increased now this is not just a local community but the clinic school airport and district office staff are here as well we hope that there is some progress because the garbage problem in the river will never be solved according to k1 and k8 both parties were also given a budget by the government to manage the collection of residents garbage in gmnp headquarters and marriot hotel and transport it by boat to the landfill facility in marudi once a month this is seen as a cheaper initiative than building a landfill in the national park itself the pressure of an increasing population causes the problem of solid waste management become a matter that needs due attention from relevant stakeholders to empower the local community the park management has also proposed to the government to provide allocations for transporting rubbish using boats handled by the local community themselves because most of them own a boat this is also able to improve their wellbeing through generating income while fostering an ecocentric attitude that exists from a good place attachment degradation of wetlands the degradation of wetlands in mulu is caused by anthropogenic activities including deforestation recently downstream and upstream maybe one of the biggest issues getting worse now is clearing along the riverbank of a stream because of the covid19 pandemic where most villagers from batu bungan village have started farming for their livelihood but the problem is that many have been clearing trees right to the riverbank which could increase erosion while this problem happened in the past it was not as severe as it is now but now it is becoming very severe because nearly all the trees on the opposite bank are all being cut down according to k4 k9 k10 and k11 deforestation for palm oil plantations caused landslides along the riverbanks particularly in the downstream region although it occurs outside the gmnp it still has the potential to disrupt the local ecosystem especially the parks highdiversity area due to the potential for environmental damage monoculture plantation activities should not be conducted within 80 kilometers of the park based on brockerhoff et al monoculture plantations are more likely to have lower levels of biodiversity compared to their surrounding native forests in addition loss of soil productivity and fertility disruption of hydrological cycles risks associated with plantation forestry practices risks of promoting pests and diseases increased risks of adverse effects of storms and fire and negative effects on biodiversity are all potential outcomes extinction of animals and plants based on table 2 respondents believe that the extinction of animals and plants in gmnp is nearly nonexistent this demonstrates that on average they are less aware of changes in population viability they must be concerned about issues that have the potential to lead to extinction i think the area of this forest is still large so animals will not be able to easily become extinct monkeys are also still in the palm oil plantation area for foraging i think the issue of extinction is not there at all however based on k7 k10 and k9 animals including pangolin and sun bear are increasingly difficult to see than before and these animals are likely facing the threat of extinction due to irresponsible hunters in the gmnp area and its surroundings we eat most of the animals in the park to the point of posing a threat to them we usually hunt mice and deer outside the national park now it is almost difficult to see hornbills pergam punai and kuang birds compared to the 1960s based on my personal opinion ulu people dont love animals other animals such as forest cats foxes bats pythons and red cats are also hunted as for the trees large and old trees were once cut down to be exported abroad you can see the view of the forest that is diminishing from the air space when taking the plane here the only remaining wood is small and young limited awareness of extinction has also been documented in other rural communities surrounding protected areas nonetheless every individual should be concerned about the extinction of these species to protect the diversity of species in gmnp it is necessary to consider the extinctioncausing factors wildlife threat the primary threats to wildlife in the area are hunting deforestation and oil palm monoculture plantations they have the right to hunt wild boar deer and mouse deer and fish in certain sections of the river for the nomadic penans they could hunt in any area of the park but there are few nomadic penans left and most of them have settled but we consider the people at batu bungan village as seminomadic and they go into the forest sometimes they were given a certain area for hunting and fishing within the park basically it has become a problem because they just live opposite the park and river so they can easily enter the park for hunting and fishing they do hunt and fishing outside the designated areas that are located next to their village the problem is that hunting is not restricted to wild boars some people hunt endangered and even totally protected species there are not many animals in terms of the abundance of mammals due to hunting it is not just restricted to penans but some berawans also hunt in the park there is much less hunting on their side there is more hunting downriver from here but not inside the park particularly for wild boar but it does not mean they did not hunt here in mulu locals living near the national park have the right to hunt wild animals that are not protected but when they hunt usually the people there will hunt anything they find although there is a law the parties here are less able to carry out effective enforcement frankly i have hunted and it is most likely in the picture but we do not hunt many animals at a time it is just a few animals that are sufficient for the number of family members we usually hunt monkeys and squirrels birds are hard to catch because they fly i use a blowpipe that contains rubber poison to hunt hunting so far is a lifestyle for the penan and berawan for survival they do not keep animals for food because they have been trained to hunt and find fish as food since a long time ago to forbid them not to hunt is quite impossible they will eat all the animals furthermore they use blowpipes which are considered silent killer tools that can catch more animals and are not so easily detected compared to using guns illegal wildlife trade is also likely to occur involving locals and outsiders k7 explained that pangolin species are in demand from buyers he also explained that some use tissue culture to breed certain species of orchids and sell them quietly similarly with phong nhake bang national park vietnam where a few residents are not concerned about selling wild animals to outsiders for their profit next disruption of the ecosystem may occur due to the conversion of forest to a monoculture plantation according to a study by ridwan et al the monoculture oil palm plantation in nearby areas will reduce the foraging and roosting activities of tropics bat species which rely heavily on forests for food and shelter the park itself is wellprotected maybe one of the issues hunting in the park is not a huge major issue other than that there are threats to the area outside the park because the boundary does not protect all the species within the park because some species move outside the boundaries one example is wrinkled bats in deer cave as you can see they fly very far from the park which is exposed to threats outside the park that could affect their population and one of the biggest problems is probably monoculture plantation outside the park this is why unesco has recommended not clearing the forest or monoculture tree plantation activities within 25 km of the boundary of the park but actually there have been some issues with it as well there have been some areas outside the park where it is designated for oil palm plantation and opposed by locals logging for oil palm plantations is happening outside the park and i dont agree imagine fitting into a palm oil plantation right next to this whs if the forest is all cut down the animals will run to the untouched virgin forest of brunei which is not far away only 21 kilometers from here here we are messed up bat species in gmnp are keystone species because their extinction will affect the cave ecosystem guano from bats is an important energy source with large varied and unique ecosystems existing around such deposits i think it affects the population outside of the park for the forage would probably affect the future of the park primarily because they forage in open areas and above the canopy now they are probably dependent on insects above the canopy since insects are abundant if the forests are cleared there will be fewer insects so they will lose food if the area is cleared for monoculture plantations they tend to introduce a lot of pesticides that will affect the bats not just bats themselves because when they fly back to caves they affect all the dependents and everything in the cave so their adolescents will also be affected if you do a lot of things around gmnp then things in gmnp will not be able to survive just in case the outstanding universal value in mulu is the swiftlets and bats in the cave but the food source is only 50 km around the cave that brings you all the way to brunei or other parts of baram but if there is no control over land use in the area there may be fewer food sources for these animals so the number of ouvs could be impacted which is very critical some berawans including k4 and k5 also stated that they always go to the gmnp forest area bordering labi forest reserve brunei and claimed that they can see more wildlife including a maroonleaf monkey and grayleaf monkey species it seems that the area is good to support the survival of the species due to the lack of human interference and provide foods and shelter this area is located in the heart of borneo priority landscape which is the bruneisabahsarawaknorth kalimantan transboundary landscape which acts as an ecological corridor that connects wildlife including endangered species such as borneo orangutans borneo pygmy elephants hornbills and mullers gibbon among others that thrive in the region however not all animal species have migrated towards labi forest reserve as claimed by residents this is because gmnp is a habitat that has the most suitable ecosystem for several species including bats obviously the park hosts a lot of wildlife like quite a few protected species especially those related to caves it depends on the species and what kind of habitats they have such as limestone because they cant go to brunei after all theres no limestone on the brunei border even the karst itself provides the surface with cavities which provides space for animals to hide especially mammals theres no support area in brunei for them brunei of course has a forest but it does not have karst and cavity caves that are found mulu has karst to support it higher elevation plays a crucial role brunei does not have high mountains so many species are also restricted to higher altitudes we here have a lot of endemic species especially frogs and reptiles that just cant go to brunei because the habitat is not suitable there by observing the animal hunting that takes place in gmnp and its surrounding area the locals are still subject to the national parks and nature reserves ordinance of 1998 and the wildlife protection ordinance of 1998 even though they have certain rights as indigenous people including being allowed to hunt certain animals traditionally local people hunt animals in this such areas for their livelihoods but these local hunting restrictions cause them to slightly change and tend to depend on governments and other ngos to provided financial aids economic dimension the covid19 pandemic has caused a significant change in the locals who have been heavily dependent on the tourism sector for survival k3 and k4 feel proud because they live in the main area of worldclass tourism which is gmnp and many benefits they receive are due to the existence of tourism it changes their quality of life via income generation opportunities we are proud because we have gmnp there are job opportunities and there are also tourists coming from miri and marudi by boat and staying here for a few days before going to the gmnp since the outbreak of the pandemic that caused economic paralysis however most respondents have become dissatisfied with their monthly income before the pandemic the majority of the local community had earned a t minimum of myr2000 per month however as a result of the pandemic the income has decreased to less than myr1000 per month the situation forcing them to engage in gardening fishing animal husbandry and other smallscale agricultural activities despite lacking agricultural expertize for their survival our income has been bad since the pandemic i dont dare to open a homestay either i experienced hardship because there were no tourists no work no money and i just stayed at home while working on small gardens it is not only the selfemployed who are affected by the effects of this pandemic in fact according to k1 the number of staff was also reduced from various positions including those working in the café housekeeping and some of the park guides the covid19 pandemic has taught everybody and given lessons on not taking everything for granted people began to realize how much money they could make from tourism things shift you can see most people are farming now which is different from their previous lives where most of them are engaged in tourism for example people in batu bungan village who work as boat operators handicraft sellers park guides or freelance park guides have lost their income but now they are turning back to where they were years before the park opened they go to the farm even here there is no market for people to buy food unless people sell to each other what they grow the shop is also empty nearby nowadays not much there they have twicedaily flights from miri as previously stated so some will bring frozen foods chicken and meat for the past few months weve just had one flight which is nothing convenient people just depend on fish and what they grow in addition a similar situation occurred at the marriot hotel where an estimated 80 of staff were laid off due to current financial constraints the hotel had to spend approximately myr150000 on maintenance particularly the electric generator despite the low number of guests next the local community faces the challenge of modifying their way of life to accommodate the pandemic as if there is no other alternative if you want to market handicrafts to outside areas you need a fast postal service and it is quite difficult to do so because the location of the post office is quite far even if you run an online business you still need the internet which is a broadband network which is limited here now young people are more stressed because many have lost their jobs they only rely on freelance work there used to be tourists who could use boats to earn an income but now there are none its really difficult because of the pandemic that has been going on for more than a year now we do a little business to cover our needs at home such as selling drinks cigarettes and fried chicken we thought of going to miri many times due to having to follow procedures including applying for a permit across the area which is quite harassing changing jobs is very difficult for me who is used to tourism even if you want to start a business you still need a lot of capital our income is uncertain we also look for umbut and sell it to the villagers based on k12 there is a freelance park guide who has been laid off and has been able to generate income through his own youtube account platform the content of the uploaded videos revolves around his life during the pandemic and it was acknowledged by k12 that he has good video editing skills and his presentation about geology in gmnp is very easy to understand by the audience in conclusion the diversification of livelihoods in gmnp in terms of different types of jobs is lower which means that almost all of them depend on the tourism sector compared to others therefore it is anticipated that the level of locals adaptability to changes caused by this pandemic will be low according to makwindi and ndlovu diversification is the most important strategy for surviving economic pressures caused by natural disasters such as this pandemic which affects the income of the majority of people all parties must understand the risk and vulnerability of relying on a single major source of income as the covid19 pandemic has a significant impact on livelihoods social dimension despite their differences in political ideology the majority of respondents believe that neighborhood life and social relations are still positive the concept of togetherness is still practiced among them through cooperative activities to collect garbage around the village and river periodically through a program organized by gmnp and marriot hotel management based on k3 k4 k5 and k8 community involvement is a crucial indicator of the success of protected area management while visiting neighbors and sharing food is still a common practice among them we also shared a wild boar if they dont share it they will buy it with us at a low price due to tourism there are also locals particularly