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introduction depression is one of the most common internalizing problems in adolescence a survey performed by the national childrens bureau in the united states in 2016 showed that the prevalence of adolescent depression was around 11 during 1 year wei also found that approximately 33 of chinese adolescents experienced depressive symptoms during the past 3 years moreover depression is associated with negative consequences including academic difficulties interpersonal dysfunction as well as health problems and it may persist into adulthood if left untreated many prior studies have demonstrated that family context and internal resources are potential factors associated with adolescent depression within the family context socioeconomic status and parenting are generally viewed as two fundamental factors ses is a multidimensional concept and most contemporary researchers agree that it is represented by a combination of family income parental education and occupational status the link between ses and adolescent depression has been found across both western and chinese populations according to the family investment model compared to parents from highses parents with lowses have less financial capital lower education and occupational status making it less likely that they are able to provide good material conditions and engage in positive parenting behaviors thereby increasing the risk for the development of emotional problems in their adolescent children parenting as a proximal family context consists of different dimensions and more specific factors derived from those dimensions for example parker et al developed a questionnaire with two dimensions of care and overprotection to measure parenting practice maccoby and martin proposed a twodimensional model with responsiveness and demandingness and rapee regarded parental control and rejection as two main parenting dimensions a large body of reviews and empirical studies investigating the association of parenting and adolescent depression showed that warmth care acceptance and other positive parenting behaviors were negatively linked to depression while negative parenting characterized by harsh control and neglect were risks for depression regardless of the differences in dimension of parenting practice there is consistency that parental care and control have a close association with individual depression for instance parental care has been shown to have a negative association with child depression andcampos et al further found that individuals with depression perceived less maternal care furthermore parental control including psychological and behavioral control is a risk factor for depression care and control are regarded as two typical dimensions of parenting and it is of particular significance to study their specific effect on chinese adolescent depression in china though a universal twochild policy was carried out recently the enforcement of the onechild policy since 1979 may result in parenting behaviors that are unique and focus solely on the only child with both parents trying their best to give their children care love and concern and with the farreaching influence of collectivism confucianism and fixed family hierarchy on chinese society children are expected to be obedient to authority and they usually experience more control from parents although children who grow up in chinese cultural setting generally consider parental control as normal a recent study found that these actions were associated with child problem behaviors the family stress model and many empirical studies have revealed that ses may affect parenting behaviors for example highincome and well educated parents tend to display more care warmth and supportive parenting while parents with financial stress are more likely to experience depression which in turn exacerbates problems in parenting in addition maternal current unemployment has been shown to be associated with depression in adolescence through ineffective childrearing behavior therefore it is possible that parental income education or occupational status may be linked with adolescent depression through parenting behaviors according to benson internal resources refer to personal characteristics which influence individual development recently sense of coherence introduced by antonovsky as a personality factor has attracted more attention and is defined as the extent to which one has a pervasive enduring and dynamic feeling of confidence antonovsky suggested that family context was one of the most important factors to have a close association with individual soc children living in highses backgrounds usually possess adequate resources and they are more likely to develop stronger soc compared with children in low ses soc enables people to cope with stress in a healthpromoting manner and individuals with higher soc experience fewer psychological problems previous studies have demonstrated the association between soc and individual depression for example moksnes et al analyzed data from 1209 adolescents in midnorway and found that adolescents with a strong soc exhibited lower levels of depression in addition some theoretical and empirical studies found that parenting as another vital family context was related to individual soc for example parental emotional closeness and affection was associated with higher levels of adolescent soc and maternal overcontrol was associated with lower levels of adolescent soc therefore it is reasonable to expect that ses and maternal carecontrol parenting would be associated with adolescent depression through their soc although many valuable findings regarding the relationships between ses parenting adolescent soc and their depression have been reported potential mechanisms among these relationships need to be further studied firstly the aforementioned studies only examined single indicators of ses rather than a combination of ses with family income parental education and occupational status secondly the main findings were primarily based on western cultures furthermore according to bronfenbrenners ecological systems theory ses and parenting are usually regarded as distal and proximal factors respectively with the distal factor affecting individual development through the proximal one in the family context however it remains unknown whether ses is associated with adolescent soc and depression through maternal carecontrol additionally to our knowledge few studies have examined the relationships between parenting and adolescent soc and less is known about the relationships between maternal carecontrol and adolescent soc especially in chinese society finally given that adolescents in lowerincome families are more likely to experience depression compared to adolescents in families with higher income it is necessary to ascertain the relationships among ses maternal carecontrol adolescent soc and depression to provide empirical support for improving the mental health of adolescent in lowand middleincome families therefore the present study examined the direct association between ses and adolescent depressive symptoms and the indirect association through maternal carecontrol and adolescent soc in a community sample of chinese adolescents we hypothesized that the main variables of ses maternal carecontrol adolescent soc and depressive symptoms were related to each other we also hypothesized that ses was associated with adolescent depressive symptoms indirectly through maternal carecontrol and adolescent soc separately and sequentially materials and methods procedure prior to data collection we introduced the study aims and procedure to class master teachers with permission of master teachers invitation letters including study information and consent forms were delivered to students and their parents after obtaining written informed consent by master teachers from the participating adolescents and their parents participants were asked to complete the selfreport chineselanguage questionnaires including ses items parental bonding instrument the sense of coherence scale and the center for epidemiologic studies depression scale during the normal school day to ensure standardization of procedures across classrooms members of the trained research team supervised questionnaire administration the study procedures were conducted following approval by the institutional review board of shandong normal university measures depressive symptoms adolescent depressive symptoms were assessed using the 20item chinese version of the center for epidemiologic studies depression scale which was designed to measure depressive symptomatology in the general population it consists of four components of depressive symptomatology somatic symptoms depressed affect positive affect and interpersonal relations the cesd has been widely used and has demonstrated good internal reliability and validity adolescents were required to rate each item on a 4point scale ranging from 0 to 3 with higher scores reflecting higher levels of depressive symptoms in this study the cronbachs alpha coefficient for depressive symptoms was 087 socioeconomic status five indicators were employed to determine ses monthly family income parental education and occupational status family income was measured on a 3point scale ranging from 1 to 3 parental education was coded on 6point scale ranging from 1 to 6 following recommendations by fuligni and zhang parental occupational status was coded on a 3point scale ranging from 1 to 3 building on previous research family income parental education and occupational status were standardized using zscores and then summed so that higher scores reflected higher family ses maternal care and control maternal care and control were assessed using the 23item chinese version of the pbi yang et al 2009 which includes care control and encouragement of autonomy subscales separately for mothers and fathers maternal care subscale and control subscale were the primary focus in the current study the pbi has been frequently used to measure fundamental parenting behaviors and has demonstrated good internal reliability and validity adolescents reported retrospectively about the parenting received from their mothers using a 4point response scale ranging from 0 to 3 six items of maternal care subscale were reverse scored the maternal care and control variables were calculated separately by summing the scores of subscale items with higher scores reflecting higher levels of maternal care and control in this study the cronbachs alpha coefficients for maternal care and control were 071 and 064 respectively although the internal consistency of maternal control scale was not high it was consistent with other studies using the control scale sense of coherence sense of coherence was assessed via the 13item chinese short version of the 29item orientation to life questionnaire which consists of three subscales comprehensibility manageability and meaningfulness the short version of the olq has been shown to be valid and reliable adolescents responded on a 7point scale ranging from 1 to 7 five items were reverse scored high scores indicated a high level of soc in this study the cronbachs alpha coefficient for soc was 085 data analyses spss 190 and mplus 70 were employed to conduct all analyses missing data in mplus were accounted for through full information maximum likelihood firstly univariate analysis of variance was used to examine gender and school stage differences in depressive symptoms maternal care control and soc secondly bivariate correlations were conducted to examine associations between main variables next the structural equation model was used to test whether ses was directly associated with adolescent depressive symptoms and indirectly through maternal carecontrol andor adolescent soc separately or sequentially according to recommendations by rogers and schmitt items from maternal parenting and adolescent depressive symptoms were randomly assigned to three parcels separately and provided three indicators of each latent variable ses was identified by five indicators family income paternal and maternal occupational status paternal and maternal education the latent variable of adolescent soc was created using three indicators including comprehensibility manageability and meaningfulness the model was estimated using the following fit indices the comparative fit index the root mean square error of approximation and the root mean square residual results preliminary analyses table 1 contains the means standard deviations and correlations among all variables main variables had skewness and kurtosis that fell within the acceptable range of no greater than ± 20 and ± 70 respectively univariate analysis of variance showed that girls scored higher on depressive symptoms f 1891 p 0001 partial η 2 002 and maternal control f 617 p 005 partial η 2 001 and lower on soc than boys f 710 p 001 partial η 2 001 middle school students scored higher on maternal care f 1131 p 0001 partial η 2 001 and soc f 2865 p 0001 partial η 2 002 and lower on depressive symptoms than high school students f 2794 p 0001 partial η 2 002 ses maternal care and soc were significantly and positively correlated with each other and they showed significant negative correlations with depressive symptoms maternal control was significantly and positively correlated with depressive symptoms and negatively with soc but there was no significant correlation with ses thus maternal control was excluded in later analyses structural equation model analyses first the measurement model including four latent variables and fourteen observed variables was tested and it provided a good fit to the data χ 2 41516 cfi 0957 srmr 0033 and rmsea 0063 we found factor loadings were significant for indicators on latent variables and all latent variables from the measurement model were significantly related with each other next a structural model was used to examine the indirect effects of maternal care and adolescent soc on the relationship between ses and adolescent depressive symptoms figure 1 shows the final model and standardized regression coefficients although the original model fitted well the direct effect of ses on adolescent soc was not significant β 001 se 003 p 005 and ses was not associated with adolescent depressive symptoms through adolescent soc β 001 95 ci 0064 0004 se 003 p 005 therefore the path from ses to adolescent soc was removed to make the model parsimonious and the new model was examined the new model also fitted well χ 2 20599 cfi 0983 srmr 0028 and rmsea 0041 the total effect of ses on adolescent depressive symptoms was significant β 020 se 003 p 0001 after accounting for maternal care and adolescent soc the direct effect of ses on adolescent depressive symptoms was also significant 83 86 figure 1 the indirect effects of maternal care and soc in the relationships between ses and adolescent depressive symptoms fi family income pos paternal occupational status mos maternal occupational status pe paternal education me maternal education ses socioeconomic status soc sense of coherence 020 total effect 007 direct effect p 001 p 0001 β 007 se 003 p 005 the specific indirect effect of ses on adolescent depressive symptoms through maternal care was significant β 002 95 ci 0043 0004 se 001 p 005 effect size 10 as was the specific indirect effect of ses on adolescent depressive symptoms through maternal care and adolescent soc sequentially β 011 95 ci 0137 0075 se 002 p 0001 effect sizes 55 the combination of ses maternal care and adolescent soc accounted for 65 of the variance in depressive symptoms given that there were gender and school stage differences in the outcome variables we tested whether indirect pathways were different for girls versus boys and for younger versus older adolescents using multiplegroup analysis we first examined measurement invariance across groups by comparing the fit of a constrained measurement model with the fit of an unconstrained model then we tested the structural equivalence by comparing a constrained structural model with the constrained measurement model according to cheung and rensvold if the difference of cfi is less than 001 this suggests model invariance results found that for gender measurement invariance of cfi 000 and structural equivalence of cfi 0001 were obtained for the school stage both the measurement invariance cfi 000 and structural equivalence cfi 0002 were verified as well therefore the indirect pathways did not differ for boys and girls and for younger and older adolescents that is to say gender and school stage could not moderate the indirect relationship discussion the present study extended our understanding of the underlying links between family ses and adolescent depressive symptoms in chinese culture by examining whether family ses was associated with adolescent depressive symptoms indirectly through maternal parenting and adolescent soc using a chinese lowand middleincome sample the results partially supported our hypotheses suggesting that ses was associated with adolescent depressive symptoms not only through maternal care separately but also through maternal care and adolescent soc sequentially consistent with the previous findings in this study girls reported more depressive symptoms than boys and students in high school reported more depressive symptoms than those in middle school the current study also found that girls reported more maternal control and lower soc than boys and middle school students reported higher soc and more maternal care than those in high school as this is a chinese sample it was possible that chinese mothers were influenced by traditional chinese notions of gender roles expectation which stated that boys should be encouraged to be independent whereas girls should be granted less autonomy and more control the extant research showed consistent findings for gender difference on soc suggesting that relative to boys girls tended to view stress they encountered in the environment as less controllable and organized their own resources ineffectively in the present study lower soc less maternal care and more maternal control were associated with higher levels of depressive symptoms which was useful to explain why girls reported more depressive symptoms than boys and why students in high school reported higher level of depressive symptoms than those in middle school one study with a sample of 40to 70yearold adults found that soc tended to increase with age but it is difficult to draw any comparisons from the current findings given that the population in the two studies varies significantly thus further work to explore the developmental tendency of soc would be warranted the results of this study suggested that the lower the family ses the less maternal care was displayed to their children and the higher the level of adolescent reported depressive symptoms similar results can be found in previous studies which show that parents with lowses experience more depression and anxiety themselves and are more like to behave toward their children in punishing and less caring ways and these children are also more likely to experience internalizing problems although our findings were similar to previous studies the results need to be interpreted with caution given the weak indirect effect of maternal care on the relationship between ses and adolescent depressive symptoms contrary to our expectations and previous studies conducted in other cultures this study did not find direct association between ses and maternal control which may be partly due to particular chinese culture relevant to childrearing to some extent maternal control is similar with guan which is the traditional chinese parenting notion of more love and more discipline chinese mothers regardless of their family ses are generally inclined to exert guan in their childrens lives additionally the lack of association also suggested that there may have been other variables our study did not include through which ses was indirectly associated with adolescent depressive symptoms as hypothesized we found that ses was associated with adolescent depressive symptoms through maternal care and adolescent soc sequentially this supported the existing theory and empirical findings that the external context including distal and proximal factors can contribute to the development of internal resources and then individual psychosocial development it should be noted that because of the relatively small direct effect the effects of maternal care and adolescent soc on the relationships between family ses and adolescent depressive symptoms need to be further examined in future research of note gender and school stage were not found to moderate the indirect pathways of maternal care and adolescent soc on the relationship between ses and adolescent depressive symptoms this may suggest that although there were gender and school stage differences in main variables the relational mechanism between ses maternal care soc and depressive symptoms was similar for both boys and girls in middle schools and in high schools given that few studies have examined school stage as a moderator of the indirect pathways from external context to individual development outcome further research is required to reach strong conclusions limitations and recommendations for future research one limitation of the present study is that we focused on the relationships of ses and adolescents perceived depressive symptoms maternal carecontrol and soc therefore adolescent selfreport was used to obtain all study variables it was possible that the results were limited by relying solely on a single reporter using multiple informant measures may reduce the influence of common method variance in future research this was a community sample and we used a depressive symptoms measure rather than diagnostic assessments of depression therefore any conclusions cannot be generalized to a clinical population further research could employ clinical populations to examine these relationships further the second limitation is that we used crosssectional data to examine the indirect relationships meaning interpretation of the indirect effects of maternal care and adolescent soc on the relationship between ses and adolescent depressive symptoms should be cautious and no causal conclusions of relationships can be established longitudinal designs should be used to establish the sequential nature of the relationship between ses parenting soc and depressive symptoms in future work thirdly our findings were based on the data reported by participants mostly in lowand middleincome families which could limit the ability to generalize to participants from higher income families finally it is generally known that mothers tend to have more emotional interaction with their children compared to fathers in both eastern and western societies especially in chinese cultures due to the historical tradition and social division of labor of men working outside while women taking care of the family inside it is reasonable to assume that mothers in china are involved much more in their childs life relative to fathers furthermore liu and wang also found that maternal parenting behaviors rather than paternal parenting influenced childrens internalizing problems therefore the present study only focused on the effect of maternal care and control it should be noted that both mothers and fathers play their unique role in childrens development in the past two decades chinese economic development has led to an increase in the number of women who work with fathers gradually becoming more engaged in their childrens daily lives indeed including both maternal and paternal parenting in the same model may illustrate a more complete picture of how parental behavior is related to adolescent development further studies should endeavor to include maternal as well as paternal parenting despite these limitations this current study broadened earlier research by investigating whether ses was associated with adolescent depressive symptoms through maternal care and adolescent soc separately and sequentially on a chinese sample the present study had both theoretical and practical implications although family ses has long been implicated as an important determinant of adolescent depression investigations exploring relational mechanisms between ses parenting soc and adolescent depressive symptoms particularly in the chinese culture were relatively scarce in particular we found that ses was associated with adolescent depressive symptoms indirectly not only through maternal care separately but also through maternal care and adolescent soc sequentially findings highlight that more attention should be given to lowand middleincome families where children are more likely to experience negative maternal parenting and may be more likely to experience depressive symptoms ethics statement this study was carried out in accordance with the recommendations of the institutional review board of shandong normal university the protocol was approved by the institutional review board of shandong normal university the parents of all participants signed written informed consent in accordance with the declaration of helsinki and its later amendments conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest	the current study investigated whether socioeconomic status ses was associated with adolescent depressive symptoms through maternal parenting and adolescent sense of coherence soc using a sample of 1220 chinese adolescents it was found that ses maternal care and adolescent soc were positively related to each other and negatively related to adolescent depressive symptoms respectively maternal control was positively related to adolescent depressive symptoms and negatively related to their soc but not significantly to ses by analysis of structural equation modeling we found that ses was associated with adolescent depressive symptoms indirectly through maternal care separately as well as through maternal care and adolescent soc sequentially this study extended our understanding by showing possible indirect pathways by which family contextual factors and individual internal resources for adolescent depressive symptoms may operate separately and sequentially the overall results highlighted the need to study adolescent depressive symptoms to find external and internal positive factors for maintaining adolescent emotional health especially in families with relatively lower income
introduction at the close of 2019 fresh drainage of undecorated acut e respiratory syndrome coronavirus 2 blowouts over the world from wuhan china spawning austere acute respiratory disorder the who classified covid19 as a worldwide hazard in march 2020 the covid19 outbreak is proving to be a historic tragedy in many aspects including health social and economic particularly in the hardesthit countries such as india china italy iran and the united states separation quarantine social separation and public detention were all performed immediately selfdistancing lockdown tactics improved diagnosis and treatment and limitations on mass gatherings are all being utilized to try to halt the viruss spread in the affected nations people in lowand middleincome nations sexual and reproductive health are expected to suffer as a result of the outbreaks load on health systems local or national lockdowns that compel health services to close if they are not judged vital as well as the consequences of physical isolation travel limitations and economic hardship will have an impact on sexual and reproductive health to stop the virus from spreading many governments are restricting peoples travels during covid19 28000 maternal mortalities and 168000 infant deaths would be terrible complications affect 17 million mothers giving birth and 26 million infants as of may 1 2021 there had been over 153 million verified covid19 infections and 32 million deaths when compared to middleor lowincome nations some industrialized countries with a greater quality of life had higher covid19 mortality rates covid19 patients have been linked to metabolic abnormalities such as hypertension diabetes obesity cardiovascular disorders cerebrovascular accident chronic obstructive pulmonary disease asthma renal problems and cancer covid19 causes a significant increase in severity and fatality all persons who provide or assist in the delivery of health services or the operation of healthcare facilities are considered part of the health workforce doctors nurses dental hygienists psychiatrists creative arts therapists dietitians and nutritionists patient care coordinators and others make up the health workforce sudden changes in work circumstances and strain are likely to significantly influence p hysicians longterm health outcomes during covid19 globally healthcare workers have responded to the task of treating covid19 patients perhaps at great expense to their health and wellbeing covid19 harmed persons who already have anxiety or mood issues the main sources of anxiety were confusion about covid19 treatment guidelines insufficient resources especially individualized safety tool and the possibility of transmission to loved ones at home during covid19 the most common indications of stress were anxiety physical tiredness and sleep difficulties during pandemics medical personnel had to cope with a higher number of patients who died at a high rate in a stressful setting highstress occupations combined with the special demands of the current covid19 crisis have undeniably raised the risk of distress burnout melancholy drug and alcohol addiction and suicide among frontline healthcare professionals worldwide during these trying circumstances healthcare personnel is at a higher risk of burnout which could have a substantial influence on their patients health and care physician tiredness affects patient care and satisfaction as well as the quality of care provided review of literature in a study by khalafallah et al analysis of 407 us to understand the impact of as part of the epidemic on burnout and job fulfilment the paper correlates emotional tiredness alienation and personal success with burnout and professional contentment according to the data during the covid19 outbreak future earnings were tied to burnout future earnings were uncertain during covid19 because of the reduced work hours during the epidemic professional life would deteriorate according to the study controllable stressors reported among neurosurgeons during the pandemic assisted in reducing burnout and increasing job satisfaction jiménezlabaig et al the researchers looked into the burnout levels of 243 spanish oncologists as well a s the consequences of the endemic on their working out and healthiness this article quantifies burnout levels using three dimensions exhaustion cynicism and efficacy and it classifies burnout into five burnout profile groups for analysis burnout ineffective engaged overextended and disengaged according to the findings creating a healthy worklife balance having access to support systems and taking enough vacation time can all help to minimize burnout during pandemics oncologists experience worry and moderate sadness as a result young european oncologists frequently experience burnout arkanudin and rupita investigated the perceptions of female nurses in indonesia on burnout throughout their performance and integrity services during the ongoing covid19 epidemic the descriptive qualitative methodology was employed in this article burnout hurts performance and service quality according to the findings handling covid19 patients causes anxiety concern and exhaustion work overload work stress poor work performance anxiety and worry are all factors that contribute to nursing burnout wu et al conducted a study on 190 wards vs those working in usual wards the descriptive statistics method was utilized in this article despite dealing directly with sick patients frontline wards showed a considerably lower rate of burnout and were also less concerned about becoming infected than the normal wards group frontline workers may have felt more in control of their situation which can assist prevent burnout torrente et al looked into the same topic of frontline and routine ward burnout during covid19 this article analyzed 674 spanish healthcare experts the descriptiveanalytic method was used on doctors nurses nursing assistants and emergency healthcare technicians this research sought to find out how common burnout is among frontline hospital staff in spain according to this study professionals who work in covid19 frontline wards had twice the risk of burnout as those working in their normal wards women had much more burnout than men owing to fear of selfinfection performance and the quality of care provided to patients for adolescent women working on the covid19 frontline during the pandemic outbreak weariness is a big issue abdelhafiz et al analyzed 220 egyptian doctors to determine the occurrence of burnout syndrome and related peril variables in a sample of egyptian physicians according to the findings the majority of respondents had lower levels of personal success while a smaller minority of respondents had high levels of depersonalization and emotional weariness with burnout syndrome the female gender was found to be associated with higher levels of emotional tiredness infection with covid19 or death from it among coworkers or family was linked to higher emotional exhaustion and lower personal achievement additionally kotera maxwelljones edwards and knutton conducted studies on burnout burnout selfcompassion worklife balance and strain are all investigated in this study on 110 people in the united kingdom this study indicated that burnout was adversely correlated with age selfcompassion and worklife balance and substantially correlated with weekly working hours and pressure the weekly working hours and worklife balance were substantially associated with burnout selfcompassion helped to reduce the relationship between worklife balance and emotional exhaustion according to this article encouraging worklife balance and selfcompassion would significantly lower burnout among psychotherapists in order to look into the prevalence and severity of burnout as well as the factors that contribute to burnout and the impact of the coronavirus on burnout syndrome dinibutun conducted a descriptive study on 200 turkish the poll found that physicians had low levels of depersonalization and personal achievement and a medium level of emotional exhaustion burnout affects both married and single people men and women the degree of financial fulfilment a person experiences has minimal bearing on burnout kelker et al conducted a study on 213 emergency medicine practitioners in the us in the early stages of the covid19 epidemic this study focuses on the characteristics and needs of emergency physicians and advanced practice clinicians including their wellbeing resilience burnout and wellbeing the majority of frontline emergency medicine provider workers experienced considerable levels of stress worry panic safety worries and relationship stress as a result of covid19 despite their resiliency the study found that covid19 also increased the stress on their relationships personal safety the impact on dependent care interpersonal conflict increased job demands and feelings of isolation have all been linked to covidrelated burnout maqsood et al the quality of worklife of the intensive care units and emergency unit workforce was assessed in a descriptive study of 290 saudi arabian healthcare workers the quality of life among healthcare workers was bad during the covid19 pandemic according to this study extra working hours were linked to reducing quality of worklife whereas demographic factors were linked to higher quality of worklife extra working hours and direct interaction with covid19 patients did not affect healthcare workers worklife balance osita onyekwele idigo and eze studied 342 nigerian health workers in a descriptive study the focus of this research was on worklife balance and employee performance as well as the impact of workload on service quality workload affects the quality of service provided by health personnel according to these researchers this exploratory longitudinal study revealed an increase in psychological discomfort among frontline employees autonomy and expertise in the workplace workrelated phylogeny gratification were linked to lower levels of psychological anguish whereas frustration was linked to higher levels of mental a gony need fulfillment was shown to be inversely connected to psychological discomfort but need frustration was found to be positively related khalafallah et al work on covid19 workflow changes personal and professional stress job satisfaction and burnout are all factors to consider in order to evaluate medical burnout the author used the abbreviated maslach burnout inventory three categoriesemotional exhaustion depersonalization and personal accomplishmentwere used to group the nine questions bivariate analysis was used by the authors to identify potential risk factors for emotional exhaustion depersonalization personal accomplishment burnout and job satisfaction burnout and work satisfaction were examined using a multivariate binary logistic regression analysis a study by maqsood et al examined the importance of the quality of worklife balance for healthcare workers in intensive care units the author used the who qolbref instrument with permission from the world health organization in this study the author also used the lastobservationcarriedforward technique the determinants of quality of life were evaluated using hierarchical regression analysis questionnaire was used to assess mental health to investigate differences between men and women chisquare was used for categorical data while tstudent was used for quantitative variables models of consciousness objective this is a literature reviewbased article so the authors mainly focus on the following area • to observe and review the worklife condition of healthcare employees by reviewing related literature methodology the study is based on the case study on healthcare employees situation and problems during covid19 of 30 articles by various researchers the problem presented above leads to a considerable need to conduct studies in the worklife condition area the work has been concentrated on understanding the worklife issues of the current healthcare workforce findings the recent coronavirus outbreak has disrupted clinical workflow and healthcare delivery following a study of the selected literature the authors offer an overview of the current state of healthcare employees during covid19 a large number of healthcare personnel experienced burnout burnout is defined as sentiments of energy depletion or tiredness increasing mental detachment from ones employment negativism or cynicism about ones career and a lack of professional efficacy the world health organization to avoid burnout maintain a good worklife balance have access to support systems and take enough vacation time job overload workplace stress poor job performance anxiety worry weekly working hours pressure safety concerns effect on dependent care and relationship strain are the most common causes of healthcare staff burnout burnout is common among young european oncologists burnout hurts performance and service quality women were more likely than males to have burnout owing to concerns about selfinfection performance and the quality of care offered to patients as well as depression worry stress and emotional weariness physicians who chose their profession deliberately experience less burnout than those who do not depression suicid al thoughts and burnout continue to afflict physicians of all specializations worklife balance and selfcompassion would be extremely advantageous in minimizing burnout among psychotherapists reconcile the tension between job and family a high level of selfefficacy is required those who possess higher familytowork conflict had worse emotional intelligence and selfefficacy overall selfefficacy is linked to emotional intelligence table 1 present articles summary recommendation the relevant authorities should change the healthcare policy the health of the healthcare workforce needs to monitor regularly and apply preventative tactics because they are t he frontline workers some studies found that equipment is not enough for providing healthcare services so an adequate level of equipment and necessary assistance to the healthcare personnel font line workers faced a huge workload during covid19 so the government and authorities recruit more healthcare workers to reduce the workload government should implement new healthcare policies to avoid burnout of healthcare workforces and review the curre nt healthcare conclusion our research shows that the pandemics uncertainty in terms of healthcare workforce policy enough equipment job security depression future income and family support is strongly linked to burnout and work life balance workload worry fear of harm uncertainty about future earnings panic attacks sleep disturbance job stress fear and exhaustion are all linked to physical and mental health problems the professional and social life patterns are altered with covid19 as a result it affects both personal and professional life the healthcare profession is currently under a lot of stress as a result of a higher number of covid19affected patients the medical staff lacked the required instruments as well as psychological supp ort as a result to retain healthcare personnel organizations and governments should monitor and give this vital help during covid19 burnout was at an alltime high in the health workforce according to the authors of this article healthcare workers require both incentive help and appropriate equipment quality of work income and welfare policies may all contribute to a pleasant and easy working environment life satisfaction increases as job satisfaction and work life balance improve workload stress and pressure at work as well as a lack of participation from superiors and coworkers all lead to job dissatisfaction as a result the government and other institutions modified their healthcare policies in the healthcare business new policies must be implemented more healthcare staff are required to keep pace with the growing number of covid19 patients data availability statement the corresponding author can provide the supporting data of this study upon a reasonable request competing interests the authors declare that they have no competing interests authors contributions all authors contributed equally to the conception and design of the study all authors have read and agreed to the published version of the manuscript	the covid19 epidemic is proving to be an unparalleled disaster in all facets including health sociological economic and financial aside from the fact that it may have a substantial influence on their health and wellbeing health practitioners all over the world have risen to the challenge of treating covid19 patients the primary goal of this research is to examine and evaluate the worklife balance of healthcare personnel during pandemics this study conducted a systematic evaluation to determine the current situation of health workforces and to assess the impact of covid19 on health workforces this paper began with 70 article reviews a brief evaluation of 70 publications 30 articles were chosen for the research based on area and analysis after examining all of the publications the study has found that the primary causes of depression burnout and suicidal thoughts include workload anxiety worry for safety future earning uncertainty and panic attack and sleep disturbance job stress exhaustion and dread these characteristics affect workers physical and mental wellbeing finally it has an impact on their worklife balance and service quality future studies could include additional publications for better results and a review of other sectors the government and organizations should provide more training organizational assistance support for healthcare pract itioners families ppe and mental health services regularly monitor the health of the healthcare workers and employ preventative measures to alleviate workrelated stress higherlevel management must recruit extra health personnel contributionoriginality this study of the literature focuses on several papers regarding the work life balance issues faced by the medical workforce during the covid19 epidemic it draws attention to the challenges experienced by healthcare personnel such as their hectic schedules burnout and insufficient support mechanisms the report points out how crucial it is to address these challenges to ensure the workforces performance and wellbeing
introduction for better wellbeing for all and at all ages by 2030 the sustainable development goals agenda was endorsed by the united nations in 2015 no poverty good health and wellbeing and quality education were highlighted among the seventeen goals 1 poverty and illiteracy are common causes that limit individuals accessibility to public health care leading to poor hygiene and illness additionally poverty illiteracy and illness have been considered factors of a vicious cycle of unhealthy lives therefore providing equitable access to health care along with quality education and raising economic standards should be strategies for improving the wellbeing of individuals in a society in thailand the national universal health coverage payment scheme for the health service was launched in 2002 so that all thais could access the public health care system equitably from birth until death the uhc is composed of various aspects that complete the health service loop ie health promotion prevention treatment and rehabilitation which aim at healthy lives for all in the country moreover other public services necessary for daily living standard education occupational training employment assistance etc should be available equitably among the people of a nation however there are gaps in the nationwide coverage of the uhc program as well as other public facilities in thailand especially among minority groups or marginalized peoples migrant workers nomads etc inaccessibility to the public health care system and a lack of health knowledge among these people to manage their own health cause them to be highly vulnerable to unhealthy living conditions and to acquire either communicable or noncommunicable diseases most of which are preventable providing accessible health services and other facilities necessary for better living conditions to these special groups of people should be systematically organized and accepted by these target groups of people the orang asali which means the first people or original people is a group of indigenous people who have lived dispersedly throughout the malay peninsula and southernmost thailand where it bordered with malaysia for 25000 to 60000 years 23 according to anthropological information the oa comprise three ethnically different groups ie the senoi portomalay and negrito 4 the senoi are the largest group of oa in malaysia while the oa in thailand are mostly negrito in thailand the oa people live primarily in two mountain ranges the banthut mountain range in the phattalung satun and trang provinces and the sunkalakiri mountain range in the yala and narathiwas provinces the latter group is close to the thaimalaysia border therefore their cultural beliefs and lifestyles are similar to those of the oa in malaysia the available research related to the oa in thailand to date mainly involve anthropology social status and lifestyle rather than living conditions health care services and education according to a systematic review the oa in malaysia commonly suffered from malnutrition lower growth rates in children soiltransmitted helminths pulmonary diseases and cardiometabolic diseases 5 these acquired diseases also occur among the oa in thailand due to similar living conditions and environments to promote secure and healthy living conditions among the oa in thailand various interventions have been applied such as providing these groups with thai citizenship and accessibility to standard education especially for schoolaged children health education and health promotion programs and resettlement areas prepared for their permanent residence according to the policy of the ministry of the interior of thailand oa in thailand are considered thai citizens as other thais are numerous operational plans have been deployed to improve their living conditions and increase their ability to access all public services and facilities in the public health sector the provision of equitable access to public health services is an aim of health care system management for the oa based on the respect for their human rights as for other thais and in response to one of the sdgs the uhc is a key measure to eliminate inequitable accessibility to health care service 6 for some time the oa in the study area have received basic living support including medical care from the local government when the requested we expect that the current registration program for the oa as thais will solidify a sustainable lifesupporting system for them the registered oa would then be able to access thai public services as other thai citizens are able to furthermore the outcomes and progression for the improvement of their living conditions can be followed systemically herein we describe a pilot program of actions to promote the oas voluntary adoption of public services and facilities including public health care services among a group of oa living in the chanae district of narathiwas province material and methods study population and setting this was a qualitative study using semistructured interviews for data acquisition the study participants were nine oa leaders and their representatives selected by the oa villagers from toapaku and biyis villages five local governmental personnel working in the offices of civil registration education agriculture and public health and six local thai community leaders or associate leaders eg the heads of thai local villages the head of subdistrict offices religious leaders etc we selected two of five oa villages in the area in which the villagers had settled permanently as the study sites two weeks after the research information objectives and process were clearly described to the oa villagers via translators verbal consents were obtained voluntarily from the oa villagers because they are not able to understand spoken or written thai additionally the gp and tc groups were informed of the study process and written consents were obtained the whole research study process was conducted in the oa settlement areas and the local governmental offices in chanae district narathiwas province with the support of the southern border provinces administrative center which acted as the coordinator for the related local governmental agencies preparation for data collection after ethical approval and consent from the study participants was obtained the research team started to gather preliminary information regarding the residential locations and the environments of the two study oa villages their usual lifestyle and significantly their willingness to adopt thai citizenship on the official side the relevant thai laws or regulations and practical guidelines for verification of the oa as thai people were reviewed the preliminary information included an initial interview with the gp and tc groups regarding what had been carried out previously and the associated outcomes then the indepth interview questions were designed and tested for content validity by three experts in anthropology public health and qualitative research the questions were divided into three sections according to the research participants ie the oa gp and tc groups we used translators who understood the oa spoken language as assistants in data collection we visited and interviewed the oa participants in their homes where we spent an average of two hours to complete each interview we spent an average of one hour to interview the gp and tc participants at their offices the interviewed content was recorded on audio recorders for later review and validation the questions used for the interviews with the study participants were as follows for the oa after receiving the information from local thai officers are you willing to adopt thai citizenship and why after receiving the information from local thai officers do you understand your rights and responsibilities after you become thai in the past how did you receive information about the registration process data analysis before we started the analysis the gp and tc reviewed and validated the indepth interview content themselves while an independent translator was used to ensure the correctness of the translation of the oas interview content we performed data analysis following the thematic analysis principle 78 which used six steps data familiarization and writing familiarization notes systematic data coding generating initial themes from coding and collated data developing and reviewing themes refining defining and naming the themes and writing the report after the analysis an action plan was codesigned by the study team staff gp and tc based on the results from the thematic analysis and the designed action plan was implemented among the oa study participants we performed a shortterm outcome evaluation and longterm evaluation was also planned to be done in the future ethical considerations ethical approval for the study was granted by the ethics committee of public policy institute prince of songkla university we strictly followed the 1964 declaration of helsinki its amendments and related guidelines for the ethical conduct of research studies all the participants identifiable information was completely anonymized results study participants characteristic we enrolled nine oa leaders and their representatives selected by the villagers of the toapaku and biyis villages five local governmental personnel and six local thai ethical considerations ethical approval for the study was granted by the ethics committee of public policy institute prince of songkla university we strictly followed the 1964 declaration of helsinki its amendments and related guidelines for the ethical conduct of research studies all the participants identifiable information was completely anonymized results study participants characteristic we enrolled nine oa leaders and their representatives selected by the villagers of the toapaku and biyis villages five local governmental personnel and six local thai community leaders or associates of the chanae district narathiwas province the characteristics of the study participants are shown in table 1 preliminary information from the initial survey initially we interviewed the gp and tc groups on three topics for preliminary information before indepth interviews and subsequent action planning were carried out the aims of this preliminary interview were to evaluate the preparedness of the study participants from the thai official sector who would be involved in the process of planning further action as well as the current thai regulations the topics of the preliminary interview included the following the settlement areas and the lives of the oa in the study area overall there were five villages of oa in the study area of which the villagers in three villages lived nomadically by hunting or harvesting natural forest products on the mountain while the remaining two groups ie the toapaku and biyis villages had permanent settlements the toapaku village had six households with 32 members while the biyis village had five households with 27 members the leaders of both villages were males whose leadership was derived from their ancestors they spoke oa malay or less frequently the thai language the preliminary information obtained from the talks with the gp and tc groups in the area included the following the oa have lived along the dusongyor mountain range in chanae district for at least 200300 years during the earlier days the forests on the mountains were rich with many natural products adequate for their household use they usually found a new place to settle when the former settlement place no longer supplied enough food and water for living tca1 there are 2 groups of oa who reside permanently in this area with a total of 11 households and 59 members they usually live in mountainous areas where a stream flows their houses called tub are simple and commonly built from bamboo and local forest woods their houses have a floor high off the ground and the roofs are made of a kind of palm leaves easily found in their living areas each house contains only one family they prefer to live and move to a new settlement together in group gpb1 these two oa groups have settled in their current living places for at least 1 year they usually harvest or hunt forest products or wild animals only enough for their consumption during the daytime and return home at night this is not like in the past when they regularly moved to a new place every 910 days when the harvestable forest products became scarce tca2 the building styles of the houses of those who settle permanently are different from the styles of those who migrate from place to place in the forest the settled houses are built with more stability they have high raised floors stable wooden support poles and roofs the tubs of the migratory oa groups are simply built using bamboo forest wood and leaves easily found in their living areas and the houses have no walls the building style of settled houses seems to indicate that they intend to stay permanently in this place tca1 current thai law and regulations and previous experience of granting thai citizenship to oa in the other provinces the district head governor and his staff followed the relevant policies of the moit and studied the laws and regulations applicable to this issue they set up legally based portals for the oa to receive thai citizenship initially the oa were clearly informed about the steps required to obtain thai citizenship and their rights and responsibilities after becoming thai citizens according to the thai laws significantly it was emphasized to the oa that their acceptance of thai citizenship was voluntary if they fulfilled the required legal criteria for becoming thai the local governors teams also studied a previous successful project of verification and providing thai citizenship to oa carried out in the betong district of the yala province as a model we follow the policy of the moit that oa in thailand are regarded as thai citizens they have the same freedoms and rights to access government facilities and support as other thais therefore we try to conduct the process of granting thai citizenship to the oa and have them legally registered as thais according to their willingness gpa3 we studied the experience of the local government in betong to deal with the status of the oa there and found that they applied the regulations for civil registration of the department of governance ministry of interior to handle any problems in betong the local governors team traced an oa individuals family tree in combination with the confirmations from local thai witnesses that the oa had grown up and lived in the area for a long time before as criteria for the approval of thai citizenship for the oa finally the oa in betong were registered into the thai citizen list and thai identification cards and numbers were provided to them we plan to use the practices in betong as a model for our plan too gpb2 historical and anthropological information confirm that the oa have settled in this area for many thousands of years we observe their physical characteristic living conditions livelihoods and languages which are compatible with the original oa described in both thai and western historical records to support their presence in southernmost thailand gpb1 323 evaluation of the oas willingness to adopt thai citizenship and the barriers of the verification process for the oa as thais two months prior to our interview the district governors team staff evaluated the oas willingness to adopt thai nationality by informing them of their rights and responsibilities as thais before they could decide freely at the same time they prepared the oa for our research team to perform the indepth interviews for data collection we informed the oa participants about the study and asked them about their willingness to adopt thai citizenship among those who lived in permanent settlements first as they were easy to contact and knew much about the local thai living conditions and cultural practices for the oa who regularly migrate for resettlement on the mountain range it was very difficult to get in touch with them gpa1 language was a significant barrier of providing clear information to the oa we assumed that there were some possible misunderstandings about the citizenship registration process and the answers of their willingness to be registered as thais between the district governors staff and the oa hence we had to contact the oa via some persons that they relied on and understood the oa language well gpb1 the oa in this area rely on their employers who have hired them for casual labor for a long time apart from the employers thai villager leaders or their assistants who usually support the oa can communicate with them well we asked these persons to help the district governors team by contacting and making an appointment with the oa before our visit to explain the details of the information to the oa every sector of the district government team including representatives of thai civil registration district land management agriculture public health education etc were prepared to respond to relevant queries from the oa tca1 indepth interview results the developed action plan and actions performed the research team with the assistance of the local governors staff visited the oa who lived permanently on the dusongyor mountain to carry out indepth interviews for data collection we interviewed the oa regarding their living conditions and health care education and other public services they required we once again explained the rights and the responsibilities they would have after they were registered as thai citizens before their willingness to accept the offer was confirmed we first traced the evidence to confirm their longtime settlement and their relative links with other oa members living in this area if the oa fulfilled these criteria according to the moits policies and regulations civil registration process as thais was done and an idc and idn were eventually given to them the district government strictly followed the guidelines for the civil registration process issued by the moit and strongly emphasized the preservation of the oas traditional ways of living despite their new nationality as thai people visiting the oa living areas to ask their willingness we found that the villagers of the two villages were willing to be registered as thais and to comply with thai laws they understood their rights as granted by thai officials and the obligatory responsibilities to thai society whilst their traditional ways of living would be preserved their reasons for the adoption of thai citizenship were that their children could attend school they could receive health care and other public services participate in health promotion programs and receive an adequate food supply the medical treatment among the oa depended on ancestral practices for example every pregnant woman went through childbirth naturally with assistance from a village midwife without a prenatal evaluation of maternal and fetal risks no vaccinations for newborns or the aged were provided although they had experience in the medicinal properties of many natural products used as medicines many complicated diseases were unable to be treated successfully we would like to have adequate food for our kids as the harvestable forest products have progressively diminished over the years on some days we catch or trap no wild animals to cook for our kids oaa1 the plants or wild animals in the forest reduced in number from previous years although we try to plant cassava trees to collect their roots the harvestable products are smaller than before so we are necessary to settle in permanent living areas and become employees instead oaa3 sometimes only one wild cock is caught for our food so we cook it for our kids first the adults have to reduce or miss their meals and wait for other cooked foods oab1 the southern border provinces administrative center has followed the living conditions of the oa for a long time because they live on high mountain ranges travelling to their living areas to provide the information about various legal and social regulations or other necessary social or living supports is very troublesome in the initial visits of the district governors staff the oa reported their willingness to be registered as thai the sbpac has had an action plan to provide thai citizenship for the oa since 2019 the actions planned are registration of the oa as thai nationals providing them with thai idcs and citizen idns as well as other welfare supports eg uhc monthly payments for the aged and newborns etc and improving their living conditions and livelihoods childrens education vocational training all the actions are based on the principle of obtaining equitable living condition with other thais and compliance with the current thai regulations and laws whilst their traditional lifestyles are preserved we asked for their cooperation in forest preservation gpa2 her royal highness princess mahachakri sirindhorn gave an idea to us to help the oa to improve their living conditions while retaining their identity through their traditional livings and cultural practices in cooperation with the supporting the minority of orang asali network the sbpac facilitates the process of providing the oa with thai nationality welfare support and improving the life skills necessary for modern living conditions gpa1 in our talks we recalled an event in which a man living in a village fell from a tree breaking his pelvic bone and required a treatment in hospital but he had no universal health coverage payment support to pay the treatment cost so we think it will be better for us to decide to be registered in the thai civil registration list so that the universal health coverage payment scheme is open to us and the cost of treatment will be covered by this payment scheme when we are necessary to visit a hospital for treatment oab2 clearance of legal issues and preparation for providing the oa with thai nationality to save the expense and time travelling to the various district offices to complete the steps of verification and registration process by the oa themselves the district governors team and associated local governmental agencies visited the oa settlements to complete the process following which the thai idcs and idns were given to them it is very troublesome for the oa to have them travel to the various district offices to complete the registration process our team and other district governmental officers will jointly visit them at their settlement sites again to trace the evidence of their long presence in this area their relative relationships or a family tree based on the legal standards of the moit before registering them as thai people and adding their names to the thai civil registration list gpb2 we will follow the regulations and legal guidelines for the registration process when the registration process is completed we will provide thai idcs to any oa age 7 years and older according to thai law gpb1 these oa are voluntarily accepting registration as thai citizens based on the policy of the moit the verification of long inhabitation in this area and relative relationships are confirmed by the local thai community leaders religious or social activity leaders or their employers gpa3 we learnt from the successful registration of the oa in betong yala province in betong they traced the evidence that confirmed the long settlement of the oa in the area and their relative relationships before providing them with thai citizenship our district governors team in association with other governmental support and service agencies will follow the same process carried out in betong gpa2 in betong the local governmental team also added a program for improvement of living conditions to the registration process for the oa there the operations yielded satisfactory outcomes to both the oa and the thai local governmental officers gpb2 the oa who receive thai nationality will have idcs and idns starting with the number 5 at the beginning which means that they are a minority person or a foreigner who have been approved to be registered in the thai civil registration list gpa2 the policy and practice guidelines launched by the moit will facilitate the local district governor and associated governmental sectors to complete the registration process gpa3 we will provide the information regarding the rights that the oa will obtain from thai government when they are completely registered as thais such as various financial and social welfare programs gpb1 the thai government asks the oa for their cooperation in forest preservation while their traditional ways of living will be preserved the adoption of thai citizenship will be voluntary depending on their own decisions the oa who have settled in the national forest and wild animal preservation zones will be informed of the same practical principles before they can decide to adopt the offers freely alternatively this group of oa can voluntarily resettle in one of the governmental resettlement areas provided for minority people gpb2 theme development after the completion of the study participant interviews the themes were developed under the thematic analysis disciplines as follows oa children had malnourishment and illiteracy that affects their growth and development e the oa demand that they will be allowed to maintain their traditional ways of living with the forest after they are registered as thai f livelihood assistance health care and alllevel education suitable for each oa individuals needs are necessary g the oa used ancestral methods to treat illnesses they experienced they had no knowledge of health prevention or promotion h they were very anxious when they needed to visit a hospital due to their misunderstanding of current medical treatments 2 studying current thai laws regulations and national policies to facilitate the process of the provision of thai citizenship to the oa by local governmental staff a because the oa are regarded as thai people the ministry of the interior thailand instituted a policy for the registration of the oa as thai citizens b related acts and regulations including guidelines for the verification of the thai citizenship process will be reviewed and discussed among the governmental sectors at both the national and local levels c the local governmental agencies will collaborate in planning and carrying out the registration process d the successful registration process carried out in the betong district of the yala province was studied as a model 3 the oa are willing to adopt thai nationality a detailed information regarding the oas rights and responsibilities as thai citizens was provided before their voluntary decision b their ethnic identities and lifestyle will be preserved c earning a living health care access and basic or vocational education for children or adults respectively were considered essential for the oa b registration process according to the developed action plan 1 the legal process of verification and registration as thai people 2 registered oa obtain equitable rights and have the same responsibilities as the other thais 3 collaborative work of related local government agencies is a key for successful registration 4 living conditions health service and education are the three main targets for the development of the oas wellbeing 5 health services under the uhc payment scheme is essential for the oa to access health care 1 the local governmental staff visited the oa living area on the mountain to ask about their willingness to be registered as thai people 2 the oa would like to accept the conditions after registration as thai 3 the registration to accept thai citizenship is voluntary 4 personal verification will be carried out by local government staff based on the moits policies and regulations 5 language was an information provision barrier 6 the registration practice successfully carried out in the betong district yala province is to be followed 7 thai idcs and idns will be provided to oa aged 7 years or over and they will be listed in the thai civil list after completing the verification process 8 a parcel of land for residence or earning a living will be provided 9 health insurance under the uhc payment scheme of the thai public health system will be provided to the oa 10 uhc will support payment for the oa to receive health services 11 oa children will be allowed to attend public schools to study thai themes codes c outcome evaluation 1 immediate afteraction evaluation of the registration process outcomes focusing on improved living conditions health services accessibility and childrens education 2 long term followups and repeated evaluations in the future are planned 1 the oas homes were redesigned for hygienic living 2 followups will be carried out to ensure the oa have received equitable social support and access to welfare programs as thai citizens 3 evaluation of the understanding of and accessibility to public health services under the uhc payment scheme among the oa and their satisfaction with the services will be evaluated 4 teachers and local thai community leaders will encourage oa children to attend a primary school 5 the oa parents and their children satisfaction with the organized education system will be evaluated official provision of thai citizenship to the oa according to the plan nearly 3 months after the survey of the oas willingness to be registered as thai and the preparation by the district governmental agencies the chanae district governors team and the associated agencies managing the legal issues and planning the process for registration and provision of thai citizenship provided thai idcs and idns to the oas in june 2022 the thai citizenship for oas was approved and thai idcs were provided to 25 and 20 oas who aged from 7 years old from toapaku and biyis villages respectively on 31 august 2022 the yala provincial governor presented the idcs and the citizenship confirmation documents to the oa who had received the approval to be registered as thais following the registration process this signifies the oa have the rights to receive various governmental supports such as health services education and monthly financial support for the aged and newborns the whole process was implemented to get rid of social inequality based on a thai strategy for national development theme which states that we will never leave anyone behind gpa3 the head of the cooperation center for development and special activities under the royal initiations under the sbpac in cooperation with the chanae district governors team the head officer of the local forest protection office narathiwas province a representative of the department of forestry and representatives from the sukirin selfdependent resettlement area visited the oa settlement areas in the forest to help them improve their housing and livelihoods options gpa1 the sbpac has facilitated the registration process for the oa so that they can access public facilities and other public supports like thai people for raising their basic living standards in health education livelihoods etc gpb1 the sbpac is requesting a parcelof land from the department of land management to establish a new resettlement area for the oa where they can grow crops and raise livestock for adequate household consumption the project is under negotiation among the related agencies now gpa2 on 31 august 2022 we received the idcs and other related welfare cards the community leader gave us the detailed information in the malay language we thank the district governors team for helping us to receive the idcs and their visit to our living areas in village no 7 tcb2 the head of the cooperation center for development and special activities under the royal initiations had the representatives of the national health guarantee office to travel with him to visit the oa additionally the district public health officers and the associated team set up a field meeting for open discussion regarding the rights for the oa after registration to access public health care services according to item 18 of the national health guarantee act 2002 gpa2 the representatives of the national health guarantee office explained the details of the rights the oa would have after the registration to the oa leaders or representatives before they transferred the information to the individual oas living on the mountain area gpb2 postaction shortterm evaluation after the registration process for the oa was completed we carried out a followup visit a few weeks later to assess how frequently the oa accessed public support as well as their satisfication we found that the oa were satisfied with the help of the local governmental agencies to improve their wellbeing and quality of life since they received their thai citizenships every individual oa was able to own a parcel of land to plant crops or raise livestock access the public health care or health promotion services and their children were able to attend the local primary schools etc the first time we visited the hospital we were very nervous and felt insecure however with the help of a local public health officer who took the injured oa to the hospital and the cooperation between the sbpac and the hospital administration staff the injured oa received the treatment free of charge initially the patient was very concerned about the hip surgery advised by the doctor that the whole flesh on his body would be taken away during the operation moreover the informal education and vocational training were provided for oa who were 15 years or older scheduled classes were regularly organized in the communityshared building in which 1020 oa youths attended each class to assist in the improvement of their living conditions they were taught to crop vegetables and raise livestock to maintain their food security additionally seeds baby chickens baby ducks etc were provided regarding public health services thirteen and five oa individuals voluntarily received one and two doses of covid19 vaccine respectively they responded well to the covid19 vaccination campaign they still preferred to use traditional herbal medicines for initial treatment except for a complicated disease for which they were willing to receive modern medical treatment from the thai community health volunteers who regularly visited them or in the district hospital when it was required the number of oa utilizing modern medical services increased discussion one principal item in the thai constitution emphasizes equitable rights of all thais to access and receive public services or support the oa in this study as well as other minority people in thailand have the rights to receive public support according to the rights outlined in the clause of thai constitution hence the verification and registration process for the oa in the chanae district of narathiwas province was undertaken all aspects of the quality of life of the study oa are significantly affected due to their migratory living style which depends on the quantity of natural products harvestable or wild animals caught for adequate consumption good livelihood for ending hunger and poverty equitable access to health care and quality education the three of the seventeen sdgs endorsed by the un have been prioritized by thai official agencies as the primary targets for upgrading the living conditions of all thais including the oa in this study additionally reducing inequality in accessing public support services with the aim for achieving the three targeted sdgs equitably was stressed in this project the verification and registration process for the oa in the current study was the first and principal action which initiated the cooperation among the related local governmental agencies under the administration of the sbpac the actions performed were based on the thematic principle of establishing equitable accessibility to public support as other thai citizens are able without the significant disruption of the oas identity and traditional living many previous projects in thailand and malaysia involving the resettlement of the oa to new living areas failed because their traditional living styles were abruptly changed due to the policies being implemented without receiving their agreement beforehand the abrupt changes from traditional to modernized living conditions adversely affected the oas traditional ways of life and cultural practices most of the resettled oas soon left the new housing provided by the officials and returned to their previous living sites in the forest we learned from our previous experiences and were aware that it is necessary to balance the preservation of the identity of this ethnic group and their traditional living style with the officially supported modern living if the changes were not familiar to the oa they would reject the offers compulsory changes by the provision of certain support programs despite seemingly useful from the providers perspective commonly bring about conflict or project failure for these reasons the sbpac first conducted integrative actions of local governmental agencies by surveying the oas requirements living styles cultural beliefs and practices and especially their willingness to adopt the registration and development programs provided for the improvement of their wellbeing after the legal conditions were fulfilled and the oas consent to join the program was obtained then the integrative actions were started the program in this study prioritized the improvements of the oas livelihoods health care and education as initial and urgent targets for receiving local governmental support because these were considered powerful influencers that interactively affected individuals wellbeing it was known that the oas lived by harvesting natural forest products for their daily household consumption they had no knowledge of how to plant vegetables or other plants or to raise livestock for their food reserves normally they followed a nomadic lifestyle migrating to a new location in the mountain range every 710 days on average when the harvestable forest products in their current living area became inadequate for consumption the increased thai population and accompanying requirements of land for agriculture and forest industries led to ecological changes in the forests both natural and manmade ecological changes in the forest have had a negative impact on the amount of forest products harvestable by the oa resulting in an insecure food supply among the oa this is the reason why some of the oa were required to permanently settle in a single living location or come down from the hills for labor work in the commercial area of the district to reduce poverty and lack of food security in response to the first and second sdg goals our program encouraged and supported the oa to settle permanently in locations along the forest margins as well as teaching them planting and livestock raising techniques after the preliminary discussions with the oa and the program were undertaken we believe that this method of providing social support is suitable for and satisfies the oa very much in that their ancestral lifestyle and beliefs have not been seriously affected the traditional health beliefs among the oa were based on their strong belief in supernatural powers rather than their own inner power or selfefficacy or control in managing their own health according to the health locus of control concept they had a lower belief in an internal health locus of control than in an external health locus of control this kind of belief causes adverse effects to a persons health 9 10 11 12 13 additionally they lacked the conceptual thoughts or knowledge necessary to generate an appropriate health belief model 14 to care for their own health this concept was also recently used to explain the lack of compliance for receiving a covid19 vaccine during the covid19 pandemic and vaccination campaign 1516 from our interviews with the oa we learned they were very anxious when discussing modern medical care their longheld perception was that attending a hospital led to a dreadful outcome or death with the help and psychological support from the local public health volunteers they felt more secure and relaxed apart from medical treatment we believe that the health education from the uhc program will enable them to voluntarily follow health prevention and promotion advice previous studies have found that improved knowledge followed by attitudes and practices together influenced soiltransmitted helminth infection control among the oa in malaysia 1718 the uhc payment scheme in thailand includes all aspects health services ie health promotion disease prevention treatment and rehabilitation and is available to all thais from birth to death local public health volunteers are the points of first contact in the system when accessing health services the uhc payment scheme ensures that all thais will receive the holistic health services equitably after the oa in this study were successfully registered as thai citizens they had equal rights as thai people to access uhc programs a study showed that the oa in malaysia were found to have shorter life expectancies than the malay people with overall life expectancies of 53 years 19 common diseases diagnosed in the oa in malaysia were sth infections pulmonary diseases liver diseases and malnutrition all of which were occasionally severe enough to cause death 520 we expect that the uhc program will be of considerable benefit for the healthy lives of the oa in this study education is another target of action planned to be promoted in parallel with improving living conditions and health care quality education either formal or informal can help the oa children or youths to understand thai or train them vocationally to offer them more choices of career in the future the oa in this study were encouraged to allow their children of school age to attend formal education while informal as well as vocational education programs were available for adult oa because the oa have only their own spoken language but no written language teaching them the thai language requires teachers who understand the oa language well we found that most of the oa parents and children appreciated this offer of educational opportunity the small sample size is a limitation of this study the difficulty of travelling to the oa living areas where they reside on the hilltops and their lifestyle of hunting or harvesting in the forest during daytime are the causes of this issue however we made an effort to include all available oa including their leaders in our interviews male oa of a comparable age range were predominantly included for the interview since they were the main group of oa making their livings and leading their family members lives conclusions we will never leave anyone behind a theme of social equality compatible with the unendorsed sdgs was the major concept of the current action plan implemented for the oa communities in this study we found that the oa in this study were satisfied with the officially provided support herein we suggest that the changing of any indigenous peoples living conditions while aiming for their better wellbeing by an official project should carefully consider their traditional beliefs and practices changing living conditions or implementing obligatory public services that markedly disrupt a minoritys ancestral beliefs and lives and significantly without their willingness to adopt these changes as if they are sharing the ownership of the project commonly result in unfavorable outcomes finally we suggest that the longterm followups of the oas accessibility to official services or support programs will elucidate the sustainable benefits and satisfaction among the recipients of the support data availability statement the study data and analysis methods are described in the material and methods section of this paper no data were deposited in other preprint servers institutional review board statement the study was conducted in accordance with the declaration of helsinki and it was reviewed and approved by the institutional review board of public policy institute prince of songkla university informed consent statement informed consent was obtained from all subjects involved in the study	ending social inequality by 2030 is a goal of the united nations endorsed sustainable development agenda minority or marginalized people are susceptible to social inequality this action research qualitatively evaluated the requirements for and barriers to full access to public services of the orang asali oa a minority people living in the narathiwas province in southernmost thailand with the cooperation of the staff of the southern border provinces administrative center sbpac we interviewed the oa local governmental officers and thai community leaders regarding the oas living conditions and health status then an action plan was developed and implemented to raise their living standards with minimal disruption to their traditional cultural beliefs and lifestyle for systematic followups a thai nationality registration process was carried out before the assistance was provided living conditions and livelihood opportunities health care and education were the main targets of the action plan universal health coverage uhc according to thai health policy was applied to oa for holistic health care the oa were satisfied with the assistance provided to them while filling the gap of social inequality for the oa is urgent a balance between the modern and traditional living styles should be carefully considered
introduction in brazilian amazonian area the fishing activity involves 368 thousand fishermen approximately and has a production of 166477 tons of annual fish moving us 130 million being the north area the main responsible for fishing production of continental waters in the year of 2009 where the states of amazon and pará they were the main producers in relation to the volume of capture of fish of the area on this year thus the amazonian area is holder of the highest values of consumption per capita of fish with 380 to 600 gday the fish is the main source of proteins of the riverine populations in the amazonian basin they can be found six fishing modalities being these subsistence commercial multi specified commercial mono specified fishes in reservoirs fishes sporting and the ornamental fishing the commercial fishing and the one of subsistence is the ones that represent larger source of jobs generation and income in the fishing section in the area besides these the ornamental fishing is described as fundamental importance for the local riverine populations being this responsible one for the subsistence of the same ones in several areas of the amazonian with prominence in barcelos area b the amazonian basin is the main area of fishing extractivist of ornamental fish of brazil happening in the areas of medio river xingu river tapajós river purus river juruá medio river solimões and medio river negro the basin of medio river negro in the state of amazonas is the area of larger representativeness of this activity of the country exporting about 20 million fishyear generating for the economy of the state about of us 3 million the ornamental fishing practiced in this area used 10 thousand people approximately in amazonas being responsible for about 600 of the income of the municipal districts of barcelos and santa isabel in negro river demonstrating to strong connection that those areas had with the international trade of ornamental fish at that time in the last decades the ornamental fishing practiced in the area of medio negro river has been suffering changes in socioeconomic scenery influenced by the economic crisis of the last decade besides linked problems the lack of organization of the local productive chain of the high taxes of imposed on the exported products of the reproduction in captivity of the main species as the cardinal paracheirondon axelrodi and the neon tetra paracheirondon innesi for countries importers as usa europe and asia besides the competition with the countries south american neighbors like colombia venezuela ecuador guyana and peru where the commercialization of the species that has sale for ornamental ends prohibited at the country they are offered without any restriction type and for values below practiced them in the national market such economical events consequently contributed in a direct and indirect way to reduction of the export volume of coming fish from the area of medio negro river taking many piabeiros and craft fishermen of ornamental fish to abandon the activity migrating for new economic activities close to the headquarters of the municipal district of barcelos such as guides in the sporting fishing in the field of ethnoichthyology many works have been carried out in the last decade adopting different themes in order to describe the different ways of use and cognitive knowledge of local communities the works with local ecological knowledge of artisanal ornamental fishermen developed in the amazon region more precisely in the basin of the middle solimões river and in the middle xingu river in addition it is important to note that there is a high correlation between the number of ornamental species and the number of ornamental species studied emphasizing the importance of including this knowledge in local fisheries management strategies it is well known that artisanal fishermen have detailed knowledge on ecological behavioral and fish classification issues and this knowledge is influenced and influenced by fishing practices this reality can be observed in the daily life of the artisanal fisherman in the amazon region through the cognitive capital acquired through years of experience in the activity they are able to employ and choose the best technique equipment and location in spite of the ornamental fishing to be an activity with more than half century of existence in the area of the basin of medio negro river and of great economic and social importance for the riverine communities it exists a lack of information related to the degree of socioeconomic contribution that this activity carries out on the community that depends on this as main sustenance source and income being necessary the rising of information that describe the aspects social ecological and economical of these activities in the area a dinâmica da pesca ornamental mudou em pouco tempo e afetou diretamente os pescadores além da baixa taxa de renovação com a participação de pescadores mais jovens ameaçando a transmissão de conhecimento ecológico para as gerações futuras como resultado notamos o aumento dos problemas relacionados à cadeia produtiva e a ausência de poder público na atividade a pesca ornamental já foi tratada como uma das principais atividades econômicas para as comunidades locais e para o estado do amazonas palavraschave socioeconomia pescadores artesanais pesca ornamental barcelos amazônia the aim of this study was describes the socioeconomic profile of the fishermen of ornamental fish of the area of medio rio negro recognized popularly as piabeiros in the municipal district of barcelos as well as the scenery of the ornamental fishing practiced locally pointing the main flood plain times to fishing main species fishing atmospheres equipment used and capture techniques material and methods study area the present study was accomplished in the areas urban and rural of the municipal district of barcelos state of amazon the city of barcelos was the first capital of the state of amazon in 1758 used as warehouse for slave expeditions and later for the vegetable extraction and installation of agricultural projects for the cultivation of coffee and tobacco the municipal district of barcelos is considered the largest municipal district in territorial extension of the state of amazonas with 11245076 km 2 located to 496 of distance of the capital manaus with thirst the right margin of médio rio negro and possesses a population about 26000 inhabitants in this area it is located the area of mariuá environmental preservation considered the largest fluvial archipelago of fresh water of the world with about of 1600 islands besides the jaú national park and araçá state park data collection the data were obtained through interviews semi structured with application of questionnaires containing open and closed questions with craft fishermen of ornamental fish known locally as piabeiros in the period among january to april of 2016 the accomplished questions were destined the obtaining of information on the socioeconomic profile and aspect of the ornamental fishing practiced in the area the average of the time of the interviews was of 30 minutes in individual ways with the due presentation of the free and illustrious term of consent to the interviewee and previous edition of plataforma brasil always with an accessible language to have owed understanding of the paper of the participation of the piabeiros in the respective study was carried out a consultation to fishing cologne of barcelos z33 for determination of the number of fishermen in active state in the ornamental fishing in the municipal district of barcelos where they were pointed 135 assets being 97 men and 38 women the places of interviews were determinate with random in the urban area after the researchers previous identification and the invitation to candidate the participation for the rural area the determination happened in agreement with the representation level that the ornamental fishing had for to present community riverine as informed for piabeiroskey in the headquarters of barcelos the present study was accomplished in the urban and rural area of the municipal district of barcelos eleven communities were visited in the rural area being these ponta da terra santa inês daracuá mulufú romão elesbão bacabal and jaqueira the field study was accomplished in the month of january in the urban area and month of april in the rural area for half fluvial in an embarkation of medium load tends exit of the headquarters of the municipal district of barcelos the area is characterized as the tributaries of larger representativeness of the ornamental fishing in the area socioeconomic and fishing piabeiros braz j biol 2020 vol 80 no 3 pp544556 547556 547 analysis of data the obtained data were used for the construction of graphs and tables and presented through descriptive statistics with calculation of relative frequency results the frequency of interviewees in the communities was showed in table 1 in which it presents the highest percentage of respondents in the urban area the naturality of the interviewees from municipality of barcelos was showed in table 2 being the city of barcelos the highest percentage recorded the area covered by the study was the municipality of barcelos with the communities of ponta da terra santa inês daracuá bacabal romão and elesbão the representation of genus was represented in table 3 in which the majority of fishermen interviewed are male the representation of age and civil status was represented in figures 2 and 3 respectively in which in urban areas the highest percentage was of fishermen aged over 60 years the representation of the educational level family income and economic activities performance of the piabeiros comparing the urban and rural areas of the municipality of barcelos was showed in figure 4 5 and 6 respectively the representation of the ornamental fishing seasons the main families of ornamental fish caught and marketed and fishing environments according to the piabeiros comparing the urban and rural areas of the municipality of barcelos was showed in figure 7 8 and 9 respectively the representation of fishing equipment used was represented in table 4 in which the rapiché and the cacuri were the instruments most used by the piabeiros the associativism representation and the main problems related to ornamental fishing according to the piabeiros comparing the urban and rural areas of the municipality of barcelos was showed in table 5 and6 respectively smaller number of interviews such as the community of jaqueira although there were efforts to reach the communities of alalaó and maquí there were not possibilities of success the field activities happen in the period of inundation of the rivers thus there were some igarapés that still met with low level of water these difficulties in the area were also pointed for leme and begossi and also for ferreira et al the comparative frequency among the interviewees showed that 5843 of the fishermen of ornamental fish are living in urban area while 4157 still live in the rural area in spite of that it looks similarity we can observe is a dispersion of those along the communities giving larger prominence the communities of ponta da pedra and daracuá that still active stay in the ornamental fishing that observation was also registered by sobreiro and ferreira et al during investigations on the social and economic profile in the community of daracuá demonstrating like present work a communitys importance for the ornamental fishing in the area it was also registered a low number of families living at these places in agreement with the residents that fact is due the decadence of the ornamental fishing in the last years starting from 2008 many of the old fishermen had to migrate for the headquarters of the municipal district discussion in relation to interviewees frequency in the communities larger frequency was observed in the headquarters of the municipal district of barcelos corresponding a total of 5843 for other side had communities that presented in search of new job opportunities besides having the access to services of health and closer education mainly for the fact of many of those residents to possess smaller children of age the medio river negro represents one of the most uninhabited areas of the amazonian with low population density caused by soil characteristics that it is predominant sandy and it doesnt favor the development of the agriculture and of the rivers that due to the low level of dissolved nutrients and low productivity would excel of the waters the river negro is recognized popularly as river of the hunger those crucial factors act as limiting for the fixation of the population studies by silva tell a historical migration of rural communities starting from 1980 towards the urban centers of the area of medio river negro mainly the headquarters of barcelos and santa isabel do rio negro that migratory process happened due to need of search of better jobs and access to education services and health thus many of those families maintained contact with their native communities for several reasons like relationships to the accomplishment of activities as the fishing cultivation of having cleared and collection of fruits of the forest as the chestnut of brazil we can notice that the practice of residences alternation accomplished by riverine communities from medio river negro is not something new and it is happening to many years under influence of the dynamics of the environmental and economical social most of the interviewees piabeiros was of the masculine gender so much the residents in the urban area as the one of the rural areas low representativeness of the womens action was observed in the ornamental fishing in spite of that it is observed that the woman has an expressive participation because carries out the work in an equalitarian way to the men scenery different to the that is found in other fishing modalities in brazil and in the amazonian where happens the division of gender of the work a lot of times the woman doesnt participate directly of the activities being that exclusive to the men and the women fits the childrens cares and the accomplishment of the daily domestic services studies conducted by carvalho júnior et al souza and mendonça and rossoni et al related the ornamental fishing practiced in other areas of the amazonia it has been demonstrating the womens smaller participation or inexistences of those in the activity with great predominance male we can mention as example the ornamental fishing in the area of the medio river xingu the ornamental fishing in the reservations of maintainable development area piagaçupurus in the bass river purus and the ornamental fishing of the area of tefé where the works describe the male predominance analyzing the womens participation in the seacontinental fishing in agreement with data of mpa it is observed that they represented 4085 of the brazilian fishermen registered in the period of 20082009 being the northeast area the one that presents equalitarian dimension among genders in the state of amazon the women represented 400 of the fishermen for this period in relation to age group a percentage was observed high in the urban area of piabeiros with superior age to 60 years on the other hand the piabeiros of the rural area presented percentage of 3514 among the fishermen with age from 34 to 38 years of age we can notice that a tendency of little renewal of proceeding piabeiros exists in the urban area because the same ones tend to migrate for another commercial activity on the other hand the perception of renewal of the piabeiros exists in the rural area caused due to lack of commercial opportunity it was also observed that in the rural area the largest group of piabeiros is in the one of age among 34 to 48 years of age in agreement with the studies driven by ferreira et al the average of age of fishermen of ornamental fish was of 45 years with variation from 35 to 71 years in the present study the average of piabeiros age in the urban area was of 5372 varying from 24 to 82 years already in the urban area the varying was of 4791 same result observed in relation to the predominance found with the resident piabeiros in the rural area should have the influence of this division because in that study there was a low number sample that was reiterated by the authors the averages of ages of the piabeiros of both study areas were above the medium distribution of the age groups of the national professional fishermen that it is among 30 to 39 years representing 266 of the total the results demonstrate that the ornamental fishing in medio river negro is composed by older fishermen with ages above 40 years it is noticed that most of the piabeiros in the rural areas as in the urban areas they are natural from barcelos to the whole they were mentioned in the interviews 32 different birthplaces it is practical common observed along the interviews that the piabeiros portrays their naturalness as being the rivers or the communities part of this characteristic is due the communities distances in relation to the urban areas especially caused by the geographical isolation of the area and the great amount of bodies of waters that difficulty the access to the urban centers most of interviewees declared married marital status in the amazonian the ornamental fishing is developed by riverine families through job of formed work of groups being is one of the main local economic activities alternative for obtaining pays and middle of sustenance the study of prang through an analysis of the ornamental fishing accomplished in the basin of medio river negro describes the participation of about 10 thousand families in the capture practices and transport of ornamental fish study made by souza and mendonça it also described the participation in the ornamental fishing practiced in the area of tefé with 875 of the fishermen of ornamental fish in marital status married with families usually constituted by six people thus 35 families were identified as dependents of the fishing and of the i trade ornamental in the area the education level presented by the piabeiros was considered low with incomplete fundamental teaching or illiterate study conducted by alencar and maia when analyzing the distribution of the brazilian fishermen for education in relationship the areas of the country noticed that most of the fishermen just possesses the incomplete fundamental teaching and the north area 828 of the fishermen with that profile for lima et al the low education level presented by fishermen of the north area links them still more the fishing because the no qualification disables that those get job in other economic activities with better remunerations this characterization is more evident when the family income of the piabeiros is analyzed it can be observed that these appear in the smallest strip of income part of the piabeiros from rural area declared to have a family income around a minimum wage or even minor than that value as mentioned by the piabeiros from urban area being the larger values to three minimum wage more concentrated by piabeiros of the urban area possibly due to the presence of piabeiros bosses being responsible for the purchase and sale of the ornamental fish in barcelos and the supply to the companies of aquarismo of manaus for silva besides the ornamental fishing the incomes of many families of the area of the medio river negro are composed by social benefits of the federal government according to the data of socioenvironmental profile of barcelos accomplished in partnership by the federation of negro river indigenous organizations indigenous association of barcelos and the instituto socioenvironmental accomplished in the period from 2009 to 2010 5554 of the residents of barcelos possess fixed income and 6222 are employed where the public employees represent 2815 of that total one those works also describe that 4882 of the families of the municipal district receive some type of financial aid of the federal government in the present study most of the interviewees informed to have the ornamental fishing as the main source of income however it is noticed that that no longer it is the main source for some mainly for the resident piabeiros in the headquarters of barcelos where 5714 not declared more to depend on the activity to survive opposite scenery to this of the urban area is described by the piabeiros of the rural areas where 7838 affirmed to have the ornamental fishing as main middle of obtaining of income many piabeiros end up carrying out other economic activities as form of complementing family income being those accomplished in the period of defeso of cardinal paracheirodon axelroldi among the months of may to july the main economic activities were the eatable fishing of fish the agriculture and guides of the sporting fishing many of these carry out occasional activities as salesperson of fish aid of bricklayer craft chambermaid and cook of boat hotel according study by silva and begossi the activities as the fishing the agriculture the craft and the forest extractives are the main economic activities in communities of the area of the medio river negro the fish eatable commercial fishing was the activity that most of the fishermen said to carry out in periods of exports of the ornamental fishing among the piabeiros of the urban area this activity represented 7143 while for the fishermen of the rural area this activity represented 4359 in the study of inomata and freitas it was described that the fishing activities represent the main source of income and generation of jobs of the primary section and the fact of the craft fishing not to demand the qualified work does with that many fishermen choose these activity the study of sobreiro showed a tendency of changes of activity of the ornamental fishing for other linked activities to the fishing section in 2011 with migration of fishermen of the urban and rural area for the eatable commercial fishing of fish this fact can be related with the scenery found in the present study where the interviewees largest portion declared preference in working in the eatable fishing instead of the sporting fishing even the sporting fishing tends expressive growth in the area getting to move us 5 million per year the equivalent to 100 of gdp of barcelos many fishermen from urban area answered that dont identify with the sporting fishing mainly due to the way of this work is developed and that activity demands that the fishermen work long hours a day besides the need of more formal communication with the tourists that fact was also described in study by ferreira et al where the craft fishermen of ornamental fish of barcelos complain of the work conditions that are exposed in the sporting fishing in the area the reports describe that these are not treated with respects by the tourists and forced to work in schedules of larger solar incidence the fish eatable commercial fishing was the activity that most of the fishermen said to carry out in periods that contain the exports of the ornamental fishing among the piabeiros of the urban area this activity represented 7143 while for the fishermen of the rural area this activity represented 4359 in the study of inomata and freitas it was described that the fishing activities represent the main source of income and generation of jobs of the primary section and the fact of the craft fishing not to demand qualification the study of sobreiro showed a tendency of changes of activity of the ornamental fishing for other linked activities to the fishing section in 2011 with migration of fishermen of the urban and rural area for the eatable commercial fishing of fish the participation in the sporting fishing was mentioned by the fishermen from rural area that carry out that activity in the fishing season that corresponds to the period from october to march in this period those fishermen are contracted mainly for local ecological knowledge that helps in the choice of best local of fishing of the tucunaré main species of that activity besides the sporting fishing the fishermen of the rural area work in the agriculture with cassava cultivation in coivara these fishermen practice the ornamental fishing only during part of the year in the period in that the exports of the ornamental fishing are closed or the financial incomes with activity are very low when the agriculture is intensified the coivara agriculture is had as one of the most important activities for the families from the negro river the field is described as the system of earth use by riverine populations with predominance of the cultivation planting of annual species where the agriculture of coivara is based in the cut and it burns of the forest vegetation for the incorporation of the present nutrients in the ashes to the soil guaranteeing like this the success of the cultivation characterization of the ornamental fishing of barcelos the ornamental fishing in the basin of the medio river negro suffer influence direct of the dynamics of the waters cycle of the negro river being to criterion of the fishermen the choice of the best time for the practice of the activity for the fisherman from the urban area the best is the ebb period and for the rural area fishermen the drought these are the factors that determine the beginning of the activity the variation of the waters in negro river is one of the main characteristics of that tributary that depending on the annual seasonality and of the place it can vary from 10 to 12 meters and those variations of the level of negro waters form new placves as lakes beaches flooded fields and igapó forests that serve as shelters reproduction places and feeding for the aquatic communities according to data of the geological service of brazil the seasonal periods of the negro river understand the following phases inundation flood ebb tide and drought for the piabeiros of the urban area the best time for the capture of ornamental fish if gives at that time of ebb tide and inundation for the piabeiros of the rural areas the best period would be at that time of drought and in the inundation however for both the dry period is described as a time of difficult displacement due to the banks of sands and existent geographical isolation in some places according study by siqueira souza et al these periods are considered as the best time for the capture of ornamental fish in the area because in time of full of the rivers in the area the fish end if dispersing to the igapó forests the food search and reproduction hindering like this the capture for the fishermen the black river show a rich diversity of species of fish approximately 450 species and many are endemic of the basin and still ignored not being classified described in this vast number of species some are used for ornamental ends with base in the reports and descriptions accomplished by the piabeiros during the interviews it was possible to accomplish the identification of the main families of ornamental fish marketed in the area being to the whole ten families characidae lebiasinidae gasteropelecidae cichlidae anostomidae oesteoglossiformes loricarridae potamotrygoniade callichthyidae and gymnotidae the piabeiros of the urban area mentioned a larger amount of families than the residents of the rural area this fact happens possibly in reason of the locomotion capacity of the fishermen to their fishing ones that are a lot of times located in more distant areas of the headquarters of the municipal district of barcelos and also that the same ones count with a structure of larger fishing than the residents in the rural area as well as the costing on the part of the middlemen of ornamental fish of the area for accomplishment of their fishing campaigns counting with support of embarkations of medium load motorized on the other hand the piabeiros of the rural area end up practicing the fishing only in close areas their places where a lot of times the atmospheres favor the capture of a smaller diversity of species of ornamental fish we can note that exist piabeiros experts in capture species from specify families such as characidae cichlidae loricarridae and potamotrygonidae that fact can be observed in the urban area and in some communities as daracuá when asked on the capture specificity the main explanation was the value commercial attachment of the species that compose these groups that compensating the expenses and generating a satisfactory markup to the fisherman the selectivity in the ornamental fishing can also be observed in other areas of the amazonian as in the case of medio river xingu that in spite of existing about 200 species of ornamental fish in the area the fishing ends if concentrating in only 10 species in reason of their high market values in the present study it is possible infer that the ornamental fishing is concentrated mainly in the familys characidae lebiasinidae gasteropelecidae cichlidae loricariidae and potamotrygonidae the main representatives of these families were the cardinal paracheirodon axelrodi rodostomos hemigrammus bleheri butterfly carnegiella spp acará disco symphysodon discus bodós and stingrays respectively corroborating the data described by chao and prang anjos et al sobreiro and ferreira et al for the capture of those species the main used equipments are the rapiché the cacuri puçá cuts and the zagaia as well as having described for of barra et al sobreiro and ferreira et al that studied the ornamental fishing in the area the rapiché was more frequently cited by the fishermen of the urban area and rural it is an accessory made by piabeiros with a flexible wood known locally by ripeira where two sticks and stitched a nylon mesh giving the appearance of basket according to the piabeiros it is a very useful tool for catching piabas in streams and in areas free of vegetation or shrubs and its use is related to the efficiency that this device demonstrates at the time of fishing the cacuri as well as the rapiché was also widely used this was cited by 29 520 of the urban piabeiros and 3514 of the rural area however different from the rapiché this equipment is constructed with a wooden arch with nylon fabrics sewn on the sides as well as a heavier wood attached to the bottom being used as a temporary trap in environments of difficult access such as flooded fields with the use of baits to attract fish the puçá like the rapiché and the cacuri is constructed with nylon canvas by the piabeiros in an artisan way with the purpose of catching the ornamental fish individually or in smaller quantities being very used in the handling or counting of fish like stingrays and acará disco during the transport the hoist according to the information of the piabeiros is a tool used for the lifting of heavy loads which has been adapted for ornamental fishing mainly for the capture of bodhi since they are fish residing in the submerged trunks on the banks of the lakes and in the bottom of the igarapés the zagaia is a wooden rod approximately 2 meters long with a trident style steel spear at the end used to catch stingrays during breeding season where the fisherman after a throw on the edges of the fish disc holds it and places it with the belly up in the bottom of the canoe forcing the delivery with release of the cubs by the female when asked about this practice of capture and not the collection of nature the piabeiros expose that such a procedure is often occasional but that greatly facilitates the capture of stingrays in the natural environment thus gaining more time and achieving an amount even greater than usual because the individuals obtained through this practice are within the maximum size limit that the market demands which is 30 cm wide for the species p motoro p schroederi and 14 cm for p cf histrix ornamental fishing occurs in several environments according to the local seasonality in this study the igarapés were the most preferred environments for those interviewed with 3696 by the piabeiros of the urban area and 3810 of the rural área in addition to the igarapé other environments were cited as lakes river banks flooded fields beaches and igapó forest it is noted that the choice of fishing sites is based on the empirical knowledge of the fishermen on the behavior of the ornamental fish species of the region such knowledge is constructed with the years of work practice in the activity which enables the fisherman to choose the best equipment technique season and place to fish with better efficiency the desired species the ornamental fishing scenario in barcelos the fishing colony z33 in the city of barcelos is the main institution in which the fishermen are associated followed by the fishermen and fishermens cooperative of ornamental fish of the middle and upper river negro however it is noted that there are fishermen who does not have any type of link with the institutions of the local fishing sector access to closed insurance is one of the main reasons for the association in the category of fishermen of both zones with the z33 fishing colony as a fundamental aid to support the family in the period of prohibition of fishing of some species of commercial importance in the region this fact is also exposed in the study by ferreira et al 2017 where part of the fishermen of ornamental fish demonstrate not to expect contributions their professional lives coming from the fishing colony among the piabeiros in the rural areas most reported not being associated with any institution in the sector with only 30 300 associated with z33 fishing colony and 303 with ornapesca others 303 to the farmers union of barcelos logistical and bureaucratic issues were the main reasons why many fishermen in this region were not associated with the sector institutions according to sobreiro as of the year 2000 ornamental fishery in the region of the medio river negro began to show signs of decline leading to the mobilization of national and regional institutions in order to promote the activity the actions of this project resulted in the creation of cooperative of fishermen and fishermen of ornamental fish of the medio and upper rio negro in 2008 where new structures and technology were introduced to improve the sanitary quality of ornamental fish in the region through an interview with president of ornapesca in december 2016 in the city of barcelos it was reported that the initial idea of this development project was to improve the working conditions storage health quality and values of ornamental fish through however the actions carried out did not have the expected results due to bureaucratic problems on the part of the government agencies which made it impossible to provide financial aid to the sector and did not comply with the proposals agreed with the fishermen currently what is seen in the ornamental fishery is a balance of the number of active fishermen in the municipality where 480 of the total number of piabeiros interviewed were active and 5119 said that they did not work on the activity however many piabeiros still live in this activity even in the face of the socioeconomic changes that ornamental fishing has faced in the last decade influenced by the reduction of the export volume of fish of origin of the negro river basin and problems related to the organization of the productive chain besides the lack of attention to the sector by the public power this is more evident when it is observed that in the rural area the number of assets 6389 is higher than in the urban area where the number of inactive is higher according to ferreira et al fishermen interviewed in their study reported that ornamental fishing in the region is in decline and that many of these fishermen only began to feel the effect of such changes between the years 2007 to 2010 this period coincides with the closure of the largest buyer of ornamental fish in the region the company turkys aquarium which owned 512 of the ornamental fish market in the state of amazonas this event may have reflected directly on the local economy where the main current related problems are related to the absence of ornamental fish buyers the reduction of sales as well as the low financial profit that activity currently provides chao and prang in their study already alerted to the emergence of problems related to regulatory insufficiencies of the activity unequal international competition reproduction and marketing of species targeted in captivity by importing countries and may influence social economic and environmental impacts we note the occurrence of other problems related to the production chain in addition to those cited by the authors such as delay in the payment of production by the middlemen and health issues due to the average age of the piabeiros that most present where many claim not to be more able to work in the activity since it has an arduous work order that requires certain physical aptitude and perfect vision for locating and identifying many species in view of the results of the present study it is well known that the dynamics of the ornamental fishery seems to have undergone changes in a short time directly affecting the category of artisanal fishermen of ornamental fish causing many to adopt other economic activities such as commercial fishing of edible fish this event should be seen with some attention because the migration of fishermen to other activities may increase the dispute over the resource with other fishing modalities in the region a fact already pointed out by other studies developed in the region this study also demonstrates a greater participation of older fishermen and a low age renewal a fact that indicates the absence of younger fishermen since the activity scenario is not more attractive for the younger ones bringing a concern regarding the transmission of the future generations should this scenario continues regarding the ecological aspects there seems to have been no change over the years in relation to the composition of the main groups of fish traded in barcelos as well as in the artisanal techniques of capture what has intensified are the problems related to the local productive chain which lacks the structure and technology to improve the quality of the animals coming from the middle rio negro basin in addition to the public attention to the activity since the ornamental fishery has already been treated as one of the most important local economic activities contributing financially and socially to the state of amazonas	the negro river basin is considered the largest area of extractive of ornamental fish in brazil this area has fundamental importance for the populations from the amazon the present study aimed to describe socioeconomic profile of ornamental fishermen known as piabeiros in the municipality of barcelos as well as the ornamental fishery fisheries area target species environments fishing techniques equipment capture techniques and main difficulties faced by the current activity this study was carried out in municipality of barcelos through semi structured interviews with artisanal ornamental fishermen n 89 the main families of ornamental fish caught and traded were characidae lebiasinidae gasteropelecidae cichilidae anostomidae loricaridae potamotrygonidae and gymnotidae the main catchment areas were igarapés lakes flooded fields beaches river banks and igapó forest rapiché was the most used equipment in the fisheries both by the fishermen of the urban areas 4381 and rural 4189 most of the fishermen are associated with the colony of fishermen of barcelos z33 the data showed that the dynamics of ornamental fishing have changed in a short time and directly affected fishermen in addition to the low age renewal with the participation of younger fishermen threatening the transmission of ecological knowledge to future generations as a result the increase of the problems related to the productive chain and absence of public power to the activity since ornamental fishing has already been treated as one of the main economic activities more important for the local communities and for the state of amazonas