from the village of long terawan who marry tourists or foreign workers this marriage which represents their acceptance of foreign culture is viewed favorably and it is a reflex that they are adaptable in accepting positive changes such as education and employment on the contrary the local community is also very satisfied with the education received by their children since the 1990s even though the location of the secondary school which is long panai secondary school is quite far from the gmnp area and it takes almost 2 h by boat the reputation of the school here is very good some former students got excellent results in malaysia education certificate ie 9a and managed to continue their studies at university cultural heritage the level of satisfaction of respondents towards culture is good in terms of traditional dances and musical instruments residents still practice them intact to be presented to dignitaries and tourists who come here as tourist products next the making of handicrafts and other forest products by the penan community shows that these skills are still in good condition although cultural heritage is not viewed as a major issue by the studys respondents who are mostly young and middleclass however some narratives in the study explain that there are still issues related to intangible cultural heritage especially in batu bungan village and long iman village which is in the penans oroo language oroo is a language commonly used by previous generations of penan for communication purposes in the forest such as navigation using signs from tree twigs and leaves the arrangement of the twigs and leaves describes the combination of words in a sentence the message can be translated if the individual understands each word that is trying to be conveyed oroo is the object of writing language used by earlier generations to leave messages for each other in the jungle sticks prepared with cuts twigs and leaves in certain positions and places will guide people and inform them about directions time dangers resources etc according to k3 the oroo language is only part of the customs and culture and can still be understood by many people especially the older generation however the language is poorly understood among the average younger generation it is because they have received a formal education in school and can read and write well thus the importance of mastering the oroo language has become less significant for them furthermore the language is rarely used and is considered an ancient language similarly based on a study by plimmer et al it was found that the language has disappeared and is no longer used by the younger generation among penans in long lamai since they were settled according to unesco the loss of indigenous languages is also detrimental to biodiversity as traditional knowledge of nature and the universe spiritual beliefs and cultural values expressed in indigenous languages provide timetested mechanisms for the sustainable use of natural resources and management of ecosystems these elements have become more critical with the emergence of urgent new challenges posed by climate change figure 3 shows k9 explaining the basic oroo language which indicates that the penan community uses twigs and leaves to form specific signals that carry certain messages this clear explanation shows that the middleaged generation is good at the oroo language it further supports the statement of k3 that the middleaged generation can still understand the language very well as compared to the youngaged generation it is in line with zaman and jengan where the respondents over the age of 60 have mastered the language because they experienced a nomadic life when they were young k9 stated that he had learned the oroo language through experiences with his father when hunting in the forest and looking for sago since childhood he was accustomed to wading through the forest for that purpose and work of cutting and carrying trees and removing obstacles along the way in the forest we did not have formal classes to learn this oroo language we are indirectly good at using that language however according to k9 some penans younger generation who live with their families and seminomads in the jungle are still able to use the language compared to the community in kampung batu bungan my 11yearsold son is already good at using sumpit he is good at using poison for hunting purposes because he always follows me to the forest and i taught him in conclusion this informal lesson has the most crucial value in the penan community the oroo are themselves expressions of social interaction given the fact that people usually travel together the reading and interpretation of the signs is also a social practice although often the meaning of oroo is rather explicit most young people do not understand oroo language especially those born in their 90 s and above the elders realized that oroo will be lost if they do not find ways to preserve and pass it through to the younger generations k9 also informed that their previous lives were more difficult and the younger generation is having lack of interest to go into the forest some were afraid to go into the woods unlike the middle age who had experienced and were trained for it furthermore as mentioned by k3 earlier words have become the primary medium of communication in society nowadays and it affects the oroolanguage to be less important the times and lifestyles slowly changed and they adapted to the new situation indirectly formal education and socioeconomic factors caused this transformation to take place due to the pandemic the tourism sector has stagnated for a while as a result local people have lost their source of income due to the lack of tourists furthermore k3 also stated that a handful of villagers are chosen to stay in the forest to avoid covid19 virus infection penan community in kampung long iman hid and ran away from home when medical officers came to their village to perform a covid19 polymerase chain reaction swab test the increasing number of covid19 infection cases everyday is likely to cause many individuals to move to the forest on the positive side they can spend time together in the woods this further strengthens the family bond and indirectly they engage in the traditional lifestyle that was practiced by the earlier generation the youngaged generation can have the opportunity to learn and experience the oroo language from the middleaged services and facilities the locals recognize that the level of services and facilities here is average and that it still requires significant attention from stakeholders particularly concerning water and electricity supply the electricity facilities here are bad on average we still use our generator some villagers use solar i also have five water tank units and one of them is given by the government we do have problems with our water supply i live on the side of the road and only rely on rain catchment water if its a dry season we dont have water there is no clean water supply in this mulu area only the national park and the marriot hotel have treated water supplies because they have filters and chlorine those of us who live in singlefamily homes do not have that water those who live by the river also use engines to pump water into their houses they are aware that the available river water is not necessarily safe to drink due to various factors clean water and electricity are basic needs for human wellbeing and everyone has the right to have access to clean water which is in line with sustainable development goals 6 authority intervention as a mediator the wellbeing of the community also depends on the authoritys role in determining their quality of life in principle in the context of tourism the authorities have the power to mediate its intensification form a policy and determine the parties that should benefit through the implementation of the policy holistic management by the authorities will encourage the local population to support the implementation of the policies carried out in this gmnp fig 3 the basic oroo language explanation by key informant it indicates that the penan community uses twigs and leaves to form specific signals that carry certain messages the symbol of two twigs of the same length indicates the presence of a team one friend family while in the forest the two twigs placed on top of the folded leaves indicate hunger signals to nonenemies while the combination of the symbol of a leaf pricked by a small twig then inserted with a tree branch carries the meaning that the individual has obtained the hunted animal in this straight direction this is in line with the findings of park and inanç that the positive behavior of locals towards conservation in protected areas is dependent on the current management strategy that involves local communities more effectively despite this their dissatisfaction with an effort that the government is trying to implement needs to be taken into account and resolved through consultation it is noted that there are several issues involving the authorities especially regarding road proposals and community conflicts in the area although the government helps a lot from an economic point of view road proposal the sarawak government has proposed new roads linking mirimarudi marudimulu and long panailong lama under the high impact infrastructure project the project will increase accessibility from mulu to other areas although this project makes it easier for locals to reach facilities such as hospitals schools and grocery stores in miri at any time however many do not support the project due to some challenges that will arise as a result of the development its not that we dont want to and its not that we really want to indeed since long ago there has been a trail or unpaved road that connects this melinau area it starts from long imanlong lamalong bedianmiri i dont want a paved road directly from here to miri the land we have now is not big enough anymore it has already been invaded and such development will only make us more trapped in my view it is enough as it is now there is no need for a road this proposed road will not only put pressure on the locals of batu bungan and long iman village but it will also affect the economy of those from long terawan village this is because water transportation from miri to gmnp will be paralyzed due to the existence of the road all this time the residents of long terawan have earned a decent income from rural businesses that have been welcomed by international tourists the village becomes a transit point for tourists to experience longhouses and mingle with the residents thus residents can also sell local products such as rice wine dried fish and other agricultural products the income of boat operators will also decrease as a result of the construction of the road therefore looking at the impact that will happen it is better to maintain air transportation as the main transport to this gmnp where the locals are indeed given a subsidy for the cost of their air ticket from mulu to miri airport which is considered reasonable in addition the construction of the road is likely to result in even worse degradation of biodiversity an increase in population will also occur due to the existence of roads that connect mulu to other areas pressure on the use of natural resources in mulu will also occur leading to encroachment hunting pollution and so on what is the guarantee that the parties involved in the construction of the road will not take timber when carrying out the project make sure they do the construction work without damaging the existing environment which may threaten us while first in protecting the park and biodiversity the road connection to miri and the rest of the area is a terrible idea it will mostly destroy the biodiversity because it will make it easy for outsiders to come in and hire locals to collect in the forest and transport it directly the wildlife trade is a big problem for us even though the local community hunts and the park is primarily for subtenants they are not involved in the wildlife trade most local communities are also against the proposed road because they worry about the competition from outsiders coming in now they monopolize transportation around here although people favor the road to mulu but not directly to here it should be because it directly limits how people come one idea to solve this problem is to have the end of the road be at the tutor river then people will travel the rest of the journey to mulu by boat it has frequently been discussed among the berawan community about this many residents support the road but they are concerned about encroachment on the park they are aware of the effects of tourism on their livelihood because they are involved in it this demonstrates that locals are highly concerned about potential threats to biodiversity in gmnp and the surrounding area posed by road construction despite opposition to the proposed road construction it was the authorities who determined the most effective means of controlling the situation to ensure the wellbeing of the community the authority should note that locals can be a direct threat to the protected area when they refuse to cooperate with them or participate in conservation activities the governments assistance in empowering the local economy creating a balance between park protection and community development is a global challenge for national park policymakers and management authorities in terms of the economy the government also provides a lot of assistance to tourism operators including homestay operators who emphasize human capital according to croes et al investment in human capital is the key to sustainable tourism development through good hospitality to tourists in gmnp some locals are given courses and facilities to operate businessrelated tourism by local authorities last year some officers from the sarawak economic development corporation came here to inspect the state of our homestay they monitor if there is a lack of facilities such as washing machines beds refrigerators and beds if before they gave us myr5000 but now the who bought us the appliance corresponded to the value there are also homestayrelated courses given by the government in miri land ownership conflicts the issue of land ownership among the penanberawan people around mulu has been a matter that has arisen recently causing the government to intervene in finding a proper solution it can be said that there is an encroaching party like the berawan people who came to our place and claimed that this land is their right their border is far away from here while they have a village they dont live there that is the issue that i want the chief minister to solve because they are still very much in power here in terms of work its not a problem recently they requested the chief minister to build a longhouse once the cm approved the construction of our longhouse here and he was attacked by a few of them this is a bad experience as far as we are concerned we are not worried due to the presence of immigrants from other villages and races we are worried i do not agree with the development right now our land is an issue we imagine our land will be taken away where else do we want to live now the chief minister is going to marriot hotel to discuss this land issue a few berawans claim that this place where we live is their land even though we have always lived here although ethnic conflicts have existed for centuries however they remain united in their opposition to forest destruction in their region which shows their place attachment is good based on zhang et al andmohamad syahrul nizam et al place attachment refers to an emotional bond which is a memory produced through experience in an area and it plays a role in fostering an ecocentric attitude unesco whs status helps here if there is no such status they namely radiant lagoon sdn bhd are already producing palm oil in the area near here we drove them away people who have a stake in radiant lagoon sdn bhd do some business here they take opportunities when running some businesses here including attempts to exploit the area which is only seen to affect the environment and not to the detriment of the local population the study carried out by brankov et al eben mannetti et al nastran and ngonidzashe et al also stated the same situation which is the conflict between locals and protected area management although it involves different issues from different groups it has similarities in terms of dependence on natural attributes in national parks conclusion caveats and policy implications the wellbeing of the community through their satisfaction with the environmental economic and social aspects of gmnp has been unraveled and some of the issues that have arisen have also been explained in detail by key informants in this study in general the local communitys perception of the environmental aspects of gmnp is good however it does not reflect the actual situation ie river water turbidity wildlife threats degradation of wetlands and solid waste issues still occur especially in areas at least 50 kilometers outside of gmnp next the constraints of the covid19 pandemic show a decrease in their income for survival they changed to gardening fishing hunting and smallscale agriculture activities for continuous food supply in terms of social aspects the services and facilities are needed to be improved especially the supply of clean