introduction billions of people use online social media applications such as facebook and instagram as part of their daily activities social media applications indeed make possible to exchange opinions get news and maintain social interactions through posts comments and likes in particular fb has been the most popular social media application for quite a long time while ig has experienced a surge in popularity in the last few years in both facebook and instagram influencers post content in the form of photos videos or texts users of these social networks can follow influencers and interact with posts by liking reacting sharing or commenting them several studies on online social networks have analysed content popularity as a function of the total number of interactions measured at the time data was crawled many works focus on predicting the popularity of posts often given their intrinsic characteristics as well as the characteristics of the influencers and their followers few works instead focus on understanding the temporal dynamics of the popularity of content generated in osns while it has been largely recognised that content popularity decreases over time different models have been proposed for the decay rate of popularity depending on the platform and content itself sometimes popularity is modelled by a negative exponential function sometimes by heavytailed functions and in other cases simply as constant however a largescale characterisation of the temporal evolution of the popularity of posts in osns is still missing in this work we aim at filling this gap by providing an experimental analysis of the time evolution of interactions with usergenerated content both on a perpost and perinfluencer basis and developing an analytical model capturing the main aspects of user interactions on osns to this end we focus on two popular social networks facebook and instagram these applications currently have a large ecosystem of influencers that try to gain popularity in different ways eg by increasing the number of posts by posting content of large or mixed interest by debating or posting a reply on others posts in this work we analyse model and compare user engagement and interactions by leveraging a dataset of more than 13 billion interactions over approximately 4 million posts of 651 italian influencers on fb and ig the collected dataset covers a period of more than 5 years from january 1 2016 to june 1 2021 we analyse such data aiming at answering the following fundamental questions what are the main factors impacting on temporal dynamics of posts published by the influencers how do followers interact with such posts in particular what is the time evolution of the reactions to these posts can we develop a model of these dynamics and exploit it for practical applications our main findings can be summarised as follows • both influencers activity and users activity exhibit a characteristic daily pattern but with a different shape • the interarrival time of posts has a longtail distribution reasonably fit by a lognormal • on average 50 of user interactions occur within the first 4 h after content creation on fb and after 2 h on ig interactions arrival rate exhibits approximately an exponential temporal decay • most of the posts are shortlived with a lifetime between 20 and 50 h after which they no longer attract interactions • the fraction of total interactions obtained within a given time interval is affected by the number of newly published posts in the same interval • the distribution of the total number of interactions is well fit by a lognormal distribution • the average number of interactions received by posts is roughly linear with the number of followers of the publishing influencer • the total number of interactions gathered by a post can be well predicted by measuring the interactions received within the first hour or even from the first few minutes our exploratory data analysis identifies the main features that should be incorporated into an analytical model trying to capture the temporal evolution of interactions received by a post we first attempt to develop such a model fitting a small set of parameters to the specificity of posts published by a given influencer interestingly we discover that many of these parameters do not vary significantly from influencer to influencer moreover they only weakly depend on the considered social network our model can provide an accurate prediction of the total number of interactions gathered by a post by observing only the initial phase of its lifetime we believe this ability of our model can have interesting applications finally we mention that a preliminary version of our work presenting a subset of the results obtained from our dataset has appeared in vassio et al this paper extends the data analysis and introduces a novel model for the temporal evolution of interactions with posts which is then validated and applied to early prediction of post popularity the remainder of the paper is organised as follows section 2 summarises some relevant related work section 3 describes the methodology we used to extract and process the data while sect 4 presents the results of our data analysis section 5 describes the complete analytical model that we have developed which is then evaluated and compared to a baseline finally sect 6 concludes the paper related work social media provide a powerful and effective platform for the exchange of ideas and rapid propagation of information hence their study is of paramount importance to understanding the opinion trends in our society and the main actors ie the influencers although a large body of literature has analysed osns the temporal dynamics of posts and interactions are still not well understood indeed the majority of existing studies ignore such temporal dynamics focusing on the spatial analysis of a single large snapshot a few works have focused on predicting content popularity considering content intrinsic characteristics and social interactions features the main factors that impact the popularity of posts on fb are identified in sabate et al using an empirical analysis involving multiple linear regressions similarly highlights the characteristics related to the dynamics of content production and consumption in ig while and predict the popularity of a future post on ig by combining user and post features instead few studies have analysed the time dynamics of content generated in osns the decay in popularity over time ie the rate of new interactions of internet memes is shown to be well modelled by a negative exponential function the work in van zwol measures the time evolution of the popularity of images in flickr finding that heavytailed distributions can represent the decay in rate of new interactions over time instead observe that the most popular flickr pictures exhibit a closetoconstant interaction rate the study in hassan zadeh and sharda models the popularity evolution of posts by hawkes point processes using twitter data to fit the required parameters gabielkov et al analyse and predict clicks on twitter posts they find that while posts appear as bursts in a shorttime frame clicks appear and decay at larger time scales with a long tail the authors leverage early interactions to predict future clicks as in our work they show that a simple linear regression based on the number of clicks received by tweets during its first hour correctly predict its clicks at the end of the day with a pearson correlation of 083 ramachandran et al propose a model that reproduces the clicks created by social media in particular the authors consider news posted on twitter and observe that hourly impressions decrease geometrically with time they model information diffusion to determine current and future clicks using a memoryless generative model with a few timeinvariant parameters finally ferrara et al show that the distribution of likes to posts on ig is best fit by a powerlaw suggesting that popularity of media as measured by the number of likes might grow by a preferential attachment mechanism however ferrara et al provide no evidence of this kind of evolution other works analyse the temporal dynamics of particular usergenerated content outside of osns for example videos on youtube exhibit various popularity decay patterns over time for some videos the decay can be modelled with heavy tail distributions while for others with an exponential distribution similarly ahmed et al show that user generated videos have distinct patterns of popularity growth over time our previous studies focus on the peculiarity of user interactions with political profiles on ig during the 2018 european and brazilian elections with the goal of identifying the structure emerging from the cointeractions we studied the appearance and evolution of communities of users obtained through a probabilistic model that extracts the backbone of the interaction networks interestingly politicians are able to attract more persistent communities over time than nonpoliticians related to the topic of popularity prediction we proposed a parallel between the osn world and the stock market influencers can be viewed as stocks while users are investors the study shows how this marketlike approach successfully estimates shortterm trends in influencers followers from external variables such as google trends finally our previous study investigates the changes in habits in osns during the covid19 outbreak it is shown how people during the lockdown due to restrictions enforced to inpresence social activities changed their interaction patterns shifting more towards the night we emphasise that a largescale characterisation of the temporal evolution of post popularity in osns is still missing in this work we aim to fill this gap by providing an experimental analysis of the time evolution of interactions with usergenerated content both on a perpost and perinfluencer basis and an analytical model that can accurately represent user interactions on osns data collection in fb and ig a profile can be followed by other profiles ie its followers a profile with a large number of followers is also called an influencer influencers post content consisting of either a photo or a video or plain text the profiles followers and anyone registered on the platform in the case of public profiles can view the influencers posts likereact to them comment on them and share them with their contacts notice that by the term influencer we refer not only to individuals but also to groups football teams newspaper and companies we monitored the activities triggered by top italian influencers on the two aforementioned social networks to this end we built lists of the most popular italian influencers including different categories like politicians musicians and athletes those marked as italian are the ones that communicate on the online social platform mainly using the italian language to get popular profiles we exploited the online analytics platform hypea uditor com for ig and socia lbake rs com and pubbl icode lirio it for fb the analysis has been restricted to the influencers with at least 10 000 followers on june 1 2021 the lists of influencers we used are publicly available 1for each monitored profile we downloaded the corresponding metadata ie the profile information and all the generated posts using the crowdtangle tool and its api2 crowdtangle is a content discovery and social analytics tool owned by meta 3 which is open to researchers and analysts worldwide to support research upon subscription of a partnership agreement furthermore for each post we downloaded the number of associated interactions along with their timestamp monitored posts are sampled by crowdtangle within the first 20 days with a higher sampling rate closer to the publication time of the post notice that on ig users can like posts whereas on fb they can react to posts with a thumbs up or other five predefined emojis thus for each post we collected the number of likesreactions the post received hereinafter referred to as interactions which crowdtangle provide in an anonymized manner moreover we also collect statistics about number of comments per post for fb and ig and number of times posts are shared for fb finally we have stored the data which takes around 110 gb of disk space on a hadoopbased cluster and we have used pyspark for scalable processing for each influencer we downloaded all the data related to the posts published between january 1 2016 and june 1 2021 table 1 reports the main features of our dataset separately for each osn in total we monitored 651 public profiles which published approximately 4 million posts accounting for more than 13 billion interactions the number of comments and shares of the posts are also reported notice that while the influencers posts are widely shared by their followers our analysed influencers rather rarely repost other influencers posts indeed we observed only around 24 thousand shared posts by the influencers on fb accounting for only about 07 of all the posts figure 1 depicts the empirical cumulative distribution function of the number of posts per influencer the 651 influencers show a large variability in the distribution of number of posts some influencers published few tens of posts while others such as newspapers pages up to 10 5 posts also in the period under study influencers on fb published more than those on ig the main reasons are twofold i on fb more influencers are actually pages or organisations rather than single individuals and ii many popular ig influencers did not exist at the beginning of the considered time period or have become active much later figure 2 depicts the cumulative distribution function of the number of followers per influencer as recorded on june 1 2021 the number of followers per influencer varies between 10k and tens of millions also the profiles in the set chosen for ig are usually more popular than those selected for fb temporal user engagement with posts in this section first we characterise the patterns of the influencers and followers activity then we study the time evolution of interactions and their relation with the number of followers finally we investigate the correlation between the interactions a post attracts and the number of newly published posts activity of influencers and followers we first characterise the daily patterns of influencers and followers activity figure 3 presents the influencers hourly activity obtained considering the time instants at which posts were published the activity is normalised by their maximum in both social networks to have comparable results the plot accounts for all the analysed 4 million posts and it is reported using a 24hour localtime clock according to the iso 8601 standard similarly fig 4 shows the daily activity distribution of the followers considering the timestamps of the followers interactions note that due to our particular selection of influencers we can reasonably expect that the vast majority of posts and this is also supported by the results in benevenuto et al where authors show that followersfriends interacting in social networks are usually within close geographical proximity of the influencer we observe that influencers and followers activities exhibit similar patterns over fb and ig they significantly decrease during the night and exhibit two peaks during the day however it is interesting to notice that followers tend to be more active later in the evening with respect to influencers moreover looking at the behaviour of specific influencers on fb and ig we observed that their followers activity over time tend to be similar to that in fig 4 although the single influencers daily activity might deviate significantly from the one shown in fig 3 this is confirmed by the results in fig 5 showing that the average followers activity per new post maintains a similar shape to the ones in fig 4 although influencers generate very few posts late at night such posts are typically fresher and encounter less competition nonetheless they still collect very few interactions during the night we now investigate the distribution of the interarrival time between different posts in particular we focus on the tail of the distribution considering timescales of several tens of hours ie timescales at which the impact of the daynight activity pattern is negligible figure 6 depicts the tail of the intertime of all posts generated by the influencers including the best fitting lognormal distribution the log scales in the plot suggest that the lognormal distribution provides a substantially better fit than what would be obtained by an exponential distribution this is due to the fact that influencers sometimes remain silent for long periods we also analysed single influencers and found that for the median influencer the average posts interarrival time is equal to 19 hours on fb and 57 hours on ig then fitting separately each influencer with a lognormal distribution on average we obtained as parameters of the lognormal 20 14 on fb and 31 13 on ig temporal dynamics of interactions we now analyse the temporal evolution of the interactions to a post considering up to 20 days after the creation of the post itself we compute for all the 4 million posts and for every sampletime the fraction of received interactions with respect to the total number of interactions obtained by a post after 20 days we consider fractions in order to compare different posts and different influencers finally we compute the average over all posts the results representing the dynamics of the average fraction of interactions over the first 3 days since the creation of the post are shown in fig 7 one can notice that the majority of the interactions occur within the first few hours on average the first hour accounts for 31 of all of the interactions on fb reaching over 80 after 1 day moreover on average 50 of user interactions occur within the first 4 h since content creation on fb and after 2 h on ig it is thus clear that the freshness of a post has a significant impact on the level of attractiveness of the post interestingly the growth of the number of user interactions is faster on ig than on fb although both curves converge after around 30 h studying the evolution of the rate of new interactions we found that at least in the first 24 h after the post creation this rate is well approximated by a negative exponential decay function as expected individual posts can have widely different patterns in terms of their accumulation of interactions over time as an example we show the results related to two specific posts on fb published by a wellknown italian influencer the temporal dynamics of interactions over the first 3 days since the post creation are represented by red marks in fig 8a and8b we notice the presence of periods in which the number of interactions is almost constant after which it increases again we verified that this behaviour is essentially due to the nonstationary behaviour of users activity during the day ie quasiflat portions of the curves correspond to night hours green vertical lines highlight newly published posts for the first example trace many posts are published within the first three days for the second trace no new post is published before the first 62 h we now turn to the interesting question of whether the total number of interactions collected by a post can be forecast by observing just the interactions received during an initial interval after publication a first strong indication that such prediction is indeed feasible is illustrated in fig 9 showing a scatterplot of roughly 3000 points each corresponding to a post published on ig by a given influencer the y axes provide the total number of interactions while the x axes correspond to the number of interactions received after half an hour 4the left plot corresponds to measurements n collected at physical time while the right plot correspond to measurements n transformed into virtual time to remove daily effects despite the large variability in the number of interactions we observe a strong correlation resulting in a pearson correlation coefficient of about 090 and 092 similar strong correlations was observed for other influencers on both ig and fb and considering different measurement times this result motivated us to develop the model that will be presented later in sect 5 in addition we computed the mean arrival time defined as the average time after which an interaction occurs after post creation the average is computed over 480 h for a given post of a given influencer using the empirical distribution of all interaction arrival times figure 10 depicts the cdf of the mean arrival time of interactions we consider posts with at least 1000 interactions and focus on the first 480 h we can observe that posts on fb are characterised by a higher mean arrival time with respect to ig 15 h for fb and 11 h for ig the faster dynamic in ig confirms what fig 7 already suggested finally we investigate the lifetime of posts to this end we consider that a post basically no longer attracts interactions after 20 days and thus we define as total number of interactions received by a post the number of interactions received after 20 days then for a given post we compute its lifetime as the time at which the post has received 95 of its total interactions we consider only posts that collect at least 1000 interactions to get statistically meaningful results figure 11 depicts the distribution of the post lifetime in hours using a log scale on the xaxis by construction the maximum lifetime is 480 h ie 20 days interestingly the difference between the two osns is small even though on average fb attracted a smaller fraction of interactions than ig within the first hours the median value of the lifetime is 33 h for both fb and ig while the mean lifetime is 50 h for fb and 55 for ig followers dynamics influencers do not have a constant number of followers over time rather such a number typically increases monotonically over time with ig exhibiting a more significant increase in the analysed time period than fb this is likely because fb is an older osn already largely widespread in 2016 figure 12 shows the temporal dynamic of the number of followers for two sample influencers on ig 5 influencer 1 is matteo salvini while influencer 2 is martina colombari figure 12 suggests that the change in the number of followers can be very different for the influencers influencer 1 started using the social network much later and his increase rate varies wildly over time likely due to reasons unrelated to the operation of the osn the increase in the number of followers of influencer 2 is instead smoother over the considered time span figure 13 shows the distributions of the total number of interactions per post considering all posts published when the number of followers is comprised within the bins specified along the x axes all posts published on ig available in our dataset are here considered we notice a strong correlation suggesting a linear dependence of the mean total number of interactions with the number of followers we found that the distribution of the total number of interactions per post is well fit by a lognormal distribution see the cdfs on fig 14 again in the figure we considered the influencers salvini and colombari on ig comparing the empirical distribution with the fit we obtain a kolmogorov distance of the lognormal of 010 and 003 respectively for influencer 1 and 2 considering the dependency with the number of followers as suggested by results in fig 13 we also computed a normalized total number of interactions dividing it by the number of followers at each post creation timestamp we call this number interactions per follower as expected the lognormal fit is even better when we consider this normalized number see cdfs in fig 15 especially for influencers whose number of followers varies significantly over the considered period indeed the kolmogorov distance decreases to 005 for influencer 1 with parameters of the lognormal 39 08 in appendix 1 we report analogous results related to other kinds of interactions ie shares and comments on fb all in all considering the followers dynamics helps to disentangle the impact of the users that potentially interact with the post and the variability of the post intrinsic attractiveness impact of newly published content as observed in sect 42 the arrival rate of new interactions decays roughly exponentially with time to better understand the nature of the arrival process of interactions generated by a specific post we asked ourselves whether this is affected by the fact that meanwhile new posts are published by the same influencer thus reducing the novelty of the post for example fig 8a shows a case in which many new posts are published within the first three days after post creation while in the case of fig 8b no new post is published within the first 62 h on the other hand after 12 h the first post sample has already collected 91 of its total interactions while the second post after the same amount of time has collected just 62 of its total interactions due to the fact that its interaction rate decays more slowly this suggests that the number of newly published content might affect the growth rate of the number of interactions received by a post to verify this we consider a fixed period of 12 h since the post creation and compute the number of new posts published within this period figure 16 shows the average fraction of interactions collected by a post after 12 h as a function of the number of newly published posts in the same period for all posts published by the previously considered influencer giuseppe conte we observe a clear correlation between the two quantities the higher the number of new posts published within the first 12 h the faster the post approaches the end of its lifetime indeed in the absence of newly generated posts a post on average collects 72 of its total interactions within the first 12 h when 7 newer posts are generated in the same period the average fraction of collected interactions increases to 82 this shows that the arrival rate of interactions also depends on how many new posts are published since the post creation as newly published content can slow down the interaction arrival rate modelling user interactions from our measurements and analysis we learnt several important lessons that can help us model the temporal evolution of the number of interactions collected by a post posts are characterised by an intrinsic initial attractiveness which varies significantly even across the posts published by the same influencer the growth rate of interactions naturally decays over time but the decay rate is itself highly diverse from post to post besides depending on the considered osn the interaction rate should be modulated by the daily pattern of user activity which appears to be independent of the particular online platform on average there is a linear dependency between the total number of interactions received by a post and the current number of followers the distribution of the total number of interactions normalised by the number of followers is well fit by a lognormal distribution whose parameters depend on the specific influencer and osn the generation of new posts by the same influencer progressively reduces a posts attractiveness level this can be explained by the fact that users focus their attention on the posts at the top of the timeline despite the intrinsic difficulties in incorporating all of the above features into a simple and tractable model our preliminary investigation suggests that it is feasible to accurately predict the total number of interactions after observing the very initial phase of the post lifetime with this objective in mind we propose the analytical methodology described in the following sections removal of daily activity effects given a trace of users interactions t i t i 0 with a given post published at time 0 we can eas ily derive a modified trace t � i in which the impact of vari able daily activity is removed let ∶ 0 24 → r be the daily followers activity averaged across all posts of a given influencer similar to what is shown for all influencers in fig 4 let λ 1 24 ∫ 24 0 𝜆dt be the average user activity across the day assuming that the post was published at hour t 0 ∈ 0 24 we define the modulating function g t ≥ 0 as which is simply a shifted and replicated version of pro viding the expected activity of users at an arbitrary time t after the post publication then an interaction which occurred at real time t i is shifted to virtual time t ′ i note that the above transformation preserves the ordering of interactions ie if t i t j then t ′ i t ′ j while removing the g mod 24 t � i ∫ t i 0 gdt λ fig 16 average fraction of interactions vs no of published posts after 12 h since their creation impact of variable daily activity by diluting interactions occurring in periods of high activity we expect the virtual trace t � i to be more regular than the real trace t i and thus easier to model and predict at last observe that if g is assumed to be continuous previous equation can be rewritten as for some ∈ t i1 t i in particular if g is sufficiently slowly varying we can approximately write figure 17 shows some examples of traces of the number of interactions accumulated over time by four posts published roughly at 1am 8am 4pm and 12pm thick curves refer to physical time t while thin curves refer to virtual time t ′ and were obtained by applying transformation we observe that the virtual time transformation removes the plateau due to low user activity late at night similarly it allows us to distribute more smoothly over time interactions accumulated over periods of high user activity like at midday or early at night from now on we will only reason in terms of virtual time assuming that any measurement n of the num ber of interactions collected by a post published at time t 0 within time t has passed through transformation producing an equal number n shifted at virtual time t ′ modelling the generation of interactions let us assume that each post is characterised by an intrinsic level of attractiveness described by a positive realvalued mark x ∈ r marks associated with posts of a given influencer are assumed to be iid with pdf f x t � i t � i1 ∫ t i t i1 gdt λ t � i1 g λ t � i ≈ t � i1 g λ 1 we can consider some simple law for f x incorporating longtail behaviour eg a lognormal distribution with parameters x x we assume that the final number n ∞ of interac tions received by a post is equal to fx where f is the number of followers at the time of the post creation note that if x ∼ lognormal fx ∼ lognormal 2 x let n be the number of interactions received within time t ′ after the post creation first we condition on n ∞ n ∞ where 1 is the indicator function we assume that follow ers access the platform according to a poisson process of rate λ which is itself a random variable with probability density function f λ let f λ e sλ be the laplace transform of f λ then is a bernoulli random variable with mean 1e t � it fol lows that moreover we note that does not depend on n ∞ hence we can obtain the laplace transform of f λ by averaging out n ∞ we found empirically that a surprisingly accurate model for f λ is a mixture of a uniform distribution in 0 a and an exponential distribution of parameter from which parameters m a have to be fitted for each specific influencer though they do not vary significantly from influencer to influencer as shown in the following figure 18 presents the fitted laplace transform f λ through parameters m a using the traces of 9204 posts published by italian politician matteo salvini on ig fitted values are m 083 a 041 07 figure 18 requires a careful explanation first of all notice the log x axes spanning from 001 hour to 24 hours since in the following we will be especially interested in the early stages of post lifetime this will be the time scale used in all plots hereinafter n n ∞ ∑ i1 1 user i interacts before t � 1 user i interacts before t � λ i n n ∞ 1 e t � n ∞ n ∞ n n ∞ f λ f λ n ∞ n n ∞ f λ m 1 a 1 𝜆 a 𝛿e 𝛿𝜆 f λ m 1 e a s a s s the vertical axes reports the fraction of residual interactions n ∞ n n ∞ by the mean across all traces of this fraction provides the sought laplace transform f λ for influ encer salvini small circles show such averaged fraction at various points in time while the black solid curve is the fitted model which turns out to be very accurate the figure also shows the ensemble of 1000 actual traces which produces a large band around the mean at last green curves above and below the mean are plotted at a distance equal to the measured standard deviation figure 18 reveals that there is a significant variability of traces around the mean which is unfortunately not captured by the model introduced so far6 however we found that the distribution of the fraction of residual interactions is approximately normal this fact is shown in fig 19 which depicts the empirical distributions of the fraction of received interactions measured at the times at which the mean fraction of received interactions is equal to 10 50 80 as denoted by vertical dashed lines in fig 18 note that the mean fraction of collected interactions is given by for which we already have an accurate model however we still lack a model providing the deviation we suspect that beyond the initial level of attractiveness x the post dynamics is characterised by random temporal fluctuations of the rate at which users interact with it these fluctuations are due to timevarying popularity generation of new posts and selfreinforcement effects due to users observing the engagement of other users in order to incorporate the effects all such elements in the model we resorted to a simple fitting of the empirical standard deviation by a 2parameter curve specifically we found that the function provides a reasonable approximation where parameters c and b can be computed for each influencer though they do not vary significantly from influencer to influencer 1 f λ c t �b e √ t � figure 20 shows the empirical standard deviation of traces of influencer salvini on ig and the best fit by the proposed function it also repeats the fit for the mean already shown in fig 17 but this time in terms of average fraction of already received interactions indeed what is ultimately important is to obtain a good estimate of the coefficient of variation cv ∕ which is also shown on the plot knowing that the fraction of received interactions within time t ′ is approximately normal and having derived param eters and as function of time t ′ we can now make analytical predictions of post dynamics for example in table 2 we report some predictions obtained for six different influencers on ig the other columns provide from left to right the average fraction of interactions collected during the first 6 min and the corresponding standard deviation the average fraction of interactions collected during the first hour and the associated standard deviation the time at which we expect to see half of the total interactions denoted as t the time at which we expect to see 80 of total interactions denoted as t the maximum standard deviation over all time we report the values observed from the collected data and the corresponding values obtained from the analytical model for each influencer table 3 reports similar results for six influencers on fb besides noticing the good fit of the model in all cases it is interesting to see that some numbers are surprisingly similar across different influencers and platforms roughly 4 of all interactions are collected within 6 min since post creation and roughly 25 after one hour on ig 50 of all interactions are collected after roughly 33 hours on fb these last figures are a bit larger 50 of all interactions are received after roughly 38 hours the similarity of results for the mean fraction of collected interactions is further illustrated in fig 21 showing on the same plot the curves 1 f λ computed analyti cally for all 12 influencers considered in tables 2 and3 at last as anticipated it is interesting to observe that the maximum standard deviation of the traces is larger on fb than on ig by a factor of about 15 model exploitation post popularity prediction one of the most interesting applications of our model is the early prediction of post popularity which can have several applications for example the social platform can use this prediction to sell advertisement slots to be shown in proximity of the post and prediction of the number of views that the post will receive in the future is crucial to bid a price for the available ad slots suppose to measure the number of interactions n received by a post published at time t 0 by a given influ encer after a period of duration t what can we infer about the total number of interactions n ∞ that the post will eventu ally receive our analysis suggests the following approach should be taken first suppose to know the number of followers f at the post creation time moreover assume that analysis of the history of post popularity of the given influencer has allowed us to estimate parameters x x of the lognormal distribution of the intrinsic level of attractiveness x then the unconditioned distribution of the random variable n ∞ is lognormal 2 x a standard maximum a posteriori estimation allows us to compute a prediction n∞ on the total number of interactions that the post will receive given observation n first we transform the observation n into virtual time n to remove the effect of daily variation of user activity this is an important step for example if a post is published late at night it might eventually become popular even if it receives just a few interactions during say the first hour we assume that analysis of the history of the post dynamics of the given influencer has allowed us to fit parameters of functions and then the conditioned distribution of random variable n n ∞ is normal n n 2 ∞ 2 a standard application of bayes theo rem provides the posterior distribution of n ∞ n and our map prediction will be the mode of it note that the above analysis also provides an estimate of the error that we will run into by our prediction since we have the entire posterior distribution of n ∞ n as an example fig 22 shows the map prediction of n ∞ for 40 posts published by influencer salvini on ig given some observation n where t ′ is shown on the horizontal axes red squares denote true values of n ∞ while boxplots provide a graphical represen tation of the posterior distribution of n ∞ n computed analytically we can observe from these sampled posts that the larger the time t ′ at which we observe the number of 2 and3 fig 22 boxplots of aposteriori distributions of n ∞ n predicted value n∞ actual values n ∞ for 40 different posts of influencer salvini on ig starting from observations n where t ′ is reported on the x axes interactions the smaller the prediction error in the total number of interactions as expected however fig 22 suggests that accurate predictions are already feasible a short time after post creation n ∞ n ∞ n n n n ∞ n ∞ ∑ n � ∞ n n n � ∞ n � ∞ n∞ arg max n ∞ n ∞ n ∞ n comparison with baseline model to better show the goodness of our approach we compare our predictions with those obtained by a baseline model in this baseline model followers of a given influencer independently access the platform according to a poisson process of rate a where a is the same for all users moreover suppose that the decision to interact with a given post is made independently from the access time to the platform and independently from user to user consequently followers who decide to interact with a given post will do so after an amount of time distributed according to an exponential distribution of parameter where is the same for all users interacting with a given post for a fair comparison with our model we will assume that the baseline model shares the same information about the history of posts of a given influencer in particular the distribution of the final number of interactions received by a post is known modelled by a fitted lognormal 2 x where f is the number of followers at the time of the post creation moreover we assume that detailed temporal history of interactions allows the baseline model to fit its single parameter against the trace of all posts generated by a given influencer finally again for the sake of a fair comparison the baseline model is applied to the temporal evolution of interactions transformed into virtual time to remove daily effects one can easily see that our model subsumes the above baseline model when f λ where is diracs delta function its laplace transform f λ e s can then be fitted against the normalized traces of the residual number of interactions as illustrated in fig 18 following the same map framework introduced before let n ∞ be an instance of the final number of interactions received by a post and n be the number of interac tions observed after virtual time t ′ since post creation notice that according to the baseline model the conditioned distribution of random variable n n ∞ can be approximated by a normal n n ∞ q where q 1e t � being the sum of n ∞ independent bernoulli random variables of mean q therefore we can apply as well to the baseline model and compute a map prediction for the final number of interactions according to figure 23 shows the average relative error of the baseline model in the prediction of n ∞ n for influencer salvini on ig considering 1000 posts for each bin ie for each bin in fig 23 we have averaged the relative error n∞ n ∞ n ∞ of 1000 different posts is available in the dataset such that t ′ falls in the bin in contrast fig 24 shows corresponding results obtained with our approach we observe a significant reduction in the prediction error as obtained by our model with respect to the baseline model especially for smaller values of the measurement time t ′ suggesting that our approach is significantly better at performing early prediction of the final number of interactions as expected the relative error of the prediction diminishes over time it is remarkable that a relative error of only 48 is incurred if an observation is available just between 001 and 002 after the post creation ie a very early prediction after 6 min the error reduces to about 28 and after about 1 h it reduces to about 16 similar results not shown here for the sake of brevity have been obtained for the other considered influencers the superiority of our approach is essentially due to the fact that the baseline model describes a homogeneous population of followers through a single parameter in contrast our model employs multiple parameters to describe heterogeneous followers accounting for the fact that different users interact with posts more or less promptly depending on the frequency with which they access the platform which is highly diverse from user to user discussion and conclusion in this work we studied the temporal dynamics of facebook and instagram for five years focusing on top italian influencers after a thorough analysis of realworld data we characterised several interesting features of the above osns including the influencers and followers activity over time the posts interarrival time and the post lifetime the arrival process of user interactions with a given post the insights gained from our dataset analysis allowed us to develop a mathematically tractable yet accurate model describing the temporal evolution of the number of interactions collected by a post we validated our model against real traces for both facebook and instagram in particular we demonstrate our models ability to perform early prediction of post popularity and the large improvements with respect to a simpler baseline the existence of many interesting possible applications that may profit from early popularity predictions such as anomaly detection and price bidding of ad slots encourages further analytical efforts in this direction to incorporate effects not yet captured by the proposed methodology appendix 1 shares comments and reactions on fb the interactions with an influencers post can be measured in different ways in this paper we focus on the total number of likesreactions but this metric can be complemented or substituted by the number of shares of the post and the number of comments on fb a user can share an influencers post and this action will appear as a new post from the user in fig 14 we presented the cdfs of the total number of likes for two influencers of ig and we showed the goodness of fit with a lognormal distribution here we repeat the analysis by also considering the number of shares and comments as different metrics for interactions on facebook figures 25 and 26 depict such different metrics along with their fittings for two of the studied influencers of fb namely jackal a comedian group and laura pausini a singer as can be seen most interactions consist of reactions while the number of comments and shares is at least an order of fig 25 cdf of the total number of interactions measured as reactions shares and comments on influencer jackal on fb at the end of the posts lifetime along with their lognormal fit fig 26 cdf of the total number of interactions measured as reactions shares and comments on influencer laura pausini on fb at the end of the posts lifetime along with their lognormal fit fig 27 cdf of the total number of interactions per follower on influencer jackal on fb at the end of the posts lifetime along with their lognormal fit fig 28 cdf of the total number of interactions per follower on influencer laura pausini on fb at the end of the posts lifetime along with their lognormal fit magnitude smaller however the behaviour of these metrics is again well approximated by a lognormal distribution regarding the first influencer the kolmogorov distance of the lognormal is 004 for reactions 006 for shares and 007 for comments for the second example influencer the kolmogorov distance is 005 for reactions 006 for shares and 006 for comments similarly to fig 15 we also report the normalised total number of interactions dividing them by the number of followers at each post creation timestamp again we analysed reactions shares and comments the results are presented in figs 27 and 28 respectively for influencer jackal and influencer laura pausini as for the examples on ig the lognormal fit is as good when considering this normalized number in conclusion shares and comments follow a distribution shape similar to the one of reactions and they are well fitted by a lognormal distribution even though their absolute number is smaller	a relevant fraction of human interactions occurs on online social networks in this context the freshness of content plays an important role with content popularity rapidly vanishing over time we therefore investigate how influencers generated content ie posts attracts interactions measured by the number of likes or reactions we analyse the activity of influencers and followers over more than 5 years focusing on two popular social networks facebook and instagram including more than 13 billion interactions and about 4 million posts we investigate the influencers and followers behaviour over time characterising the arrival process of interactions during the lifetime of posts which are typically shortlived after finding the factors playing a crucial role in the post popularity dynamics we propose an analytical model for the user interactions we tune the parameters of the model based on the past behaviour observed for each given influencer discovering that fitted parameters are pretty similar across different influencers and social networks we validate our model using experimental data and effectively apply the model to perform early prediction of post popularity showing considerable improvements over a simpler baseline
introduction the adverse effects of high population growth are numerous pressure on land and natural resources accelerating climate change persistent food insecurity insu cient availability and quality of public infrastructure and increased infant and maternal mortality are amongst the major sustainable development challenges aggravated by large population numbers and high fertility rates in asia and latin america the demographic transition the process in which countries evolve from high mortality and fertility rates to low mortality and fertility rates started in the 1950s with a drop in total fertility rates from 6 to 2 births per woman between 1950 and 2015 subsaharan africas demographic transition on the other hand started signi cantly later and is proceeding at a slower pace leading to a total fertility rate still as high as 5 births per woman in 2015 as a consequence ssas population numbers are projected to continue to grow for the next several decades this will result in a doubling of the population between 2010 and 2050 in some countries possibly even tripling and ultimately leading to a more than quadrupling of its population over the short period of one century in the last decades scholars have intensively studied the drivers behind reductions in total fertility rates 1 household income parents education and the changing position of women within the household and society have been put forward as major drivers but the mechanisms are not well understood the quantityquality tradeoff theory assumes that a lower tfr will improve the quality of childraising however empirical evidence does not always support this as it is di cult to disentangle the factors that jointly determine the quantity and quality aspects of childraising investigating preferences for childraising might shed more light on the mechanisms this holds especially for rural ssa where actual fertility might diverge from desired fertility because of insu cient access to family planning yet few studies investigate parents preferences for childraising mainly due to the di culty of accurately measuring preferences and the tradeoffs that parents are willing to make in this study we use a discrete choice experiment to assess mens and womens preferences for childraising in rural senegal and uganda to our knowledge we are the rst to empirically investigate qq tradeoffs in fertility decisions from a preferences perspective and to apply a dce method within the framework of the qq tradeoff theory respondents are asked to choose between different hypothetical scenarios which describe the number of children and how they would be raised in terms of education health care and nutrition using mixed logit models and interaction terms between the attributes we quantitatively evaluate the tradeoffs that people make in their choices in addition we test whether preferences for fertility rates and the qq tradeoff differ according to household poverty status parental education and gender thereby contributing to the literature on the drivers behind the demographic transition understanding childraising preferences of households in ssa is important from both a theoretical perspective to understand the factors in uencing the demographic transition and from a policy perspective to develop more effective familyplanning programs and policies the casestudy regions rural senegal and rural uganda are relevant as both countries are suffering from high tfr therefore remaining in the predemographic dividend 2 phase moreover both countries experience low secondary completion rates high prevalence of undernourishment child mortality and other problems connected to high fertility rates 1 the number of childbirths a woman would have if she were to live to the end of her reproductive life and bear children in accordance with agespeci c fertility rates of the speci ed year 2 the demographic dividend corresponds to a period in a countrys demographic transition when the ratio of work age population to young dependents increases rapidly due to a fast decline in the countrys fertility this leads to a window of opportunity for rapid economic growth as there are more people in the labour force and less people to support literature review the demographic transition theory describes the evolution in society from high mortality and fertility rates to low mortality and fertility rates the driving forces behind the demographic transition and especially those that reduce fertility continue to be a source of discussion among demographers and economists three main models are put forward economic and investment models risk and mortality models and cultural transmission models economic and investment models mainly focus on the inverse correlation between income and population growth risk and mortality models consider fertility reduction to be the logical consequence of the reduction in infant mortality when the chances of children surviving the rst ve dangerous years are higher parents will reduce their fertility accordingly cultural transmission models explain the demographic transition through societies perception of children and preferences for ideal family size the transformation of social structures and networks and prestigeseeking behaviour in this paper we combine insights from economic and investment modelsand more speci cally the quantityquality tradeoff theory with insights from cultural transmission models which emphasise the importance of the preferences of individuals households and societies with regards to fertility the qq tradeoff theory founded by becker and colleagues relies on the premise that the quantity and quality of children are related because the shadow price of quantity depends on the quality of childraising of these children and vice versa the shadow price of quality of childraising depends on the quantity of children a household has to raise the theory explains why fertility reduces when incomes rise and why a negative correlation might exist between the quantity and quality of childraising some models however assume that children do not only imply a cost to the household because of mutual help between siblings in extended families children helping with productive and reproductive tasks in the household or economies of scale concerning childraising the empirical literature demonstrating the existence of the qq tradeoff remains inconclusive the main bottleneck in studying the qq tradeoff empirically exists in removing confounding factors that jointly determine the number of children and the quality of their upbringing these are parents and societys characteristics such as education and income level labour market opportunities social norms pension schemes or education policies many studies rely on seminatural experiments such as unanticipated twin births or mothers employment and autonomy the literature studying fertility preferences and their socioeconomic drivers is much less comprehensive however especially for ssa this gap could to some extent re ect data limitations as preferences are di cult to measure and the usual method to ask for a respondents desired number of children has been proven to overestimate respondents actual wanted fertility but it is also linked to the general idea of unreliability and variability of stated fertility preferences still several studies show that desired fertility rates can be highly predictive of later fertility outcomes the few studies that analyse fertility preferences show that on average fertility desires in ssa is markedly higher than fertility desires in other parts of the world but that desired family size is lower on average for women for better educated individuals for households with higher economic welfare and in a context of lower population density and lower child mortality background and data we focus on two regions the mount elgon region in eastern uganda and the saintlouis region in northwestern senegal both regions are rural areas with a strong connection to a secondary urban centre and are characterised by their high dependence on agriculture high poverty rates and weak infrastructure development the mount elgon region is located in the humid tropics and is a densely populated mountainous area dominated by smallholder farmers and a commerciallyoriented coffeebanana farming system the saintlouis region is located in the semiarid tropics and is a diverse area including agricultural communities focussing on smallscale commercial horticulture and rice production livestock communities relying on rather extensive and seminomadic grazing systems and largescale horticultural companies hiring labourers from nearby communities population density is higher in the mount elgon region than in the saintlouis region but both regions are characterized by high population growth rates respectively 39 and 34 in the mount elgon and saintlouis region the wolof and peulh ethnicities are the two most prevalent in the saintlouis region both ethnicities have traditional hierarchical customs that attribute a major importance towards having a large family and where polygamy is common as the islam is the dominant religion in the research area everyday life is ruled by islamic and customary patrilineal laws 3 both the introduction of the islam and the imposition of the french colonial system 4 that incentivized the growing of cashcrops on large monocrop elds using animal drawn ploughs lowered the position of women in the rural senegalese society and increased even more the value of having a large household the mount elgon region in uganda also knows a patrilineal tradition and is mainly populated by the bagisu ethnicity with a minority of people from the sabiny ethnicity the bagisu and sabiny attach a high value to children and a womans worth is highly connected to the number of children she bears there is a religious diversity in the research area composed of protestants catholics and bornagain christians polygamous marriages are common but wives do not necessarily live under the same roof in theory bagisu women are under control of their father or husband however the status of men highly depends on his marital status livelihoods in the area are highly dependent on womens labour and divorce and remarriage is fairly easy for bagisu women womens independence might therefore be larger than expected british colonial rule 5 introduced the growing of cashcrops mainly coffee in the region however as the growing of coffee is highly labourintensive and animal drawn ploughs are of little use on these steep cultivations the shift in cropping systems did not signi cantly alter the position of women in the bagisu society while in both countries family planning programs have been high on the political agenda since 2010 contraceptive uptake remains low especially in rural areas in 2011 senegal signed the ouagadougou call to action and thereby committed to double the budget for family planning programs this resulted in the national action plan for family planning and a government commitment to increase contraceptive uptake to 45 by 2020 still recent gures show that the uptake of modern contraceptives among married women remains as low as 28 in 2012 uganda committed to providing universal access to family planning to reduce the unmet need for family planning from 40 to 10 by 2022 and to increase the modern contraceptive prevalence rate to 50 by 2020 resulting in the launch of the family planning costed implementation plan modern contraceptive uptake among married women is currently 39 in uganda we use data from a quantitative household survey and a discrete choice experiment survey data were collected in 2016 from respectively 464 and 758 households in senegal and uganda households were sampled using a multistage 6 strati ed random sampling method with strati cation based on distance to an asphalt road and wage employment status in senegal and urbanization level and altitude in uganda a structured quantitative questionnaire was used to collect data on household demographics farm production land and nonland assets living conditions and employment the discrete choice experiment was implemented in 2017 with 250 households in each region which were randomly selected from the household survey sample within a household both husband and wife completed the dce separately resulting in a total sample of 1000 respondents 7 the dce was followed by questions on attribute nonattendance and attribute ranking and the respondents current and preferred number of children table 1 describes the socioeconomic characteristics of the sampled households and respondents the average household size as well as the variation in household size is larger in the senegal sample than in the uganda sample which relates to multiple generations living together in extended families in senegal versus a singular couple plus children living in nuclear households in uganda households in the senegal sample live closer to the main surfaced road compared to households in the uganda sample polygamy is common in both regions but is slightly more prevalent in the senegal sample only 7 and 16 of the respondents have completed lower secondary education in respectively the senegal and uganda sample which is lower than the national averages of 18 for senegal and 24 for uganda female and poor respondents are on average less likely to have completed lower secondary education compared to male and nonpoor respondents the majority of the sampled households is poor 8 with a higher incidence of poverty in the uganda sample than in the senegal sample male respondents prefer and actually have on average a higher number of children than female respondents there is a gap between respondents preferred number of children and their actual number of children in the senegal sample which could relate to uncompleted fertility or undesired infertility in uganda respondents preferred number of children is below their actual number of children which could relate to an unmet need for family planning and contraceptives female and poor respondents are on average less likely to have completed lower secondary education compared to male and nonpoor respondents male respondents prefer and actually have on average a higher number of children than female respondents secondary educated respondents actually have on average the same number of children compared to nonsecondary educated respondents however only secondary educated respondents are able to realize their preferred household size as they do not experience a signi cant gap between their preferred number of children and the number of children they actually have respondents who do not hold a secondary education diploma would prefer to have a higher number of children than the number they actually have 9 table 1 near here 3 the wolofs inheritance and family relationships were partially determined by matrilineal decendency patterns while the peulhs traditions were highly patrilineal already before the arrival of the islam 4 the rst french settlement in senegal dates back from the 17 th century with the establishment of saintlouis town the french colonial period in senegal began in 1884 and ended in 1960 with the independence of senegal 5 the british colonial rule in the study region began in 1904 and ended in 1962 with the independence of uganda 6 twostage sampling design in senegal and threestage sampling design in uganda 7 the original ugandan sample consisted of 265 couples of which we dropped two because of outlying data and 13 because the couples mean age was older than 80 years 8 a household is de ned as poor when per adult equivalent total household income falls below the international moderate poverty line of 31 per person per day 9 difference signi cant at the 1 signi cance level methods design of dce discrete dces provide a link between observed behaviour and economic theory they are based on lancasters consumer theory which posits that consumer preferences are shaped by the individual characteristics a good or service possesses and not by the good as a whole during a dce a respondent is asked to choose between hypothetical scenarios that consist of attributes with varying attribute levels in our study the alternatives describe different situations of childraising with in line with the qq tradeoff theory speci c emphasis on the quantity of children and the quality of childraising as the validity of a dce largely depends on the choice of the attributes a detailed literature review and multiple key informant interviews and focus group discussions in senegal and uganda were implemented prior to the design of the experiment to identify and select attributes that represent the quality of childraising in total we specify four attributes with the rst referring to the quantity aspect of childraising and the next three to the quality aspect covering education nutrition and health care table 2 near here the rst attribute speci es the number of children and consists of six levels the range of 1 to 12 children is based on the observed number of children in the study regions as derived from the quantitative surveys the second attribute is de ned as the share of children from the household that can complete lower secondary education the attribute contains three levels none half and all of the children in both countries lower secondary education comprises 4 years after which a certi cate of completion is awarded in uganda we consider private schools that charge high tuition fees as focus group discussions pointed towards a very low quality of public schooling in senegal we consider public schooling as private schools are not available in rural areas while no o cial tuition fees are charged in senegalese public schools costs remain high as children have to commute or stay overnight books and school supplies are expensive and informal maintenance fees are charged the third attribute is de ned as the number of days a week a household can eat a complete meal including carbohydrates proteins and vegetables for the main meal of the day on the other days an incomplete meal is consumed the attribute consists of three levels zero four and seven days a week in senegal a very known local dish thieboudienne is taken as an example which comprises rice sh and vegetables in uganda a complete meal is de ned as containing posho or matoke beans and green leafy vegetables the fourth attribute is de ned as the quality of health care institute the household can consult when a child has a severe fever the attribute contains three levels lowquality mediumquality and highquality a lowquality health care institute is de ned as a small health care facility located in almost every rural community with only a health worker or nurse present basic treatments can be performed using basic equipment but diseases cannot be diagnosed a mediumquality health care institute is operated by a larger staff of at least one nurse one midwife and one assistant nurse medical equipment is more advanced and basic disease diagnosis is possible in a highquality health care facility at least one doctor is stationed often complemented by different specialists diagnosis and treatment of more complex or uncommon diseases are possible the three quality attributes are similar in both countries but are adapted to the local context we use choice sets with three alternatives and visual illustrations to assist illiterate people with making their choice we present 12 choice cards to each respondent and randomize the order to avoid learning bias hence we obtain 36000 observations in total as information is missing on one choice card of two respondents we retain 35994 observations for the dce analysis we use a bayesian design which accounts for uncertainties around the true values of the a priori information of the parameters using the de ciency criterion the determinant of the variancecovariance matrix of the parameter estimators is minimized and the e ciency of the design is increased as we hypothesize that respondents have positive preferences for the quality attributes we use small positive priors for these levels we hypothesize a positive but diminishing preference for the number of children so priors are higher for 4 and 6 children and lower for 1 2 9 and 12 children while the inclusion of an optout or status quo option is common practice in dces as it increases the realism of the choice task we did not include an optout or status quo option in our choice experiment this means that respondents are forced to make a choice between the three proposed scenarios the decision not to include an optout option was guided by the fact that an optout option reduces the e ciency of the experiment because of a higher number of nochoices and because the respondents are confronted with these forced choices in daily life without the possibility to optout if characteristics do not match with their preferences the application of a forced choice structure entails some consequences for the data analysis and interpretation of the results as research shows that individual willingness to pay is different in forced and unforced choice sets we do not calculate welfare estimates based on the estimated coe cients moreover we need to remain cautious when interpreting the results the experiment was introduced to both spouses together the attributes were explained in detail and the hypothetical character of the experiment was emphasized after the introduction the spouses were interviewed separately by an enumerator of the same gender each experiment started with a test card to check whether the respondent understood the rationale of the study 10 analysis of dce discrete choice modelling is embedded in the random utility theory framework and assumes that respondents choose the alternative that yields the highest utility level from each choice set following this framework we separate the utility respondent i derives from alternative j into an observable deterministic component linearly depending on the attributes of the alternative and individualspeci c socioeconomic characteristics and a stochastic component capturing unobserved heterogeneity across alternatives and individuals as utility is a latent variable we cannot directly observe the utility the respondent derives from a speci c alternative therefore we use the probability that respondent i chooses alternative j as an approximation expressed in terms of a logistic distribution we use a mixed logit model which is most common and allows for preferences to be heterogeneous across respondents and maximum likelihood estimation we estimate different speci cations of the mxl treating all attributes as random and using 1500 halton draws to analyse respondents fertility preferences as well as the qq tradeoff a rst model speci cation is a basic mxl including only main effects in a second speci cation we add a quadratic term of the quantity attribute to control for nonlinear preferences in models three to six we test whether respectively gender education level poverty status and country are correlated with fertility preferences by adding interaction terms with four binary variables in separate models female respondent owner of a lower secondary education diploma household poverty status and country in a fourth model speci cation we assess the qq tradeoff by adding interaction terms between the quantity attribute and the three quality attributes in models to we test whether gender education level poverty status and country are correlated with the qq tradeoff by adding doubleand tripleinteraction terms with these four variables limiting potential bias a dce is a stated preference method and is inherently subject to hypothetical and social desirability bias on the one hand we expect these biases to be low in our dce the choices that the respondents are forced to make are similar to the decisions they face in daily life in addition enumerators were carefully selected such that they share the same gender and ethnicity as the people they interview with the survey taking place in the private setting of the own household with husband and wife interviewed separately on the other hand dces are typically used to infer preferences on consumer goods or in an environmental valuation setting these choices can be considered to be more trivial or independent from the choices you previously made in life and are less likely in uenced by hypothetical or social desirability bias for example the hypothetical character of choosing between a conventional or an organic apple might be less in uenced by the fact that you actually bought conventional apples a week ago than that the choice between a hypothetical household of two or eight children might be in uenced by the fact that you actually have seven children moreover buying apples in the supermarket is likely to be less of a taboo topic when compared to a households fertility enumerators were trained to emphasize the hypothetical character of the experiment such that respondents focus on the characteristics of the household presented on the choice cards and to not take into account characteristics of their actual living conditions or possible social monetary or physical limitations even though we tried to reduce the hypothetical bias to a maximum complete mitigation is impossible the remaining hypothetical bias could in ate the preference for the number of children in cases where the respondents actual number of children is bigger than the number of children they would have preferred on the other hand the hypothetical bias could de ate the preference for the number of children in cases where the respondents actual number of children is lower than the number of children they would have preferred we nd other studies that use a dce to infer preferences on more di cult unconventional or once in a lifetime choices or taboo topics dieci we control for attribute nonattendance as previous studies show that ignoring one or more attributes could lead to biased estimates by using the information on respondents attribute nonattendance statements we test for scale heterogeneity using the generalized multinomial logit model developed by fiebig keane louviere and wasi we cluster standard errors at the respondent level the results of the stated attribute nonattendance and scale heterogeneity checks are presented in table a1 in the appendix the estimates of both the stated attribute nonattendance and the scale heterogeneity models are similar in magnitude sign and signi cance level compared to estimates of the basic mxl model estimates we therefore conclude that the mxl model estimations are not sensitive to attribute nonattendance and scale heterogeneity and base our results and interpretation on these estimates 10 the test card contained three scenarios of which one scenario dominated the other two if the respondent did not choose the dominant scenario every aspect of the experiment was explained again results estimation results for the rst six mxl speci cations are presented in table 3 in general we nd that respondents derive positive utility from more children as well as from the three quality attributes the model including a quadratic term shows that respondents marginal utility derived from an additional child increases with the number of children at a diminishing rate the number of children at which utility is maximized is 75 from all the attributes related to quality of childraising childrens education contributes most to respondents utility followed by nutrition and health care models to show that interaction terms with gender education poverty and country dummies are signi cant partially explaining preference heterogeneity while main effects are robust to the inclusion of interaction terms we nd that women prefer fewer children and have stronger preferences for education and health care than men respondents who completed lower secondary education have stronger preferences for education and nutrition than respondents who did not nonpoor respondents prefer fewer children and have stronger preferences for health care and nutrition than poor respondents and ugandan respondents have stronger preferences for education but weaker preferences for health care and nutrition than senegalese respondents table 3 near here table 4 presents the results of the qq tradeoff analysis the basic model shows that main effects are robust to the inclusion of interaction terms between children and the other attributes all interaction terms have signi cantly negative coe cients implying that parents are willing to have fewer children if they can raise them under better circumstances hence our results point to the existence of a qq tradeoff in fertility preferences the estimates indicate strong effects when half of the children can complete lower secondary education compared to none of the children respondents marginal utility of an additional child reduces from 013 to 003 a decrease of 79 with access to highquality health care compared to lowquality health care the marginal utility of an additional child reduces to 001 a drop of 91 however the interaction term between the number of children and all children completing lower secondary education is signi cantly positive when all children can complete lower secondary education compared to none of the children respondents marginal utility of an additional child increases from 013 to 019 an increase of 35 the latter effect implies that respondents want to have more children if they can assure all of them will obtain a lower secondary degree we do not nd evidence for differences in the qq tradeoff between men and women or between nonor primaryand secondaryeducated respondents the only difference we nd between poor and nonpoor respondents is that the nonpoor make a tradeoff between the number of children and mediumquality health care while the poor do not while senegalese respondents experience a qq tradeoff for mediumand highquality health care for ugandan respondents the coe cient becomes insigni cant for highquality health care and even negative for mediumquality health care table 4 near here discussion and conclusion the results of the choice experiment on fertility preferences and the quantityquality tradeoff point to four main ndings first our results con rm that subsaharan african households prefer to have many children which is re ected in a utilitymaximizing point around 75 children this number is similar to the survey response on the preferred number of children indicating that the choice experiment re ects peoples preferences accurately this utilitymaximizing point resulting from the choice experiment does not correspond to an economic optimum as costs of childraising are not taken into account so we cannot directly compare this with the prevailing tfr of 47 in senegal or 51 in uganda yet it is worrying that desired fertility rates remain very high despite many family planning campaigns in both countries second we nd that women prefer fewer children than men which has been validated by other studies in many different settings including ssa in addition we nd that women have stronger preferences for education and health care this nding supports a recent experimental study in uganda that shows that health care training for mothers has a greater impact on childrens health compared to health care training for fathers while this study notes that their results could be driven by norms about whose domain child health is and not necessarily re ect a stronger preference of the mother concerning their childrens health our results put the ndings of nyqvist and jayachandran in another perspective third we do not nd proof of a negative correlation between parents education and preferences for more children this contradicts various existing studies yet our results are in line with a study that nds lower fertility rates among more educated women in egypt and attribute this to an older age at marriage and not to changes in fertility preferences the results show that poorer households prefer to have more children which supports other studies that nd proof of higher fertility rates among the poor we need to note that in our sample sociodemographic characteristics such as education and poverty status are correlated with ethnicity in the senegalese sample wolof respondents are more likely to be secondary educated compared to respondents from other ethnicities 11 in the ugandan sample bagisu respondents are less likely to be secondary educated and more likely to be poor compared to sabiny respondents 12 in addition there is a possible link between reproductive characteristics and ethnicity especially in rural ssa where ethnic or religious identity continues to have major implications for social mechanisms the empirical literature nds ambiguous evidence for the role of ethnicity on reproductive characteristics while kollehlon shows signi cant fertility differentials across different ethnicities in nigeria even when controlling for other socioeconomic characteristics other scholars nd that the onset of parenthood and contraceptive use in ghana can mainly be explained by socioeconomic characteristics such as education and age while ethnicity does not have a signi cant explanatory power given the correlation between ethnicity and other sociodemographic characteristics in our sample and the possible link between ethnicity and fertility it would be interesting to further unravel fertility preferences and the qq tradeoff by jointly controlling for multiple sociodemographic characteristics such as ethnicity education and poverty status this was however not possible in our analysis due to modelling restrictions and the large number of interaction terms this requires fourth our results imply that the qq tradeoff is a twosided story on the one hand for most of the quality attributes we nd evidence of the existence of a tradeoff with the quantity of children the preference to have many children are found to decrease with access to better education nutrition and health care these results add a fertility preferences perspective to the many empirical studies that prove the existence of the qq tradeoff on the other hand quantity and quality are found to be complementary to some extent when all children in the household can attain a lower secondary school diploma parents in our sample prefer more children these ndings could be explained by the type of human capital investments associated with the quality of childraising shortrun investments for more basic quality aspects like better nutrition and health care seem to induce parents to prefer fewer children while investments with a higher return in the long run like education seem to increase parents desired number of children this dual nding can to some extent explain why previous studies nd ambiguous effects concerning the existence of the qq tradeoff and shows why a focussed analysis considering preferences and multiple aspects of childraising can bring important nuances in the study of the qq tradeoff in fertility we can deduce three important policy implications first our results support the rationale that resources put in the hands of women will be used more for the bene t of their children second our results imply that policies aiming at increasing access to education free of charge or based on a general taxation system can unintentionally result in increased household fertility as parents do not have to make the qq tradeoff anymore such unintended fertility effects have been modelled by azarnert de la croix and doepke palivos and scotese and rosenzweig and validated empirically for vietnam mexico and india third family planning programs are considered to be an important instrument for population reduction and control and are often centred around the availability of and awareness on contraceptives our results show that fertility preferences in ssa continue to be biased towards large families but that important differences exist in fertility preferences related to gender and poverty status a narrow focus on contraception in family planning programs might reduce the effectiveness of such programs in regions with high fertility preferences a broader focus of family planning programs such that also changes in fertility preferences are triggered and more speci c targeting of these programs might strengthen their effectiveness care is needed in generalizing our ndings as they are limited by the choice experimental method used and the casestudy speci city at country and temporal level we will discuss these limitations consecutively first we use a choice experiment which is an attractive economic tool to elicit the stated preference of respondents it makes use however of hypothetical scenarios which reduce complex reallife situations such as fertility and childraising to very basic situations described by a few attributes and attribute levels and is therefore inherently subject to hypothetical and social desirability bias while the enumerators were trained to emphasize the hypothetical character of the choice experiment focussing on the importance of considering the hypothetical household as presented without taking into account possible monetary social or physical limitations of the actual household we cannot be 100 sure that respondents did not consider their actual reality when choosing between scenarios as children remain an important asset in ssa both from a labour perspective and from an oldage support and insurance perspective preferences with respect to the quantity of children could have been in ated because of these considerations especially for households who do not have savings in other forms this hypothetical bias could explain the disparity between revealed and stated preferences second our ndings on fertility preferences and the qq tradeoff are derived from speci c regions in rural uganda and senegal while there are some differences between preferences among ugandan and senegalese respondents most preferences remain robust across the different regions still care is needed in generalising results as preferences could differ in diverging cultural ethnic spatial and temporal contexts studies have proven that fertility preferences can be highly variable over the course of a lifetime but we did not speci cally target young people who have not started their childbearing years yet moreover as described by libois and somville in nepal when nucleus households are strongly rooted in the extended family as is often the case in ssasocial norms can counter the qq tradeoff as households with a lower number of children may be morally required to host kin the analysis of fertility preferences and the qq tradeoff in light of these lifetime dynamics and extended kinship networks could be an interesting avenue for further research 11 tested with twosided ttest difference signi cant at the 10 signi cance level 12 tested with twosided ttest all differences signi cant at the 1 signi cance level competing interests the authors have no relevant nancial or nonnancial interests to disclose author contributions all authors contributed to the study conception and design material preparation data collection and analysis were performed by kaat van hoyweghen goedele van den broeck janne bemelmans and hendrik feyaerts the rst draft of the manuscript was written by kaat van hoyweghen and all authors commented on previous versions of the manuscript all authors read and approved the nal manuscript supplementary files this is a list of supplementary les associated with this preprint click to download reveconhouseholdsuppldocx appendixdocx	to attenuate the adverse effects of high population growth in lowincome countries and to achieve the sustainable development goals knowledge on rural fertility preferences and the existence of a quantityquality tradeoff between the number of children and childraising quality is key to tackle this we implement a choice experiment in senegal and uganda we include three quality and one quantity aspect of childraising and three socioeconomic drivers of fertility resulting in a comprehensive assessment we show that rural households prefer to have many children but women and nonpoor respondents demonstrate a lower preference for many children than men and poor respondents we nd that the quantityquality tradeoff is a twosided story on the one hand for most of the quality attributes we con rm the existence of a tradeoff on the other hand quantity and quality are complementary when all children in the household can attain a lower secondary school diploma our results imply that broadening the currently narrow focus on contraceptive uptake in family planning programs and more speci c targeting of such programs to people with low fertility preferences could improve their effectiveness
introduction the issue of mistrust between medical patients on the one hand and medical providers and professionals on the other remains a worldwide phenomenon that is arguably growing in recent decades this issue has taken on an extremely pernicious dimension in the form of violent retaliative acts against doctors and nurses as well as declining levels of public trust in healthcare institutions more generally on the international scene the former problem is especially pronounced in china whereas the latter is especially pronounced in the united states with the disastrous global impact of the covid19 pandemic the issue of peoples attitudes toward the healthcare system and healthcare workers has become more widely important than ever healthcare workers have been subjected to extreme and in many cases unprecedented stressors while dealing with the pandemic and trust that they will be protected is a key predictor of healthcare worker motivation and wellbeing during a pandemic it is therefore critical to understand and interrogate how covid19 has influenced or failed to influence peoples prior trust in and attributions about the healthcare system and healthcare workers the pandemic also underscores the importance of addressing this imperative from a crosscultural perspective of particular importance for the present project is the fact that despite the apparent origination of the covid19 outbreak in china the spread and consequences of the virus have been more severe to date in the united states relative to china in the current project we hope to shed light on how the pandemic may have exacerbated crosscultural variation in attitudes toward healthcare as a function of medical uncertainty we present the first systematic evidence to date concerning differences in how people in china and the united states respond to the anxiety of medical uncertainty with compensatory psychological defense mechanisms we adopt a cultural perspective on scapegoating which suggests that universally people may react to the anxious uncertainty of loss of personal control by scapegoatingdisproportionately blaming andor aggressing againstparticular viable targets however the viability of a target is in large part determined by cultural factors specifically we expected that whereas targeted aggression against specific healthcare workers may be a culturally afforded scapegoating mechanism in china people in the united states may be comparatively more likely to blame the healthcare system as a whole in the face of medical uncertainty we further expected these differences in culturally afforded scapegoating to be mediated by different patterns of controlseeking in the different cultural contexts we tested these ideas in an initial exploratory study conducted prior to the outbreak of the covid19 pandemic and then performed a confirmatory study investigating the robustness of these relationships during the pandemic scapegoating in the face of medical uncertainty the current research examines a specific psychological mechanism that we propose contributes to violence against doctors and nurses in china and to healthcare system distrust in the united states namely lack of perceived personal control on the part of patients and their relatives in situations of heightened medical uncertainty our present model draws on current research and theory regarding the psychological process of scapegoating as a control maintenance mechanism studies show that when people are threatened by perceptions of uncontrollability in their lives they evince an increased tendency to attribute blame and power to enemy individuals groups and organizations who may be scapegoated cognitively and motivationally it is reassuring to see evil in the world not as due to random unpredictable forces but rather as stemming from focal individuals who can be controlled and on whom one can exact retribution or from organizations and institutions that can be politically or economically held accountable undergoing experiences of illness whether ones own or that of loved ones can be a major threat to perceived personal control thus it stands to reason that in situations of medical uncertainty people will be motivated to scapegoat particular targets to which blame for the illness and its effects may be attributed 1 however we crucially propose that the cultural context in which individuals are immersed will influence both the exact nature of the controlseeking motive they are seeking to satisfy in the uncertain situation and the nature of the target that will be afforded as most viable for blame and attendant aggression or distrust cultural pathways controlseeking and trust in china and the united states our research can be understood in terms of a cultural pathways approach which suggests that relatively universal psychological processessuch as the motive to maintain perceived control over ones health and to make attributions when that control is threatenedare shaped by particular cultural imperatives and affordances we assert that different cultural patterns of controlseeking and trust in the united states and china are important in this regard first we emphasize the distinction between primary and secondary controlseeking as originally defined by rothbaum et al primary controlseeking refers to attempts to influence ones environment to suit the desires of the self and is a predominant cultural imperative in more historically independent settings such as the united states on the other hand secondary controlseeking refers to a set of strategies for adapting the self to fit environmental requirements and is a more common imperative in historically interdependent settings such as china in particular in the healthcare context a form of secondary controlseeking labeled vicarious controlputting trust in powerful others and authority figures to control the self s outcomes is of special relevance given 1 of course we do not argue that scapegoating is the only or even the most prominent defensive psychological response to medical uncertainty but given our interest in addressing the important applied phenomena of aggression and distrust against healthcare workers and the healthcare system it is probably one of the most important responses to understand and hence the focus of our empirical efforts it is also important to acknowledge that scapegoating can have many important motivations and consequences but we focused in the present context on its control maintenance function the fact that patients are placing their wellbeing in the hands of healthcare professionals it is also critical to take into account divergent cultural patterns of trust when it comes to understanding how lay people relate to the healthcare system and workers particularly in context of medical uncertainty in this regard we must distinguish between different levels and types of trust given that peoples interactions with healthcare workers are of a local and interpersonal nature whereas their beliefs about the broader healthcare system represent a form of institutional or governmental trust generally recent research on the cultural psychology of trust suggests that people in the united states and in china have relatively different patterns of trust at the interpersonal and institutionalpolitical levels to summarize this research cursorily people in the united states have relatively high levels of interpersonal but relatively low levels of institutional trust whereas people in china tend to have more comparable levels of trust across persons and institutions indeed chinese people evidence a relatively unique topdown structure of trust reflecting the centralized nature of the chinese government such that people tend to have high levels of trust in the overall governmental system but lower levels of trust in local representatives of institutions in china research suggests that traditionally people are oriented toward more passive forms of coping with stressors by adjusting the self to better fit the environment or to restore a kind of imbalance between the personbody and the environment thus people in contemporary china may be oriented toward seeking secondary control when it comes to their health and in particular toward vicarious controlfor instance they may wish to place their trust in physicians by contrast we expect people in the united states to have more of a primary controlseeking orientation toward the health domain people in the united states may be especially likely to view themselves as consumers of healthcare services and expect that their needs for autonomy and full information will be honored when they consult with healthcare experts for example alden et al found that among us participants independence values were related to the desire for shared decisionmaking in medical situations surprisingly cultural psychological research on trust has generally not assessed peoples level of trust specifically in the healthcare domain but given the broader patterns of trust described above it is reasonable to assume that in china people may have relative trust in the national healthcare system overall but less trust in local representatives of that system whereas in the united states this relationship may take the opposite form we now consider more applied research on developments in doctorpatient relationships and healthcare system trust in these two countries applying the theoretical constructs of culturallypatterned scapegoating controlseeking and trust to illuminate these developments aggression against healthcare workers in china prior to the covid19 pandemic levels of aggression and violence against healthcare professionals in china in recent years had nearly reached the state of a public emergency these acts have a clear negative impact on the mental wellbeing of professionals in china in a sample of nearly 2500 medical providers from the fujian and henan provinces 50 reported at least one incident of patientinflicted violence over the previous year and experience of violence was a significant negative predictor of quality of life even controlling for other relevant factors indeed many medical professionals in china now report regretting their choice of career leading some to anticipate an impending crisis in the health services explanations for this phenomenon in china typically focus on social structural and economic causes the troubled transition to the commodification of medical services in china since 1980 has led to widespread issues of mismatched expectations and insufficient funds and insurance for healthcare on the part of the public from the side of medical providers overwork and underpayment combines with a problematic incentive structure to generate overprescription and a lack of facetime with patients while such explanations and corresponding intervention recommendations are clearly important we propose that it is also crucial to understand the psychological mechanism underlying the rise in violence against medical professionals two assumptions from the preceding section may explain the cultural pathway to scapegoating of these professionals in the chinese context first people in china are motivated to seek secondary and particularly vicarious forms of control in the healthcare context and second people in china have relatively high trust in central institutions but relatively low trust in local institutional representatives this combination of factors suggests that in the face of medical uncertainty or frustration chinese individuals will be relatively likely to aggress against the healthcare workers in whom they had hoped to place their trust but who appear to have failed them beyond testing this empirical account it is also important to understand if these same factors persist under the recent conditions of the covid19 pandemic distrust of the healthcare system in the united states attitudes toward healthcare on the part of the public are also becoming increasingly negative in the united states in recent decades this shift has happened less on the terrain of attitudes toward and aggression against individual healthcare workers and more on the level of institutional trust toward the healthcare system which has declined in the united states over the past halfcentury for example a variety of studies have documented variation in healthcare system trust as an important determinant of use of medical care and healthrelevant outcomes in the united states it is important to acknowledge that at least some data suggest these general declines in institutional trust are independent of peoples interpersonal trust in their own physicians a number of sociological explanations have been proposed for this decline in healthcare system trust prominent among these is the general commercialization and privatization of healthcare in the united states which prompts individuals to suspect the healthcare system and big pharma of exploiting peoples health problems for profit healthcare issues have also become heavily politicized in the united states in recent years with global trends toward political polarization finding one lightning rod in debates around the affordable care act the issue of public trust in the healthcare system professionals and epidemiologists clearly played a role in the us national response to the covid19 pandemic to be specific high public levels of distrust in medical professionals which could be strategically stoked by the trump administration almost certainly contributed to this nations relatively costly and ineffective public health response as in the case of the rise of aggression against healthcare workers in china we believe it is important to understand patterns in healthcare system trust in the united states from a psychological vantage the cultural pathway to scapegoating of the healthcare system in the united states may be explained by our assumptions about controlseeking and the cultural psychology of trust many people in the united states may find their motives for primary controlseeking frustrated in the health domain particularly in light of rising costs of medical care lack of insurance for many residents and the current seriousness of the covid19 outbreak but given that us residents typically show a combination of low governmentalinstitutional and high interpersonal trust they would likely respond to these threats not primarily by aggressing against their local healthcare providers but rather with increasing distrust of the healthcare system this novel account has not yet been tested due to a lack of attention to healthcare trust in the cultural psychology literature in sum our framework makes the following predictions hypothesis 1 people in china will have a greater tendency to aggress against specific healthcare workers in situations of medical uncertainty whereas people in the united states will show greater tendencies to distrust the healthcare system as a whole hypothesis 2 these culturelevel differences in scapegoating mechanisms will be partially mediated by different patterns of controlseeking such that primary controlseeking will partially explain us individuals greater health system distrust and secondary controlseeking will partially explain chinese individuals greater aggression against doctors prior research supporting the framework in china some prior evidence supports the first half of our framework namely that threats to control in the medical context are associated with greater aggression against doctors among chinese participants yang et al demonstrated that chinese people tend to blame doctors for the outcomes of uncertain medical scenarios to a greater extent when they dispositionally lack control an additional study examined whether a situational threat to control would make participants more likely to blame doctors yang et al asked participants to read scenarios about a patients experience in the hospital they manipulated whether the disease course was chaotic or not and whether the patients condition improves or worsens at the end of the narrative they predicted that participants would attribute more responsibility to doctors when the patients condition turned worse and the disease course was chaotic ie doctor blaming would serve the psychological need to make sense of uncontrollable suffering by scapegoating a focal human agent importantly this study recruited participants from both china and the united states consistent with the current model among chinese participants there was a strong interaction effect such that when a patients condition worsened in a scenario attribution of blame to doctors was especially high when the disease course was chaotic while a similar effect was observed among us participants it was much less pronounced and overall us participants tended to attribute more responsibility to doctors when the hypothetical course of a patients illness was positive these suggestive prior studies leave questions unanswered when it comes to our theoretical framework specifically they failed to distinguish between motives for primary and secondary control they did not assess healthcare system distrust andmost important in the present contextthey were conducted prior to the covid19 pandemic and so did not examine these important processes in light of this historical event to address these issues we conducted two surveys comparing chinese and us samples study 1 was conducted prior to the covid19 pandemic and represented an exploratory first attempt to test hypothesis 1 of our framework as well as the suitability of different measures of our variables for testing the model after the pandemic began we carried out study 2 as a confirmatory test of hypotheses 1 and 2 we did not have a strong a priori rationale to expect that the experience of covid19 would change the processes specified by our theoretical account if anything we expected the strong threat to control posed by the pandemic to exacerbate these culturally specific processes study 1 method participants first responded to a series of measures localized to the healthcare context including healthspecific loc health system distrust and fatalism in personal health 2 participants next responded to general measures of perceived control specifically the personal mastery and perceived constraint subscales developed by michinov finally participants responded to a series of vignettes that described uncertaintyinducing healthcare experiences they were asked about their level of frustration and their desire to aggress against the healthcare provider in each scenario materials when possible existing and validated translations of measures were used for the chinese participants when this was not possible a back translation process was utilized in which a native chinese speaker not involved with the research process translated into english the items that had been translated by the researchers and any discrepancies with respect to the original englishlanguage items were resolved healthcarespecific control measures participants first completed measures assessing perceptions of control and controlseeking tendencies specifically in the context of healthcare and personal health the first of these was the healthspecific loc measure to which participants responded on a 6point scale associated with aggression against doctors however because this is a culturespecific effect independent of our broader theoretical crosscultural model we did not include this measure in study 2 and do not focus on the results from this measure in our reporting of study 1 3 while gender was not a focus of this investigation we conducted additional analyses in which we controlled for gender in order to rule out the possibility that the uneven gender representation could be driving nationlevel differences controlling for gender did not affect any of the nationlevel differences reported below further the only variables that displayed main effects for gender were internal health loc t 355 p 0001 d 079 and frustration at the healthcare scenarios t 326 p 0001 d 096 such that males scored higher than females on internal health loc and females reported more frustration than males this 18item measure breaks into 3 subscales internal health loc consists of items such as i am in control of my health powerful others hloc consists of items such as health professionals control my health chance hloc consists of items such as most things that affect my health happen to me by accident participants also completed a measure of healthspecific fatalism the predetermination subscale from the shen et al measure to which participants responded on a 5point scale this 10item scale consists of items such as my health is determined by fate global control measures participants also completed michinovs outcome measures participants also completed measures of our primary theorized outcomes of interest the first was health system distrust assessed with the scale developed by shea et al to which participants responded on a 5point scale this 9item measure consists of items such as the health care system lies to make money the second outcome measure was aggression against doctors this measure was validated in prior research in china participants responded to 3 vignettes that described uncertaintyinducing healthcare experiences for each scenario participants responded to 2 items the first indexed frustration with the scenario and the healthcare provider to what extent are you frustrated with the doctors behavior the second indexed the primary theorized outcome of aggression against doctors to what extent do you have the urge to hit the doctor we created composite indices by averaging responses to each item type across the 3 scenarios results culture meanlevel differences the current study was conducted in an exploratory fashion nevertheless we hypothesized that there would be certain meanlevel differences between the two cultural groups specifically we expected that us participants would score relatively higher on measures of primary controlseeking and chinese participants would score relatively higher on measures of secondary controlseeking we also expected that whereas chinese participants would score relatively higher on aggression against doctors us participants would score relatively higher on health system distrust all descriptive statistics are presented in table 1 primary controlseeking we had one healthspecific measure and one global measure of primary controlseeking as expected us participants scored higher on internal hloc t 565 p 0001 d 045 however contrary to expectations chinese participants scored higher on personal mastery t 233 p 002 d 019 secondary controlseeking we had three healthspecific measures and one global measure of secondary controlseeking as expected chinese participants scored higher on powerful others hloc t 1101 p 0001 d 087 fatalism t 374 p 0001 d 030 and perceived constraint t 538 p 0001 d 042 however contrary to expectations there was no observed culture difference on chance hloc t 071 p 048 outcome measures as expected us participants scored higher overall in health system distrust t 886 p 0001 d 070 while chinese participants scored higher in aggression against doctors t 741 p 0001 d 058 interestingly participants from the two cultures did not differ in their expressed level of frustration at the medical uncertainty scenarios t 121 p 023 patterns of association this exploratory study had two primary purposes the first was to test our expectations concerning culture meanlevel differences the second was to examine patterns of association among the variables in order to determine which operationalizations of primary and secondary controlseeking might be most effective to use in a subsequent confirmatory study testing our multiple mediator path model to reiterate our guiding model suggests that relative tendencies toward health system distrust in the united states should be driven by primary controlseeking whereas relative tendencies toward aggression against doctors in china should be driven by secondary controlseeking withincountry correlations are presented in table 1 however we examined associations across the entire dataset in order to determine which variables would be most important to include in a subsequent confirmatory study we eliminated chance hloc from our deliberations because there was no culture meanlevel difference on this variable suggesting it would be unlikely to be a useful indicator for our model in a subsequent study we noted that our measure of health system distrust was related to our measures of primary controlseeking however in both cases these relationships were negative rather than positive as our theoretical model would suggest in other words participants who scored higher in internal hloc or personal mastery reported less health system distrust we noted that our measure of aggression against doctors was not related to our primary controlseeking measures and instead consistently positively related to our secondary controlseeking measures as our model would suggest however we additionally noted that among the secondary controlseeking measures powerful others hloc was best able to discriminate between the outcome measures because it was negatively related to health system distrust but positively related to aggression against doctors on the other hand the other secondary controlseeking measures seemed to be associated with general negativity toward healthcare discussion our initial exploratory study yielded several preliminary conclusions that helped shape our subsequent confirmatory study designed to test our multiple mediator path model first meanlevel comparisons generally supported our expectations for crosscultural differences us participants scored higher on health system distrust whereas chinese participants scored higher on aggression against doctors in addition chinese participants scored higher on our secondary controlseeking measures given that participants from the two countries scored similarly in the level of frustration they expressed at the medical uncertainty scenarios this provides initial support for our guiding framework which suggests that people in china and the united states have relative tendencies to resolve tensions in the healthcare domain using different culturally afforded defenses given crosscultural differences in these important applied phenomena a critical task is to determine the cultural pathways that afford these divergent responses across national settings examination of the meanlevel differences and overall patterns of association yielded additional useful information we were particularly interested in distinguishing between our different measures of primary and secondary controlseeking to prepare our subsequent confirmatory study when it came to primary controlseeking the measures did not perform in expected ways for two apparent reasons first contrary to expectations and the prior literature chinese participants scored higher on the personal mastery measure second these measures were associated with health system distrust but in a negative direction in hindsight these patterns were not surprising given the important distinction between presence of control and desire for control which has been noted in prior literature but to which we paid insufficient attention in designing study 1 the study 1 results suggest that if a patient already has their needs for primary control satisfied they do not need to invoke culturally afforded defenses in connection with the healthcare system and indeed our theoretical account only suggests that desire for rather than presence of primary control should be associated with scapegoating defenses this indicated to us that we should select a new measure of primary controlseeking for study 2 specifically a measure that indicated not presence of but desire for primary control in the medical domain if we could operationalize participants desire for a primary control that they currently lack this might be positively associated with use of health system distrust as a defense mechanism at least among us participants when it came to secondary controlseeking the measure of powerful others hloc seemed most promising for a subsequent study of the secondarycontrol seeking measures this was the only one to show a culture meanlevel difference with a large effect size in addition this measure distinguished well between our two outcomes in that it was negatively associated with health system distrust but positively associated with aggression against doctors this suggests that specifically seeking secondary control in the health domain by yielding power to others may be associated with the culturally afforded defense of violence against healthcare workers at least among chinese participants these findings fit with our theoretical account given the importance of vicarious control as a specific form of secondary controlseeking in the medical domain study 2 we had two primary goals for study 2 first we planned to replicate and extend our exploratory study 1 findings in light of our guiding hypotheses hypothesis 1 was supported in study 1 but we wanted to confirm this pattern in a second sample in addition we wanted to test hypothesis 2 using a confirmatory approach and applying multiplemediator path models we planned to use the information from study 1 regarding which operationalizations were most effective and consistent with our theoretical framework to update the materials for study 2 specifically we observed that powerful others hloc was a promising operationalization of vicarious control as a relevant form of secondary controlseeking in the healthcare context and we also felt the need to develop a new measure of