water and electricity some of the local communities are very satisfied with the cultural aspects of their lives which include traditional elements such as handicrafts dance and musical instruments based on the narratives the oroos secret sign language of penan which is their identity is increasingly threatened due to changing lifestyles and the need for documentation and promotion of tourist products for the language authority intervention also greatly affects the wellbeing of local communities due to policy implementation in terms of environmental economic and social aspects local support towards the government can determine the holistic management of biodiversity conservation and sustainable tourism in the natural area like gmnp therefore the bottomup approach is seen as an idea that should be emphasized by stakeholders which is the involvement of all parties in the decisionmaking process starting from the ground level and it is important in understanding the wellbeing of the complex community communication involving all stakeholders can determine the form of community empowerment and lead them to support a balanced form of management the holistic management in a protected area particularly unesco world heritage site will provide good periodic reporting which is a reflex that the site is wellmanaged by stakeholders and there is no significant threat that makes the site listed on the list of world heritage in danger the elements of biodiversity conservation and wellbeing are among the emphasis in the periodic report which is carried out every six years by appointed assessors in particular the process involves an assessment of the detrimental elements of a property whether its condition is stable or not and the unesco world heritage committee will provide recommendations based on the report in addition to the global branding as whs any protected area also has the potential to be proposed as one of the iucn green list of protected and conserved areas if the components include good governance sound design and planning effective management and successful conservation outcomes in good conditions the situation in gmnp explains that the local community has met certain wellbeing criteria based on definitions from various literatures that explain the relationship among the environmental social and economic domains the social psychological aspect demonstrates that it is the key in achieving wellbeing finally place attachment is interpreted as a catalyst for a resilient community in gmnp this study has highlighted the challenges posed by the pandemic to a tourism community residing in one of the protected unesco world heritage sites the empowerment of local communities constitutes comprehensive conservation of biodiversity the conceptual framework of this study can be applied to other studies on related topics such as the wellbeing of local communities in protected areas in both developed and developing countries this mixedmethods study provides greater insight than a quantitative study alone into community wellbeing environmental economic and social issues the role of authority intervention and the covid19 pandemic as a mediator this is due to the fact that in general local communities living in protected areas have similar environments ie they rely on biodiversity characteristics that may provide slightly different benefits and challenges based on their perspectives future research will benefitted with broaden the scope of the study towards psychosocial aspects and sociodemographic factors that may have an impact on the respondents own level of wellbeing it is also recommended for the future research to explore the community wellbeing in terms of economic aspect particularly the value of biodiversity conservation in gmnp it is potentially could provide a new context into the existing data that relates to human wellbeing taking into account how challenging it is to conduct sampling during this pandemic the mixed method approach can reduce the likelihood of bias in research findings we acknowledged that this study has its data limitation however it could represent a pragmatic and prioritize a meaningful knowledge on the application of quantitative and qualitative methods arbitration between these two approaches is crucial to understand the communitys perspective through the eyes of key informants and the generalizations of laymen in addition this study includes local communities residing in the isolated area who on average have a low level of literacy and limited internet access thus it limits the ability of online surveys even though this mixed method is deemed appropriate for use during this pandemic researchers must be aware that data reliability may be compromised thus it is recommended that researchers engage in data triangulation to ensure its reliability by engaging in reflection that consistent with the studys objective epistemological stance and design in addition the extent to which threats and biases in the study can be adequately managed data availaibility all data generated or analyzed during this study are included in this published article competing interests the authors declare no competing interests ethical approval the study was approved by the universiti putra malaysia ethics committee for research involving human subjects all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards before being approved by jkeupm this study has obtained a research permit from the sarawak forestry corporation for a oneyear period from 2020 to 2021 it has to comply to the first schedule of the national parks and nature reserves regulations 1999 in order to meet ethical principles we have collected primary data using a physical questionnaire from local communities living near gunung mulu national park voluntarily taking into account certain aspects such as being over 18 years old and having lived in the study area for more than five years meanwhile 12 key informants have agreed to be involved in the recorded interview session informed consent before participants agreed to participate in this study they were given an information sheet that explained the nature of the research in terms of methodology benefits of the study possible side effects and complications and confidentiality informed consent for participation and publication was obtained from all participants in this study all participants gave their informed written consent additional information correspondence and requests for materials should be addressed to suziana hassan reprints and permission information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the local communities living around national parks or areas like world heritage site whs are crucial stakeholders to such settings their wellbeing needs to be unraveled so that the holistic management of the national park is in good condition to stabilize its status as whs through the support and empowerment of the community numerous studies have been conducted on the biodiversity and geology of gunung mulu national park gmnp but the community psychology aspect that is the foundation of conservation efforts has not been addressed therefore this study aims to examine the community wellbeing dimensions in terms of environment economics social aspects as well as authority intervention based on the perspective of the local community and professionals with an emphasis on the current issues in gmnp quantitative and qualitative approaches were used in this study through a questionnaire to 99 local communities and individual interviews that were conducted in gmnp and four nearby villages data were analyzed descriptively with four themes environment economics social and authority intervention the findings showed that locals were satisfied in residing area in terms of environmental conditions however it does not reflect the actual situation ie river water cloudiness wildlife threat degradation of wetlands and solid waste issues are still happening the constraints of the covid19 pandemic portrayed that they were very dissatisfied with their monthly income which is very low compared to before in terms of social the services and facilities especially treated water and electricity need improvement it also noted that authority intervention especially related to road proposal financial and skills assistance and community conflicts could influence locals support for the planning and policies implemented in the national parks or whs areas this study suggests that relevant stakeholders should emphasize bottomup approaches by considering aspects of community wellbeing that stem from multiple dimensions in order to achieve holistic national park management

introduction peru has enabled the most restrictive measures in its national public health history to control the current covid19 outbreak 1 2 3 4 the first patient with covid19 in peru was detected in lima on march 5 2020 5 five days after classes in schools were suspended nationwide and on march 12 all classes at universities were suspended nationally 6 on march 15 a state of emergency border closure and lockdown was declared with the order of social isolation for 15 days 7 which has been extended multiple times and currently it has been announced to be until june 30 2020 those measures were very similar to the ones imposed in china which have affected peoples lives jobs health and wellbeing 8 increasing stress and anxiety 910 during the covid19 outbreak because of the social isolation in peru the covid19 crisis is expected to affect peoples mental health especially that of healthcare workers after the first case was detected on march 5 2020 the confirmed cases increased rapidly overwhelming healthcare workers furthermore personal protection equipment access burnout due to long work hours not seeing their families for many days the high risk of becoming infected and the psychological harm of uncertainty have been reported to affect the physical and psychological status of healthcare workers in china 11 and iran 1112 however at the best of our knowledge this has not been properly studied in peru as it has already been reported in china 13 14 15 singapore 16 iran 1217 italy 1819 france 20 united kingdom 21 and spain 2223 the covid19 crisis is causing an increase in burnout or anxiety 2425 which resulted in an unprecedented psychological impact 26 27 28 and affecting peoples life satisfaction that is one of the most critical indicators of mental health 2930 we aim to use early evidence in peru to help mental health service provide in screening people with psychological issues during the covid19 outbreak from a novel perspective of typhoon eye theory 13 31 32 33 it has been observed that people who reside far from the epicenter of an outbreak usually overestimate the likelihood of becoming infected 34 which has been reported for covid19 13 and earthquakes 32 this study identifies the vulnerable regions where individuals are more likely to suffer from wellbeing issues and helps to guide medical professionals attention toward the more mentally vulnerable groups based on the distance from the epicenter in the covid19 outbreak in peru lima the ripple effect refers to the phenomenon that the mental health issues are more problematic for people around the center of the epicenter which was the case for mental health services during the sars and ebola outbreaks 35 36 37 however because tremendous amount of social media exposure and information have been perceived during the covid19 outbreak 38 our research group already has reported that in china individuals wellbeing deteriorates over distance from the epicenter 13 as depicted by the psychological typhoon eye theory 3132 in this study we test whether the typhoon eye theory works and for whom it works in the covid19 outbreak in peru we performed our analysis on healthcare workers as they are a covid19 vulnerable group we selected age as a variable because it has been reported that the younger population are usually more adaptive to a natural disaster or to the outbreak of a virus 3940 however younger population also tend to access information on covid19 more frequently via digital sources such as social media 41 which causes them to be exposed to more negative content 42 family size is an indicator of social support that one could receive during crisis like the current one 43 because it served as an important resource to buffer stress and anxiety 44 we surveyed healthcare workers in 15 of the 24 provinces in peru these locations vary in their travel distance from the epicenter of lima we used anxiety distress and turnover intention scales to assess the mental health of healthcare workers in peru after 1 month of lockdown and social distancing measures turnover intention is defined as the likelihood of an employee to leave his current job 45 overall drawing from psychological typhoon eye 3132 this study provided a snapshot of adult healthcare workers mental health during the ongoing covid19 pandemic to enable more targeted mental health support in peru methods study design we conducted a crosssectional survey from april 10 2020 to may 2 2020 after 1 month of lockdown and social distancing measures in peru because of the covid19 outbreak at the beginning of the survey the number of confirmed cases in peru was 5897 and 169 deaths 46 whereas at the end of the survey the number of cases increased to 42534 and the number of deaths increased to 1200 47 we surveyed healthcare workers from 15 47 participants the online survey reached 400 healthcare workers in healthcare organizations such as hospitals clinics first emergency responders medical wards nursing home dental clinics pharmacies and other healthcare institutions we received responses from 303 of them who worked in 111 healthcare facilities including 55 healthcare facilities in lima 33 healthcare facilities in loreto and 23 healthcare facilities from the other 22 cities their distance to the epicenter ranged from 0 km to 1292 km all survey participants provided their informed consent before the enrollment the survey was approved by the tsinghua university ethics committee the participants remained anonymous and had the option to finish the survey at any time and their information was kept confidential the participants were not involved in any of the planning execution and reporting stages of the study outcomes and covariates healthcare workers anxiety distress and turnover intention were assessed using the sevenitem generalized anxiety disorder scale 48 the kessler psychological distress scale 49 and the twoitem turnover intention scale 50 respectively the total score of anxiety was considered as normal mild moderate and severe whereas the psychological distress was considered as low moderate and serious the cutoff value to consider the presence of anxiety was 10 51 and 13 for psychological distress 52 the healthcare workers reported their age gender family status education occupation type of healthcare organization job level exercise hours per day in the past week and chronic health issues education included the categories of high school technical bachelors medical specialty masters and doctorate participants reported whether they had any chronic disease because comorbidities increase the chance of complications in a person with covid19 53 and because people with ongoing medical issues could be more anxious using their work locations we calculated the distance of their cities to the epicenter of lima for each participant statistical analysis data analysis was performed in stata version 160 with a significance level set at p 005 and all tests were twotailed we used linear regression to predict anxiety distress and turnover intention using unweighted data the average distance of the participants to the epicenter of lima was 424 km with a sd of 490 km the participants scored an average of 154 in the gad7 anxiety scale and the average surpassed the cutoff of severe anxiety at 15 51 in the k6 distress scale the participants scored an average of 192 higher than the cutoff of mental distress disorder at 13 52 predictors of anxiety distress and turnover intention the regression results in table 2 examined the predictors of anxiety mental distress and turnover intention of healthcare workers in peru during the covid19 outbreak education level had a negative association with anxiety the effects of gender age work level type of contract and type of institution on anxiety were not significant in the case of mental distress the predictors were not significant there was a negative association between age and turnover with younger healthcare workers aged among 1824 years in comparison to 3544 years healthcare workers in the private sector had a higher turnover intention than those in the public sector the effects of gender education level and work level on turnover intention were not significant results the distance to the epicenter as a predictor first margin analysis revealed the relationship between the distance to the epicenter and anxiety was significantly negative a ripple effect taking all the other covariates equal this relationship however might vary when other variables changed the regression results in table 2 indicated a significant interaction effect between the distance to the epicenter and the type of institution on anxiety the interaction effect between the distance to the epicenter and job contract on anxiety was not significant yet margin analysis showed the relationship between the distance to the epicenter and anxiety was