primary controlseeking that would indicate desire for rather than presence of primary personal control in the healthcare context but second the covid19 pandemic occurred before we were able to follow up on our study 1 results due to the obvious importance of the pandemic for peoples experiences of medical uncertainty we additionally modified the study 1 materials to include vignettes pertaining to the covid19 situation given the historic moment an additional goal of study 2 became determining whether the study 1 findings and our original hypothesized relationships would be observable during the pandemic we had no strong reason to believe a priori that the basic pattern of results would change and therefore retained our original hypotheses method data were collected at the beginning of may 2020 similar to the procedure of study 1 participants first responded to a series of vignettes that described uncertaintyinducing healthcare experiences however study 2 also included scenarios related to the covid19 pandemic following the healthcare vignettes participants responded to measures of primary controlseeking health system distrust secondary controlseeking and positive cognitive reframing for descriptive statistics and zeroorder correlations for all the variables reported below see table 3 finally because the threat of covid19 may have been experienced by participants as more distal or proximal depending on whether they lived in an area that was heavily impacted by the virus a single item was included to assess results for the chinese sample are reported below the us sample above the diagonal indicates significant meanlevel differences between countries at p 0001 for correlations p 001 whether participants had lived or stayed in a region impacted by covid19 materials healthcare uncertainty vignettes participants first reported their frustration and desire to aggress in response to the series of scenarios reported in study 1 then participants read and responded to scenarios that related to potential healthcare situations involving the covid19 pandemic for example in one vignette participants read about the following scenario imagine your grandfather has had a high fever for 5 days at this time after going to the hospital for a blood test and ct test he was highly suspected of having new coronavirus pneumonia since there were no vacant ward beds in the hospital the doctor prescribed medicine and let the patient go home for isolation similar to the general vignettes participants reported their predicted frustration and desire to aggress against the doctor based on each scenario responses were provided on 5point likert scales primary controlseeking to assess participants desire for personal control in their healthcare participants responded to a modified version of the desirability for control scale this scale includes three subscales all of which were modified to reflect decisionmaking in healthcare contexts including desire for leadership willingness to relinquish control and desire for determining ones own life secondary controlseeking the full healthspecific locus of control scale was again included but based on the exploratory study 1 results and our theoretical framework the subscale measuring trust in powerful others was the focus for the present study health system distrust health system distrust was assessed with the same measure used in study 1 positive cognitive reframing as an exploratory measure a measure of positive cognitive reframing was included to assess the degree to which individuals positively reinterpret their healthcare experience we included this measure because recent evidence suggests that people in china have shown more positive forms of coping with the covid19 pandemic compared to us residents accordingly while we did not formulate new hypotheses for study 2 we wanted to explore the possibility that chinese residents might show more positive coping in the covid19 context rather than aggression against doctors the 4item measure was taken from the cope inventory results invariance analyses of primary outcomes in order to determine the degree of factor structure similarity between the us and china for the primary dependent variables invariance analyses of health system distrust and aggression toward doctors were conducted a confirmatory factor analysis model was specified in which health system distrust and aggression toward doctors were treated as latent factors with their respective items serving as the indicators by adding constraints to these models we can determine whether the items are capturing the same underlying construct whether participants in both nations are similarly responding to the items and whether the means are comparable these analyses were conducted in the r software package and utilized weighted least squares estimators and robust fit indices the acceptability of different levels of invariance can be determined by examining changes in fit statistics while chisquare changes can be overly sensitive cfi and gammahat can be examined for changes to determine whether each consecutive model should be rejected with changes of 001 indicating that the more constrained model is acceptable fit statistics for these cfas are presented in table 4 in the case of both sets of modelsone examining health system distrust and aggression in the general healthcare scenarios and the other examining health system distrust and aggression in the covid19 specific scenariosthe configural metric models had acceptable fit and all factor loadings were significant further the constraints added to the metric models did not lead to a substantial decrease in the model fit in both cases the implementation of additional constraints in the scalar models resulted in worse model fit this is not surprising as scalar invariance is a high psychometric standard for betweencountry comparisons yet the lack of support for scalar invariance demands a degree of caution in interpreting the findings reported below we think that the present research addresses an applied issue of significance and given the relative absence of violence against doctors as a social issue in the us these differences are unlikely to be entirely the result of response biases or other sources of error general healthcare uncertainty scenarios to assess the hypothesized mediation model the data were fit to a structural equation model in which personal and external control were specified as mediators of national differences in the tendency to blame the health system vs aggress against medical providers in addition given the likely relationship between the mediating and outcome variables these pairs of factors were allowed to covary because the purpose of these analyses is to understand the relationship between the underlying latent factors rather than the relationship between itemlevel we applied a parceling method to increase model parsimony and improve the participant to parameter estimate ratio thus three parcels were calculated for shared decisionmaking external locus of control and health system distrust by randomly sorting and averaging items into three indicators per latent factor the resultant model along with factor loadings and standardized path weight estimates is depicted in figure 1 though the chisquare fit index was significant 45895 p 0001 other fit indices that are less impacted by sample size suggest that the models fit is within acceptable limits in addition to having acceptable fit all of the latent factor loadings and path weights in the model depicted in figure 1 were significant generally this model offers support for the present predictions as chinese participants reported greater levels of secondary controlseeking and aggression against doctors in contrast americans reported greater primary controlseeking and health system distrust further the relationships between primary controlseeking and health system distrust on the one hand and secondary controlseeking and aggression against doctors on the other hand were both positive and significant to more precisely test whether national differences in responses to medical uncertainty were mediated by the proposed constructs a second model was examined in which crossmediating pathway loadings were eliminated this model configuration allows for the examination of indirect effects through the hypothesized mediators by themselves the mediation model also displayed acceptable though less ideal fit 53044 p 0001 cfi 0908 srmr 0078 rmsea 0094 90 ci0087 0102 to examine the hypothesized mediating role of control preferences and to calculate bootstrapbased confidence intervals the model was run with a bootstrapping approach utilizing 5000 resamples see table 5 for indirect effects and confidence intervals as indicated by the results reported in table 5 the effects of country on both outcomes were partially mediated by the hypothesized constructs in other words while both of the direct relationships between country and health system distrust and aggression against doctors were significant part of the national differences in these outcomes were accounted for by the proposed controlseeking preferences covid19 specific healthcare scenarios importantly for the present purposes we also sought to determine whether the models could be replicated when considering the covid19 scenarios specifically we examined the same models as above but substituted the covid19specific scenarios for the general uncertainty scenarios the exact same analysis sequence was conducted with a full path model being tested first followed by a test that focused on the hypothesized mediating pathways analyses of the full model suggest an adequate fit to the data 48597 p 0001 cfi 0916 srmr 0058 rmsea 0091 90 ci0084 0099 with all factor loadings and predicted paths yielding significant relationships again to explore the predicted mediational pathways more directly we analyzed models in which the crossmediating pathways were eliminated this model again yielded adequate fit indices 54786 p 0001 cfi 0905 srmr 0077 rmsea 0096 90 ci0089 0103 to assess the indirect relation between country and outcomes through the hypothesized controlseeking mechanisms we assessed those indirect effects with a bootstrapping method utilizing 5000 resamples the results of these analyses are depicted in table 6 once again the confidence intervals for both indirect effects did not contain zero suggesting that the national differences in health system distrust and violence against doctors were partially mediated by the proposed controlseeking tendences covidaffected vs unaffected areas and positive cognitive reframing to explore whether individuals controlseeking and scapegoating tendencies were moderated by living in covidaffected areas betweensubjects anovas were conducted in which the effects of nation covidaffected area and the interaction of these two factors were assessed on all measures included in the study these analyses yielded nonsignificant main effects of covidaffected area and country by area interactions for frustration and aggression in the general healthcare scenarios frustration in the covidspecific scenarios primary control seeking and health system distrust there were however significant effects of living in a covidaffected area for secondary controlseeking positive cognitive reframing and aggression toward doctors though the latter main effect was qualified by a country by covidaffected area interaction see table 7 for the full statistical results of anovas that yielded significant results the analyses depicted in table 7 suggest that in addition to national differences in most of the variables in study 2 whether or not participants lived in an area affected by covid19 was related to greater secondary controlseeking positive cognitive reframing and aggression toward doctors in the scenarios specific to covid19 this latter finding was qualified by a country by covid19affected area interaction such that the tendency for chinese participants to want to aggress toward doctors was more extreme among chinese living in covid19affected areas in terms of our exploratory variable of positive cognitive reframing it was in fact the case that people in china engaged in this form of coping to a relatively greater extent however examination of mean levels of aggression against doctors in china between studies 1 and 2 suggests that use of this coping discussion a highpowered confirmatory study study 2 added several important pieces of information to the initial exploratory results obtained in study 1 first crosscultural mean differences and crosssectional patterns of association offered confirmatory support for our theoretical model replicating study 1 chinese participants showed a relatively greater tendency to aggress against doctors in hypothetical scenarios involving both general medical uncertainty and covid19 also replicating study 1 us participants showed higher levels of distrust in the health system importantly extending on study 1s initial findings we also found support for our multiple mediation model such that the crosscultural differences in outcomes were partly mediated by variation in controlseeking us participants seek primary control to a greater extent which is related to their relative tendency toward health system distrust and chinese participants seek secondary control to a greater extent which is related to their relative tendency toward aggression against doctors importantly this model replicated in both the context of general medical uncertainty and covid19 specific scenarios relevant to the current necessity for understanding how people respond to global pandemics there were interesting patterns related to covid19 in the data some of which appeared culturally generalizable and one that was culturespecific in particular in both countries reporting living in an area that was severely impacted by covid19 was associated with secondary control strategies in particular more secondary controlseeking in the medical context as well as positive cognitive reframing finally and attesting to the importance of our scapegoating conceptualization we found that the crosscultural difference in tendencies to aggress against doctors was moderated by living in a covidimpacted environment such that among chinese participants greater tendencies to aggress were observed among participants living in more impacted areas general discussion distrust and discord between patients physicians and the healthcare system is a major and growing international problem the present paper applies a novel explanation for this phenomenon drawing on a conceptualization of cultural pathways to scapegoating in the face of medical uncertainty it draws on prior work addressing the specific issue of violence against doctors in china from a scapegoating perspective to propose and test a theory of how chinese and us culture afford different viable scapegoating targets in the health domain in order to satisfy varying needs for primary and secondary control this work therefore importantly extends our understanding of the psychology of control and trust to a prominent applied context one that has more relevance than ever before in light of the massive healthrelated uncertainty caused by the covid19 pandemic from one vantage point our findings speak to processes that generalize across cultures even if they manifest in slightly different ways people living in both china and the united states tend to scapegoat certain viable targets when encountering medical uncertainty for themselves or their relatives it is significant that our confirmatory study 2conducted under conditions of a global pandemicyielded essentially similar support for these general tendencies as was observed in study 1 suggesting a degree of both crosscultural and historical stability on the other hand we observe consistent cultural variation in the specific manifestation of scapegoating tendencies in the face of medical uncertainty as well as the processes driving these tendencies replicating prior research on scapegoating as well as the cultural psychology of trust people in china had a greater tendency to aggress against local healthcare workers in situations of medical uncertainty by contrast people in the united states showed relative tendencies to distrust the healthcare system as a whole further these culturelevel differences in scapegoating mechanisms were partially mediated by different patterns of controlseeking the observed cultural differences in primary and secondary controlseeking are consistent with previous findings historic conditions favorable to individualism have given rise to strong motives for primary personal control in the united states but people in china and other asian cultures have historically favored patterns of acceptance and adjustment to the status quo at the same time the state of illness itself forces upon the patient a strong sense of uncertainty and lack of control the covid19 pandemic in particular has posed a strong threat to peoples sense of control in many settings around the world but just as sociopolitical public health and economic responses to the crisis have varied as a function of cultural context so too will the psychological defenses people employ against the threat to control posed by this tidal wave of medical uncertainty limitations given that this research stemmed from prior applied work on the phenomenon of violence against doctors in china and additionally sought to examine a second important applied phenomenonhealthcare system distrust in the covid19 contextwe approached study design from a more applied perspective in other words we prioritized operationalizing our theoretical constructs in ways that were highly germane to the context of healthcare and the doctorpatient relationship as well as not including additional more abstract measures in order to avoid participant fatigue this was particularly the case for our confirmatory study 2 design these decisions came at a cost to the theoretical clarity of our data for example although we used a scapegoating framework to develop our hypotheses we did not directly measure attributions of blame in the current studies an important component of scapegoating that we have in fact measured in earlier studies of aggression against doctors and although there are more direct measures of primary and secondary control available we elected instead to use measures specifically intended for the way these processes manifest in the healthcare domain eg in terms of vicarious controlseeking in the doctorpatient relationship ultimately these decisions limited our ability to definitively test our theoretical framework in this applied context nevertheless given that the patterns of data support our hypotheses and that we developed these hypotheses from an underlying framework the findings are at least consistent with a theory of cultural pathways to scapegoating some researchers might also consider the fact that we selected measures for inclusion in our confirmatory study 2 based partly on their performance in our exploratory study 1 to be another limitation of the present research from this perspective it could be argued that we selected the measures that were most likely to support our theoretical account while ignoring relevant measures that might have cast doubt on the framework while we concede that some researchers may view our approach in this light we personally feel that this represents a confusion between exploratory data analysis and what are referred to as questionable research practices because we have openly acknowledged that study 1 was conducted in an exploratory spirit any conclusions from that study need to be interpreted with due caution however the aim of exploratory data analysis is often to develop theory and methods for future confirmatory study which is exactly the approach we adopted here we did not focus on new or specific measures of primary and secondary controlseeking in study 2 simply because they performed in study 1 but also because the patterns were consistent with prior research and our theoretical account for instance in hindsight the choice to operationalize primary and secondary control in study 1 using measures of presence rather than desire for control was a poor design choice based on our theoretical framework accordingly we selected different measures for inclusion in study 2 and these data provided confirmatory evidence for our account nevertheless it is important for future research to attempt to further replicate the pattern of results seen in these studies which remain applied and somewhat preliminary in nature beyond the outcome variables our studies also attest to the ongoing need for further examination of the relationship between need for and presence of primary and secondary control ideally future work would investigate these phenomena from a more purely theorydriven perspective as stated the applied nature of our work in the healthcare context limited our ability for theory refinement practical implications the concept of uncertainty in illness explains the patients treatment of diseaserelated stimuli patients often do not know the precise symptoms of the disease do not understand the generally complicated methods of treatment and care lack information related to the diagnosis and severity of the disease and recognize that the course and prognosis of the disease cannot be predicted with certainty the covid19 pandemic has exacerbated these processes of uncertainty in illness for many people given the highly contagious nature of the disease its disproportionate impact on certain vulnerable individuals and a general lack of certainty about the disease among health professionals particularly in the early days of the pandemic within this general context of uncertainty in illness it is important to consider the nature of the doctorpatient relationship the patient is at a disadvantage when it comes to information and resources being ill results in a sense of uncontrollability focused on the possible future threat danger or other upcoming potentially harmful events according to our framework and present pattern of results chinese individuals are motivated to adopt secondary control strategies to compensate for lack of personal control attendant on the experience of illness perhaps unsurprisingly because chinese individuals wish to place their faith in powerful others to control and resolve their illness experience they resolve continued frustrations and uncertainties by blaming and even aggressing against these local representatives of the healthcare system in comparison us residents seem motivated to maintain a sense of primary control despite the inherent uncertainties of the illness experience however in this cultural context of trust aggression against doctors is not an afforded response rather those seeking greater primary control blame the broader healthcare system for their negative illness experiences this attributional style may allow these individuals to maintain the perception that they can locally control their health at the same time that they trace their health problems to broader systemic factors while the current research has focused on investigating problematic tendencies within the two cultural settings this comparative research also highlights the fact that national leaders and healthcare professionals stand to learn from each other by recognizing divergent cultural strengths for instance the chinese government has continued political support for its healthcare reform from 2009 until now enabling conditions to achieve national universal health coverage the health insurance system has been reformed and different kinds of medical insurance have combined to promote health equity it is possible that these recent efforts on the part of the chinese government contribute to laypeoples relative trust in the healthcare system as a whole given the calamity posed by covid19 in the united states and the role that was likely played by distrust in the healthcare system it is important to recognize the potentially pernicious consequences of this distrust at the same time in the united states people seem to maintain a general respect for the healthcare professions and tend to respect and trust their individual doctors even if they devalue the healthcare system as a whole given the ongoing dilemma of violence against doctors in china social leaders and public health professionals might look to the structure of doctorpatient relationships in the united states for insight into how to restore a sense of trust between individual patients and their local providers generally speaking our data underscore the importance of considering unique cultural pathways to trust and scapegoating in the context of medical uncertainty especially when it comes to the important questions of what local practitioners and statefederal policymakers can do to improve trust and decrease scapegoating for instance in the united states relative levels of trust in and aggression against local practitioners is not the most pressing issue instead trust in the healthcare system as a whole needs to be addressed this suggests the importance of policy regulation transparency and clear communication regarding issues such as insurance pharmaceuticals and vaccines at the broader federal level in the united states however the opposite pattern in china may prevail which suggests that local healthcare workers may be welladvised to pursue individuallevel solutions to establish and maintain patient trust in both cultures however our data also point to the importance of meeting patient needs for control in this context in whatever manner those needs may be culturally shaped provided their written informed consent to participate in this study 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 university of arizona irb the patientsparticipants author contributions qy and ds designed the studies and facilitated data collection iy performed primary data analysis jw facilitated data collection and completion of the studies qy ds and iy drafted the manuscript all authors approved revisions and final version of the manuscript 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	for years violence against doctors and healthcare workers has been a growing social issue in china in a recent series of studies we provided evidence for a motivated scapegoating account of this violence specifically individuals who feel that the course of their or their family members illness is a threat to their sense of control are more likely to express motivation to aggress against healthcare providers drawing on existential theory we propose that blaming and aggressing against a single individual represents a culturally afforded scapegoating mechanism in china however in an era of healthcare crisis ie the global covid19 pandemic it is essential to understand cultural variation in scapegoating in the context of healthcare we therefore undertook two crosscultural studies examining how people in the united states and china use different scapegoating responses to reassert a sense of control during medical uncertainty one study was conducted prior to the pandemic and allowed us to make an initial validating and exploratory investigation of the constructs of interest the second study conducted during the pandemic was confirmatory and investigated mediation path models across the two studies consistent evidence emerged that both in response to covidrelated and noncovidrelated illness scenarios chinese relative to us individuals are more likely to respond by aggressing against an individual doctor while us relative to chinese individuals are more likely to respond by scapegoating the medical industrysystem further study 2 suggests these culture effects are mediated by differential patterns of primary and secondary controlseeking
introduction adolescents face many sexual and reproductive health problems worldwide including unplanned pregnancy sexually transmitted infections and human immunodeficiency virus infections adolescents account for 42 of new hiv infections globally and four in five young people with hiv live in subsaharan africa lesotho has the secondhighest hiv prevalence in the world accounting for 227 and one of the highest hiv incidence rates among adolescent girls and young women accounting for 033 the maternal mortality rate in lesotho of 544100000 live births is the second highest in southern african development community countries in lesotho adolescent girls and young women frequently report limited knowledge in sexual and reproductive health issues and engage in risky sexual behaviors they are at increased risk of early sexual debut unprotected sex and multiple sexual partners exposing them at risk of acquiring sexually transmitted infections including hiv and unintended pregnancy providing sexual and reproductive health education to young women is challenging in this rural mountainous country and where health professionals face constraints related to time and resources new tools to deliver health education are needed in lesotho 94 of people aged 1829 years use smartphones and 3g data coverage is available in almost 90 of the country the high penetration of mobile technologies provides an opportunity to explore the use of new tools delivered on mobile phones as an alternative to the traditional facetoface provision of health education embodied conversational agents are computerbased animated characters designed to simulate facetoface human interactions they are an effective medium to educate patients with limited health or computer literacy as the humancomputer interface relies only minimally on text comprehension and prioritizes conversation making it more accessible to patients with limited literacy skills nonverbal conversational behaviors such as hand gestures that convey specific information through pointing shape or motion are channels for conveying information on semantic content that enhances message comprehension an eca called gabby was designed to deliver sexual and reproductive health information to african american women of reproductive age in the united states that demonstrated significant improvement in addressing reproductive health risks this paper describes the process used to adapt gabby for use in lesotho and provides qualitative data regarding the success of the adaptation collected from potential end users and ministry of health leadership methods conceptual model the pen3 cultural utility model guided the adaptations which provides valuable guidelines for ensuring a culturespecific intervention by identifying and organizing a communitys culture in the planning processes the model includes the cultural identity domain the relationship and expectation domain and the cultural empowerment domain adaptations were also guided by the heuristic framework for cultural adaptations of barrera et al which includes information gathering preliminary adaptation design preliminary adaptation tests adaptation refinement and cultural adaptation trial information gathering for adaptation to understand the adaptations needed the northeastern university team leader visited lesotho in january 2020 meetings were held with moh managers for adolescent health hiv family planning and nursing to elicit recommendations with regard to potential adaptations meetings were also conducted with district nurses and with young women seeking healthcare services the meetings elicited details with regard to how basotho use their hands facial gestures and body language in conversation and ideas regarding the use of basotho language and cultural references such as idioms that could be incorporated into the new system the persona of the new character was explored to identify those that would lead to greater trust in the health information being delivered interviews highlighted the importance of promoting engagement with the new system images of basotho women were used to create the character decisions were made regarding the characters appearance behavior nationality sex age occupation and name the moh officials were asked to recommend topics that they believed to be critical for improving sexual and reproductive health for adolescents and young women the topics agreed upon for gabby was developed in the united states to deliver health education that women could access on desktop computers nkabanenkholongo et al 103389fdgth20231224429 inclusion in the system were family planning hiv and aids tuberculosis healthy eating and folic acid supplementation boston university and the lesotho team then used the lesotho national guidelines on these topics to prepare the dialogs to be delivered by nthabi technical adaptations were required to deploy the prototype gabby interface to now be displayed on smartphone screens the new nthabi system interface was designed to display only the face and response options of the characters the development team sourced lesotho mobile phones to gain information regarding the specifications penetration of devices to increase the accessibility and use of the system a decision was made to ensure that the app can be completely downloaded into the users mobile phone thereby enabling use even outside of wifienabled environments data pertaining to user usage and the content discussed would be downloaded when the user is next in a wifienabled environment recruitment and enrollment of participants the participants were recruited to use nthabi in accordance with predetermined eligibility criteria aged 1828 owned a smartphone spoke english and lived in the leribe or berea districts of lesotho a purposive sampling technique was employed to recruit participants when they accessed services at the adolescent and maternal and child services at district hospitals the nthabi app was downloaded onto the participants mobile phones after they provided informed consent the participants who were unable to download the app were provided with an internetaccessible tablet device all participants were asked to use the system daily for 4 weeks focus groups of participants using nthabi young women who used the nthabi system were contacted to arrange for their participation in focus groups to elicit their perceptions of the system four focus groups were conducted between july and august 2022 the groups were facilitated by the first author using an interview guide with openended questions designed to explore the cultural and clinical adaptation ease of use problems encountered willingness to continue use and possible future use focus group participants were provided a stipend of 50 maloti key informant interviews with moh leaders purposive sampling was employed to recruit moh program managers and adolescent health nurses to participate in key informant interviews they were asked to review the content of a video shared on whatsapp of the key parts of the nthabi interactions for 35 days in june and july 2022 interviews to elicit their perceptions were conducted using an interview guide with openended questions used to explore cultural and clinical adaptation and perceptions of use to deliver health education in the country these participants did not receive a stipend data analysis data analysis was headed by the sefako makgatho university team all interviews and focus groups were approximately 1 h and were audio recorded the study team members transcribed semiverbatim all audio recordings into microsoft ® word and checked for accuracy and extraneous sounds remarks or repetitions were omitted in the transcription in addition words were added as appropriate for clarity they were not returned to participants for correction before analysis all identifying data were removed and sesotho words were translated into english all qualitative data were imported into qsr internationals nvivo v12 software for coding and analysis we conducted a thematic analysis using a combined inductive and deductive approach to coding starting with broad codes from the interview guide and allowing room for new codes to emerge given the heterogeneity of respondent demographics we coded all interviews instead of stopping when saturation was researched within particular thematic areas a coding tree was produced that contained emergent categories of barriers and facilitators and recoded the data the core major and minor themes were determined through iterative inputs from authors on the resultant thematic map the demographic data were collected from the participants at enrollment and were presented as counts frequencies and means all information was stored on encrypted tablets results initial consultative meetings initial consultative meetings were held with eight moh directors or program managers four district nurses who were aged 2550 years and nine women aged 1828 years based on these discussions it was recommended that the lesotho version of gabby would be a young female nurse named nthabi wearing a lesotho nurses uniform and using sesotho words and idioms her hairstyle complexion use of gestures and mannerisms would be relatable to young women in lesotho english was chosen as the preferred language for nthabi since a sesotho speech synthesizer was unavailable to promote engagement a professional mosotho woman artist and storyteller was engaged to write 60 daily installments of a serial story each ending with a cliffhanger that could motivate users to use the app daily such serialized stories are popular in lesotho nkabanenkholongo et al 103389fdgth20231224429 description of participants who used nthabi a total of 41 participants who met the eligibility criteria were recruited to use the new app after giving consent the participants were assisted to download the nthabi app onto their mobile phones of the 41 eligible participants 16 participants were able to download the app onto their phones if the app could not be downloaded the participants were loaned a lenovo© android 11 os platform tablet to use overall eight out of 16 participants who were able to download nthabi app on their mobile phones used the app consistently the other eight encountered challenges related to phone memory and freezing of the phone which leads them to uninstall the app in total 25 participants used the lenovo tablets provided by the research team and eight participants on their phones focus group discussions and key informant interviews all 33 participants who used nthabi participated in focus groups the mean age of the participants was 23 years and 27 of them were single all had completed high school or above and 22 were unemployed all the 10 health leaders who participated in the key informant interviews had received tertiary education and were employed table 2 summarizes the five themes and subthemes that emerged from the key informant interviews and focus group discussions figure 2 lesotho version of gabby for use on mobile phones theme 1 appearance and mannerisms the participants described nthabi as a mosotho nurse who is friendly wears her uniform neatly and provides relevant health education to young women who do not have access to sexual and reproductive health content due to cultural and health provider barriers such as judgmental attitudes and lack of confidentiality the participants described nthabi as relatable to basotho young women dress code both end users and moh interview participants approved of the nthabi character being dressed as a nurse wearing a nurses uniform implies that the information shared by nthabi is from a reliable source i think she looks good like the fact that she is a nurse as this gives young people an assurance that the information that she is providing is credible complexion and skin tone most participants agreed that nthabis skin tone and complexion were relatable to basotho young women the skin tone indeed is relatable to basotho immediately you see her you definitely can say that is a mosotho woman hairstyle most participants liked nthabis hairstyle and said that it resembled hairstyles of young basotho women although there were suggestions to use other styles i would prefer that the hair be short african hair … plaited in a way that is common in the country it can be an essence just a simple thing just to show that she is an african gestures the gestures she used in conversation such as using her hands facial expressions and the humility gesture were viewed positively end users and key informants agreed that nthabi used her hands properly and her facial expressions and the humble character that she portrayed in conversation were culturally appropriate and relatable to young basotho women i was also surprised with the way the application used gestures this is a commendable innovation truly she is relatable to basotho young women theme 2 acceptability of language used both end users and key informants appreciated that nthabi presented information in a tone that is not offensive to the basotho culture yes we can listen to nthabi with our parents because she chooses her words well and that shows she is culturally sensitive as basotho girls there are some words that cannot be used publicly but nthabi seems to know that as well nthabi is able to provide information about everything even those that a parent or elderly person isnt comfortable talking about because they are embarrassing the participants also believed that they would be comfortable sharing their healthcare needs freely with nthabi rather than with healthcare providers because nthabi is nonjudgmental and they often feel judged by nurses i found nthabi to be nonjudgemental for instance say i am 18 years old and i am pregnant there are certain things i will be told about how much i have been dating etc this results is feeling discriminated and being uncomfortable to visit the facility again … nthabi on the other hand is open theme 3 accessibility relevance and engagement users applauded the nthabi app since they could access it at times convenient to them rather than relying on having to go to the health center or the hospital end users said the information provided was important and they did not feel rushed when talking to nthabi it was interesting to have a nurse in ones pocket who is accessible anytime you want to reach out rather than having to go through long queues at the health facilities to get health information nthabi is able to ask whether you would like to continue talking to her or if it is enough for the day meaning she has time for us not rushing like nurses the participants also reported that the serialized local stories motivated them to use the system every day the story about thabo and mpho made me more excited i will always want to know what happens next with mpho theme 4 relevance of health content end users and key informants reported that the five health topics covered by nthabi are relevant in lesotho i learned so much about family planning i did not know about additional methods that i learned from nthabi theme 5 suggested modification end users and key informants suggested several recommendations for additional content including hiv preexposure prophylaxis sexual reproduction teen pregnancy cervical cancer and sexually transmitted infections it is very important to actually mention something about cervical cancer because we know our adolescents actually start to have their sexual debut even before they reach mature age the majority of participants suggested that nthabi should use the local language sesotho so that information can reach the nonenglish speaking population there were also suggestions with regard to her accent please consider translating all this information to sesotho so that young people can have language options nthabis accent should also be rectified because she rolls her tongue a lot and one needs headsets in order to hear other words properly she isnt audible enough when you play her on speakerphone finally the participants suggested that nthabi could be adapted further for use by boys and young men i also thought the information can be appropriate for boys please consider an application for boys as well discussion this study found that young women and moh key informants in the lowmiddleincome country of lesotho considered the cultural and clinical adaptation of an evidencebased embodied conversational agent system to have been successful the clinically tailored culturally sensitive and trustworthy content of the nthabi system has the potential to improve accessibility of sexual and reproductive health information in the rural mountainous country of lesotho in southern africa lesotho faces significant challenges in terms of its healthcare workforce capacity and the effective dissemination of health education there is an urgent need to develop ways to provide trustworthy information regarding sexual and reproductive health including family planning and condom use to reduce sexually transmitted infections hiv unplanned pregnancy and unsafe abortion in lesotho new technologies are now available to provide evidencebased health education to remote settings with fidelity conversational agent technology interactions have been shown to be an effective medium to deliver health education in a variety of topic areas including to users with limited health literacy nthabi provides a new opportunity to deliver health education possibly as an alternative to the traditional facetoface provision of health education the study highlights the importance of adaptations of new technologies that represent the unique way of life behaviors beliefs values and symbols in the basotho context once interactions are defined in relation to appropriate cultural cues such as language appearance gestures and humility there is a higher probability of acceptability and usability substantial testing regarding nthabis physical appearance age and name was undertaken by the research teams the study demonstrates that involving stakeholders in the adaptation process can increase the acceptability of systems such as nthabi community participation allowed the system to take on characteristics of the local environment in which it was developed the adaptations considered the language cultural appropriateness and context in such a way that is compatible with cultural patterns meanings and values of young women this involvement led to incorporation of culturally persuasive features and addressed issues of potential misfit among the technological human and contextual factors in this way our findings align with the findings of other studies that utilized the pen3 cultural utility model that promoted acceptability nthabis persona as a nurse as well as the incorporation of storytelling as a persuasive feature to promote engagement was a new innovation in the nthabi adaptation these characteristics were not features of the american gabby system however these were recommended in lesotho as a way to provide assurance that the health education she delivers is reliable and to promote its utilization these stories of engagement appear to be important in enhancing user experience and encouraging longterm usage as indicated by the majority of research findings the moh leaders who were involved recognized the potential of this technology to provide widely scalable health education including in population health efforts at the district or national level increased awareness among government officials could lead to further research development and facilitation of implementation assistance in the country focus group and interview participants expressed that expanding sexual and reproductive health education for boys should be considered in the future in an australian adaptation gabbys ability to be sensitive to different cultures and languages seemed to be more important than her physical appearance and accent in lesotho the participants had differing views on nthabis accent as some felt it needed to be modified to sound more like the local accent furthermore it was recommended that she uses the local language which shows the necessity of harnessing local meanings and contextual factors in adapting evidencebased interventions the participants in lesotho emphasized the importance of physical characteristics character hand gestures sesotho name and using sesotho words and idioms this finding complements the findings of the study conducted by fendtnewlin et al which emphasized that it must be acknowledged that straightforward extrapolation of the existing evidence base is not always appropriate despite the high penetration of smartphones among young women in lesotho only eight of the 33 participants succeeded in downloading the app onto their mobile phones primarily due to limited memory on many phones and the unavailability of the app in the google play store especially for the latest huawei phones such as the p50 pro the research team opted to offer full downloadability of the app onto mobile phones thereby allowing its use in nonwifi environments in order to increase the accessibility and use of the system the results showed that possible improved accessibility is balanced by the size of the app which limits the downloading of the app to phones the app could be accessed more easily if it were on the cloud and the participants were able to access the internet however this would limit accessibility balancing offline accessibility and wide usage of mobile phones needs to be addressed and should be an important consideration in future developments this study is limited in that it was an exploratory qualitative study of users perceptions the findings should be confirmed using quantitative methods such as a survey instrument and improved knowledge acquisition while the results reflect successful adaptation it is not known whether the adapted nthabi system will improve users health knowledge or change attitudes and behaviors ultimately systems such as nthabi will need to be tested to measure impact on important clinical outcomes conclusion the culturally adapted nthabi character and trustworthy relevant content has the potential in enhancing the accessibility of sexual and reproductive health information for young women in lesotho furthermore this approach has the potential to serve as an alternative to traditional facetoface health education methods suggested modifications include adopting the local language and accent and adapting nthabi for use by boys and young men balancing the size of the app and accessibility in nonwifienabled environments is needed in future deployments health alliance teams involved in this study the authors are grateful for their participation data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical clearance was obtained from the boston university institutional review board sefako makgatho university health sciences ethics review committee and the lesotho ministry of health research ethics committee 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	introduction young women from the lowmiddleincome country of lesotho in southern africa frequently report limited knowledge regarding sexual and reproductive health issues and engage in risky sexual behaviors the purpose of this study is to describe the adaptation of an evidencebased conversational agent system for implementation in lesotho and provide qualitative data pertaining to the success of the said adaptation methods an embodied conversational agent system used to provide preconception health advice in the united states was clinically and culturally adapted for use in the rural country of lesotho in southern africa inputs from potential end users health leaders and district nurses guided the adaptations focus group discussions with young women aged 1828 years who had used the newly adapted system renamed nthabi for 34 weeks and key informant interviews with ministry of health leadership were conducted to explore their views of the acceptability of the said adaptation data were analyzed using nvivo software and a thematic content analysis approach was employed in the study results a total of 33 women aged 1828 years used nthabi for 34 weeks eight 242 of them were able to download and use the app on their mobile phones and 25 758 of them used the app on a tablet provided to them focus group participants n 33 reported that adaptations were culturally appropriate and provided relevant clinical information the participants emphasized that the physical characteristics personal and nonverbal behaviors utilization of sesotho words and idioms and sensitively delivered clinical content were culturally appropriate for lesotho the key informants from the ministry leadership n 10 agreed that the adaptation was successful and that the system holds great potential to improve the delivery of health education in lesotho both groups suggested modifications such as using the local language and adapting nthabi for use by boys and young men conclusions clinically tailored culturally sensitive and trustworthy content provided by nthabi has the potential to improve accessibility of sexual and reproductive health information to young women in the lowmiddleincome country of lesotho