significant and showed a ripple effect only among fulltime healthcare workers and not among temporary healthcare workers second margin analysis revealed the relationship between the distance to the epicenter and anxiety was significantly negative a ripple effect taking all the other covariates equal this relationship also varied when other variables changed the regression results in table 2 indicated a significant interaction effect between the distance to the epicenter and the type of institution on anxiety margin analysis showed the relationship between the distance to the epicenter and anxiety was significant and 21 11 21 13 0 3 28 22 9 3 31 6 10 2 12 0 1 8 18 5 4 10 4 4 0 2 0 0 6 4 0 4 4 2 1 0 1 0 0 1 3 0 education level high school 1 0 0 0 1 0 0 0 0 0 technical 67 2 3 1 41 1 9 25 40 36 0 0 1 0 0 0 0 0 1 na not applicable includes other occupations such as medical technologists dentists psychologists biologists administrators ambulance drivers physician auditors students and providers of general services showed a typhoon eye effect only among healthcare workers in public institutions and not among healthcare workers in private institutions the interaction effect between the distance to the epicenter and job contract on anxiety was also significant moreover margin analysis showed the relationship between the distance to the epicenter and anxiety was significant and showed a ripple effect only among fulltime healthcare workers and not among temporary healthcare workers third margin analysis revealed the relationship between the distance to the epicenter and turnover was not significant taking all the other covariates equal the regression results in table 2 indicated a significant interaction effect between the distance to the epicenter and the type of institution on turnover margin analysis showed the relationship between the distance to the epicenter and turnover was significantly negative among healthcare workers in both public institutions and private institutions discussion since 2012 peru implemented the community mental health model as recommended by the who 54 as an approach to provide care in the community through specialized facilities called community mental health centers however as reported in 2019 actual fulltime employees of these centers reported that there are critical barriers that still need to circumvent 55 some of them include lack of consistent training resources structure and policies that effectively support the use and importance of these centers in the evaluation and adequate treatment of mental health conditions 55 this situation also gets worsened when general practitioners in peru consider themselves as not very competent in diagnosing and treating mental disorders this was reported in a selfperception survey that evaluated the competence of peruvian general practitioners in diagnosing and treating major depression anxiety disorder alcohol dependence and schizophrenia 56 it is reported that of the 434 responders 705 believed they were competent in diagnosing depression 733 for anxiety 676 for alcohol dependence 620 for schizophrenia and when the four mental disorders were combined only 416 of participants selfperceived competence in providing an adequate diagnosis 56 these results highlighted the need to improve medical education so as to develop the skills necessary to confront mental health disorders 56 there is a very limited number of studies that have assessed mental health in the general public and healthcare workers in peru and to the best of our knowledge this study is the first to report the mental health of healthcare workers in peru during the covid19 outbreak our study shows that overall people who were geographically further from the epicenter in peru during the outbreak experienced less anxiety and mental distress corroborating the ripple effect and disconfirming the typhoon eye theory 1113 31 32 33 however this relationship can change depending on the type of institutions and contract the relationship between the distance to the epicenter and distress for healthcare workers in public institutions was positive showing a typhoon eye effect distance to the epicenter is a crucial factor for psychiatrists to consider to screen the mentally vulnerable groups 133057 but research needs to first establish whether the distance to the epicenter carries a ripple effect or a typhoon eye effect furthermore our results indicate that healthcare workers with a lower education level were more anxious and younger healthcare workers and those in the private sector were more susceptible to turnover an important factor to consider is that at the beginning of the survey the number of confirmed cases in peru was 5897 with 169 deaths 46 whereas at the end of the survey the number of cases increased to 42534 and the number of deaths increased to 1200 47 this significant increase in confirmed cases and the accompanying coverage in the national and international media could have also caused increased anxiety and distress in healthcare workers in addition the reported precarious health system and saturation of every hospital in peru with covid19 patients 3 could have also caused an increase in turnover intention for healthcare workers similar to iran 17 china 13 and the united states 58 we did not identify a universal risk factor that could predict specific mental disorders in peruvian healthcare workers this is expected as each country has their own medical system clinical capacity access to ppe labor conditions lockdown policies and cultures limitations the context of this study has a clear epicenter of covid19 lima in peru however it is not always the case as observed in south korea 59 our data were collected in peru a geographically large country and it remains unclear whether the typhoon eye effect or the ripple effect will generalize in other countries most of which are smaller the epicenter of lima is in the midwest of peru whereas the epicenter of wuhan is in the middle of china and the epicenter of new york state in the united states is in the northeast thus we suspect that either the typhoon eye effect or the ripple effect might play out differently in term of pace and patterns conclusion our results show that perus healthcare workers anxiety and mental distress decreased as the distance from the epicenter increases corroborating the ripple effect and disconfirming the typhoon eye theory a lower education level increased the anxiety levels whereas age and gender did not affect the anxiety and distress levels the turnover intention was not associated with the distance to the epicenter nor gender but it was higher in younger healthcare workers in the private section our results can help guide mental health service providers toward vulnerable groups of healthcare workers that are closer to lima the covid19 epicenter in peru we urge for more research to assess the mental health of healthcare workers and general public in peru a country that was not given the importance it deserves

we conducted a crosssectional survey to assess the anxiety distress and turnover intention likelihood to leave their current job of healthcare workers in peru during the covid19 pandemic our results reported that 217 healthcare workers in peru experienced severe anxiety whereas 261 of them experienced severe mental distress a higher level of education related with a lower level of anxiety younger workers had a higher level of turnover intention than their older colleagues did healthcare workers in the private sector had a higher turnover intention than those in the public sector most importantly people who were geographically far from lima the epicenter in peru during the outbreak experienced less anxiety and mental distress corroborating the ripple effect and disconfirming the typhoon eye theory however the direction of these relationships can change depending on the type of institutions public versus private and the type of employees contract full time versus part time our research helps provide insights for clinical professionals in identifying the vulnerable groups to mental disorders in peru this is the first study to assess anxiety mental distress and turnover intention in healthcare workers in peru during the covid19 pandemic

introduction child labour has been a serious problem and a challenge for many countries around the world especially the developing countries globally it has been a challenge and longterm goal in many countries to abolish all forms of child labour in developing countries it is considered as a serious issue these days child labour refers to children who miss their childhood and are not able to have the basic amenities which a child should have recently the international labour organization estimated there are around 215 million children between the ages five to fourteen who works worldwide they are often mistreated and work for prolonged hours in very bad conditions this can affect their health physically mentally and emotionally these children do not have the basic rights like access to school or health care according to ilo the largest numbers of child labourers are working in hazardous work and the total number of child workers is increasing even though it is forbidden by law these children are vulnerable to diseases and they struggle with longterm physical and psychological pain the main cause that induces children to work is poverty these children work for their survival and their families although not all the work that children do is harmful or brutal some work may provide successful learning opportunities such as babysitting or newspaper delivery jobs but not if the work exposes them to psychological stress like human trafficking prostitution and pornographic activities international organizations have made great efforts to eliminate child labour across the world many countries have adopted legislation to prohibit child labour nonetheless child labour is widespread throughout the world it is not easy task for low income countries to achieve banning child labour in most african countries a large proportion of households still live below the poverty line of less than 5 us dollars per day due to factors such as weak economic base galloping inflationary measures high rate of unemployment the inadequate incomes of parents as well as ineffective machinery to enforce child welfare policies the result is that it has affected children in the rural areas find it difficult to survive as a result of economic status of their parent these adverse socioeconomic situation as highlighted above which are also compounded by the challenging political and cultural crises in many countries as evidenced by civil wars genocide famine drought hivaids epidemic and structural adjustment programs makes life in the rural areas unbearable for the children consequently african children who are always at the receiving end are often placed in the margins of public arena through their joining both the wage and nonwage markets some of these activities are sometimes hazardous to their health and education the effects of child labour are visible on different levels in the society on the child the mental health of the child is negatively affected indeed children engaged in hazardous industries have been observed to suffer from oral abuse from their employers consistent fear of job termination low selfesteem and a loss of imagination and future direction in life also physical stress due to the age and maturation of the child is affected leading to low concentration at school and breakdown of health of the child physical consequences that range from malnourishment diseases musculoskeletal disorders from heavy labour physical and sexual abuse to injuries exposure to toxic agents and prolonged working in cramped and hazardous conditions have been well documented these physical effects of the industrial sector have been detrimental to the wellbeing of the child worker at the household level childrens economic production has become an important aspect of economic survival strategies many children spend several hours working outside the home in order to bring additional income to the household a significant proportion are involved in petty trading and services or even working as street beggars in urban areas therefore their involvement in these activities poses serious threats to the continued survival of the society distort government policy with respect to education of the youth due to high dropout rate it distorts acquisition of vocational skills and relevant education thereby destroying the economic sector socially children in industries have been found to experience negative consequences to their educational development and performance the prevalence of illiteracy low school attendance and low enrollment has been attributed to childrens economic participation okoye and tanyi carried out a study on the perception of child labour in south eastern nigeria a study of onitsha metropolis investigating the perceptions of nigerians on child labour a sample of 360 respondents was used for study the findings indicate that majority of the respondents perceive such chores like babysitting fetching water splitting firewood sweeping farming and cooking as child labour also the sex of the respondents was found to be the most important predictor of perception of chores that constitute child labour from the study it can be said that the forms of child labour reported by the authors are simply child work and not obviously child labour as has been highlighted earlier forms of child labour similarly asamu in a study examined child labour and its social implications on children in selected cities in nigeria a sample of 826 child labourers was selected as respondents for the study findings from the study revealed that child labour activities fall into different categories namely bus conducting car washing hawking begging weaving tailoring hairdressing and autorepairing among others the study also showed that most children who engage in child labour are largely from the lower economic stratum of the society and the incidence of child labour was also significantly related to the rate of childs health status school attendance academic performance their delinquent behaviours contact with parent and childs exploitation by employers the study highlighted that children who engage in economic activities are found to be different with respect to their social development from the study it can be deduced that the forms of child labour are farreaching and wideranged factors that influences child labour practices ekpenyong and sibiri conducted a study on street trading and child labour in yenagoa the study showed that chronic urban poverty can compel parents to send children of school age to work to boost family income thus for many hours each day children of poor parents are engaged in economic ventures including hawking plaiting of hair and being apprenticed to various trades the study explained the basics of child labour its causes and its effect on its victims and society as a whole a sample of 300 respondents was used for the study the findings of the study established that street trading and child labour are a great menace to both the individual and society from the study it can be deduced that poverty is a leading cause of child labour especially among the majority of child labourers in another study carried out by mfrekemfon and ebirien on child labour a public health problem in nigeria the study showed that child labour deprives them of their childhood interferes with their ability to attend regular school and this is mentally physically socially or morally dangerous and harmful the study also showed that this has become a concern not only at the international level but national as well because of the unhealthy circumstances and multiple health implications children are subjected to the study indicated that child labour does not only deprive children of their education but also their physical and mental development the study however highlighted some of the causes of child labour to include poverty unemployment low income corruption demand for cheap labour and many others from the study it can be said that the causes of child labour on the child labourers are mostly economic they are numerous and averse to the development of children however taking a different stride shailong onuk and beshi conducted a study on the socioeconomic factors affecting children hawkers in lafia local government area nasarawa state nigeria this study examined why children are sent out to hawk on highways and other places the sample size comprises 100 children under 15 years of age findings from the study revealed that large family size were major reasons why parents send their children out for hawking the study also showed that the income from the child hawker supports their mothers mostly in polygamous homes or a singleparent home it can be inferred from the study that child labour is more consistent in most polygamous and single parent homes however the study did not consider that some single parents and mothers in polygamous homes would rather do all the labour to promote the welfare of their children without putting them through the risk associated with hawking in the same vein elegbeleye and olasupo conducted a study on parental socioeconomic status as correlate of child labour in ileife nigeria the study investigated the relationship the outcome of the study showed that a significant relationship exists between parental socioeconomic status and child labour from the study it can be said that the financial status of parents can influence their decision to engage their children in child labour practices effects of child labour on child development early childhood is generally recognised as the most crucial life phase in terms of developmental malleability for this is when maturation processes are accelerated and genotypic milestones emerge the negative impact of deprivations in these critical periods can be very large importantly the time sensitivities of early childhood are also socially structured by influences that include the institutions of education as early cultural learning selects and reinforces specific cognitive and psychosocial competencies unequal participation in earlychildhood and primary education further determines longterm trajectories in the sense that institutions teachers and assessment systems all tend to promote some children over others depending on their perceptions of childrens characteristics and potential significantly the childenvironment influence operates in both directions in that children do not simply absorb and react to external forces but are instrumental in shaping their own environment by selecting and even creating those settings that are compatible with their individual characteristics in nigeria child labour practices manifesting in the different forms seems to be on the increase this is perhaps due to economic crisis which started in the 1980s the nigerian economic crisis has made life worse for children of the poor whose parents have either lost their jobs or suffered a drastic decline of income problems such as malnutrition high infant mortality overcrowding and others have been exacerbated as many nigerian families were pushed below the poverty level even as a small class of people profited from the economic crisis the economic crisis has also led to the abandonment of traditional and family responsibilities with serious effect on the underprivileged and the children the outcome of this is clearly visible in the high increase of children who engage in child labour in both the formal and informal sectors child labour according to unicef involves all works which are harmful to a childs health these works include any work that violates childrens fundamental human rights and any work that is dangerous or threatening it also includes works that exhaust childrens strength and damage their bodies whatever works that prevents children from going to school to gain basic skills and knowledge for their future development is included in the definition of child labour with this child labour is a challenge that every modern society has to contend with child labour has devastating effects on children their families communities in which they live and generally on national development the consequence of child labour on child development is glaring obvious and at times irreversibly permanent they include health hazard physical abuse fatigue poor school performance academic wastage sexual abuse accident youth violence among others physical and health consequences of child labour include stunting breathing problems owing to exposure to toxic substances accident proneness contamination of cuts and wounds while cognitive problems include not attending schools class retention and high dropout rate and achievement deficits social and physiological consequences include isolation of working children from their families and peergroups stigmatization of work by peers lowering of selfesteem of children and perception of relative deprivation child labour exposes the child to a lot of hazards like sexual defilement sexual assaults neglects and threat of punishment for speaking out as exemplified above the consequences of these acts usually result in an unwanted pregnancy sexually transmitted diseases psychological problems and a gradual withdrawal from a healthy relationship with the opposite gender nseabasi and abiodun noted that street hawking exposes the male and female child to dangers posed by fraudsters and actual murderers because of their vulnerability at odd hawking hours they are usually under personal jeopardy harsh and hazardous conditions such as becoming an easy target to occult predators child labour does not only deprive children of their education but also their physical and mental development is taken away from their childhood children may not be aware of the short and long term risk involved in their work due to their long hours of work child labourers are normally denied basic education normal social interaction personal development and emotional support from their family and they may face physical danger and even death bassey baghebo and otu argued that child labour has physical consequences on the child these range from malnourishment disease musculoskeletal disorders from heavy labour physical and sexual abuse mfrekemfon and ebirien opined that child labour can result into injuries to the children and expose them to toxic agents in the process growth deficiency is common among child labourers they tend to be shorter and lighter and grow with it into adult life long term health problems such as respiratory disease asbestosis and different cancers are common in countries where they are forced to work with dangerous chemicals hivaids and other sexually transmitted diseases are common among children forced into prostitution exhaustion and malnutrition result from children performing heavy manual labour for long hours under unbearable conditions and not having enough money to feed labour rights for the nigerian child and the way forward the law governing the rights of a child in labour issues in nigeria is the labour act section 59 of the act provides that no young person shall be employed in any work which is injurious to his health or which is dangerous or immoral the act further provides that no child under the age of 16 years shall be employed in circumstances in which it is not reasonably possible for him to return each day to the place of residence of his parents or guardians the section forbids a child less than 16 years from working underground or on machines it further forbids young persons from working for a longer period than four hours in one day it places additional restrictions on the employment of a child or young person on a ship or any vessel and it prohibits absolutely the night employment of young persons from the above one can see that the labour act does not prohibit child labour rather it only places restrictions on where when and how childs labour may be employed there should be public enlightenment at the grass roots or community levels on the present situation of child labour and its implication on the society the family planning system should be made compulsory so as to prevent parents from having more children than they can care for poverty alleviation programmes should be improved upon to raise the standard of living of low income families and upon meeting specific conditions beneficiary households must undertake certain activities or investments such as getting their children enrolled in school and allowing them to progress academically by staying in school without undue distraction the government local ngos and civil societies should join hands and work together to ensure that children are protected from hazardous jobs that can impair their health status and their educational development the role of the social worker in child labour the national association of social workers code of ethics states that the primary duty of the social worker is to enhance human wellbeing and help meet the basic human needs with particular attention to the needs and empowerment of people who are vulnerable oppressed and living in poverty they provide interventions and enhance human coping capabilities and competence to solve personal and social problems so as to create a more caring conducive equitable and just society social workers provide clients with interventions such as assessment counselling taskcentred work advice educationinformation giving advocacy among others according to ngwu the social worker plays the following roles in relation to child labourwelfare services broker role the social worker makes linkages between community and the clients to highlight the dangers of child labour seek alternative ways of supporting the parents income and mitigating the practice of child labour advocacy role the social worker advocates on behalf of the clients to get the desired services from the society and their families enabler role the social worker helps the child and the family to find potentialities and resources within themselves to solve their problem objectives of the study the general objective of the study was to examine the socioeconomic factors that influence child labour the specific objectives were as follows 1 to find out if christians are more likely to involve their children in labour practices than those who are from other religions 2 to ascertain if younger adults are more likely to involve their children in child labour practices than older adults 3 to investigate if working class persons are more likely to involve children in child labour practices than nonworkingclass persons research design the study utilized the crosssectional survey research design crosssectional survey research design entails the observation of a sample or a crosssection of a population at one point in time this design helped this study as well as facilitated the researchers effort to identify the socioeconomic factors that influence child labour in nkanu east local government area of enugu state research hypotheses the following hypotheses guided the study 1 christians are more likely to involve their children in labour practices than those who are from other religions 2 younger adults are more likely to involve their children in child labour practices than older adults 3 working class persons are more likely to involve children in child labour practices than nonworkingclass persons test of hypotheses hypothesis one substantive hypothesis christians are more likely to involve their children in labour practices than those who are from other religions null hypothesis christians are not more likely to involve their children in child labour practices than those who are from other religions to test hypothesis one religious affiliation was crosstabulated with involvement in child labour practices the result revealed that among those involved in child labour practices 932 were christians while 68 were other religions while among those not involved in child labour practices 931 christians while 69 were other religions the chi square test result shows that computed ᵡ² is 7171 while the critical ᵡ² value is 3841 and df1 the test shows there is a statistically significant relationship between religious affiliation and the involvement in child labour practices accordingly the substantive hypothesis which argued that christians are more likely to involve their children in child labour practices than those from other religions is hereby accepted while the null hypothesis which state that christians are not more likely to involve their children in child labour practices than those from other religions is hereby rejected hence religion influences child labour hypothesis two substantive hypothesis younger adults are more likely to involve their children in child labour practices than older adults null hypothesis younger adults are not more likely to involve their children in child labour practices than older adults to test hypothesis two age of respondents was crosstabulated with involvement practices the result revealed that 505 of younger adults and 495 of older adults are involved in child labour practices on the other hand 601 of younger adults and 399 of older adults are not involved in child labour practices the chi square test result shows that computed ᵡ² is 5322 while the critical ᵡ² value is 3841 and df1 the test shows there is a statistically significant relationship between age of respondents and child labour practices as a result of this the substantive hypothesis which states that younger adults are more likely to involve their children in child labour practices than older adults is hereby upheld while the null hypothesis which states that younger adults are not more likely to involve their children in child labour practices than older adults is hereby rejected thus age of respondents influences child labour practices child hypothesis three substantive hypothesis working class persons are more likely to involve children in child labour practices than nonworkingclass persons null hypothesis working class persons are not more likely to involve children in child labour practices than nonworkingclass persons discussion of findings child labour remains a multifaceted social problem in many developing countries child labour is one of the deadliest form of work a child is engaged in which tends to affect not just their present state but the future at large findings from this study in table 48 revealed that majority of the respondents indicated house chores as a form of work children engage in this means that children help their parentsguardian with house chores in the study area this finding is in agreement with that of ilo according to him child work is a responsibility and a training to the child through assisting in house jobs that do not hinder their education and health the study also revealed that 535 of the respondents agreed that house chores is a form of training this finding agrees with that of mfrekemfon and ebirien according to mfrekemfon and ebirien child work is considered to be a part of childrens training to be responsible adults however the findings of okoye and tanyi has a differing view according to their study 706 of the respondents perceived house chores such as babysitting fetching water splitting firewood sweeping farming and cooking as a form of child labour and not child training although participants in the idis reemphasized that children are to engage in house chores and other minor jobs for their development and proper training morning sales they know they will be caned and punished for late coming so they dont bother going to school findings from table 413 revealed that respondents majority indicated that poverty is the reason parents engage their children in child labour however the findings is in agreement with that of mapaure and amuda according to mapaure the major reason children work is poverty they work for their survival and the survival of their families amuda also disclosed that a significant proportion of children are involved in petty trading and services in other to bring in additional income into the house finding of the study in table 417 also revealed that majority of the respondents mentioned that child labour practices have negative effect on the child this finding is in agreement with the findings of amuda nseabasi and abiodun and bassey baghebo and out according to amuda the involvement of children in child labour activities poses serious threats to the continued survival of the society and distorts government policy with respect to the education of the child which is evident in the increased school dropout rate nseabasi and abiodun also noted that street hawking which is a form of child labour exposes the male and female child to dangers posed by fraudsters and murderers because of their vulnerability at odd hawking hours furthermore bassey baghebo and out argued that child labour has physical consequences on the child which ranges from malnourishment disease musculoskeletal disorders from heavy labour physical and sexual abuse furthermore in the literature several scholars found out that various socioeconomic factors influence child labour practices in the view of osiruemu and onuoha revealed that economic crisis evident in the country has made parents suffer loss of job which in turn has affected their income this agrees with the hypothesis three of this study as displayed in table 440 conclusion the current study sought to examine the socioeconomic factors that influence child labour in nigeria since child labour poses threats to the growth and development of a child and the society at large there is need to stop all forms of child labour through cutting down the various socioeconomic factors that influences child labour practices from this study it can be concluded that since majority of the respondents indicated that child labour practices has negative effect on the child there is the need to eradicate all forms of child labour through championing sensitization and enlightenment programmes people who still choose to children in child labour after these sensitization and enlightenment programmes should be severely punished by the law to deter others from engaging in such acts also providing jobs and skills acquisition programmes for those in the nonworking class sector should also be established to enable people financially independent and carter for them and the entire family recommendations based on the findings of this study the researcher endorses the following recommendations to aid government institutions nuc unicef community leaders social workers and the public as a whole addressing the socioeconomic factors that influence child labour in nigeria the recommendations are as follows  majority of the respondents revealed that poverty was the major reason people engage in child labour therefore the federal state and local government should ensure that the basic needs of the citizens are met also programs of free education should be introduced all over the country to enable the poor go to school in terms of alleviating poverty small scale business should be provided to the people loans should be given to people willing to start up a business to boost their resources  majority of the respondents who are christians indicated that they involve in child labour there is need for church leaders including the christian association of nigeria body the pentecostal fellowship of nigeria to reconscientize and educate her members on the dangers involved in child labour also during church services issues such as child rapemolestation drug abuse child traffickingkidnapping and other effects of child labour should be discussed to discontinue peoples involvement in child labour  there is need for policy makers especially in the education sector to review and modify the curriculum in order to include activities that makes school attractive for the child doing this encourages the child to always be in school and on time thereby issues of school dropout is restrained  scholarships and other forms of monetary support should be given by philanthropist and wellmeaning community members to support people in training their children government and international bodies should also partner with schools to award and recognise children putting in efforts in their academic  family size was considered as a factor influencing child labour therefore family planning should be a must for people government and other health related bodies should make family planning kits reachable and affordable for everyone social workers on their own part should create awareness by organizing enlightenment programmes for the general public specifically those in the nonworking class sector christians those with low education and the general public on the factors influencing child labour as well as its dangers on the child the family and the society at large also in curbing