introduction eastern europe and central asia remains the only region globally where hiv incidence and mortality continue to increase 1 there are numerous economic political programmatic and social reasons for the ongoing volatile epidemic in the region including suboptimal hiv prevention and treatment in prisons 2 although diverse eeca countries have commonalities in drug policy and addiction treatment practices rooted in shared postsoviet value systems that prioritize collective needs over individual autonomy 3 harsh policies criminalizing drug use 4 result in the concentration of people with or at high risk for hiv in prisons 25 where highrisk behavior such as drug injection often continues 67 nationally representative surveys of prison populations show that hiv prevalence is 12 8 51 9 and 37times 10 greater in prisons than in the community in ukraine kyrgyzstan and azerbaijan respectively 2 as drug use continues to remain largely criminalized implementation and scaleup in prisons of evidencebased strategies for hiv prevention and treatment will be crucial tools for curbing the epidemic 2711 nearly all prisoners including those with substance use disorders return to their communities mostly in urban settings thus transitioning prisoners contribute greatly to urban health and health service delivery as incarcerated individuals contemplate release many experience a heightened sense of optimism about brenewing their life known as penal optimism 12 which extends to feeling optimistic about recovery and community reintegration 13 penal optimism is considered a psychological phenomenon of planning fallacy when individuals have excessive optimism bias towards the future exaggerating their abilities underestimating their challenges and avoiding difficult realities 1415 similarly during imprisonment prisoners often minimize challenges that may impede their plans to make positive changes in their lives after release 16 qualitative research in the usa and elsewhere suggests that former prisoners often find themselves bin a world of chaos characterized by competing demands on their limited resources with basic needs like food and shelter taking priority 17 for people who inject drugs allowing ones health needs to fall off this list of key priorities has grave implications for transitional care particularly for addiction treatment and continued recovery 1819 discontinuity of care 20 21 22 relapse to drug use overdose and resultant death are common immediately after release 23 risk of death from opioid overdose increases more than sevenfold in the first 2 weeks after release 24 and 1 in 200 prisoners with a history of injecting opioids dies from overdose in the month following release 232526 indeed the only evidencebased therapy for opioid use disorder in prisoners is to use pharmacological treatment with methadone or buprenorphine within prison and continue it postrelease aside from overdose risk postincarceration relapse increases exposure to hiv infection 27 studies 28 show that rates of engagement in hiv care and receipt of art decline more than twofold after release 212228 a comprehensive review that included eeca countries reported that art adherence drops after release especially for women due to relapse to substance use unstable housing and unemployment reduced access to health care and inability to access art in the community 29 to develop effective transitional programs from prison to community care there is a need to better prioritize health tasks in prison that may shape planning for continued healthcare after release despite evidence that while in prison individuals underestimate the difficulty of meeting postrelease health challenges there are no data on whether individuals incorporate their health status into how they prioritize their postrelease needs despite the overwhelming evidence that treatment for substance use disorders within prison and continued after release is associated with the best possible health psychological legal and social integration outcomes in this study we examine a crosssectional survey of prisoners within 6 months of release that met criteria for substance use disorders examining three eeca countries we examine the relative importance of healthrelated tasks compared to tasks of everyday life explore the correlates of prioritizing healthrelated tasks and consider whether there are meaningful differences in findings by country methods study design the design for the parent study has been described previously in each of the three countries ukraine 8 kyrgyzstan 9 and azerbaijan 10 briefly using a random sampling scheme 30 prisoners being released within 6 months were recruited to participate from all prisons excluding juveniles and hospital prisons both first time and recidivist prisoners were included the target size of the sample was based on estimates of the number of inmates in nonspecialized facilities in each country meeting eligibility criteria proportional to the number of prisoners within 6 months of release in each facility 8 9 10 following informed consent respondents answered survey questions using computerassisted structured interviews that included demographic characteristics criminal justice history social circumstances prior to incarceration preincarceration substance use selfperceived health status sexual and drug risk behaviors prior to incarceration validated measures of alcohol use disorder depression and social support and reentry challenges and likelihood of recidivism all instruments were translated and backtranslated into both russian and ukrainian kyrgyz and azerbaijani respectively 31 all participants were then tested for hiv hepatitis c virus hepatitis b virus and syphilis counseled and referred for treatment among the combined sample of 1280 prisoners 577 selfreported previous drug use aside from cannabis or alcohol which was defined as having a substance use disorder and were included in the current analysis drug use in eeca is often underreported unless it is nonrecreational and regular drug use is the major risk factor for hiv in eeca and also for increased morbidity mortality and social harm after release in prisoner populations 2732 study settings azerbaijan is an upper middleincome country 33 of 98 million people with 40000 prisoners hiv prevalence is 37fold higher in prisoners than in the community the predominant religion is islam and there are estimated to be 71283 pwid 34 with an hiv prevalence of 19 to 24 35 the coverage of oat using methadone in azerbaijan was 02 or 155 pwid in 2014 falling far below the whorecommended coverage of at least 20 34 kyrgyzstan is a lower income country 33 of 61 million people with 10195 prisoners 36 about half of the population is muslim hiv prevalence in prisoners is 51fold higher than in the community 9 and oat is provided in prisons the oat program in kyrgyzstan has about 1200 clients 37 with coverage at 18 ukraine is a lower middleincome country 38 that is the most secular among the three included countries ukraine has a population of about 42 million and a prisoner population of about 60000 39 hiv prevalence among prisoners is 12 times higher than in the community 8 it is estimated that there are 340000 pwid 40 mostly of opioids with high prevalence of substance use disorders among incarcerated individuals 8 while in all three countries opioid agonist therapy was introduced as part of hiv prevention and harm reduction efforts 4142 the addiction treatment community has been slow to adopt it as evidencebased drug treatment azerbaijan has a small pilot oat program in the community and ukraine offers oat using buprenorphine and methadone only in the community with relatively low coverage while kyrgyzstan offers oat both in the community and in prisons data analysis basic characteristics of study participants include demographic characteristics preincarceration income recidivism history of drug use and oat hiv hcv hbv and syphilis test results medical screening variables and a set of validated screening instruments for alcohol use disorders using the audit 43 depression using the cesd 10 44 healthrelated quality of life using the mos short form 36 45 and social support 46 an alcohol use disorder was met if the scores were 8 or higher for males and 4 or higher for females 47 and depression if the cesd was 10 or greater 48 the composite social support scale is an integervalued measure and ranges from 1 to 5 46 to measure the general health status of the study participants we constructed a multicomorbidity index as a weighted sum of the following conditions asthma skin ulcers abscesses arthritisjoint pain gonorrhea and other stis seizures high blood pressure liver problems pneumonia cancer heart disease and tuberculosis weights were based on whether the condition is acute or chronic and symptomatic versus asymptomatic for example an acute asymptomatic condition contributed a value of 1 to the multicomorbidity index and a presence of a chronic symptomatic condition added a value of 4 to the total the total value of the mci ranged from 0 to 26 hiv hcv hbv and syphilis infections were analyzed separately and are not included in the index the who tuberculosis screening questionnaire captures the presence of tb symptoms based on selfreport 49 as recommended by the who for high prevalence settings positive screening was defined as having a cough for at least 2 weeks or the presence of both sputum and unexplained weight loss 49 because sensitivity is high for this symptom survey those screening positive should undergo confirmatory testing to determine the need for treatment specificity however is low making this symptom survey not a true indicator of tb disease the outcomes of our analysis included assessment of each postrelease task individually as very easyeasyhardvery hard or not applicable and identification of one most important postrelease task for the first outcome categories beasy and bvery easyŵ ere collapsed into beasy and bhard and bvery hardî nto bhard the list of potentially challenging postrelease tasks was compiled based on previous research in this area 1950 and included a total of 18 items of these healthrelated tasks included getting access to hiv care getting treatment for illnesses other than hiv getting help staying off drugs and getting oat since the task of getting access to hiv care only applied to a small subsample our analysis focused on the latter three potential challenges to provide a comparison of how incarcerated individuals perceived the relative importance of their postrelease tasks we selected three bcomparison tasks of everyday life namely finding a job or a stable source of income reuniting with family andor friends and staying out of prison following release we used a proxy measure for whether a task was perceived as important this proxy measure identified a task as applicable versus not applicable correlates of identifying a healthrelated task as applicable were analyzed using logistic regression and this analysis was performed separately for the three healthrelated tasks of interest a parsimonious model was derived using bayesian lasso method 51 this method provides a more conservative way to perform variable selection and estimation of regression coefficients compared to traditional stepwise methods 52 statistical analyses were performed in spss and r significance of betweencountry differences was assessed using anova and chisquared test for continuous and categorical variables respectively r package bebglmnet 53 was used to implement bayesian lasso and we used threelevel hierarchical priors with normalexponentialgamma distributions to perform variable selection and estimation of regression coefficients and their 95 credible intervals ethics statement this study was approved by both the institutional review boards at the yale university school of medicine and institutional review boards in ukraine azerbaijan and kyrgyzstan further safety assurances were provided by the office for human research protections results characteristics of the participant population as seen in table 1 there was substantial diversity between participants in azerbaijan kyrgyzstan and ukraine for several characteristics religion education rate of recidivism history of oat physical and mental wellness scores and results of screening for diseases such as tuberculosis and hiv in ukraine almost 80 of participants completed high school or received higher education in comparison to just over half of participants in kyrgyzstan and just over a third in azerbaijan the rate of recidivism was generally high in our sample but was the highest in kyrgyzstan while in ukraine and azerbaijan it was hrqol for physical health was similar to the general population level but for mental health it was markedly lower hiv prevalence was the highest in ukraine at 238 and the lowest in azerbaijan at 68 the three countries were similar on other health indicators such as prevalence of depression hepatitis b and c and multicomorbidity index participants perceptions of reentry challenges figure 1 illustrates participants perceptions of reentry challenges in terms of healthrelated challenges about half of participants considered that getting treatment for illnesses other than hiv and getting help staying off drugs is hard and about two fifths of participants considered that getting methadone treatment is hard yet a sizeable proportion of participantsbetween one fifth to over one thirdconsidered that healthrelated challenges were not applicable to them at all this is particularly striking because all participants in our sample had a substance use disorder with 80 having an opioid use disorder in terms of competing everyday life challenges 61 of participants reported they thought finding a job and 54 indicated staying out of prison would be hard interestingly while many participants considered healthrelated tasks as not applicable very few participants considered everyday life challenges as irrelevant table 2 illustrates country differences in participants perceptions of healthrelated reentry challenges in kyrgyzstan where over two thirds of participants reported a history of oat involvement almost half of participants reported that getting help staying off drugs was not applicable to them and over two thirds of participants considered getting methadone treatment after release as nonapplicable to them participants perceptions of importance of reentry challenges figure 1 illustrates participants perceptions regarding what in their view was the most important task upon reentry overall about two thirds of participants identified that finding a job or a stable source of income was the most important task while only 03 of participants thought that the most important task was getting methadone treatment the overwhelming majority of participants did not consider healthrelated tasks associated with their addiction treatment to be most important postrelease furthermore many participants did not consider getting help staying off drugs and getting methadone treatment as applicable to them at all thus instead of determining the correlates of stated reentry challenges beasy versus bhard in our regression analyses we assessed the correlates of stated reentry challenges as bapplicable versus bnot applicableĉ orrelates of considering reentry challenges as applicable regression analyses demonstrated that participants in kyrgyzstan were least likely to consider any of the healthrelated postrelease tasks to be applicable participants in ukraine were less likely than those in azerbaijan to consider methadone treatment as applicable but the adjusted odds ratio for ukraine was not nearly as extreme as that for kyrgyzstan those with more education were less likely to consider getting help staying off drugs applicable conversely those with a history of injecting drug use were more likely to consider getting help staying off drugs and getting methadone treatment applicable likewise participants who reported moderate and especially heavy injection habits in the 30 days prior to incarceration were also more likely to consider getting help staying off drugs and getting methadone treatment relevant having had previous experience with oat was a statistically significant correlate of higher likelihood of considering getting methadone treatment meeting screening criteria for moderate to severe depression also positively correlated with higher likelihood of considering methadone treatment however 95 credible interval for this covariate includes the null having higher levels of comorbidity was significantly correlated with choosing healthrelated reentry tasks as applicable participants who were hiv positive and aware of their status were more likely to consider treatment of illnesses other than hiv as applicable while having a positive hiv status and being aware of it did not correlate with a higher likelihood to consider addictionrelated reentry tasks as applicable scoring higher on the multicomorbidity index was associated with higher likelihood of considering all three healthrelated reentry tasks applicable a number of candidate covariates were not found to be associated with considering any of the healthrelated postrelease tasks applicable of those the most notable are age recidivism hrqol hepatitis c and b status and positive symptomatic screening for tb discussion most prisoners with substance use disorders return to urban settings that are often unequipped to deal with the myriad of health and social needs of individuals who have spent considerable time outside the fabric of these communities results from this study of soontobereleased prisoners with substance use disorders point to three main findings first overwhelmingly prisoners prioritize basic needs over all else including health as central to the transitional process to improve support and preparation for release and reintegration for transitioning prisoners a clear understanding of why prisoners prioritize everyday life challenges over health needs is essential especially since good health is crucial to overcoming everyday life challenges maslows hierarchy of needs provides a useful framework for understanding these challenges 54 which posits that individuals prioritize basic needs over secondary needs the findings here are similar to those reported elsewhere in prisoners in other settings where basic needs are prioritized over addiction treatment 181921 unlike treatment for other conditions addiction treatment with oat results in improvements for most basic and secondary needs like improved family reintegration employment criminal activity healthrelated quality of life and other health benefits 25556 the challenges of soontobe released prisoners social reintegration 57 rather than indifference to health may explain why despite the high prevalence of morbidity and a universal history of drug use in our sample in all three countries study participants prioritized finding a source of income reconnecting with family and staying out of prison as most important an alternate interpretation of this finding may be that tasks related to finding a job reuniting with family and staying out of prison are viewed by soontobe released prisoners as more essential to immediate survival than those related to health 58 rather than focusing on health issues transitioning prisoners may prioritize reuniting with family or friends easy 338 values may not sum up to totals due to missing values and percentages may not sum up to 100 due to rounding az azerbaijan kyr kyrgyzstan ua ukraine a p value for chisquare test or fishers exact test those things that are more meaningful to them like work that is socially affirming and reintegrating with family as activities essential to the fulfillment of social roles and obligations qualitative research on people in eeca countries suggests that social and relational connectedness is central to a sense of purpose in life and conversely feeling unneeded by others who do not value what one has to give may lead to worsening mental and physical health and even suicide 59 while such socially affirming activities appear to be important to transitioning prisoners what is concerning is how these individuals do not understand the positive role of addiction treatment in family reintegration employment reduced criminal activity and healthrelated quality of life which is often required to meet these socially affirming activities interventions that connect the role of oat and dispel myths related to its use will be crucial to realistically meet the expectation of transitioning prisoners with substance use disorders it is concerning that over a third of participants considered starting methadone as bnot applicable despite most of them injecting nearly daily before incarceration one possible explanation why these participants considered these challenges as irrelevant could be that they did not consider their drug use a chronic relapsing disease despite data from multiple clinical trials in communities 60 and in prisoners documenting its efficacy and the high relapse rate after release from prison in its absence 61 62 63 data from two eastern european countries suggest that methadone is not perceived an effective treatment 5556 64 65 66 including in prisons 136768 russia retains a strong influence in the eeca region with its staunch ban on all oat for treatment of opioid use disorder alternatively prisoners might inaccurately believe in their willpower to remain off drugs or have future plans on using heroin as a more natural and healthy substance than methadone 69 either way informed decisionmaking aids that provide culturally accurate information 70 71 72 should be considered to help prisoners with substance use disorders plan for their transition to the community second for those prisoners with higher levels of medical comorbidity this subset of participants was more willing to prioritize their health during transition to the community while having hiv did not change the odds of seeking help for addiction problems participants with poorer general health considered getting help to stay off drugs more frequently this could indicate that individuals in poorer health may recognize the need to accomplish healthrelated tasks like staying off drugs alternatively it could indicate these individuals perceived fewer available resources to pursue street drugs after release 73 third in kyrgyzstan where oat coverage is highest a significantly smaller portion of prisoners prioritized methadone treatment compared to the other two settings where oat coverage is lower and unavailable in prisons one explanation for this finding is that oat was introduced in select eeca countries in the mid2000s not as a treatment for addiction but for hiv prevention 74 thus policy makers providers and even patients might perceive methadone as means to control and reduce the hiv epidemic rather than as an evidencebased addiction treatment in some contexts this approach might have shaped patients attitudes towards the treatment research in other global settings revealed that individuals underprivileged by judicial and social regimes may experience oat more as a tool wielded by those who wish to control them as the harm and less as a treatment meant to improve their health and wellness 75 another possible explanation may be that informal control of the prisons in postsoviet settings by the prisoners themselves plays a strong role in shaping meanings of methadone in this context qualitative research is urgently needed to explore how the meanings of harm reduction and oat intersect in daily experiences of pwid and prisoners in eeca countries besides these three main findings we want to highlight several other interesting observations from our analyses it was striking that recidivists did not prioritize postrelease tasks any differently than participants incarcerated for the first time this could signify the persistence of planning fallacy 1415 during subsequent reincarcerations or misalign the impact of relapse to drug use as a contributor to reincarceration on recidivism 76 further understanding the impact of oat on reducing recidivism may need emphasis in assisting prisoners with opioid use disorder in setting their priorities 76 interestingly more educated participants were less likely to consider getting help staying off drugs our qualitative research in ukraine showed that pwid perceive oat engagement as a sign of deteriorating health 56 thus higher education may indicate participants higher socioeconomic status underlying more resourcefulness but also higher drug use stigma with methadone perceived as the last resort of those who are breally sickŵ e noted several interesting country differences none of the study participants in azerbaijan identified any of the three healthrelated tasks as the most important a few study participants in kyrgyzstan said that getting help staying off drugs was the most important reentry task but despite the availability of methadone no one identified such treatment as a priority only in ukraine a small number of participants chose getting methadone treatment and getting treatment for general health conditions as the main postrelease task although the severity of health problems was comparable in all three countries it is possible that the perceived criminalization of drugs is more severe in ukraine than in kyrgyzstan and azerbaijan one limitation of our study was crosssectional design as we only measured expectations for postrelease challenges and not actual postrelease behavior during incarceration participants could try to resolve cognitive dissonance 7677 regarding competing postrelease challenges by defining challenges over which they felt least control such as drug use as not applicable previous research showed that pwid perceive more hiv and drugrelated stigma postrelease than within prison and intentions to make changes in drug use are stronger in prison than after release 13 also participants in prison may have overvalued their own selfefficacy and thus not felt that bhelp getting off drugs was necessary as they believed they would be able to do so on their own 69 consequently after release our participants little interest in healthrelated challenges may decrease further longitudinal research must examine how pwids attitudes and behavior concerning addiction treatment change during postprison transition it would also be desirable for future surveys after release to ask participants to choose and rank their top three reentry challenges in order to expand analysis options our findings have implications for policy and practice concerning is the high exposure to methadone in kyrgyzstan yet the relatively low interest in this treatment multiple factors may have contributed to this finding including the perceived ineffectiveness of this treatment in a setting where methadone coverage is more prevalent feelings toward methadone by other prisoners are extraordinarily negative leading to bullying and ostracism such as reported in moldova 68 in this context prisoners in the eeca region would benefit from potentially multiple types of interventions including those delivered by professionals and peers or through use of informed or shared decision aids such strategies would focus on how abstaining from illegal drugs and initiating oat may help released prisoners reclaim jobs reunite with family avoid overdose and reincarceration as the prison environment also shapes participants values and norms custodial and clinical prison staff may benefit from similar interventions to enhance their understandings of prisoners treatment goals 1378 the key implication is that despite the availability of oat prisoners may forego treatment future studies should explore effective methods to overcome barriers by using informed decisionmaking aids or delivery of effective motivational sessions using professionals or peers implementation science studies that overcome scaleup barriers are urgently needed to address patientlevel factors it is crucial to balance the evidence with prisoners own priorities and design oat programs in a way that would integrate support in addressing other social needs like employment support or job training conclusions prisoners in ukraine kyrgyzstan and azerbaijan prioritized postrelease everyday challenges like finding a source of income and reconnecting with family over healthrelated tasks despite their history of drug use and multiple comorbidities methadone was not viewed as an effective strategy for staying off drugs understanding and addressing the disconnect between the evidence and the belief that devalues that addiction is a disease that can be effectively treated like other chronic diseases will be crucial for scaleup in designing programs for released prisoners national and international organizations in eeca must consider educating prisoners and prison staff in how prioritizing addiction treatment helps accomplish other community transition goals funding this work was supported by grants r01 da029910 r01 da033679 and r36 da042643 from nida	facing competing demands with limited resources following release from prison people who inject drugs pwid may neglect health needs with grave implications including relapse overdose and noncontinuous care we examined the relative importance of healthrelated tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in ukraine azerbaijan and kyrgyzstan a proxy measure of whether participants identified a task as applicable easy or hard versus not applicable was used to determine the importance of each task correlates of the importance of healthrelated reentry tasks were analyzed using logistic regression with a parsimonious model being derived using bayesian lasso method despite all participants having substance use disorders and high prevalence of comorbidities participants in all three countries prioritized finding a source of income reconnecting with family and staying out of prison over receiving treatment for substance use disorders general health conditions and initiating methadone treatment participants with poorer general health were more likely to prioritize treatment for substance use disorders while prior drug injection and opioid agonist treatment oat correlated with any interest in methadone in all countries only in ukraine did a small number of participants prioritize getting methadone as the most important postrelease task while communitybased oat is available in all three countries and prison
introduction rural development is a purposeful process to improve the life quality of the rural community and address issues related to society the economy and the environment as a tool rural development is expected to build a prosperous competitive rural community this context requires support from multiple parties including the government private stakeholders nonprofit institutions and the rural community in their effort at rural development the government plays a vital role in providing support and facilities while ensuring that the rural development program can run in an effective and efficient manner friedman and allonso stated that regional development is a strategy to utilize and combine internal factors and external factors as potentials and opportunities for improving the production of goods and services in respective regions while internal factors include natural resources human resources and technology resources external factors are opportunities and threats that often arise from interactions with other regions alkadri describes regional development as a harmonious relationship between natural resources human resources and technology resources that is nurtured by considering the environmental capacity in community empowerment this current study is particularly significant in the field of village tourism development as it theoretically develops a model that connects important variables in rural development including leadership entrepreneurship and the local communitys ability to develop creative tourism products and sustain them as a business the external role serves as a moderating variable that is crucial in determining whether it strengthens or weakens the potential of village communities andri stated that efforts to accomplish rural development goals are currently facing different challenges from the past the first challenge is related to external factors such as international development in the liberalization of investment flow and global trade the next challenge is the internal conditions which include to name a few the transformation of economic structure spatial migration and sectoral issues food security agricultural land availability investment and capital problems science and technology challenges human resources environmental issues and others in spite of this the government of indonesia has attempted to address these challenges through regulations such as the rpjmn 20152019 which is parallel to the visions of president joko widodo in the third point of nawacita namely building indonesia from the outskirts by strengthening the regional and rural areas in the vicinity of unitary state have tourism objects but are difficult to develop autonomously so there needs areabased development the potentials of the three villages are presented in table 1 these tourism potentials are not optimally managed by the apparatus and community in three villages a study by piani reported that although the government of banyumas regency has formed the coordinating team for development of rural area of the agrotourism in kendeng mountain somagede subdistrict using collaborative governance approaches and engaged the community subdistrict government and universitas jenderal soedirman there is lack of positive results for tanggeran kliting and kemawi villages this finding shows that the original plans for the tourism potential failed to achieve without apparent development upon evaluation of the development of rural tourism in tangeran klinting and kemawi it was found that there needs to be a synergy and solidarity between the apparatus and the community in each of the three villages in addition developing rural areas take collaborative actions between the village government and support from the regional government olberding in harsanto stated that collaborative practice to achieve regional economic development may be undertaken in two ways first every village develops its agrotourism potential by competing with other villages as a result agrotourism can flourish in one village but fail in others or worse fail in all locations due to competition second the collaboration between villages to develop areabased agrotourism the second way is technically able to produce multiple benefits and profits so that tourism potentials in each area can develop therefore it is the ideal option for the government of banyumas regency to improve agrotourism through collaborative practice in three geographically close villages namely tanggeran klinting and kemawi areabased development approach and collaboration between villages are new concepts implemented in banyumas regency nevertheless collaborative practices face multiple challenges some studies found issues related to the collaborative administration model that did not support synergy and partnership between the stakeholders commitment lack of coordination lack of trust between stakeholders and limited access to information according to huxham et al collaborative competency determines the level of success of the collaboration based on these issues this study aims to build a model of collaborative competency from actors engaged in areabased rural development literature review rural development is a concept implemented in many regional areas in indonesia based on law number 5 of 2014 on village aiming to put forward villages as one of the development objects andri in his study concluded that villages need to be perceived as the potential basis of economic activities and expected to be the new paradigm in the overarching economic development programs in indonesia meanwhile badri stated that the current development has undergone significant changes in both the concepts and the process today the concept of development is no longer limited to the agriculture sector and basic infrastructure but instead moving towards the development of information communication and technology further considering community participation as one of the vital elements in the development process it is necessary for the rural government to first ignite community participation as one of the targets of rural development itself the concept of rural community development proposed in the present study is the collaborative competency model the term competency was first introduced by boyatzis as the capability of individuals embodied in their attitude parallel to work demand woodruffle stated that competency should not be considered an element but rather a concept to illustrate ones understanding of the relationship between the expected implementation and the desired implementation of a project based on the information of the previous implementation meanwhile wibowo mentions that competency is the ability to carry out or execute a job or a task by harnessing skills and knowledge supported by the appropriate attitude required at the respective workplace spencer spencer defined competency as the basic characteristics of an individual through the causeandeffect relationship with the criterionreferenced effect or high spencer are motive trait selfconcept knowledge and skill competency measurement involves evaluating individual or group capabilities in carrying out particular tasks or work and how they demonstrate knowledge skills and attitudes required for the job the measurement may take the form of tests direct observations or interviews further competency development would engage learning and improving necessary skills to achieve success at work or career it may be carried out through training formal education or work experience obtained from work competency is also related to human resource management which includes a series of selection development and performance evaluation of employees the implementation of competencebased management of human resources can help organizations to identify aspiring employees who demonstrate a particular aptitude to achieve success in certain positions and enable the development of effective evaluation of work performance as the employment world gets more competitive employees capacity and skills become crucial factors in an organizations success accordingly competency development and measurement are important to optimize organizational performance and individual careers the term collaboration refers to a partnership between two or more individuals or groups to achieve common goals collaboration requires open communication coordination information and resource sharing and enabling individuals and groups to harness each others forces to reach shared goals collaboration is a crucial practice in many sectors including business education and research some types of collaboration include internal collaboration within an organization interorganization collaboration interregion collaboration and global collaboration while internal collaboration engages partnerships between individuals or units within one organization interorganization collaboration involves a partnership between multiple organizations interregion collaboration refers to a partnership between different regions within one or different countries and global collaboration is an interindividual or intergroup partnership between different countries to achieve shared goals collaboration can provide multiple benefits such as improved creativity better effectiveness and enhanced capacity to address complex problems however collaborations are not without challenges which may include communication barriers poor coordination and different perception or goals that may hamper the improvement of collaboration the implementation of information communication and technology also enables more effective collaboration technology tools like video conferencing platforms online collaboration platforms and software for project management enable individuals and groups to collaborate effectively regardless of being in different locations unambiguous and open communication can help ensure that every individual in the team shared common goals and work in parallel in the collaboration every individual also needs to consider individual differences and uniqueness and find a way to integrate their contribution to the whole project a previous study by ernawati specifically discusses four types of collaborative competency attitude culture knowledge and skills riggio stated that collaborative competency is the individual or groups capability to work together with other people to reach shared goals this type of competency includes the ability to communicate effectively build a positive working relationship appreciate the difference and uniqueness of others and handle conflict well the study also demonstrated the importance of collaboration among various stakeholders such as government local communities and the private sector furthermore transformational leadership has a positive impact on creative behavior whereas transactional and laissezfaire leadership styles have negative effects moreover effective succession planning and management can enhance the positive impact of transformational leadership on creative behavior therefore the study recommends that leaders in jordanian medium and small companies adopt transformational leadership styles and implement effective succession planning to foster a creative work environment and achieve better organizational outcomes in a more complex and dynamic working environment collaborative competency has never been more important to create a productive and innovative working environment in collaboration individuals with different backgrounds and employment experiences come together to create better and more innovative solutions additionally collaborative competency is the key solution to complicated problems that cannot be addressed singlehandedly some crucial elements of collaborative competency according to ribbers and wijnhoven are as follows 1 the capacity of effective communication individuals must be able to listen and talk clearly and effectively to ensure that the intended message is delivered and understood correctly by other people 2 the capacity to build a positive working relationship individuals must be able to build a positive relationship with other people including the ability to appreciate the differences and uniqueness of others 3 the capacity to work as a team individuals must be able to work in a team and contribute their skills and knowledge to come up with better and more innovative solutions 4 the capacity to mitigate conflict correctly individuals must be able to address conflict well and solve problems constructively data and methodology type of research this research applied a qualitative approach which according to marshal and rosman leans towards describing and emphasizing contexts research backgrounds and subjective references to obtain reliable data the researchers delved into the vast amount of information related to the experience knowledge and facts from the informants about the collaborative development programs between the villages of klinting tanggeran and kemawi location and research sampling techniques this study was conducted in banyumas regency focusing on three villages as the research loci klinting tanggeran and kemawi the location was selected purposively because the three villages were in the middle of developing intervillage collaborative programs for agrotourism in their area these villages have great potential for tourism to flourish research data collection methods data collection was performed through three techniques first focus group discussion with people whom we perceived capable of discussing the topics related to collaborative competency namely the actors of intervillage collaboration in somagede subdistrict second indepth interviews to collect robust data through facetoface surveys with informants with or without an interview guide and the interviewer is involved in their social life for a relatively long time third documentation which collects data from written sources related to the focus of the research problems in form of documents owned by the object or subject of research lastly the observation that requires the researchers to field visit to relevant sites and events in terms of space time place actors activities things and feeling data analysis methods this research utilized a descriptivequalitative analysis design data were built up from the results of interviews and focus group discussions for further analysis and deduction data processing used maxqda to codify narratives emerging from the interviews the data were subjected to the steps of data flow analysis proposed by miles huberman which includes data reduction data presentation and deductionverification in the current study this method was implemented through several steps first data and information were categorized sorted and simplified to compile the main problems related to the roles of stakeholders in the management of primary education units that were obtained from observations and nonstructured interviews from the key informants second the results of data categorization were subjected to triangulation using notes and documents obtained from the field third these issues were grouped into relevant concepts with the research problems then drawn into conclusions results and discussion this section elaborates on the findings of the collaborative competency study on the actors of intervillage collaboration for rural development four relevant competencies are communication giving and receiving feedback decisionmaking and conflict management each aspect is explained in detail below santosa explains that communication including the behavior of actors or external parties and the way they influence the interests and interpretation of others is one of the processes toward conflicts effective communication between parties may occur when trust is built among them communication wahyuningrat harsanto b t collaborative competency for rural area development in indonesia similarly the pattern of communication competency in the intervillage collaborative programs found several issues related to communication in sectors as illustrated in figure 1 below figure 1 shows an intercorrelation pattern between issues and actors in the collaborative competency of communication in this term the respondents agreed that communication is a crucial factor in the success of rural area development in kendeng mountain reflecting on the pattern of issues emerging in communication some issues revolved around the strong sectoral ego misunderstanding or misperception extremely passive communication between authoritative parties the ambiguous flow of communication between institutions and conflicts of interest that potentially harmed the collaborative practices implemented in three villages further embodiment showed that some stakeholders were involved in supporting and bridging the communication process between villages it demonstrates that at least they engaged multiple stakeholders including a higher education institution as the supporting partner the subdistrict government as the leading sector to manage the administrative area the regency government as the actor for program monitoring and evaluation and other institutions such as giving and receiving feedback feedback or giving advice is an important element in an organization armstrong stated that feedback given to individuals about their performance is crucial for performance management in this regard feedback provides information on performance results events critical incidents and significant behavior while positive feedback informs the recipients of their good conduct and constructive feedback offers suggestion on how to do something better negative feedback tells the recipients of their poor performance it has been reported that feedback can reinforce effective behavior and point out where and how behavior should be changed rusli lutan explains that feedback is acquired knowledge relative to particular tasks actions or responses given based on these expert definitions we conclude that feedback is information related to individual and management capacity to keep improving collaboration between institutions creates a mutually influential or interdependent relationship similar to the pattern of network involvement in figure 2 the intervillage collaboration will lead to a high level of interdependency especially between collaborating villages and other stakeholders such as rural collective business entity bkad and subdistrict government in other words when one party is underperforming the overall collaboration will suffer giving and receiving feedback is a crucial competency in order to produce the best performance to achieve shared goals nevertheless giving and receiving feedback may be perceived as taboo because local culture and tradition have suggested that correcting other people should be avoided in order to remain sensitive to others feelings as mentioned before giving and receiving feedback becomes urgent when problems like sectoral ego emerge however despite establishing a memorandum of understanding between the parties each village frequently upheld its own reflecting on previous studies we highlighted that the contributing factors to the success of giving and receiving feedback for the community to create constructive collaboration practices in rural development are 1 give and receive feedback using emotional intelligence embodied in polite emotionally controlled manners 2 give and receive feedback sensibly for their shared problems 3 give and receive feedback trustfully 4 give and receive feedback that focuses on performance rather than personal character decision making ansell and gash define collaborative governance as a regulation set by one or more public entities which directly involve nonpublic stakeholders in the process of making collective formal decisions oriented towards consensus and forum discussion aiming to stipulate or implement public policies or management of programs and public assets agrawal and lemos engaging both approaches we concluded that decisionmaking competency is a crucial aspect of the issue of collaborative governance the pattern of the narratives and actors in decision making which emerged from the present study is as follows figure 3 illustrates the relationship pattern between actors and narratives emerging from the decisionmaking process in carrying out collaborative rural development similar to giving and receiving feedback competency collaboration and intercorrelation patterns have made decisionmaking as a required instrument in the overall competency because every decision made will affect the achievement of targets in shared interests discussions and arguments about decision making highlighted the program planning and execution in which the decision makers should fully consider all aspects to come up with the decision which is the best and acceptable solution for all parties to arrive at the best decision alternatives in collaborative rural development some elements need to be considered first decisionmaking needs to better understand the problems currently faced the situation may turn worse when every stakeholder promotes their interests so decisions made should uphold mutual interests so that no party feels disadvantaged then the decision maker should anticipate the potential issues or challenges after the decisions have been made therefore the ability to gather information and analyze data is crucial to arrive at the right decision by considering all available information and relevant data about the issues decisionmakers are expected to produce several alternatives with their risks and benefits then these alternatives should be communicated in the forum for collective analysis to arrive at mutual decisions developing such a competency pattern is also expected to encourage mutual respect between parties so that the collaboration will be strengthened and impact the progressive development of the rural area that provide benefits for the local community as explained by mitchel disagreement and conflict behavior are the common roots of conflict this issue is fueled by the sectoral ego of each village which wants better development for their area than others meanwhile each village has previously agreed to form a partnership and collaborate in rural development some findings of this study concluded that conflict management must meet several elements first it must have an accommodative capacity which means that each village must be openminded to different aspirations perspectives and opinions in this way every collaborating party should have mutual understanding and respect one of the ways to manage conflict is by listening to others opinions respecting differences and upholding others interests proportionally second collaborative capacity is the capacity to turn conflict into a positive by offering opportunities to parties involved in the conflicts to enable them to collaborate third the capacity to compromise is crucial to arrive at common ground disputes frequently occurred between the three villages and conflicts of interest and disagreement will always exist therefore every party should try to compromise and respect one another to come up with a mutual agreement conclusion this study develops a collaborative competency model between the actors of intervillage collaboration to develop rural areas there are four aspects of competency required in this process first communication is crucial in collaborative development to build rural areas because communication enables all parties to express and achieve the shared goals in rural development second giving and receiving feedback is an important competency to carry out collaborative development in rural areas positive or negative feedback may offer beneficial impacts on both organizations and individuals engaged in the collaboration third decisionmaking is required in every implementation of collaboration because the decision will impact the achievement of mutual goals lastly conflict management is vital for implementing collaborative development in rural areas because it serves as an evaluation system in the development of collaboration conflict management the last aspect of this finding is management conflict competency conflict is a dispute between multiple interests values actions or directions that have historically integrated into life conflict either positive or negative is inevitable the positive aspects of conflict may emerge when conflict can help identify the process of managing ineffective resources clarify ambiguous ideas and information and explain the misunderstanding the root of prevalent conflict includes four aspects different knowledge and understanding different values different interests and personal affairs or historical background in this conflict management competence we found the patterns between actors and narratives as follows figure 4 illustrates the narrative patterns emerging from the management conflict competency in intervillage collaborative development the conceptual definition of conflict management is the process arts knowledge and all resources available for individuals groups or organizations to achieve the goals of conflict management conflict management is a series of actions and reactions between the actors and external parties in a conflict this competency requires the involved parties to manage conflict because it potentially	the aim of this study is to formulate a model of collaborative competence for village government officials in the context of rural development in indonesia this study is conducted to fill the research gap on collaborative competence in the context of rural development in indonesia which is considered a strategic key to supporting village development in the countrythe collaborative competency model is the concept of rural community development proposed in this study boyatzis 1982 defined competency as an individuals capability manifested in their attitude parallel to work demand according to woodruffle 1992 competency should not be considered an element but rather a concept to demonstrate ones understanding of the relationship between the expected and desired implementations of a project based on previous implementation information designmethodologyapproach this study uses a qualitative approach with descriptive analysis which emphasizes on context research settings and subjective references rural development in indonesia has received focused attention through nawacita and banyumas regency in central java has built an agrotourismbased site in the villages of tanggeran klinting and kemawi in the gunung kendeng area somagede district the results of this study are expected to contribute to the development of social sciences particularly regional developmentthe results have three key elements are required for effective conflict resolution for starters each party must be open to different perspectives and opinions while demonstrating mutual understanding and respect second a collaborative capacity that allows parties to turn disagreements into opportunities for collaboration finally despite existing conflicts of interest and disagreement the ability to compromise is required to reach a mutual agreementthe findings of this study indicate that effective collaborative capabilities among all parties involved including the government community and private sector are necessary for the development of rural areas in indonesia this highlights the significance of cooperation and collaboration among different parties in striving to enhance rural welfare and development in the country additionally this research contributes to the advancement of social sciences particularly in the realm of regional development consequently this article serves as a valuable resource for researchers and practitioners seeking to enhance their collaborative competencies within the context of rural development in indonesia
family members as primary decisionmakers if extended families shape the objectives and constraints of households then neglecting the role of this network may lead to an incomplete understanding of healthseeking behaviour understanding the decisionmaking processes behind careseeking may improve behaviour change interventions better intervention targeting and support healthrelated development goals this paper uses data from a cluster randomised trial of a participatory learning and action cycle through womens groups to assess the role of extended family networks as a determinant of gains in health knowledge and health practice we estimate three models along a continuum of healthseeking behaviour one that explores access to pla groups as a conduit of knowledge another measuring whether womens health knowledge improves after exposure to the pla groups and a third exploring the determinants of their ability to act on knowledge gained we find that in this context a larger network of family is not associated with womens likelihood of attending groups or acquiring new knowledge but a larger network of husbands family is negatively associated with the ability to act on that knowledge during pregnancy and the postpartum period introduction economists have long expressed health gains as the result of a household production function in which careseeking is an input models of health production and health care demand commonly account for the role of nuclear family members in shaping investments in health building on work by becker jacobson postulates a framework in which family members have common preferences in health production assuming that family members will obey all decisions made by the family bolin et al then present a model in which investment in health is decided through a bargaining process within the family 1 they stress the importance of conflicting interests between husband and wife and in later work allow for conflict and strategic behaviour within the nuclear family few studies considered that nuclear families are embedded within extended family networks if extended families shape behavioural objectives and constraints then neglecting this network may lead to an incomplete understanding of healthseeking behaviour the role of extended families may be particularly relevant in poorer settings that are frequently characterised by missing or incomplete safety nets missing markets and correlated shocks to economic and physical wellbeing understanding the adoption of new knowledge or health care practices in this context may support behaviour change interventions improve intervention targeting and support healthrelated development goals while previous studies have analysed the determinants of maternal and neonatal care in nepal none have yet focussed on the potential role of kinship networks in promoting health gains or losses outside of the health and development discourse existing literature proposed community and kinship networks as a source of private transfers and financial risk sharing savings and credit associations are practical examples of financial risk sharing within community networks the analysis of financial transfers between households had also highlighted their role as risk sharing mechanisms indicating that such transfers usually take place between close relatives other studies of labour markets showed how family networks relay information about job or business opportunities granovetter similarly documented the role that networks play in matching workers and employers emphasising the important role of weak ties over strong ties in diffusing new information and knowledge montgomery in contrast proposed a model in which employed workers help their employer identify suitable recruits who are often relatives munshi provided evidence of how information about business opportunities circulates in family and ethnic networks if information about employment opportunities is circulated in this way it is possible that information about appropriate health behaviour and access to services is also circulated through extended family networks while the literature on risk sharing suggested that extended family networks may positively impact appropriate careseeking other work suggested that this impact may be negative numerous studies from economics anthropology and sociology have found mixed results some studies show that networks and family ties can have a negative effect on individual wellbeing when cultural norms and traditions prevent acting on new information including the adoption of innovative and potentially beneficial behaviours and technologies for example adongo et al found that a high risk of social ostracism and familial conflict prevented the uptake of contraceptive use in rural ghana even when services were freely available similarly sear et al found that the presence in the household of the husbands mother and to a lesser extent the husbands father increased the probability of a woman giving birth in rural gambia ie it increased her fertility rate together with the associated health risks of high fertility in that context conversely several other studies conducted in africa and asia showed that family networks may have a positive influence in matters related to the different stages of childbirth for example aubel et al found that senegalese grandmothers have the ability to learn to integrate new information into their practices and to positively influence the practices of women in reproductive age their results supported the need for future maternal and child health matters programmes to involve grandmothers and in so doing to build on their intrinsic commitment to family wellbeing a number of studies have focused on the role of maternal and paternal grandmothers and kin and found that maternal grandmother and maternal kin have a positive effect on child survival child health and nutrition similarly karmacharya et al focused on the associations between grandmothers knowledge and infant and young child feeding practices and tested whether the associations are independent of or operate via maternal knowledge their findings suggested that grandmothers correct knowledge translated into mothers correct knowledge and therefore optimal infant and young child feeding practices in the context of an intervention aiming to change health practice through information dissemination the expected effect of extended family networks on healthseeking behaviour may be positive or negative 2 larger families might however exert more pressure on women to adhere to traditions and social norms in spite of new information received this would result in less appropriate careseeking in societies with norms that promote the seclusion of women or the use of traditional practices that carry health risks this paper uses crosssectional data from rural nepal to empirically test the influence of family networks on positive health practices in this study we proxy family networks with the number of female relatives living in the same village development committee distinguishing between womens own relatives and her husbands relatives husband and own relatives are differentiated because women in this context tend to live with their husbands families after marriage usually in extended family groups data collection was embedded within the surveillance system of a cluster randomised control trial to reduce neonatal and maternal mortality the intervention comprised communitybased womens groups working through a participatory learning and action cycle henceforth pla 2 the pla groups disseminated information about appropriate health care practices for pregnant women and their newborn children women were free to attend or not attend the groups and were free to act or not act on the information shared in the groups evaluation of the trial showed that the intervention reduced neonatal death by 30 in the intervention areas and that women in intervention areas were more likely to have antenatal care an institutional delivery a trained birth attendant and hygienic care compared with women in control areas in this paper we explore whether larger family networks are positively or negatively associated with the adoption of these and other potentially beneficial careseeking practices by women during the perinatal period this paper is organised as follows section 2 describes the study location and further detail on the data and data collection section 3 describes the analytical 2 manandhar et al focus on the effect of the participatory intervention with womens groups on birth outcomes as summarised above morrison et al focus on the functioning of the womens groups they describe the implementation including the community entry process facilitation of monthly meetings community planning and implementation and evaluation of strategies to tackle problems within the group discussions they find that the womens groups developed varied strategies to tackle problems of maternal and newborn care wade et al compare perinatal careseeking before and after the intervention they analyse whether the programme increased antenatal care the use of a boiled blade to cut the cord appropriate dressing of the cord and retaining colostrum among those not initially following good practice women in intervention areas were significantly more likely to do so later for all four outcomes mesko et al focus on information gathered from case studies and focus group discussions with women family members and health workers they find that early pregnancy was often concealed preparation for birth was minimal and trained attendance at birth was uncommon family members were favoured attendants particularly mothersinlaw they find that there were delays in recognising and acting on danger signs and in seeking care beyond the household in which the cultural requirement for maternal seclusion played a part methodology and section 4 presents the main results section 5 concludes with a brief discussion of the results and implications for future research in this area data study area the study was based in the district of makwanpur a central region of nepal it had a population of nearly 400000 people covering an area of 2500 km 2 and including both hills and plains most residents were engaged in smallscale agriculture at the time of the trial there were more than 15 ethnic groups the largest of which was tamang followed by brahmin and chetri the district was geopolitically divided into 43 vdcs the district hospital in the municipality of hetauda had facilities for antenatal care and delivery perinatal care was available through a network of primary health centres health posts subhealth posts and outreach clinics traditional birth attendants were available throughout the district but their services were costly and often not affordable for families data as mentioned previously data collection for this study was embedded within the surveillance system of a cluster randomised control trial to reduce neonatal and maternal mortality for the trial 12 pairs of vdcs were selected within the district and one of each pair was randomly assigned to the intervention or control group in the intervention clusters pla meetings were organised to identify existing perinatal problems and formulate strategies to address them at a local level 3in the second phase of the programme the intervention was extended to the original control areas during that phase a substudy aimed to collect data on social networks spread of information demographic and socioeconomic characteristics previous pregnancies distance to group meetings and distance to health care facilities these data were collected from the same 12 pairs of vdcs between january 2007 and may 2008 at 1 month postpartum women were interviewed about antenatal care delivery and postdelivery care homecare practices maternal morbidity neonatal morbidity and health service use as well as information on demographic and socioeconomic characteristics a subsample of women were also asked questions about social networks spread of information within the family participation in womens group meetings and distance to the pla group meetings and health care facilities these women were asked to list up to five female4 relatives currently living in the same ward and the same vdc5 relatives were categorised as sisters wives of brothers husbands sisters wives of husbands brothers mother and motherinlaw this categorisation makes it possible to distinguish between own family and husbands family as described later in section 3 the sample used for the analysis in this paper consists of 1749 women who answered both the main trial questionnaire and the additional social network questionnaire the demographic and socioeconomic characteristics of the sample are described in detail in table 1 in summary the average age of the women in our sample is 26 years and the average age at marriage is 17 years in all 52 of women in the sample have no education and only 47 of women were able to read a basic line of text the most common source of drinking water is the river and public pipes and most homes are constructed from mud and stone most women