this study examined the socioeconomic factors influencing child labour in nigeria the instruments for data collection were the questionnaire and the indepth interview schedules the sample size used for the study was 621 615 for the quantitative distribution and 6 for the idis the quantitative data gathered were analysed with statistical package for the social sciences using percentages and chisquare χ 2 statistics was used to test the three hypotheses while the qualitative data gathered was analysed in themes as complement to the quantitative data the study found that religious sex χ 2 615

relationship 16 for some feminist critics however this postmodern emphasis on dissolving dualisms and its attention to actions rather than actors means that gender has been overlooked in science studies dismissed as a social ghost that block s real explanation of science in action in science studies as whelan points out there appears to be particular resistance to the issues of women in and women into science and technology that are assumed to be the sole concern of feminist science studies 1 as we have seen above a concern with womens underrepresentation in and differential experience of science is central to policy and organisational studies the standoff between these positions is summed up by singleton as one in which feminists accuse contemporary social theories of science of being apolitical while science studies scholars attribute epistemic conservatism or a failure of theoretical nerve to feminist arguments epistemic communities 1 7 we are nevertheless convinced that there is much to be gained from combining insights from these different approaches in order to realise this potential we need to identify an analytical bridge based on shared understandings across these fields of study the concept of epistemic community feels intuitively useful and relevant here although it is rarely used in either social studies of science or women and science approaches however like both these approaches the concept of epistemic community privileges the collective or relational aspects of knowledge production in particular contexts rather than focusing on independent atomistic knowers this chimes with social studies of science which emphasise contingent dynamic and unbounded networks composed of nonhuman as well as human actors studies of women and science also work with a concept of communities here however the focus is on institutionally embedded stable and facetoface collectives although it is odd that research in these two areas does not map coherently to explicit discussions of epistemic communities currently circulating in academic literatures there is much to be gained from thinking of science in these terms in particular the communities of practice approach draws attention to the facetoface interactional and performative dimensions of epistemic processes here knowledge production and learning are analysed in terms of their tacit embodied and situated qualities rather than dynamics of abstraction codification and networking key elements of a rounded approach to gender practice and organisation in science methodology 18 our tactic here is to resist the temptation to attempt a theoretical resolution of these disparate concepts of epistemic community and contested visions of how epistemic actors work together in knowledge production instead we start in the laboratory and work through a series of observations of the concrete practices and relationships of bioscientists we use them to build an iterative interpretation which foregrounds the need to look at both organisation and practice in science we develop our analysis through explorations of data generated with researchers in two biology laboratories in one department of a british university participant observation studies were conducted over ten months as part of the knowing project 2 during the intensive phase of the observation lasting for approximately five months we visited both laboratories for the equivalent of one or two days per week although the visits were often clustered in three to four day stints in order to get a sense of the labs weekly routines the observation study focused on the routine activities of researchers however we also attended laboratory meetings department seminars and administrative meetings as well as one specialist conference fieldnotes were written up and analysed alongside interview and focus group transcripts using thematic coding in nvivo software 3 we also undertook more contextual forms of analysis by selecting longer examples from the fieldnotes in order to avoid fragmenting our accounts of the researchers daily practices these longer extracts from our empirical material feature strongly in the following section of our analysis unpacking epistemic communities the laboratory 21 we begin by positioning the laboratory as a local site at which a specific epistemic culture comprising people materials machines techniques skills and ideas is instantiated and performed science studies conceptualises these ensembles of networked actors as epistemic cultures which are distinctive to particular fields of inquiry we found numerous ways in which labs functioned as distinctive epistemic microcultures and communities of practice in our study we discuss them below in relation to three themes shared routines and rhythms in the laboratory the passing on of tacit knowledges and embodied skills and collective identities in each case we show how these are rooted not in abstract definitions of disciplines or fields but in material practices and we explore them by looking closely at extracts from participant observation data gathered in two laboratories a longestablished embryology group headed by a male professor and a newer and very successful plant laboratory with a female leader 4 we go on to discuss how gender is largely subsumed or hidden from view in this practicefocused analysis in order to bring gender to light we adopt a more organisational lens to look at laboratory life in the following section entitled organising knowledge work shared routines 22 as the following fieldnotes illustrate the laboratory groups were bound together by distinctive daily weekly and longerterm temporal routines and rhythms which were intimately related to the experimental materials and methods that they used … a departmental porter pick s up a batch of pig or cow ovaries from the abattoir once or twice a week one of the postdocs explains you cant vary the routine you cant have the ovaries to order as and when you want them for a particular set of experiments if you stop for a couple of week s say the routine will be disrupted with no guarantee of further deliveries lab observation fieldnote once or twice a week researchers gather in the culture lab ante room to clean pig ovaries to prepare them for gathering eggs then three or four of the group will sit at benches for an hour or so aspirating eggs from small cystlik e lesions on the ovaries suck ing the eggs up through a needle into a syringe containing a small amount of solution to preserve them lab observation fieldnote technician on thursday the pig people will do the oviducts and then culture the cells… researcher im a mouse person so i have to deal with the mouse timetable which is different lab meeting fieldnote 23 in the embryology lab the arrival of animal tissues demanded immediate attention resulting in intense cooperative activity routines for dealing with the ovaries were shaped by external considerations the group had to coordinate their action in relation to the abattoir and the porter once in the lab preparing materials took place in small spaces for concentrated periods of time as researchers and technicians worked together to aspirate eggs from fragile and shortlived ovarian tissue before moving on to fertilise them and culture embryos for mouse people in the same lab things were a little different mice could be obtained from departmental supplies more or less to order for particular experiments so researchers were able to organise their own timetable for harvesting eggs for all the researchers however the laboratorys methodological commitment to modelling in vivo embryo development in in vitro conditions set up the experimental timetables dictated by the growth of embryos from two cells to a manycelled mass 24 in the larger plant lab researchers grew their own plant material for experimentation the routines and rhythms of this lab involved comparatively little intensive collective work rather researchers were occupied separately in similar and parallel tasks growing and watching and then cutting and experimenting on the plants is the thread that joins them and that runs through everyones day anticipating when the plants will be at the right stage for whatever theyre needed for walk ing back through what is needed to have those plant materials at that time is k ey to how everyone schedules their mediumterm routines lab observation fieldnote 25 the basic temporal building block in this lab was the six weeks it took for the seeds of their chosen plant model to produce a plant that could itself set seed the labs work involved analysing the relationship between plant genotypes and phenotypes and so they studied several generations of mutant genes and plant crosses adding on additional sixweek cycles to their timetable most researchers worked alone on their own preparation and individually conducted their own experiments however all were involved in the same routine experimental tasks collecting drying and labelling seeds planting growing and observing plant morphology pollinating collecting and storing the next generation of seeds they passed in corridors and overlapped at the bench or in glass houses as each individually attended to the demands of growing material 26 in both labs then temporal structures bound researchers together in local epistemic communities in the embryology lab these were clearly marked by periods of collaborative activity and direct interaction in the plant lab they were present in the form of the shared routines that researchers individually followed embodied skills and communities of practice 27 in the plant laboratory methods for sharing techniques and passing on embodied skills and tacit knowledges appeared to be particularly important in producing the group as an epistemic community since researchers rarely physically worked together here the idea of communities of practice offers useful insights this approach emphasises hierarchical aspects of the organisation of knowledge communities in particular the apprenticemaster relationship and the ways in which strong community ties are built around replicating and preserving existing knowledge by passing on particular ways of doing things resulting in cultures of work and professional identities that can clash with standards elsewhere in both laboratories we observed the key roles played by experienced postdoctoral researchers and technicians as mentors and teachers of postgraduates and even undergraduate students at the bench this was most clearly foregrounded in relation to mundane preparatory experimental tasks and in relation to the use of experimental equipment in particular the standardised kits that are increasingly common in postgenomic bioscience many of these processes have written scripts or protocols and these are excellent examples of what latour calls immutable mobiles textual forms of representing knowledge which remain consistent as they move through scientific networks and which are therefore crucial to the universalisation and standardisation of knowledges and techniques however protocols and instructions also have to be enacted and performed in specific circumstances contingencies failures and unexpected hitches are an ordinary part of translating technical documents into practical experiments and here the sharing of tacit and informal skills and knowledges come into play 28 in both laboratories a good deal of activity was concentrated on the physical manipulation movement and care of very small objects in the plant lab techniques included sowing individual seeds onto growth media and later collecting separating and preparing for storage the tiny seeds from the plant critical tasks in the embryology lab included the aspiration of ovarian tissue drawing eggs and fluid from mammalian ovaries using a syringe and the use of mouth pipettes to transfer eggs and embryos around various dishes and plates three of the researchers are sitting around two tables in more or less the same positionfeet crossed under their swivel chairs head fixed over the microscope right hand operating the tube end of the mouth pipette rubber end between lips …later one of the postgrads … explained to me that she was frustrated with herself because the process of preparing the fertilised eggs was slow for her because she was uncomfortable with the mouth pipette technique … one of the postdoctoral researchers said it was lik e riding a bik eimpossible to explain in the abstract impossible to describe necessary to find you own way bodily two of the lab group are so practised in this technique that they can and do talk while pipetting out of the side of the mouthpiece lab observation fieldnote 29 in both cases these techniques demanded both the passing on of acquired and embodied skills and for researchers to learn to improvise a style suited to their particular strengths for the most part researchers would work closely with someone at the next academic level for a period to take on the relevant skills although experienced technicians play a significant role we see in action here the hierarchies of skill that lave and wenger refer to as well as the constitution of communities through passing on particular practices in the embryology lab the teaching of practical techniques was accompanied by narratives in which postdoctoral researchers talked admiringly of their own predecessors and mentors in terms of their effortless skills although they usually referred to their own technical competence selfdeprecatingly they also pointed out that mouth pipetting was now a relatively unusual technique in bioscience labs this was frequently commented on by a new member of the group with a different disciplinary background drawing attention to the distinctiveness of specific laboratory work cultures experimental materials and collective identities 210 crucial elements of experimental practice materials machines and methods also helped to constitute aspects of selfconscious group identity in the laboratories in the embryology lab people frequently referred to themselves in terms of the animal model that they worked on there were mouse people cow people and pig people although there was a degree of overlap in practice which reflected the laboratorys historical commitment to exploring early embryo growth in a range of animal models in the plant lab the researchers selfidentified as plant people informally in more formal settings they were plant biologists this label enabled and produced wider connections within the biology department for example taking part in a plant biology seminar series with invited speakers and working with plant specialists in the departments technology facility and glasshouses the distinctive characteristics of methodologies and resistances of materials were also cited when members of both groups explained that they worked in a slow field in a context that demands high outputs in terms of publications and new knowledge claims researchers felt that they were at a disadvantage working with materials that demanded a lot of care and nurture in both cases the groups worked with whole living organisms and the replication of in vivo conditions necessitated by epistemologies that focused on the growth and development of these entities as we have seen above these materials take their own time which may not be easy to reconcile with external schedules of career and research outputs researchers often compared their materials unfavourably with more conventional biological models where as one postdoctoral researcher put it you dependably get results the idea of the slow field also had the connotation of being unfashionable and adrift from cutting edge science this was particularly marked in the embryology lab but the plant biologists also on occasion remarked that plants arent sexy 211 these forms of collective identification are particularly important when we consider another key aspect of laboratory groups that the members are everchanging this was one of the first things pointed out to us by members of the plant lab when we began the observation study the lab leader remains a fixed point and is recognised as such by the department the institution and the wider discipline especially in the convention of referring to the group and its work using the name of the leader most of the other researchers however are passing through for a fixed period of time before moving on to another post the question then is how laboratories achieve a coherent and continuous identity over time one partialanswer is that groups work within an intellectual and analytical framework set out by the laboratory leader in the plant lab this was partly driven by new developments within the wider field of postgenomic biology in the embryology lab there was a sense of the accretion and inheritance of successful experimental practices building over many years into a coherent methodological approach however in both cases the shared analytical vision was realised in experimental practice through interactions and exchanges between researchers in shared spaces at the bench in the two laboratories that we studied the everyday community of practice emphatically did not include the lab leaders both of whom no longer worked at the bench and were not present in the daytoday experimental work of the group 5 thus the routines skills narratives and identifications that were generated through practice and passed on through generations of researchers can be seen as crucial both to developing new knowledge and innovation and to the preservation of skills and incremental development of techniques that are entangled in knowledge work epistemic communities as gendered spaces 212 this data indicates how we can read laboratories as facetoface communities constituted in and by their practice the production of new knowledge in both cases depended on embodied skills daytoday routines performed in shared spaces and the reproduction of epistemic cultures that brought together specific combinations of materials machines and knowhow this approach tends to generate a vision of the lab as a mutually supportive community that develops over time and is reinforced through shared daily practice it emphasises cooperation relationality and sameness in which the only hierarchies are those of skill and experience seen from this angle the relevance of gender to the practice of lab science is difficult to establish the labs we studied featured women in equal numbers to men in all positions from professors to phd students and technicians both men and women were involved in all aspects practical intellectual mentoring and social of the epistemic community both labs had wellliked and academically admired senior postdoctoral researchers male and female who took the lead in activities from organising the celebrations for a successful phd candidate through teaching key experimental skills to new researchers to coauthoring journal articles with junior colleagues we noticed that the temporal routines masterapprentice relations of the laboratories and even to a certain extent the experimental identities of the laboratory groups could be gendered experimental routines do not necessarily fit with family life apprenticeship relations took on a different flavour when the authority figure approached their role with a paternal or a maternal sensibility and soft toys and fridge magnets of animals are associated with femininity for example however these gendered interpretations seemed marginal when we commented on them to participants they treated them as irrelevant and were quick to point out other differences and similarities between men and women in the laboratory which did not chime with any kind of overarching notion of the gendered laboratory these findings appear to reflect the enormous influx of women scientists into biology and other life sciences over the past 25 years 6 and to support the claims of the women and science policy literatures that that lingering structural blocks to the advancement of women in academic science are steadily being overcome however this vision of an increasingly equitable work culture is hard to reconcile with largescale issues of womens underrepresentation and lack of progression in science careers the mutually supportive epistemic community constituted in practical activity then is only one part of the story in order to understand gender in the laboratory we need a better appreciation of how different kinds of practice are defined and valued both within and outwith the lab this requires us to place the laboratory in the wider organisation of the discipline and the university organising knowledge work 31 in this section we complement the image of the nonhierarchical epistemic community that emerges from our research focus on daily practice with a contrasting picture of gendered inequalities produced through differential evaluations of different types of work we begin by describing the singular and linear career path for bioscientists that has become increasingly dominant in recent years underwritten by powerful institutions including the main funding body for life sciences the biotechnology and biological sciences research council universities themselves and powerful professors in the field we go on to consider the tensions and inequalities that sit alongside this focusing upon the organisational context of contractual insecurity particularly for postdoctoral researchers secondly we look at how these organisational conditions produce inequalities at the level of the laboratory itself through a discussion of the gendered meanings and performances of housekeeping work we argue both that women tend to be concentrated in nonprogressing reproductive housekeeping roles in the laboratory and that the association of certain kinds of epistemic work with women reinforces a gendered culture in which conventionally masculine attributes are valued and undervalued work is feminised precarious positions and the science career 32 in the knowing study and especially in the uk we found a dominant discourse of the standardised career embedded in both national and organisational policies the ideal career path in the biosciences was linear and concentrated beginning with a phd undertaken immediately after the undergraduate degree and progressing immediately to a period of shortterm postdoctoral research posts postdoctoral research was defined as a transient career phase leading either to a permanent corefunded lectureship or an independent research fellowship in 2002 the roberts report estimated that only around 20 of postdoctoral researchers in science engineering and technology subjects in the uk would find permanent posts in academic research and large numbers of postdoctoral researchers are continuously moving through the system 7 this was reflected in our research findings especially in a focus group undertaken with lecturers and professors in the biology department in the words of one of our participants current policy in uk universities aims to mak e the postdoc duration short and well defined as a training period and then they need to move on focus group male professor 8 33 another professor emphasised that …there is no such thing as a long term postdoc in the biosciences i feel quite strongly that there shouldnt be any interview female professor others endorsed the idea that t heres no position as researcher as such in the uk no setting for using your sk ill to work in a group as a researcher focus group as one senior professor in our focus group put it researchers should not remain in laboratories as perennial postdocs in the past he explained there were people who were somehow managing to spend nine and ten years maybe work ing in labs but werent particularly going anywhere … the pressure wasnt on they were on two years three years one year with not much chance of an academic post maybe weve tak en note of that now and are trying to avoid that situation focus group male professor 34 the ability of postdocs to progress in science is of course predicated on their capacity to establish a reputation in their field in the form of concrete outputs novel findings highly cited publications winning independent grant funding alternatively researchers are encouraged and supported to leave academic research this situation is captured in the circulation around the biology department and the main uk disciplinary grant funding council of the emphatic message that postdoc is not a career observation fieldnote bbsrc earlycareer researchers support meeting 35 this sat somewhat awkwardly against our observations that much of the crucial work of organising the materiality of the laboratory supporting the progress of more junior researchers and even developing the detail of future research projects was performed by researchers in the most institutionally precarious and marginalised positions these researchers were on fixedterm or otherwise openended contracts that depended on continuing external grant funding they included one or two technicians whose invisible contributions to both the practical and the epistemic aspects of science work have been well acknowledged in the sociology of science here however we focus on the position of postdoctoral researchers our observations and discussions with people in the laboratory about their own trajectories and those of others who had passed through suggested that researchers in the labs divided into two groups many were progressing towards a stage where they would try to convert their epistemic experience into an independent research fellowship or lectureship others had passed into a stage where this seemed less likely researchers in these positions might be described as hanging on or stuck in terms of their job descriptions they were fulfilling their roles conducting original research writing up findings in publications developing project and funding applications in terms of the epistemic community of the laboratory they were supporting colleagues juniors in particular enhancing skills and techniques and developing the groups epistemic work however their continuing employment and scientific career prospects were highly uncertain 36 we were particularly struck by the fact that most postdocs in these positions were female with one notable exception we observed the career trajectories of three experienced postdoctoral researchers in the embryology lab and seven postdoctoral researchers in the plant lab 9 during the study all three men in the plant lab progressed along the career track into more permanent academic positions the others six women and one man did not one of the female postdocs in the plant lab was hoping with the support of her lab leader to move sideways into an academic lab manager role one male postdoc in the embryology lab was in the course of negotiating his next position as he came towards the end of a second postdoctoral project the other three female postdocs in the plant lab continued to work on precarious fixedterm research projects and expressed uncertainty about their futures of the two female postdocs in the embryology lab one moved sideways to work on a research project at another university and the other remained in the lab working primarily as an editorial assistant on a journal edited by the labs leader her position in the organisation of scientific work gives a particularly vivid example of the tensions between institutionalised career expectations and the epistemic life of the lab during our study we observed an incident where this researcher was brought into the lab by a second year postgraduate student who was panicking because she could no longer see through the microscope some of the cell cultures she had been growing t expertly manipulated the microscope examined the barely visible cell cultures and diagnosed the problem as well as reassuring the student seen as part of the practice and culture of the laboratory group her skill and experience were invaluable the postgraduate student called t the goddess of the cells and our fieldnotes observe that in the lab she was whitecoated expert and reassuring as a perennial postdoc however she was institutionally marginal 37 hanging on and getting stuck in nonprogressing academic roles is a structural tendency of academic career systems whose disadvantages are borne by individual researchers rather than by the organisation as a whole at the heart of this clash between organisational imperatives and the daytoday practices of epistemic communities is a contradiction between what we call the visibly individual excellence that must be demonstrated by researchers in order to gain organisational recognition and career progression and the everyday epistemic work on which communities of practice depend the idea of gaining a name in a particular field is telling individual reputation and personal visibility are crucial in conventional definitions of scientific success but this name must be built in and out of particular communities of practice in an important sense then demonstrating visibly individual excellence means dissociating oneself from the community that makes it possible we discuss the some of the problematic dynamics produced by this situation next lab housekeeping 38 our study suggested that the consequences of this tension between individual excellence and everyday epistemic work were gendered albeit in complex ways we have argued elsewhere that the intense linear career based on building visibly individual excellence reproduces a masculine model of scientific success the admittedly smallscale findings reported here tend to suggest that it also empirically benefits men in what follows gender inequities in epistemic work are explored through the example of what we call laboratory housekeeping feminist studies of women in academia have argued that women are disproportionately responsibilised for communal caretaking particularly in teaching and administrative roles while men are positioned to take up competitive leadership and epistemic styles with the emphasis on producing research outputs here we show how these dynamics are reproduced within research practice itself we found that lab housekeeping was mainly but not exclusively performed by women perhaps more importantly however the organisation of knowledge work was itself being gendered as feminised practices were devalued 39 by housekeeping we refer to the range of tasks activities and roles that are dedicated to the reproduction and maintenance of the laboratory this includes taking care of workspaces experimental materials and technological equipment similar to the activities of lab caretaking discussed in knorr cetina we extend this notion to refer also to the work of maintaining the epistemic community itself and its ongoing knowledge projects star and strauss refer to similar sorts of activities as articulation work for the most part such work disappears into the doing like domestic tasks of reproduction it is repetitive routinised and frequently undervalued it constitutes the material foundations on which more valuable activities experiments and analysis are built and hence involves the labour required both to support measurable visible outputs of knowledge practices and keep the labs individual and collective work moving 310 technicians of course have dedicated roles in this respect but housekeeping is undertaken by everyone as part of their laboratory life indeed viewed from the angle of practice few hard and fast distinctions can be drawn between real epistemic work and merely supporting activities this has certainly been the argument from science studies which insists that all knowledge is produced through practical activity and explicitly rejects the idea that there is anything special about sciences cognitive theoretical or methodological processes in rather different ways this was also the case for bioscientists in our study few made hard and fast distinctions between the practical and analytical aspects of science when discussing their own work professors and laboratory leaders were more likely in interview settings to make claims to the specific value of intellectual or analytical vision in academic research but even here they acknowledged that the bench was a space for analytic reflection and that analysing data to make findings could sometimes be seen in terms of a set of relatively prescribed operations