belong to households where the main occupation is agriculture women lived an average of half an hour from the nearest pla group meeting place and just over an hour from the nearest health care facility in table 1 the 15 ethnic groups in our sample are collapsed into four categories as follows tamang brahminchhetri magar and other the wider anthropological literature6 describes tamang as the major tibetoburmanspeaking community in nepal who maintain the belief that they originate from tibet most tamang are selfsufficient in terms of food and are the ownercultivators of their land the tamang community is divided into clans that are exogamus preferred marriage is between crosscousins the brahminchhetri population has had a dominant role in the formation of the nepali nation they rank highest in the cast hierarchy and form the majority of influential and wealthy people of traditional nepal their main occupations are farming and government service among them the richest are landlords senior officers in the army or political leaders brahminchhetris do not practice crosscousin marriage village exogamy is observed magar are mostly hindu agriculture is the basis of the magar economy which is largely selfsufficient magar are endogamous magar women occasionally marry outside the group but men almost always marry within the group where they can marry anyone within the magar community except members of their own patrilineage again crosscousin marriage is preferred the residual group of ethnicities is heterogeneous it includes privileged ethnicities such as the newar as well as less privileged ethnicities such as praja and kami newar are the indigenous people of nepals kathmandu valley and are prominent in every sphere from agriculture business education and government administration to medicine law religion architecture fine arts and literature methodology to explore the potential role of family networks in influencing health behaviour in this context we construct three linear regression models first we estimate the number of times a woman attended pla groups to establish the determinants of participation next we estimate the level of knowledge regarding positive health care practices and the determinants of that knowledge finally we estimate the determinants of positive care practice in this study we proxy family networks with a count variable that enumerates the number of female relatives living within the same vdc distinguishing between womens own relatives and husbands relatives on average women in the sample had 126 husbands female relatives and 142 own female relatives within the same vdc as group participation level of knowledge and positive careseeking are all enumerated by continuous variables we estimate linear regression models specified as follows pla c α β 1 wife rel c β 2 husband rel c θx c φ 1 dist pla c φ 2 dist healthinst c ε where pla indicates the number of times a women attended the group in cluster c the variables wiferel and husbandrel represent respectively the number of womans and husbands relatives x is a vector of sociodemographic characteristics summarised previously in table 1 including age age at marriage previous pregnancies and ethnicities this vector also includes a proxy of wealth that is measured using a multidimensional poverty index the index used in this text covers the same three dimensions as the human development index ie education health and standard of living7 and captures a set of direct deprivations that batter a person at the same time in this context where households may arguably be described as homogeneously poor it is a more comprehensive measure of deprivation that differentiates households in a meaningful way the variable distpla and disthealthinst indicate respectively time to reach the nearest pla and the nearest health institution ε is an error term that we assume to be independently distributed the subscript c stands for the cluster in the model of level of knowledge we also include pla participation as an independent variable in a model specified as follows health know c α β 1 wife rel c β 2 husband rel c γpla c θx c φ 1 dist pla c φ 2 dist healthinst c ε health knowledge is measured using a count variable that adds up a womans knowledge of 18 good behaviours during the three key stages of childbirthie pregnancy delivery and the postnatal period in each instance respondents were asked what care in their opinion mothers needed during each stage to reduce respondent bias the list of possible behaviours included positive negative and neutral behaviours these behaviours are summarised in table 2 where good behaviours included in the health knowledge count are numbered and those excluded from the count are not a womans level of health knowledge is then the sum of the good behaviours of which she is aware in this sample respondents were aware of an average of 456 positive behaviours in the model of positive health care we additionally include level of knowledge as an independent variable in a model specified as follows healthcare c α β 1 wife rel c β 2 husband rel c γ pla c δ health know c θx c φ 1 dist pla c φ 2 dist healthinst c ε health behaviour may include a range of possible behaviours as listed in table 3 as with health knowledge these behaviours span the three key stages of pregnancy delivery and the postnatal period to construct a single variable for health behaviour respondents were asked which behaviours they undertook these responses were then combined using a firstorder factorial from a principle components analysis to form a normalised index of careseeking with a value between 0 and 1 a count measure is not appropriate for this variable as the behaviours are not additive in the same way as knowledgefor example a delivery might take place in a health facility or it may be conducted at home by a skilled birth attendant both of these behaviours are positive but are mutually exclusive the constructed health behaviour index has a high scale reliability coefficient of 07845 and skewness of 03668 table 4 shows the descriptive statistics of outcome variables in the three models presented namely the number of times of pla attendance level of knowledge and positive health care index by four age groups although there is no clear agedependent pattern for the number of times pla were attended both level of knowledge and the positive health care index are higher for younger women and are the lowest for older women results the results for the three linear models of pla participation health knowledge and health behaviour are summarised in table 5 in all the regressions confidence intervals consider heteroscedasticity robust standard errors clustered at the community level moreover given the number of communities we adopted the wildcluster bootstrapt procedure by cameron et al this procedure is shown to improve inference in cases of less than 30 clusters which is our case as the total number of committees participating in the programme is 24 estimates for pla participation in column 1 suggest that family networks do not significantly affect pla participation however women who married later in life or are living further from the nearest pla group will attend less often conversely women who have had previous pregnancies or are multidimensionally less poor attend a greater number of groups estimates for health knowledge in column 2 indicate that more frequent pla participation significantly and positively affects health knowledge the only other significant determinant of health knowledge is multidimensional poverty less poor women have greater knowledge of maternal and newborn care as with pla participation family networks do not affect the level of health knowledge estimates of positive health care practices in column 3 show further that the level of knowledge is a positive and statistically significant determinant of good practice other positive determinants of good practice include older age at marriage and being family networks and healthy behaviour 241 multidimensionally less poor in contrast with the two previous models the number of husbands relatives in a womans family network negatively and significantly predicts care practice this finding suggests that women living in larger husbands family networks are less likely to adopt good health care practices even with the same level of knowledge as contemporaries with smaller husbands family networks other significant negative determinants of health practice include current age having had a previous pregnancy distance from a pla group distance from a health institution and being of tamang magar or other ethnicity relative to brahminchhetri discussion and conclusion this paper reviewed the existing literature on the role of family networks in shaping healthseeking behaviour while there have been a number of studies describing the effect of nuclear families on decisionmaking the potential role of extended family networks is less well understood existing evidence was used to explain how the expected effect of extended family networks on healthseeking behaviour may be positive or negative this paper used crosssectional data from rural nepal to empirically test the role of extended family networks on the acquisition of knowledge about positive health care practices and then the impact of networks on the practice of positive care in that context we measure family networks by counting the number of female relatives living in the same local area distinguishing between womens own relatives and husbands relatives we find that in this context family networks do not affect womens ability to attend pla groups as the source of knowledge nor womens ability to absorb and recall knowledge gained at the group however family networks are a significant and negative determinant of womens ability to act on the knowledge gained and engage in positive health practices we find further that the differentiation between own and husbands family network is an important one in this context while a womens own family network has no significant effect on health behaviour the size of her husbands family network has a direct and negative effect on health behaviour the difference in the effect of the two networks is perhaps unsurprising given that women in this context live within the maritalhusbands home and are thus physically located within the husbands extended family network as such this network might be considered to consist of strong ties these data thus provide early evidence for the hypothesis that larger families exert more pressure on women to adhere to traditions and social norms in spite of new information received this would result in less appropriate careseeking in societies with norms that promote the seclusion of women or the use of traditional practices that carry health risks unfortunately our data do not allow us to better investigate the role of tradition and social norms and our interpretation of the results remains speculative indeed there may be other factors driving the results the main alternative factors leading husbands family network not to supportencourage positive health care practices during the different stages of childbirth might be perceptions by members of the husbands family network that antenatal care or postnatal care were not beneficial based largely on their own past experiences the scarcity of resources under their control and power relations between mothersinlaw and other husbands family members on the one side and daughtersinlaw from the other side in addition we find that a higher multidimensional wealth index positively predicts participation in knowledgegenerating activities the level of health knowledge and good health practice pla participation is the only other significant predictor of knowledge aside from multidimensional poverty level of knowledge in turn positively predicts health practice as does close proximity to a health institution notably having married older positively predicts health practice but negatively predicts group pla participation and thus ostensibly knowledge acquisition this is independent of the effect of education captured within the mpi although marrying older negatively affects pla participation it does not however significantly affect a womans level of knowledge in this context where very early marriage is the norm and 90 of women are married by 20 years of age older age at marriage may be capturing something other than an age differentialinstead measuring a girls willingness and ability to delay marriage older age at marriage will result in older age at first parity and possibly also a higher status within the household women in our sample who marry older have a higher level of education women with a higher level of education similarly have a higher level of health knowledge a brief analysis of pla nongroup participants in this context further shows that women who marry older have a higher level of knowledge than nonparticipants who marry younger however among group participants the difference in health knowledge is no longer significant the pla groups raise the level of knowledge among attendees and women marrying younger attend more pla groups resulting in a levelling effect controlling then for level of knowledge women who marry older are then more likely to be able to act on their knowledge one known limitation of this analysis is our inability to control for the possibly differential and mediating effect of individual empowerment on the acquisition of health knowledge and on resulting behaviour change age at marriage may in part be capturing this effect and more work is required in this area conversely current age is not a significant predictor of knowledge and is a negative predictor of health practicesuggesting instead that older women may be more likely to adhere to traditional behaviours or less likely to adopt new ideas perhaps unsurprisingly distance from a pla group negatively predicts group participation and health practice similarly the distance from a health facility negatively predicts practice in conclusion then the extended husbands family networks within which women reside in rural nepal are negatively associated with medical best practices for maternal and child health while no significant association is found for womans family networks one potential explanation is that husbands family networks exert pressure on women to adhere to traditions and social norms that conflict with current thinking around medical best practice this results in s lower translation of new knowledge into practice in this context we find that analyses of extended family networks should differentiate between womens own relatives and husbands relatives or risk a misleading null result overall although these findings relate directly to the surveyed communities in nepal they may also apply to other comparable societies where families live in extended family groups with norms that promote the seclusion of women or the use of traditional care practices that carry health risks these findings suggest that health information and behaviour change interventions targeted at women in this context will need also to engage the wider family network to maximise their effectiveness strategies to delay age at marriage or reduce multidimensional poverty may also improve womens ability to act on health knowledge trial which combined plas with the strengthening of health management committees to increase skilled birth attendance all of the 43 vdcs in makwanpur district were randomised to intervention or control with 21 in intervention and 22 in control no groups were run in control clusters of the lhmc trial by ucl or mira the trial ran from 2010 to 2012 after which all activities closed the intervention used the principles of the four d cycle of discovery dream design and destiny a consultant conducted a training of trainers with mira researchers representatives from the district public health office district development committee and family planning association of nepal fourday workshops were then conducted in local health facilities in each of the intervention vdcs over 4 months these workshops were attended by a districtlevel representative who had also attended the training of trainers during the workshop participants were exposed to the description of the maternal and newborn health situation in nepal and government strategies and priorities after briefing participants about the fourd intervention participants were invited to follow the dcycle • discover the success of their health institutions and remember who provided support or resources to facilitate this success • dream of how health institutions and the quality of services should be in order to guarantee appropriate maternal and newborn care • design a strategy to achieve their vision • destiny the last phase of this intervention is completed after health management committees have implemented their plans and participants present their accomplishments and the lessons learned suspension of active engagement in the area from 1 october 2012 to january 2014 all interventions programmes and surveillance activities led by ucl and mira ceased in the region followup activities are planned but not currently ongoing appendix 8 1 the primary participatory learning and action group trial as mentioned in section 2 our study takes advantage of an existing surveillance system designed around a large cluster randomised controlled trial of participatory action and learning groups the original trial was conducted between 2001 and 2003 and led by the ucl institute for global health in partnership with nepali ngo mother and infant research activities the intervention consisted of monthly communitybased participatory learning and action group meetings facilitated by a local nonhealth professional group participants explored health issues around pregnancy childbirth and newborn health the primary cycle consisted of a series of 10 meetings where the following issues were discussed 1 the work of the mira team is introduced 2 discussion of how mothers and babies might die 3 discussion of how women approach maternal and neonatal issues 4 discussion of common local maternal and neonatal problems 5 planning of methods to collect information on the relevant issues in the community 6 sharing of the information collected identification of the most important problems 7 discussion of strategies for addressing these problems 8 planning of the involvement of other community members 9 preparation for a meeting with other community members 10 presentation of the previous work to other community members discussion of strategies with other community members the form of the intervention could not be defined in advance as the nature of the discussion levels of involvement and potential solutions differ from group to group expanding the primary trial location and activities given the significant impact on mortality of the primary trial ucl and mira had an ethical commitment to offer the intervention to the control areas after a 2year preparation period from 2003 to 2005 the original intervention was rolled out in the control arm while a revised intervention focusing on careseeking for childhood illness and involving men in maternal and newborn health was rolled out in the intervention arm the local health management committee trial in january 2009 all participatory learning and action group activities were suspended in preparation for a new trial the local health management committee	family networks may serve as a source of private transfers and risk pooling extended family networks might therefore increase womens ability to act on information received and to access appropriate care family networks and healthy behaviour 233
introduction social support from family and friends is crucial for maintaining health and wellbeing it is a broad concept based on interpersonal interactions in which individuals perceive they have access to reliable friends or family members to rely on both during good and challenging times 12 good social relationships provide emotional and practical resources people need to feel cared for and valued which can encourage the adoption of healthier behaviors 3 for this reason social support is widely recognized by the scientific community and the world health organization as an important health determinant given its protective effects on individuals physical and mental wellbeing 34 it also demonstrates a positive association with health promotion behaviors quality of life and selfrealization directly influencing how individuals perceive their health 56 while most research on health demography and social epidemiology has focused on older adults investigating midlife health is equally essential for several reasons from a demographic perspective middleaged adults form a substantial and growing segment of populations in many countries influencing key demographic indicators such as population size aging trends and healthcare use 7 often referred to as the sandwich generation a term that describes those middleaged adults who are effectively pressured between the obligation to care for their aging parents and support their children 89 middleaged individuals juggle multiple roles serving as parents caregivers and sources of support for both younger and older generations 10 the level of social support they receive and perceive can significantly impact their mental and emotional wellbeing caregiving abilities and overall quality of life 11 from a public health perspective selfrated health and social support have significant implications for health promotion and disease prevention especially during middle age a critical period when many chronic diseases emerge 1213 furthermore social support plays a pivotal role in buffering the effects of stress and adverse life events access to adequate social support can provide individuals with emotional and practical resources to cope with stressors and reduce their negative health impacts 11 studies exploring the potential effects of social support on selfrated health among middleaged adults dwelling in brazil and how it varies among men and women are scarce which is a surprising gap considering the shared concern about the prevalence of loneliness among individuals in recent decades 141516 men and women in midlife may experience distinct social expectations roles and stressors that can influence their selfrated health understanding this relationship is crucial to address their specific health needs and promote gender equity in health 17 this study contributes to the current literature by examining whether social support is associated with selfrated health among middleaged brazilian adults and how this relationship varies among men and women by identifying the factors associated with poor selfrated health and possible gender disparities this study can inform the development of targeted interventions to improve the health of middleaged brazilian adults methods study design and participants this crosssectional study relied on data from the brazilian national health survey a nationwide populationbased survey conducted in 2019 by the brazilian ministry of health and the brazilian institute of geography and statistics the pns 2019 aims to describe the health situation and lifestyles of the brazilian population and is representative of geopolitical macroregions states metropolitan areas and 27 capitals of the federative units the pns 2019 draws upon a multistage probabilistic sampling design including individuals aged 15 years old or over residing in private households ie built for the exclusive purpose of habitation the selected sample included 31296 middleaged adults who answered questions about social support and selfrated health no ethical approval was needed as this was an analysis of publicly available data with no personally identifiable information main outcome measures health differences between men and women were analyzed as gender disparities in health despite physical and physiological characteristics such as chromosomal genotype hormonal levels and internal and external anatomy playing a role in health differences this study recognizes that socially constructed roles behaviors and expectations associated with being male or female play the most significant role 18 gender encompasses a wide range of nonbiological traits attitudes and behaviors 19 disparity was used in this context to refer to systematic avoidable and unfair inequalities in health and its social determinants occurring within and between population groups and disproportionately affect vulnerable populations due to inequalities in underlying social political and economic institutions 2021 individuallevel selfrated health was assessed using the following question in general how would you rate your health answers to this question range from very good to very poor this variable was dichotomized considering individuals who rated their health as good or very good as having good selfrated health and individuals who rated their health as fair poor or very poor as having poor selfrated health information on social support was based on the following variables in the pns 2019 how many can you count on in good or bad times from this question social support was defined as the perceived availability and adequacy of emotional informational and tangible resources provided by family membersrelatives or friends during times of need or stress the variables on social support in pns 2019 present four distinct categories none one two and three or more thus in this study lack of social support refers to individuals who reported having no family members or friends to rely on social support is the main explanatory variable that was hypothesized to link with selfreported health but other control variables were included as well the set of covariates considered in this study encompasses various aspects including demographic and socioeconomic attributes health behaviors and healthcare access all of which can significantly influence an individuals selfrated health to capture the demographic characteristics age was categorized into four groups 4044 4549 5054 and 5559 years additionally household location region of residence marital status and raceskin color were included as relevant factors affecting selfrated health socioeconomic attributes were measured by schooling level which was divided into three categories low middle and high moreover being a current smoker was used as a proxy for health behaviors as smoking habits can significantly impact overall health and wellbeing to account for physical and mental health status binary variables were included for chronic diseases obesity and depression diagnosis the latter was assessed by investigating whether the individual had ever received a diagnosis of depression from a physician or mental health professional this study also incorporated a dummy variable for health insurance coverage to assess the impact of healthcare access on selfrated health statistical analysis after selecting eligible individuals and potential variables for this study a descriptive analysis was conducted based on the dependent variable and its covariates categorical variables were described by their absolute and relative frequency pearsons chisquared test with yates continuity correction was used for categorical variables when comparing differences between groups in the descriptive analysis cramers v was employed to measure the association between the nominal variables pvalues above 005 were interpreted as insufficient evidence to differentiate groups logistic regression models were employed to test for differences in selfrated health between middleaged adults separate models were estimated for men and women to analyze gender differences in the association the models were adjusted for potentially confounding variables such as sociodemographic characteristics adulthood socioeconomic status health behaviors and physical and mental health status cad saúde pública 2023 39e00106323 a set of models was generated to test the additive and interactive effects between the variables sensitivity and residual analyses were also performed in the preliminary model selection rounds odds ratios a measure of association that compares the odds of an event occurring in one group to occur in another were used to present the results only the final fitted models were presented in this study results were considered significant at pvalue 005 all estimations were performed using r program with appropriate methods to handle complex survey designs such as pns 2019 results figure 1 illustrates the proportion of individuals based on selfrated health social support received from family members and social support received from friends for both men and women with 95 confidence intervals the overall prevalence of poor selfrated health among middleaged brazilians was 407 with a significant difference between men and women suggesting a higher prevalence of women reporting poor selfrated health compared to men approximately 57 of women and 53 of men reported not receiving any social support from family members more than 65 of the sample reported receiving family support from three or more members with a higher proportion of men in this category regarding social support from friends 214 of women reported having no friends to rely on in good or bad times for men this value was slightly lower around 195 moreover concerning social support from friends a higher proportion of men have three or more friends to rely on compared to women table 1 shows other sample characteristics stratified by gender regarding schooling level approximately 20 of women had a high education level compared to 17 of men most women in the sample presented cases of chronic physical mental or longterm illness compared to men furthermore the prevalence of depression was greater among women than men the sample population predominantly resided in urban areas with most participants concentrated in the northeast and southeast regions most participants selfdeclared as mixedrace smoking habit is more prevalent among men compared to women in the sample there is a higher proportion of women with obesity compared to men additionally the proportion of women with health insurance also surpasses that of men cad saúde pública 2023 39e00106323 table 2 presents the results of the logistic regression for the overall population and stratified by gender results from the overall model showed that men are 176 less likely to report poor selfrated health than women whereas other factors were equal social support was also associated with lower odds of reporting poor selfrelated health for example middleaged adults with two friends are 163 less likely to report poor selfrated health than those without friends those who receive support from three or more friends have an even lower chance of reporting poor selfrelated health with a 248 lower risk than individuals who receive no support from friends table 2 risk of presenting poor selfrated health among middleaged men and women by selected covariates brazilian national health survey general men women or pvalue or pvalue or pvalue gender women regarding family support received from familyrelatives individuals who reported receiving support from three or more relatives were 165 less likely to report poor selfrelated health than those who did not receive any support however there was insufficient evidence to establish differences in selfrated health between individuals with only one or two family members compared to the base group at a 95 ci factors associated with a greater chance of reporting poor selfrelated health also included age such as those in the 5559 age group living in rural areas residing in the north or northeast regions having low schooling level and being black or being mixedrace marital status was not associated with poor selfrated health among middleaged brazilian adults regarding health characteristics individuals diagnosed with a physical or mental illness were 729 more likely to report poor selfrelated health than those without any diagnosed disease additionally those who have not been diagnosed with depression did not smoke and had no obesity were at lower risk of reporting poor selfrealted health results from models stratified by men and women revealed interesting gender disparities in the association between social support and selfrated health the results showed that social support received from friends is a more significant factor for womens selfrated health than mens specifically women with three or more friends are 269 less likely to report poor health than their counterparts without friends on the other hand men with three or more friends are 222 less likely to report poor health than men without friends these differences are significant compared to the reference group without friends however it was not possible to establish differences in selfrated health between individuals with only one or two friends compared to the baseline group at a 95 ci regarding family support the results suggest a weaker association with selfrated health for both men and women compared with social support received from friends except for men with three or more family members they can rely on in this case having three or more family membersrelatives that men can count on in good or bad times is associated with a 245 lower chance of reporting poor health than men without family support however in the case of women the genderseparated logistic regression model did not provide enough statistical evidence to establish an association between family support and poor selfrated health at a 95 ci the variables related to sociodemographic characteristics adulthood socioeconomic status health behaviors and physical and mental health status for men and women showed a consistent pattern with the general model specifically poor selfrated health for men and women was associated with residing in rural households living in the north or northeast regions having low education being black or mixedrace having a disease diagnosis suffering from depression smoking habit having obesity and lacking health insurance discussion this study investigated whether the lack of social support was associated with poor selfrated health among middleaged brazilian adults and how it varied among men and women the results revealed several findings that shed light on the importance of social support in shaping selfrated health outcomes after adjusting for potential confounders this study showed that having no friends or family to rely on in good or challenging times was associated with poorer selfrated health our findings also suggest that gender differences significantly affect selfrated health among middleaged brazilian adults specifically men were less likely to report poor selfrated health than women with a 176 lower likelihood when controlling for other factors this gender disparity in selfrated health aligns with the socalled gender paradox which refers to the observation that although women tend to have a higher life expectancy and lower mortality rates than men they tend to report poorer selfrated health and experience more chronic health conditions than men 22 the fact that women often tend to rate their health lower than men can be attributed to a combination of social and cultural factors in the social dimension one possible explanation is that women may have a higher awareness of their own health status than men and therefore may be more likely to report poor health 23 when considering the sandwich generation concept in which middleaged adults are responsible for caring for aging parents and supporting their children the current literature suggest that women are more affected than men due to societal norms placing a greater caregiving burden on them 24 this situation leads to increased stress and challenges in balancing work and family responsibilities impacting womens selfrated health and resulting in lower health ratings compared to men 25 women may also be more willing to seek medical attention and report symptoms leading to a higher likelihood of a diagnosis of chronic health conditions 26 conversely men may be more likely to deny or downplay health problems leading to underreporting of poor health 27 moreover men may be less likely to seek or receive emotional support from their social networks due to cultural norms that encourage them to be selfreliant and independent 28 these interconnections between worklife balance the sandwich generation phenomenon and cultural norms can collectively contribute to the observed gender disparities in selfrated health among middleaged brazilian adults despite the widely diffused idea of a gender paradox in the literature the debate surrounding this concept has been inconclusive while some studies propose that men and women differ significantly in their selfrelated health evaluations due to the influence of various biological social and cultural factors other studies suggest that men and women may be more similar in how they incorporate a wide range of chronic and acute health conditions functioning healthcare use and health behaviors in their selfrated health evaluation 29 our study on the other hand diverges from this previous idea given that there are marked differences between selfrated health of brazilian men and women even controlling for chronic conditions health behaviors and socioeconomic status as also observed in other settings 30 such discussion highlights the complexity of the relationship between gender and selfrated health regarding social support the results demonstrated that a substantial proportion of middleaged brazilian adults receive support from family and friends however gender differences were visible in the patterns of social support received the logistic regression analyses revealed that social support from both friends and family members was associated with better selfrated health among cad saúde pública 2023 39e00106323 middleaged adults these findings align with the social support literature indicating that strong social networks and interpersonal relationships positively impact individuals selfrated health 31 the observed gender disparities in the association between social support and selfrated health are particularly intriguing the results suggest that social support from three or more friends shows a more significant impact on womens selfrated health compared to men women with three or more friends were 269 less likely to report poor health whereas for men the reduction in the odds of reporting poor health was 222 this finding could be explained by gender differences in coping mechanisms and the tendency of women in maintaining closer relationships with their friends placing more importance on social support received from them 4 the results are consistent with previous research suggesting that social support from friends is a strong predictor of health outcomes 32 conversely family support seems to play a minor role in shaping womens selfrated health compared to social support from friends for men having three or more family members they can rely on was associated with a 245 lower chance of reporting poor health this result aligns with previous research demonstrating the importance of family support in promoting mens health and wellbeing 27 receiving support from three or more family members may be particularly important for brazilian men possibly due to cultural norms that place greater emphasis on family relationships and support 33 although no significant association between family support and poor selfrated health was found for women such outcome must be cautiously interpreted the complexity of womens social networks and the influence of varying cultural norms regarding the role of family support in their lives may underlie these findings for instance women may rely more on external support systems beyond immediate family members 34 such as friends or community networks which could contribute to the muted impact of family support on their selfrated health additionally societal expectations of women as caregivers may lead to potential underreporting of health issues possibly masking the true relationship between family support and selfrated health among women 35 to achieve a deeper understanding of these genderspecific patterns further research should explore the underlying mechanisms and cultural dynamics that could be driving the observed association between family support and selfrated health among women this study contributes to the literature on social support and selfrated health by investigating gender differences in the association between social support and selfrated health among middleaged brazilian adults however some limitations should be considered first the study crosssectional design does not allow us to establish causality or temporal relationships between social support and selfrated health longitudinal studies are needed to investigate the directionality of the association between these variables second the study relies on selfreported social support and selfrated health measures which may be subject to bias selfrated health may be subject to varying perceptions based on individual characteristics such as culture age and gender future research could benefit from incorporating objective health measures to validate selfrated health assessments as proposed by lazarevič 36 similarly the perception of social support can also be influenced by several factors including the quality and closeness of interpersonal relationships the availability and accessibility of social resources and the persons ability to seek and use available support future studies should also consider the influence of cultural and contextual factors on the association between social support and selfrated health this line of investigation should expand beyond the scope of our study addressing other latin american countries cad saúde pública 2023 39e00106323 conclusion in conclusion this study provides evidence into the association between social support and selfrated health among middleaged brazilian adults with a specific focus on understanding gender disparities in this relationship our findings demonstrate that both friends and family social support are linked to better selfrated health in middleaged adults particularly social support from three or more friends presents a more pronounced impact on womens selfrated health compared to men whereas family support plays a more significant role in promoting mens health our study contributes to the ongoing discussion about the impact of social support on health and emphasizes the importance of further research to explore the underlying mechanisms shaping gender differences and other aspects of the association between social support and midlife health resumen el apoyo social de la familia y de amigos se reconoce como un importante determinante social de salud basado en sus efectos protectores sobre el bienestar físico y mental de los individuos aunque la mayoría de las investigaciones se ha centrado en adultos mayores investigar la salud en la mediana edad también es esencial una vez que estos individuos también son susceptibles a los resultados perjudiciales para la salud resultantes de un apoyo social inadecuado de amigos e de la familia este estudio contribuye al debate al investigar si el apoyo social está asociado con la autoevaluación de salud entre adultos brasileños de mediana edad y cómo esa relación varía entre hombre y mujeres usando datos de la encuesta nacional de salud realizada en 2019 se utilizaron modelos de regresión logística para evaluar diferencias en la autoevaluación de salud contabilizando factores de confusión la muestra se compuso de 31926 adultos de mediana edad de los cuales el 525 eran mujeres la prevalencia general de autoevaluación de mala salud fue del 407 con diferencia significativa entre hombres y mujeres los resultados de este estudio sugieren que no tener amigos o familiares en los que confiar en buenos o malos momentos se asoció con la peor autopercepción de salud sin embargo la fuerza de esa asociación es diferente según el género ya que el apoyo social de amigos es más importante en la autoevaluación de salud de las mujeres que en la autoevaluación de los hombres por otro lado el apoyo familiar se asoció con la autoevaluación de la salud masculina particularmente para hombres que tenían tres o más personas de la familia en los que confiar estudios futuros deben tener en cuenta factores culturales y contextuales para mejor comprender otras dimensiones del apoyo social y su asociación con la salud en la mediana edad diferencias de género apoyo social persona de mediana edad additional information orcid hisrael passarelliaraujo	social support from family and friends is recognized as an important social determinant of health given its protective effects on individuals physical and mental wellbeing while most studies have focused on older adults investigating midlife health is equally crucial since middleaged individuals are also susceptible to the harmful health outcomes of inadequate social support from friends and family this study contributes to the debate by examining whether social support is associated with selfrated health among middleaged brazilian adults and how this relationship varies between men and women using data from the nationwide brazilian national health survey conducted in 2019 logistic regression models were employed to assess differences in selfrated health accounting for confounding factors the sample comprised 31926 middleaged adults of which 525 were women the overall prevalence of poor selfrated health was 407 with a significant difference between men and women results from this study suggest that having no friends or family members to rely on both during good and challenging times was associated with poorer selfrated health however the strength of this association differs by gender with social support from friends playing a more critical role in womens selfrated health on the other hand family support was associated with male selfrated health particularly for men with three or more family members they can rely on future studies should consider cultural and contextual factors to better understand other dimensions of social support and its association with midlife health
introduction the concept of altmetrics created by priem et al is proposed as an alternative to more traditional citationbased metrics altmetrics is a new approach to measure scholarly impact on the basis of activities in social media platforms it is a new approach to evaluate the impact of scientific outputs mainly based on the academic use on social media it targets various types of scientific outputs using a wide variety of data sources and indicators comparing to traditional research evaluation using the number of publications and citations although altmetrics is regarded as a democratizer of science and its reward system as it potentially overcome the matthew effect reflected in traditional citationbased metrics previous studies indicate that existing altmetric indicators are biased against nonenglish speaking countries such as china japan russia iran and latin america due to their low visibility in english social media scholars from nonenglish speaking countries having different scientific communication behavior on social media may use their local social media platforms which are not fully covered by current altmetric studies focusing on international social media platforms in english china is the largest social media market with the most social media users who use their local chinese social media instead of international ones due to the data availability and the language barrier few altmetric studies pay attention to the local altmetrics in china and analyze the academic use of social media among chinese scholars thus it is necessary to have an indepth understanding of the characteristics of social media commonly used in china for conducting the altmetric studies regarding china which has its unique social media culture and administration regulations the purpose of this paper is to explore the chinese local social media platforms discover the academic use of chinese social media as well as related altmetric indicators and review the local altmetric literature local social media platforms for academic use in china according to imedia research there are around 800 million social media users in china wechat qq and sina weibo are the top three social media platforms in terms of the number of users accounting for 737 433 and 170 of the chinas population respectively these big three are also included in the top 10 global social media platforms with 1151 731 and 497 million global users respectively in addition to these wellknown three there are various local social media tools or platforms that are used by chinese scholars which have been divided them into seven categories as shown in table 1 documentsharing documentsharing social media is an online platform offering storage for users to share their documents users are encouraged to upload their course materials research articles business proposals industry standards notes as well as other professional documents they can generate income when these documents are downloaded by other users normally readers could freely access the abstract or some free pages but need to pay for downloading the full document the platforms profit from the commission price difference and vip membership that allows readers to download documents at a discount price although users are required not to upload documents of which they are not authors or copyright holders some copyright infringements are still claimed regarding documentsharing in these platforms these documentsharing social media platforms vary by their coverage copyright policy document format and marketing strategy yi reports that doc88 is the largest one in terms of the coverage while baidu has the largest group of users according to baidu there are over 50 million users and around 800 million documents contributed by more than 180 thousand authors in baidu library although billions of documents are shared in these documentsharing platform few are downloaded or acknowledged by users the impact of such documents could be assessed by their online usage including the number of clicks views and downloads the documentsharing platforms also allow users to leave comments ratings and recommendations for these documents which could also be used to evaluate their quality or impact blog the blog platform is a discussion or informational diary that is published online and managed by individuals the bloggers could create their personal blogs on a blog site and post their personal articles from time to time some chinese scholars would like to share their research and opinions through such academic blogs as sciencenet and csdn blog and other general blogs like sina blog sciencenet is an academic blog with more than one million users most users are scientists or researchers they use sciencenet blogs to discuss scientific research with their peers establish friendship with other researchers in addition to the individual bloggers some research institutions also set up their official blog at sciencenet to disseminate knowledge and research csdn blog is dedicated to creating a communication platform for it developers providing technical people with comprehensive information and knowledge exchange and interaction most csdn bloggers are technical persons working in computer science or information science although sina blog is a general blog covering various topics some chinese scholars also use it to promote their research and carry out academic exchanges although each blog is free to read and share they are ranked by the number of readers recommendations and comments only those high ranking blogs could be displayed in the homepage while the rest need to be browsed and searched thus these indicators could be used to evaluation the impact of the blogs news the newstype social media contain massive information representing the timely scientific news and stories in addition to sharing scientific news and updates regarding research and development chinese scholars also disseminate their recent research via some local newstype social media including guokrcom tencent news biooncom and china social science net guokrcom is an open and diverse community in science and technology consisting of three sections scientists interest groups and q a these three sections allow users to follow their interested people or groups read recommended articles and share their own articles tencent news is a mobile application based on ios and android platform it features a combination of news videos and microblogs providing mobile users news and updates at the very first time there are 15 news channels in tencent news of which science and technology is one biooncom is a news platform for the biotech industry providing news consulting service and industry analysis most bioon members have masters or doctoral degrees in the field of medicine or biology china social science network is a national social science academic research network sponsored by the chinese academy of social it has 54 channels and more than 1300 columns for social scientists from different disciplines community in china the social media is also used as an interactive community platform for scientific communication with members mainly from universities research institutes and enterprises for r d users use the community forum to exchange academic resources share research stories and help each other the popular social media communities in china include dxy douban and xiaomuchong dxy is a leading online healthcare community in china connecting health practioners health researchers patients pharmaceuticals and insurance companies it has served over one hundred million public users and six million professional users indeed 71 of the health practioners in china are dxy users xiaomuchong is an academic platform sharing academic resources for scientific researchers it covers academic content such as fund application patent standards studying abroad graduate admission paper submission and academic assistance most members come from universities research institutions and enterprises for r d douban is a reading community for educated youth in addition to the collection of books movies music and other products douban offers a review and recommendation platform that users could express their comments and recommendations for all contents q a compared with social media community q a social media only focus on the interaction between questions and answers online q a platforms connect users with different backgrounds scholars with special expertise in their disciplines obviously become the active users in q a platforms in addition to answering questions as requested some users also share their knowledge experience and insights to others the most popular q a platforms in china are baidu zhidao and zhihu baidu zhidao developed by baidu is a leading searchbased interactive knowledge question and answer sharing platform everyone could provide the answer for a given question as the answers are ranked and returned as the search result compared with searchbased q a platforms zhihu focuses on providing comprehensive answers on the basis of a group of experts in different disciplines similar to quora zhihu users can actively participate in the q a process by editing questions and commenting on answers that have been submitted by other users which helps zhihu surpass other competitors and become the largest q a platform in china according to yiguan there were over 220 million users in zhihu in which more than 40 are 24 years and under general scholars also use general social media platforms such as wechat sina weibo for academic use scholars could create an official wechat account to disseminate their research and promote related business they also could use sina weibo to post their message like tweets many scholars would like to disseminate their research via general social media platforms to gain higher impact considering the large number of users in wechat and sina weibo the number of active wechat users have been over 12 billion over 200 countries and regions as of the first quarter of 2020 although wechat is a social networking tool with the function of instant messaging people could share information including academic content via two approaches personal friend group and public account sina weibo looks like the chinese version of twitter users post texts less than 140 chinese characters with photos music or videos similar to twitter sina weibo is also used to disseminate knowledge and promote research local altmetric indicators in china with the academic use of social media some altmetric indicators have been developed by different social media platforms to measure the social impact of papers books journals and individual scholars paper the local altmetric indicators at the paper level in china generally come from three categories of social media platforms documentsharing blog and general these social media platforms provide various altmetric indicators to measure the social impact of research papers as shown in table 2 which are retrieved and summarized in this study the social impact of a paper is measured on the basis of the readership and quantified by the number of readings comments likes and other indicators most indicators are objective as counting the number of actions by the readers while some indicators are subjective as representing readers personal opinions books altmetric indicators for books are developed in some reading community platforms to recommend books these indicators could be grouped into two categories library collection indicators and network utilization indicators the library collection indicators measure the quantity of the reading including number of readings number of collecting libraries number of downloads number of recommendations number of collections and number of comments the network utilization indicators measure the quality of reading including numbers of book reviews academic community discussions news reports reader reviews and mentions among various reading community platforms douban is the most famous one for book recommendation in order to allow readers to rate and recommend books the following 14 indicators are included in douban which has been copied by other reading community platforms •douban score journals although the journal impact factor is the most popular indicator for assessing academic impact of journals some altmetric indicators are also constructed to evaluate social impact of journals in some community platform for example xiaomuchong one of the popular platforms for scientific communication includes the chinese periodical evaluation section in its platform the evaluation criteria include number of forum replies number of posts viewed number of posts reviewed number of the helpful labelled by users review speed publishing speed review cost publishing cost and editorial communication wang selected 420 journals reviewed in xiaomuchong and constructed a journal impact evaluation model measuring both the academic impact and the social impact of journals the academic impact is based on the traditional citation impact while the social impact is measured by four dimensions as below •social attention number of journals viewed number of comments number of webpage views •comprehensive editorial communication editorial communication review quality •time cost publication speed review speed •economic cost publication fee acceptance rate review fee in addition liu and liu constructed a framework for evaluating the impact of chinese academic journals their framework consists of citation indicators online usage indicators and social media impact indicators in addition to the traditional citation indicators online usage indicators include total online usage journal usage factor usage annual index and usage halflife while social media impact indicators include total number of blog posts and average number of blog posts scholars sciencenet is a comprehensive website promoting science to build an influential chinese scientific community in addition to news reports it also provides blogs for scholarly communication zhao established some indicators to evaluate the scholarly impact of these sciencenet blogs including blog status post status and evaluation status another study regarding the sciencenet blog also contributed three evaluation indicators blogger enthusiasm communication coverage and blog post quality the enthusiasm of bloggers includes the number of blog posts the number of activities the number of points and gold coins and the number of topics the spread coverage includes the number of friends the number of visits and the number of visits per article and the quality of the blog is measured by the number of blogs recommended by the website in addition to the general platform measuring social impact of individual scholars some altmetric indicators assessing health physicians are also provided by some health websites including good doctor sohu health zhihu yimaitong and xunyiwenyao such altmetric indicators are developed to measure the scholarly impact the social media impact and online diagnosis impact of a health physician local altmetric studies in china the concept of altmetrics has been paid attention by chinese scholars as it was coined by priem et al we conducted the keyword search using altmetrics and china to retrieve the literature from the core collection of web of science in addition we also searched keywords altmetric as well as other variants from chinese cnki database and local chinese literature after manual validation 52 english and 327 chinese papers regarding altmetric studies were identified as shown in figure 2 the number of altmetric studies in china have been increasing since 2012 until 2019 when the number of altmetric research declined since altmetrics is a new imported concept it was translated into different chinese names the first paper introducing altmetrics in china was published by liu who named altmetrics as xuan zhe ji liang xue on the other hand altmetrics was also named as bu chong ji liang xue and ti dai ji liang xue although the last translation has been accepted by most chinese scholars some scholars still prefer to use the altmetrics other than any chinese translation in their publications altmetric research in china mainly focused on theoretical discussion and literature review regarding the production development and research tools of altmetrics some studies discussed the needs of altmetrics stakeholders content of altmetric data user motivation context analysis and data quality chinese scholars also conducted some empirical research as investigating the comprehensive evaluation model integrating altmetrics and citation indicators the factors associated with altmetric indicators and design and develop of altmetric indicator on sina weibo news report policy documents social impact of individuals books journals datasets and papers due to the limited availability of chinese social media data many empirical studies conducted by chinese researchers used international data such as altmetriccom plumx plos alms or directly from twitter and mendeley few researches used local chinese altmetric data in their altmetric studies indeed the plugin of plumx or altmetriccom has been embedded in the institutional repositories of some chinese universities in addition to the impact of academic use on social media some chinese scholars also explored and compared the characteristics of the local social media platform xiong found that xiaomuchong users were highly active while sciencenet blogs were most influential fan compared zhihu douban and guokr com using alexa ranking of thirdparty statistical data and ranked them from high to low in terms of access traffic yan found that dxy community is highly professional questions and requests were answered and replied to quickly in summary although chinese scholars publish a lot of papers introducing the altmetrics and reviewing their literature few studies have tried to measure the dissemination of research via local chinese social media although chinese scholars conduct many altmetric studies investigating the influence of scholarly activities on various socia media tools local chinese social media such as wechat weibo have rarely been studied discussion and conclusion although social media has been frequently used to promote research and some altmetric indicators have been developed in china chinas altmetric studies still face the challenges due to the limited availability of data source most local chinese social media dont provide or limit the use of apis alternatively researchers have to use the web crawlers or other programming to obtain the data which hinders the development of chinas altmetric studies in addition various scholarly identifiers such as doi pubmed id isbn and so on are used in altmetric studies linking the publications with their social media activities however document identifiers are not assigned to some chinese local publications so that we could not establish the relationship between academic activity in social media and the mentioned publications which is one of the main obstacles to the acquisition of chinese altmetric data as a result few altmetric studies investigate the academic use of local social media and test the local altmetric indicators as this study presents although various altmetric indicators have been developed and applied the validity and reliability of these indicators have never been validated which needs to be explored in future research as the largest source country of international scientific literature with the largest social media user population chinas local altmetrics is inevitable to be a popular research topic within or outside the scope of bibliometrics the local social media platforms altmetric indicators as well as local altmetric studies reviewed by this paper could build a foundation for future studies focusing on local altmetrics in china	altmetric indicators are largely affected by countries or regions especially for nonenglish speaking countries such as china japan russia etc although china is the largest county in terms of the number of social media users we still know little on the academic use of local social media tools and local altmetric indicators in china the purpose of this paper is to present the landscape of local altmetrics in china including the local social media platform for academic use local altmetric data sources and indicators as well as the local altmetric studies conducted by chinese scholars