however our data also suggests that this blurring of the distinction between routine practice and epistemic production does not translate easily into the structured ways that institutions value both specific researchers and the different kinds of work that they do 311 we use the idea of housekeeping primarily as an analytical concept which emphasises gendered divisions of labour however it was suggested by the domestic metaphors that were present in the laboratories in the way that researchers and technicians described their work during our initial tour of the plant lab one of the female researchers described one of the preparation rooms as the k itchen of the laboratory a senior lab technician described her role as the mother of the lab supervising machines and experimental preparation and clearing up observation fieldnote in the larger plant laboratory the senior technician coordinated these tasks which were prominently displayed in the form of lists of roles such as filter hood monitor or bin prefect and so on the jokey titles were perhaps designed to offset the worries that the senior technician expressed that allocating these jobs would be seen as fussy bossy and infantilising observation fieldnote caretaking issues that concerned everyone were often raised in the weekly lab meeting in the smaller lab maintaining stocks and organizing the work appeared to happen in an ad hoc and more or less spontaneous fashion managed through daytoday interactions rather than explicitly raised in particular settings 312 as we have indicated above all members of lab groups were expected to take part in these activities to some extent however it was very noticeable in our study that male researchers exhibited a reluctance both to undertake and especially to be publicly associated with mundane housekeeping tasks they rarely engaged with these discussions in lab meetings and responded with indifference when they were raised in lab settings we have a number of examples of this in our data some incidents were relatively trivial and private as we observed when a very junior female phd student halfjokingly told off an experienced male postdoc in the embryology lab for not tidying up after himself havent you ever heard of emptying the bin observation fieldnote it could also manifest in more serious tensions such as when the embryology labs incubating machines became infected interfering with and slowing down the groups experimental work two of the labs female researchers explained their growing frustrations with the labs male postdoc who was reluctant to break off from his experimental programme for the three or four days required to disinfect the machines observation fieldnote in the plant lab housekeeping issues arose from the groups increasing success in producing useful experimental material in the form of different lines of genetically modified seed stock they found themselves with a haphazardly organised store of seeds which took up precious physical space in the laboratory this became particularly pressing after the departure of a very successful male postdoctoral researcher who in the previous year had made a significant finding and secured a lectureship at another university leaving behind a good deal of unlabelled material and some rather frustrated colleagues 313 consequently the lab leader recognised a need to reinvent the groups archiving and storing systems the task of conceptualising and communicating the new seed archive system was given to a male member of the group who had recently completed a phd and who was working there on a very shortterm contract while applying for research fellowships the lab leader took great pains to present this task as a necessary and valuable one and other group members volubly agreed especially in the lab meeting at which the researcher gave his presentation on the seed archive our observation notes stress that the presentation was very detailed precise systematic but that he referred several times during the talk to how tedious and boring this must be for everyone or adopted an ironic tone to talk about how important and fascinating the issue of the seed archive is after the meeting we asked if we could look at the slides from the presentation and he very reluctantly agreed explaining that he doesnt lik e the thought of being k nown for giving such a boring talk or being the seed archive guy although far from conclusive this male researcher seemed to be experiencing and perhaps more importantly publicly performing some discomfort and embarrassment at being associated with this trivial housekeeping work italicised extracts from observation fieldnotes 314 this response contrasted strongly with the orientation of many female researchers in the lab including the two senior postdocs who carried out the physical reorganisation of the seed stock that the exphd student had designed these female researchers commented on the value of housekeeping to the epistemic life of the group and on their pleasure in this work explicitly contrasting it with the instrumental modes of operating associated with the valued norms of academic career paths ive always k ind of thrown myself a bit more into sorting things out and ive always been the one thats managed the students theres certain people you can see in the lab that you k now are going to run their own labs theyre very very focused on their research… they cant be bothered with the minutiae of whats going on in the lab theyve got a very strong mentality about their experiments and stuff the focus is on the next thing and getting it done… interview female postdoc 315 other female researchers who unlike male colleagues moving through their laboratories found themselves negotiating the problems of being a perennial postdoc wondered whether they were too fulfilled by the bench stuff interview female postdoc they contrasted this to their male colleagues tendency to take the strategic view always think ing about the possible outcome interview female postdoc others felt that they had few choices other than to pursue supporting roles in large laboratories as they had not been ambitious enough earlier in their career to aim at a later stage to establish their own lab observation fieldnote female postdoc 316 these examples are suggestive rather than conclusive but they do indicate some of the ways in which housekeeping was interpreted and performed in gendered ways by researchers in the laboratory we do not want to suggest that only women undertook laboratory housekeeping indeed we have been keen to assert that when knowledge production is viewed as a matter of practice rather than cognition distinctions between reproductivesupport roles and properly epistemic practice are hard to maintain and defend we do suggest however that in the context of a career structure that recognises only findings and outputs and of academic institutions which undervalue necessary epistemic and practical workers by allowing them to continue to be contractually insecure and nonprogressing housekeeping can be seen as a liability in relation to the production of visibly individual excellence if such work is to be made into a successful career trajectory its outcomes must be made visible in the form of publications and individual reputation this logic of academic life emphasising product over process has been reinforced and modified in recent years by audit and performance regimes particularly in relation to quantifying research outputs research work that cannot be translated into publication capital or remains invisible to audit and promotion mechanisms might be valuable to oneself ones peers and ones students but it does not count in formal career terms active goaloriented productive tasks are more highly valued than relational and reproductive ones taken together with the large numbers of women who have entered the biosciences in particular as postgraduates postdoctoral researchers and technicians we believe we can point to gendered organisational cultures that feminise work that is characterised as collective materially oriented ongoing and supportive in contrast to highly valued masculine work which is associated with outputs reputation publications individual excellence and linearity conclusion 41 we have been concerned in this paper with gendered inequalities in academic research and the ways in which they are shaped both by epistemic practices and organisational structures we have explored the kinds of work that are necessary to the production and reproduction of knowledge communities which form the social and epistemic contexts of the production of facts but which do not themselves become directly visible in terms of outputs and individual reputation they include the relational work of supporting junior colleagues the communal work of passing on skills and techniques and the indispensable tasks of housekeeping and articulation work that maintain and extend laboratory communities as contemporary science studies has made clear producing knowledge is not simply a matter of individual cognition or intellectual insight but is rooted in collective action and is social through and through recognising the importance of this practical work by focusing on the epistemic community of the laboratory tends to produce an image of science work as cooperative and mutually supportive however feminist critiques of science have shown over and again that epistemic communities viewed at the institutional level are deeply marked by gender inequalities in this paper we have tried to relate these institutional patterns of inequality to the ways in which everyday work in the laboratory is organised and performed by researchers we have sought to open up the laboratory as both a community of practice and as a site where work is structured and valued in line with wider institutional priorities 42 we do not endorse a monolithic rigid or static conception of organisational structure that determines a gendered division of labour within epistemic communities we recognise laws account of the complexities of ordering in organizing modernity which addresses the plural dynamic and openended modes through which scientific work is arranged and argues that organisation is not a reified singular entity but rather a site of productive power we recognise that organisations are concepts as much as entities that their ontological status is not given and that institutions can be seen as temporary patterning s of a mosaic of tactical interactions and alliances which form relatively unstable and shifting networks of power always prone to internal decay and dissolution however organisational processes and divisions such as the twotier fixedpermanent contract system in universities the insecurity of contract research positions and the differential distribution of reward for different kinds of work shape the experiences of researchers and the unequal constitution of epistemic communities obdurate patterns of inequality such as contractual status and gendered differentials in career success cannot simply be dissolved into another type of practice if ordering is a form of practice it is one which can have unequal outcomes that need to be recognised it is perhaps not surprising that formal organisationsuniversities funding bodies do not recognise the necessary and communal everyday work of housekeeping in epistemic communities deleting the work is an unavoidable part of ordering organisations need to ignore simplify and reify complex processes however high profile initiatives to support womens progress and participation in science are unlikely to be successful unless we also ask basic political and feminist questions cui bono who is doing the dishes where is the garbage going what is the material basis of practice who owns the means of knowledge production 43 the idea of knowledge work as messy practice and of ordering as dynamic contingent and prone to dissolution makes science studies resistant to the usefulness of the concept of community it is too rigid too stable too bounded it assumes a social cohesion that is seen as part of the problem the preferred focus is on dynamic shifting knowledge networks that come together around problems rather than in institutions the idea of community seems too close to the mertonian emphasis on the institutional nature of science with its stable norms and structures but what is lost in this shift away from institutions is perhaps ironically a sense of individuals and their experiences if the idea of epistemic community has any value it is precisely its multivalence it allows us to see shared practices and tacit knowledges but it also functions as a lens to direct our attention to who is involved in epistemic production and how in the context of organisational structures of value seen from this perspective epistemic communities allow us to bring to light both the work and the organising principles that reproduce gendered inequalities in science notes 1 it is emphatically not the case that feminist science studies are reducible to these kinds of policy and liberal equity concerns as our brief outline of debates in feminist epistemology begins to indicate wylie et al offer a useful contemporary overview of the range of strands of analysis at work in feminist science studies 2 knowing was funded by the european communitys sixth framework programme for research and technological development see acknolwedgements above the final international comparative project report felt ulrike knowing and living in academic research can be found online at 3 a number of semistructured individual interviews and focus groups were conducted as part of the knowing project here we refer specifically to four interviews with bioscience researchers who worked in the laboratories where we undertook our observation studies and to a focus group conducted with academic staff working in the wider biology department 4 the identities of individual participants and institutions have been concealed some details of the work of the two lab groups have been changed in order to preserve the anonymity of participants 5 in a focus group with different lab leaders within the same biology department however we found that earlier career staff did still work at the bench and gave accounts in which they emphasised their reluctance to give up experimental work and with it a sense of ownership and control over the whole research process 6 the proportion of female academics in the biosciences in the uk was around 40 at the time of our study notably higher than the proportion for the natural sciences as a whole which is around 26 according to hesa statistics for biosciences from the academic year 200304 women comprised 115 of professors 195 of senior lecturers and senior research fellows 373 of lecturers and 452 of researchers 7 in 2005 shortterm project and programme funding accounted for 68 of the total research income of uk higher education institutions in the academic year 200506 just under 41 of the uks 164875 academic staff were on a fixedterm contract most of them are researchonly staff who are particularly numerous in the biological sciences women are overrepresented generally in contract researchonly roles in uk higher education institutions 8 for the remainder of this paper we adopt the conventions of the participants in our study by using the term postdoc to refer to postdoctoral researchers working on shortterm externally funded research contracts in the biosciences 9 in fact there were 5 female postdoctoral researchers in the plant lab during the study but one had only recently begun her first postdoc project having completed her phd some months before so we do not include her case here there was also an unpaid postdoctoral researcher loosely affiliated with the embryology lab she had also completed her phd very recently and during the course of the observation fell out of contact with the lab so we do not include her case here

over the past thirty years there has been a significant turn towards practice and away from institutions in sociological frameworks for understanding science this new emphasis on studying science in action latour 1987 and epistemic cultures knorr cetina 1999 has not been shared by academic and policy literatures on the problem of women and science which have focused on the marginalisation and underrepresentation of women in science careers and academic institutions in this paper we draw on elements of both these approaches to think about epistemic communities as simultaneously practical and organisational we argue that an understanding of organisational structures is missing in science studies and that studies of the underrepresentation of women lack attention to the detail of how scientific work is done in practice both are necessary to understand the gendering of science work our arguments are based on findings of a qualitative study of bioscience researchers in a british university conducted as part of a european project on knowledge production institutions and gender the uk study involved interviews focus groups and participant observation in two laboratories drawing on extracts from our data we look first at laboratories as relatively unhierarchical communities of practice we go on to show the ways in which institutional forces particularly contractual insecurity and the linear career work to reproduce patterns of gendered inequality finally we analyse how these patterns shape the gendered value and performance of housekeeping work in the laboratory