introduction the research of network science is experiencing a blossom in the last decade which provides profound implications in very different fields from finance to social and biological networks 1 considering the enormous data scale most studies merely focus on a small group of influential nodes rather than the whole network take social networks for instance influential nodes are those that have the most spreading ability or playing a predominant role in the network evolution notably a popular star in online social media may remarkably accelerate the spreading of rumors and a few super spreaders 2 could largely expand the epidemic prevalence of a disease 3 the research of influencer identification is beneficial to understanding and controlling the spreading dynamics in social networks with diverse applications such as epidemiology collective dynamics and viral marketing 45 nowadays individuals interact with each other in more complicated patterns than ever it is a challenging task to identify influencers in social networks for the various kinds of interactions as we have known the graph model is widely utilized to represent social networks however it is incapable of dealing with the multiple social links for example people use facebook or wechat to keep communication with family members or friends use twitter to post news use linkedin to search for jobs and use tiktok to create and share short videos 6 it is easy to represent each social scenario via a graph model separately in spite of they are belonging to the same group of individuals the neglect of the multiple relationships between social actors may lead to an incorrect result of the most versatile users 7 with the proposal of multilayer networks 89 we are able to encode the various interactions which is of great importance and necessity of identifying influencers in multiple social networks in this paper we design a novel node centrality measure for monolayer network and then apply it to multilayer networks to identify influencers in multiple social networks this method is solely based on the local knowledge of a networks topology in order to be fast and scalable due to the huge size of networks and thus suitable for both realtime applications and offline mining the rest of this paper is organized as follows section 2 introduces the related works on influencers identification in monolayer network and multilayer networks section 3 presents the mathematical model and the method for detecting influencers section 4 exhibits the experiments and analysis including comparison experiments on twentyone realworld datasets which verifies the feasibility and veracity of the proposed method section 5 summarizes the whole paper and provides concluding remarks related works the initial research on influencers identification may date back to the study of node centrality which means to measure how central a focal node is 10 a plethora of methods for influencers identification are proposed in the past 40 years which can be mainly classified into centrality measures link topological ranking measures entropy measures and node embedding measures 1112 some of these measures take only the local information into account while others even employ machine learning methods nowadays it has been one of the most popular research topics and yielded a variety of applications 7 such as identifying essential proteins and potential drug targets for the survival of the cell 13 controlling the outbreak of epidemics 14 preventing catastrophic outages in power grids 15 driving the network toward a desired state 16 improving transport capacity 17 promoting cooperation in evolutionary games 18 etc this paper investigates the problem of identifying influencers in social networks by introducing a family of centralitylike measures and gives a brief comparison in table 1 degree centrality 19 is the simplest centrality measure which merely counts how many social connections a focal node has defined as dc n ∑ j a ij 1 where n is the total number of nodes a ij is the weight of edge if i is connected to j and 0 otherwise the degree centrality is simple and merely considers the local structure around a focal node 20 however this method is probably mistaken for the negligence of global information ie a node might be in a central position to reach others quickly although it is not holding a large number of neighbors 21 thus betweenness centrality 22 is proposed to assess the degree to which a node lies on the shortest path between two other nodes defined as bc ∑ s is ti t g st g st 2 where g st is the total number of shortest paths g st is the shortest path between s and t that pass through node i the betweenness centrality considers global information and can be applied to networks with disconnected components however there is a great proportion of nodes that do not lie on the shortest path between any two other nodes thereby the computational result receives the same score of 0 besides high computational complexity is also a limitation of applying for largescale networks analogously closeness centrality 23 is proposed to represent the inverse sum of shortest distances to all other nodes from a focal node defined as cc n 1 ∑ j i d ij 3 where n is the total number of nodes d ij is the shortest path length from node i to node j the closeness centrality is capable of measuring the core position of a focal node via the utilization of global shortest path length while it suffers from the lack of applicability to networks with disconnected components eg if two nodes that belong to different components do not have a finite distance between them it will be unavailable besides it is also criticized by high computational complexity eigenvector centrality 24 is a positive multiple of the sum of adjacent centralities relative scores are assigned to all nodes in a network based on an assumption that connections to highscoring nodes contribute more to the score of the node than connections to lowscoring nodes defined as ec k 1 1 ∑ j a ij x j where k i depicts the eigenvalue of adjacency matrix a x k 1 ax depicts the eigenvector stable state of interactions with eigvenvalue k 1 1 this measure considers the number of neighbors and the centrality of neighbors simultaneously however it is incapable of dealing with noncyclical graphs in 1998 brin and page developed the pagerank algorithm 25 which is the fundamental search engine mechanism of google pagerank is a positive multiple of the sum of adjacent centralities defined as pr k n ∑ j1 a ji pr k1 k out j i 1 2 n where n depicts the total number of nodes ∑ n i1 pr 0 0 k out j is the number of edges from node j point to i likewise this method is efficient but also criticized by nonconvergence in cyclical structures as we have known the clustering coefficient 2627 is a measure of the degree to which nodes in a graph tend to cluster together defined as c i ∑ j ik jk i a ij a ik a jk ∑ j ik jk i a ij a ik 6 it is widely considered that a node with a higher clustering coefficient may benefit forming communities and enhancing local information spreading however chen et al expressed contrary views that the local clustering has negative impacts on information spreading they proposed a clusterrank algorithm for ranking nodes in largescale directed networks and verified its superiority to pagerank and leaderrank 28 therefore the effect of clustering coefficient on information spreading is uncertain which may benefit local information spreading but prohibit global information spreading in 2016 ma et al proposed a gravity centrality 29 by considering the interactions comes from the neighbors within three steps defined as g ∑ j∈ψ i k s k s d 2 ij g ∑ j∈γ i g where k s and k s are the kshell index of i and j respectively ψ i is the neighborhood set whose distance to node i is less than or equal to 3 d ij is the shortest path length between i and j these methods consider semilocal knowledge of a focal node ie the neighboring nodes within three steps which are successful in many realworld datasets such as jazz 30 ns 31 and usair network 32 etc however they are also with high computational complexity by globally calculating kshell in 2019 li et al improved the gravity centrality and proposed a localgravity centrality 33 by replacing kshell computing and merely considering the neighbors within r steps defined as lg r ∑ d i j≤rj i k i k j d 2 ij where k i and k j are the degrees of i and j respectively d ij is the shortest path length between i and j this method had been extremely successful in a variety of realworld datasets however the parameter r requires the calculating of network diameter which is also a timeconsuming process the abovementioned centrality measures have been utilized to rank nodes spreading abilities in monolayer networks the ranking of nodes in multilayer networks is a more challenging task and is still an open issue the information propagation process over multiple social networks is more complicated and conventional models are incapable without any modifications zhuang and ya ǧan 36 proposed a clustered multilayer network model where all constituent layers are random networks with high clustering to simulate the information propagation process in multiple social networks likewise basaras et al 37 proposed an improved susceptibleinfectedrecovered model with information propagation probability parameters most of the recent endeavors concentrated on the multiplex networks where all layers share the identical set of nodes but may have multiple types of interactions rahmede et al proposed a multirank algorithm 39 for the weighted ranking of nodes and layers in large multiplex networks the basic idea is to assign more centrality to nodes that are linked to central nodes in highly influential layers the layers are more influential if highly central nodes are active in them wang et al proposed a tensor decomposition method 7 which utilize the fourthorder tensor to represent multilayer networks and identify essential nodes based on candecompparafac tensor decomposition they also exhibited the superiority to traditional solutions by comparing the performance of the proposed method with the aggregated monolayer networks in a word it is of great significance in identifying influencers in multiplex networks our purpose in this work is to devise a measure that can accurately detect influential nodes in a general multilayer network modeling and methods network modeling the problem of finding influential nodes is described as extracting a small set of nodes that can bring the greatest influence on the network dynamics with a given network model g where v v 1 v 2 v n is the node set and e is the edge set the identification of influential nodes is to pick a minimum of nodes as the initial seeds which can achieve the maximum influenced scope described as a arg min a∈v max σ 10 where a is the initially infected nodes σ denotes the final influenced node set this problem is simplified as topk influencers identification by additional setting a k which has recently attracted great research interests 40 41 42 a variety of realworld social networks are in fact interconnected by different types of interactions between nodes forming what is known as multilayer networks in this paper we employ a multilayer network model 9 which can represent nodes sharing links in different layers the multilayer network model is defined as m where g g α α ∈ 1 l is a family of graphs g α which represents layers of m and c depicts the interactions between nodes of any two different layer given by c e αβ ⊆ v α × v β α β ∈ 1 l α β the corresponding supraadjacency matrix can be represented as m       a 1 i 12 • • • i 1l i 21 a 2 • • • i 2l • • • i l1 i l2 • • • a l       ∈ r n×n 13 where a 1 a 2 a l are the adjacency matrix of layer 1 2 l respectively n is the total number of the nodes which can be calculated by n ∑ 1≤l≤l v l the nondiagonal block i αβ represents the interlayer edges of layer α and layer β thus the interlayer edges can be represented as i l αβ1α β i αβ 14 take the 911 terrorists network 43 for instance the edges are classified into three categories according to the observed interactions which are plotted in figure 1 methods we employ the susceptibleinfectedrecovered spreading model 44 as the influence analysis model it has three possible states • susceptible state where a node is vulnerable to infection • infectious state where a node tries to infect its susceptible neighbors • recovered state where a node has recovered and can no longer infect others in a network if two nodes are connected then they are considered to have contact if one node is infected and the other is susceptible then with a certain probability the latter may become infected through contact 45 a node is considered to be recovered if it is isolated or immune to the disease in detail to check the spreading influence of one given node we set this node as an infected node and the other nodes are susceptible nodes at each time step each infected node can infect its susceptible neighbors with infection probability β and then it recovered from the diseases with probability γ the differential equations are shown in figure 2 for simplicity we set γ 1 the process of the sir model is plotted in figures 3 and4 with the famous krackhardts kite network 46 the process of sir model on krackhardts kite network in panel all the nodes are in susceptible state while we select one node to be infected and the neighbors will be infected soon as shown in panel finally the network will reach a stable state ie the number of recovered nodes will reach a maximum as shown in panel 1xpehuri6xvfhswleohvqihfwlrxvdqg5hfryhuhgv 6xvfhswleohv qihfwlrxv 5hfryhuhgv in this paper we define the node influence as the energy derived from the neighbors given as i nf r ∑ d ij ≤r ∑ j∈γ d 2 ij w ij k j 15 where r is the truncation radius γ is the set of neighbors of node i d ij is the shortest path length between node i and node j k j is the degree of node j w ij is the weight of edge e ij for unweighted networks w ij 1 analogously we apply the proposed inf measure to multilayer networks by the following modifications i nf m r ∑ d ij ≤r ∑ α x j and y i y j or x i x j and y i y j meanwhile they are considered as discordant if x i x j and y i y j or x i x j and y i y j if x i x j or y i y j pairs are neither concordant nor discordant therefore kendalls tau coefficient is defined as τ n c n d 05n where n c and n d indicate the number of concordant and discordant pairs respectively the range of τ is 1 1 table 6 shows the computational tau results with the comparison of standard sequence from sir model simulations q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q qq q qqq qq q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q celegans dmlc power as shown in table 6 the proposed measure outperformed the competitors in most cases even in the escherichia network the computed tau result of inf was close to that of cc thus it was also competitive in this network jazz if setting the limitation of identifying k influencers we conducted experiments on the realworld datasets with topk nodes by computational centrality nodes and compared the recovered nodes to compare the varying parameter k with the obtained τ we conducted experiments on the abovementioned datasets and set the ratio of ββ c as shown in figure 8 q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q celegans dmlc power as shown in figure 8 the proposed node influence method is quite competitive in most of the datasets although second to the performance of betweenness indicator in dmlc and jazz datasets jazz analogously we conducted experiments on the nine multilayer networks by removing nodes with maximum centralities the results are plotted in figure 9 q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q qq q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q qq q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q csaarhus londontransport euairtransportation as shown in figure 10 the runtime accumulated from either group indicated that the proposed inf measure was efficient which was close to that of dc and superior to bc cc and lgr krackhardt lazega humanhiv1 padgett kapferer vickers discussion influencers identification is a fundamental issue with wide applications in different fields of reality such as epidemic control information diffusion viral marketing etc currently degree centrality 19 is the simplest method which considers nodes with larger degrees are more influential however for the lack of global information a node lying in a bridge position might be neglected for holding a small degree the betweenness 22 and closeness 23 centrality consider global information but they are holding a high complexity which are not suitable for applications in largescale networks local gravity is a balanced method however the determination of parameter r requires computing network diameter which is also timeconsuming thus a novel node influence measure is proposed in this paper which merely considers the local neighboring information of a focal node with the complexity of o experimental results on 21 realworld datasets indicate the feasibility of the proposed measure firstly the experiments of counting subgraphs with removing influential nodes show that the capability of the proposed inf measure by removing the nodes according to the inf indicator the networks are more easily broken up as shown in figures 7 and9 secondly we apply the sir model to evaluate the node influence which suggested the proposed inf measure is competitive to other indicators in most cases although inferior to bc on jazz and dmlc networks it is also competitive by analyzing the structures of these two networks we find that the nodes of jazz network are densely connected and most of the nodes are holding the same number of neighbors which brings difficulties to identify which node is more influential on the contrary there is only one node holding a large number of neighbors and the others only holding few neighbors in dmlc network which is also difficult to identify influencers overall the proposed method outperforms the other indicators in most cases finally we compare the running time of each indicator on the 21 realworld datasets experimental results show the efficiency of the proposed measure conclusions aiming at solving the problem of identifying influencers in social networks this paper proposes a novel node influence indicator this method merely considers the local neighboring information in order to be fast and suitable for applications in largescale networks extensive experiments on 21 realworld datasets are conducted and the experimental results show that the proposed method outperforms competitors afterwards the time complexity is compared and we verify the efficiency of the proposed indicator overall the proposed node influence indicator is capable of identifying influencers in social networks the contribution of this work is likely to benefit many realworld social applications such as promoting network evolutions preventing the spreading of rumors etc as part of future works the influencers in dynamic networks can be further studied by applying the proposed inf measure into a multilayer network model with numerous ordinal layers the nodes influence can be calculated by accumulating the local neighbors across all the layers besides the effect of layers needs to be taken into consideration in a word we hope the findings in this work will help to improve the researches in this promising field author contributions xh designed the method and wrote the original draft dc revised the manuscript tr and dw checked the manuscript and made some modifications all authors have read and agreed to the published version of the manuscript	social network analysis is a multidisciplinary research covering informatics mathematics sociology management psychology etc in the last decade the development of online social media has provided individuals with a fascinating platform of sharing knowledge and interests the emergence of various social networks has greatly enriched our daily life and simultaneously it brings a challenging task to identify influencers among multiple social networks the key problem lies in the various interactions among individuals and huge data scale aiming at solving the problem this paper employs a general multilayer network model to represent the multiple social networks and then proposes the node influence indicator merely based on the local neighboring information extensive experiments on 21 realworld datasets are conducted to verify the performance of the proposed method which shows superiority to the competitors it is of remarkable significance in revealing the evolutions in social networks and we hope this work will shed light for more and more forthcoming researchers to further explore the uncharted part of this promising field
background the effects of financial crises on health have been studied for decades the evidence suggests that recessions have damaging effects on many health indicators particularly mortality and suicide 1 there is also evidence that financial crises can have some positive effects on health although in general results are more heterogenous 2 furthermore periods of financial crisis are associated with higher psychological stress among the population and greater use of mental health services 34 increased levels of anxiety and depression are equally recorded 5 in turn these conditions are associated with an increase in the number of attempted suicides and premature deaths due to episodes of violence and suicide 67 and increased consumption of alcohol 8 however the effects of an economic downturn do not have the same impact on all individuals and all countries sex age level of education marital status size of household employment income belief systems and social relationships are individual factors which have a bearing on better or worse resilience 9 and socioeconomic factors can also play a part in this impact analysis of the policies implemented by some countries during times of economic crisis reveals the link between these policies and impact on mental health among the population 10 11 12 austerity measures such as the massive cutbacks made as a result of the crisis in different european countries have had a harmful effect on mental health 11 precisely when individuals may require more care due to mental health problems cutbacks in the healthcare sector may lead to reduced services for prevention early detection and treatment of mental health problems in this respect vulnerable groups people in financial difficulty and people with health issues would be at higher risk 13 the metaanalysis by paul and moser 14 showed that the negative effect of unemployment on mental health was more pronounced in countries with a low level of economic development unequal distribution of income or weak unemployment benefit systems the effect of contextual factors has been noted in highly diverse geographical areas distant from spain such as asia where the economic crisis appears to have had a lower impact on health in malaysia than in thailand or indonesia unlike its neighbours malaysia rejected world bank advice to make cutbacks in healthcare spending 12 spain has stood out as one of the countries most severely affected by the socalled great recession 15 one of the most overwhelming effects of which is unemployment 15 16 17 to analyse the impact on health of the crisis in spain two particularities must be taken into account on the one hand the healthcare system provides almost universal coverage and on the other there are differences between regions as a result of political decentralisation an example of this is the spending gap per inhabitant between the regions with the highest and lowest spending reaching 62 in 2014 18 as regards social protection this gap was 87 18 a recent study detected major differences in austerity measures during the recession 19 whilst in the basque country policies for austerity and privatisation were almost nonexistent the trend in other regions such as la rioja madrid and the balearic islands was clearly in the opposite direction this reality may determine variations in the impact of the recession depending on the region where people live as a result of how different autonomous community governments have responded to the recession studies on the impact on mental health of contextual factors between regions in the same country are limited 9 10 11 12 13 14 20 and we consider that looking at regions in a single country facilitates comparison given similarities in the population as regards culture values and belief systems various articles have addressed the impact of socioeconomic crises on mental health in spain 35 8 13 1518 2125 they have focused only on analysing the effect of individual factors but in addition to these individual variables there are contextual variables which can either lessen or intensify the adverse effects of the crisis amongst which are the variables relating to the political and institutional context such as economic indicators public welfare services indicators and labour market indicators the impact of the crisis on the health of the population could be lessened or intensified by policies affecting the financial security and social conditions of families 1 the aim of this study is to analyse the socioeconomic factors impacting on mental health during the recession in spain methods design crosssectional descriptive study of two periods before the recession and after the recession study population individuals aged 16 years old resident in spain polled for the national health survey in 2006 and 2012 there were 25234 subjects in 2006 and 20754 subjects in 2012 variables dependent psychic morbidity measured through selfreferred poor mental health yes no according to the goldberg health questionnaire 12 items adapted and validated in our environment individual independent sociodemographic variables a axes of social inequality age socioprofessional class level of education low level equates to no schooling or primary education medium level equates to secondary education and midgrade vocational training and high level equates to advanced vocational training and university qualifications nationality b other employment situation marital status social class has been determined based on current or most recent professional occupation according to national occupation classification cno2011 psychosocial variables social support contextual independent the contextual variables were selected on the basis of their availability for the years analyzed and the degree of disaggregation by region the geographical unit of analysis is based on nuts2 regions of eurostat to calculate socioeconomic indicators we used data from the national institute of statistics 2627 eurostat 28 and bbva foundation 29 data analysis all the analyses were performed by sex and for the total population prevalence was calculated for the psychic morbidity variable and the independent proportions comparison test was applied to compare significant changes the chisquare test was used to compare determinant bivariates between the two periods two multilevel logistic regression models with random effect were constructed to determine change in psychic morbidity according to individual and contextual variables respectively in the first model the study period and predictor variables at the individual and socioeconomic level were included and intercepts at the nuts2 region level were included as random effect in the second model contextual variables were included individually and adjusted for individual characteristics and intercepts at the nuts2 region level were included as random effect in all models whether the differences are significant was assessed by using the wald test for each predictor correction of the clustered robust variance was done by the observed information matrix the magnitude of effects is measured by the odds ratio and 95 confidence interval and a significance level of 005 will be set for hypothesis checking in the indicator models for the macroeconomic context the magnitude of association was expressed for a change of approximately one standard deviation of the context variable analysed statistical analyses were performed using stata software results between 2006 and 20112012 the pattern of psychic morbidity differed between men and women among men poor mental health has increased significantly in the 30 34 age group and in the 45 59 age group also among single men and married men men with a low level of education and normal social support country of origin was not found to have any link to differences in prevalence of poor mental health since this was significant for spaniards and foreigners alike nor was any link found between socioprofessional class and differences in prevalence of psychic morbidity among women groups which showed significant differences in mental health between 2006 and 2012 were the 16 29 age group and the over60 age group married women and widows also showed a significant decrease in the prevalence of poor mental health similarly to working women retired women and women studying in accordance with the first multilevel logistic regression model for men widowers presented a higher risk of poor health compared with single men as did separated or divorced men by contrast married men presented a lower risk of psychic morbidity than single men as regards employment situation unemployed men presented a higher risk of psychic morbidity in comparison to working men and retired men lastly a link was found between better social support and lower risk of psychic morbidity among women widows presented a higher risk of psychic morbidity compared to single women as did separated or divorced women as regards employment situation homemakers presented a higher risk of psychic morbidity than working women and retired women lastly a link was found between better social support and lower risk of psychic morbidity table 1 prevalence of poor mental health 2006 and 2012 values in grey p 005 according to the second multilevel logistic regression model among the macroeconomic variables studied those associated with worse mental health for men and women alike were lower healthcare spending per capita and a higher percentage of temporary workers by contrast risk of poverty income per capita per household gross domestic product and employment rate were not found to be linked to worse mental health among women the only contextual variable associated to a worse mental health was healthcare spending per capita among men the contextual variables associated to a worse mental health were healthcare spending per capita and percentage of temporary workers discussion the severity of the current economic crisis has hit spain far harder than other european countries with the possible exceptions of portugal greece and cyprus 25 the recession has had a significant impact on conditions and levels of employment and on poverty rates in spain as a whole although with considerable differences between autonomous communities in this respect in a prior study comparing regions zapata states spain is currently a natural laboratory for exploring how negative macroeconomic changes affect health 25 as regards limitations parmar 2 states that the majority of studies on crises and health are subject to biases pointing above all to reverse causality or not taking possible prior trends into account in this study in the first place we have used a short period to study the impact of the crisis with two cutoff points and therefore it is quite possible that mental health has continued getting worse it was not possible to measure the trend since in previous years the health survey has not measured psychic morbidity in the second place given the crosssectional nature the possible existence of reverse causality cannot be overlooked there may be some uncontrolled confusion bias given that other variables are not taken into account which may or may not have an effect on state of mental health yet in spite of these limitations our study is the first of its kind to analyse a multilevel design to investigate the impact of contextual variables during the recession in spain and its possible consequences on mental health the socioeconomic factors linked to mental health were healthcare spending per capita and percentage of temporary workers estimating the contribution of factors which can affect the health of the population is a complex and inexact task 30 what does seem clear is that a robust health system can level out inequalities since it enables support to be given to the most vulnerable sectors of the population 31 by contrast a weaker health system would leave the most vulnerable less protected and these groups are the most exposed in the recession and therefore at higher risk of worse mental health although spain has a national health system which provides universal coverage there is considerable variation in healthcare spending and services from one autonomous community to another 32 it is difficult to find reliable data on healthcare spending specifically for mental health since budges are not broken down by medical fields however it is not unreasonable to believe that it may have suffered the same fate as spending as a whole at least as regards the most general figures and trends inequalities in healthcare spending have a twopronged effect a differences in resource allocation for service provision in different regions and b differences in public health insurance contributions by individuals or families 33 there is an additional area as regards provision of mental health services which professional associations for mental health have condemned for years spain is still bringing up the rear in comparison with other european countries in terms of numbers of mental health practitioners as shown by official who figures 34 the link between worse mental health and percentage of temporary workers can be understood given that economic recessions can have a direct effect on people who keep their jobs these individuals face situations of stress and anxiety caused by possible reduction in income greater employment insecurity and increased workload recessions can likewise have a disproportionate negative impact on subgroups in the vulnerable population such as persons with a preexisting mental disorder or a low socioeconomic level or the unemployed 35 the literature shows contradictory results for the relationship between unemployment and mental health some studies have found that unemployment is associated with poorer mental health particularly amongst women 36 whilst others have found that during recessions or in cases of higher regional unemployment when the number of unemployed people increases and unemployment becomes a status the psychological cost and stigma of being unemployed diminishes and the subjective wellbeing of the unemployed improves 37 taking into consideration the context variables found in our study these differences would be nuanced by factors such as per capita healthcare spending or percentage of temporary workers in the light of these findings one might think that different political responses to economic crises would give rise to different mental health outcomes among the population for example in spain unemployment levels in the 70s and 80s were accompanied by a corresponding increase in risk of suicide in sweden however the banking crisis of 1990 left a lot of people unemployed but the suicide rate dropped even during this period this marked difference has been attributed to the protection provided by the swedish welfare state 3839 as regards the measures which should be taken during economic crises to palliate effects on mental health kentikelenis and papanicolas 4041 state the need to safeguard programmes for vulnerable groups such as the mentally ill and drug addiction rehabilitation programmes to increase the number of general practitioners working in rural areas to taken on the cost of nonmedical illnesses among patients and to prescribe a higher proportion of generic drugs in order to make savings in spending on drugs other studies have highlighted the effectiveness of policies such as active programmes to incentivise the labour market which have a significant impact on reducing suicide rates 38 policies which aim to prevent individuals from taking on too much debt and for making it easier to pay off debts could be beneficial for people whose excessive levels of debt cause them stress 41 similarly policies or initiatives such as financial mediators have huge potential for mitigating the effects of recession 42 as regards health centres it has been found that health initiatives for exploring the subjective perception of aloneness can be effective in improving mental health and should focus particularly on individuals in poor health and the unemployed 43 similarly effective are programmes which support the role of primary care professionals in detecting persons at risk of suicide or other psychological problems 42 therefore instead of making cutbacks in healthcare and social welfare there should be higher spending on measures for social protection during times of recession and increased support for mental health programmes in the health sector particularly in primary care 4445 additionally there should be more comprehensive and cooperative consolidation of the mental health network within healthcare which takes into account the specific needs of the individuals which this healthcare sector focuses on 45 conclusions lastly data will be required in following years in order to analyse whether fresh government cutbacks to healthcare and social spending 35 and the policies implemented by different autonomous communities will have a medium and longterm impact on mental health among the spanish population furthermore it is to be noted that social inequalities in spain have increased since the beginning of the financial crisis moreover various studies have highlighted that increased social inequalities are not only an effect of the crisis but also a determining factor of the crisis therefore a more sustainable economic model should make reduction of social inequalities one of its primary goals 46 key points various articles have addressed the impact of socioeconomic crises on mental health they have focused on analysing the effect of individual factors and have left out other factors linked to welfare state public services and economic indicators which would be proxies for public policies implemented at the regional level the impact of the crisis on the health of the population could be lessened or intensified by policies affecting the financial security and social conditions of families the findings of this study emphasize that policies during periods of recession should focus on support and improved conditions for vulnerable groups such as temporary workers healthcare cutbacks should be avoided in order to prevent increased prevalence of poor mental health among the population availability of data and material please contact author for data requests additional file additional file 1 contextual indicators abbreviations bbva banco bilbao vizcaya argentaria gdp gross domestic product ghq goldberg health questionnaire isced international standard classification of education noc national occupation classification nuts nomenclature des unités territoriales statistiques authors contributions irp designed the study mrb and cbt conducted the statistical analysis irp mrb and cbt drafted the article all authors provided input during the preparation of the manuscript and approved the final version competing interests the authors declare that they have no competing interests	background periods of financial crisis are associated with higher psychological stress among the population and greater use of mental health services the objective is to analyse contextual factors associated with mental health among the spanish population during the recession methodology crosssectional descriptive study of two periods before the recession 2006 and after therecession 2011 2012 the study population comprised individuals aged 16 years old polled for the national health survey there were 25234 subjects 2006 and 20754 subjects 2012 the dependent variable was psychic morbidity independent variables 1 sociodemographic age socioprofessional class level of education nationality employment situation marital status 2 psychosocial social support and 3 financial gdp per capita risk of poverty income per capita per household public welfare services health spending per capita labour market employment and unemployment rates percentage of temporary workers multilevel logistic regression models with mixed effects were constructed to determine change in psychic morbidity according to the variables studied results the macroeconomic variables associated with worse mental health for both males and females were lower health spending per capita and percentage of temporary workers among women the risk of poor mental health increased 6 for each 100€ decrease in healthcare spending per capita among men the risk of poor mental health decreased 8 for each 5percentage point increase in temporary workers conclusions higher rates of precarious employment in a region have a negative effect on peoples mental health likewise lower health spending per capita policies during periods of recession should focus on support and improved conditions for vulnerable groups such as temporary workers healthcare cutbacks should be avoided in order to prevent increased prevalence of poor mental health
introduction university students classroom performance is an important parameter for predicting their learning and academic achievements 1 2 3 4 as a negative form of classroom performance classroom silence among university students is a behavioral manifestation in which no verbal interaction occurs during classroom learning 5 this form of classroom performance often does not lead to better learning gains on the contrary it may significantly and negatively affect university students deep learning and thinking and indirectly affect their academic performance 6 numerous experimental and empirical studies showed that interactive learning benefitted university students a qualitative study revealed that teacherstudent interaction was one of the factors that improved university students learning outcomes 7 there were also studies based on an empirical comparative perspective that demonstrated that the gains of interactive learning were significantly better than those of silent passive individual learning 89 although some experimental studies proved that there was no significant difference in the impact of interactive or traditional classrooms on undergraduates performance however interactive classrooms could make classroom instruction more efficient in addition interactive classrooms were more helpful than traditional classrooms in closing the scores gap between students which was particularly beneficial for students with lower scores 10 in higher education institutions worldwide university classroom silence is particularly prominent in the chinese learner population 11 12 13 14 15 16 17 therefore the phenomenon of classroom silence and the challenge of improving chinese university students classroom learning performance have received much attention from researchers and practitioners regarding the classroom silence of chinese university students existing studies have shown strong interest in two types of contexts the first type of research explored the silence of chinese students in overseas university classrooms these studies mainly investigated the chinese students reticence in university classrooms overseas such as in new zealand 18 in the united states 151920 and in australia 21 to interpret and understand the causation of undergraduates classroom silent behavior by students learning from teachers with different cultural backgrounds for example wilkinson and ollivergray 18 conducted an exploratory study of chinese learners lack of participation in classroom discussions which was a frequent problem in new zealand universities based on the concept of cultural learning encounters the study unpacked the different interpretations of nonparticipation and excessive speaking by new zealand and chinese students and highlighted the need to create a culturally collaborative teaching model in university classrooms with international students based on a comparison of three different forms of a teaching organization because the subjects of such studies were in crosscultural contexts the cultural sensitivity of researchers often tended to make them much more concerned with the role of cultural factors in the reticence of chinese students in classroom settings therefore the findings of such studies are of less relevance in explaining chinese university students performance in classroom silence in local cultural contexts the second type of research investigated the silence of chinese undergraduates in foreign language classrooms at chinese universities and its influencing factors 131417 22 23 24 25 for example liu and jackson 25 investigated the performance of 93 nonenglish major firstyear freshmen at a top chinese university in the english classroom through viewing course videos reflective diaries and interviews the researchers found that although students selfreported a strong willingness to speak their actual speaking behavior was low the reasons behind this were complex including multidimensional factors such as language culture education psychology and personality but among them the lack of english language ability or students lack of confidence in their english proficiency was the most important constraint he 22 investigated 302 nonenglish majors from two chinese universities on the phenomenon of learning anxiety in university english classes from the questionnaire a lack of vocabulary or background knowledge was the primary cause of anxiety and silence from the interview students listed 16 reasons for anxiety and silence of which 14 were factors directly related to english language ability in contrast to the first type of research this type of research broke out of the confines of cultural centrism however as the language medium in the classroom was english researchers tended to consider the lack of english language skills as the dominant cause of chinese university students classroom silence focus was on factors such as lack of selfconfidence fear of classroom participation and fear of losing face due to poor performance to explain chinese learners silent performance in english classes at domestic universities 1314 therefore such research was constrained by classroom language contexts and could not well reflect the silence of chinese university students in classroom situations where the native language was the medium of communication obviously the studies above mainly discussed the speech situation of chinese undergraduates in foreign languagemediated classrooms but the studies on overseas classrooms also involved cultural heterogeneity in addition to language barriers however for chinese university students classrooms at chinese universities that use their mother tongue as the medium of communication are the more important learning environments considering this some studies have begun to focus on the third classroom situation for example zhang and mcnamara 16 studied students participation in mathematics and chinese classes at shandong university and found that a lack of classroom interaction between teachers and students was common 1314 lv analyzed the types of students silence in general education classes at nanjing university and the complex psychological factors behind them 626 in addition some studies have begun to explore strategies to improve such silence in the classroom 27 28 29 however compared with the first two types of research the research in this area was still very weak especially for indepth understanding of the silencing mechanism of chinese university students two insights can be drawn from current studies on the one hand chinese undergraduates classroom silence exists in a wide range of classroom contexts on the other hand there is some variability in the attribution of chinese students classroom silence from studies based on different classroom contexts this suggests that changes in context may bring about changes in silence factors which reflects the need to focus on new contexts therefore this study intends to explore in depth the native languagemediated classroom context at domestic universities which has received less research attention but is the primary classroom learning environment for chinese university students to further verify whether classroom silence still exists among chinese undergraduates in conditions free from cultural differences and language adaptation and if so what are the features and reasons of silence in this situation answers to these questions will help us deepen the understanding of chinese university students classroom reticence that is when the language and culture that have been summarized by present studies are no longer the main reasons what are the key factors contributing to this phenomenon since the professional courses of nonforeign language majors in chinese universities are the most extensive native language classroom situations this study will focus on the phenomenon of classroom silence among chinese university students in such situations and further select the education major courses as the specific research context professional courses for undergraduates majoring in education are the main site for these students to learn educational theories knowledge and skills after one to two years of professional study these students have already acquired the preliminary professional quality of education have a certain professional judgment ability on what is a good classroom and have strong sensitivity as well as reflection on educational issues at the same time most of these students are potential future teachers and their classroom learning experiences at the undergraduate level have a profound impact on their subsequent classroom teaching practices since china entered the 21st century curriculum reform has been continuously promoted one of the trends in the reform is to highlight the dominant position of students and emphasize students classroom participation for this reason new classroom learning methods such as cooperative learning have also been proposed 3031 therefore investigating the current situation and causes of classroom silence in professional courses of university students majoring in education will not only help to expand the understanding of classroom silence among chinese undergraduates but also can partially predict whether these future teachers will grow to be enablers or hindrances to the curriculum reform so that action can be taken as early as possible but we know very little about it due to omissions in existing studies to sum up the purpose of this study is to reveal the specific representation and formation mechanism of professional classroom silence of chinese undergraduates majoring in education specifically taking university students majoring in education at a normal university in china as the participants the grounded theory method is used to explore the experience of silence in the professional class and the complex factors behind it and to develop a corresponding substantive theoretical model to expand and deepen the recognition of chinese university students classroom silence due to the similarities of cultural backgrounds the conclusions of this study will also be applicable to explain the phenomenon of classroom silence among asian university students elsewhere in addition due to the particularity of the participants the relevant findings of this study will also help to grasp the reasons for the success or failure of curriculum reform that advocates students classroom interaction in terms of the contribution of teacher education materials and methods this study uses a grounded theory approach to collect data analyze information and construct theory originally invented by glaser and strauss 32 the grounded theory approach was intended to oppose the deductive paradigm of using experience to generate theory grounded theory advocates for the discovery of theory from experience and then using theory to reflect the experience and serve an understanding of experience the goal of grounded theory is to generate a theory from empirical material to explain a pattern of behavior that is relevant to the participant or to the problem with which the participant is involved generally such a theory is a substantive theory that is relevant focused on individuality and complexity and explores a particular phenomenon and its intrinsic connections when the substantive theory accumulates to a certain extent it can also be developed into a more generalized formal theory in general grounded theory is a generative rather than a validated methodology 32 and the flow of qualitative investigation using the grounded theory approach is shown in figure 1 to sum up the purpose of this study is to reveal the specific representation and formation mechanism of professional classroom silence of chinese undergraduates majoring in education specifically taking university students majoring in education at a normal university in china as the participants the grounded theory method is used to explore the experience of silence in the professional class and the complex factors behind it and to develop a corresponding substantive theoretical model to expand and deepen the recognition of chinese university students classroom silence due to the similarities of cultural backgrounds the conclusions of this study will also be applicable to explain the phenomenon of classroom silence among asian university students elsewhere in addition due to the particularity of the participants the relevant findings of this study will also help to grasp the reasons for the success or failure of curriculum reform that advocates students classroom interaction in terms of the contribution of teacher education materials and methods this study uses a grounded theory approach to collect data analyze information and construct theory originally invented by glaser and strauss 32 the grounded theory approach was intended to oppose the deductive paradigm of using experience to generate theory grounded theory advocates for the discovery of theory from experience and then using theory to reflect the experience and serve an understanding of experience the goal of grounded theory is to generate a theory from empirical material to explain a pattern of behavior that is relevant to the participant or to the problem with which the participant is involved generally such a theory is a substantive theory that is relevant focused on individuality and complexity and explores a particular phenomenon and its intrinsic connections when the substantive theory accumulates to a certain extent it can also be developed into a more generalized formal theory in general grounded theory is a generative rather than a validated methodology 32 and the flow of qualitative investigation using the grounded theory approach is shown in figure 1 we adopt the grounded theory approach commonly used in qualitative research to systematically collect and analyze empirical data for several reasons first since the purpose of this study is to explore the nature of silence in the professional classroom of chinese university students majoring in education a deductivebased approach is not applicable grounded theory is a proven method for exploring essentials allowing concepts and categories to emerge naturally with greater objectivity and has been successfully applied in many fields for example burns and schneider 33 used grounded theory to reveal the elements of leadership programs that had the greatest impact on the alumnis lives and careers as well as recommendations for how the program could better prepare students for the future second the grounded theory approach is good at refining and summarizing the students learning experiences because grounded theory describes and conceptualizes respondents perspectives behaviors and lived experiences in the context of their lives it ensures a participantcentered understanding 34 third the nature and formation mechanism of classroom silence among chinese undergraduates majoring in education have not been thoroughly studied and grounded theory has important applications when theory and research are underdeveloped and underdefined 35 fourth based on research in other contexts the nature and mechanisms of silence in the classroom are complex and involve a variety of relevant factors which is we adopt the grounded theory approach commonly used in qualitative research to systematically collect and analyze empirical data for several reasons first since the purpose of this study is to explore the nature of silence in the professional classroom of chinese university students majoring in education a deductivebased approach is not applicable grounded theory is a proven method for exploring essentials allowing concepts and categories to emerge naturally with greater objectivity and has been successfully applied in many fields for example burns and schneider 33 used grounded theory to reveal the elements of leadership programs that had the greatest impact on the alumnis lives and careers as well as recommendations for how the program could better prepare students for the future second the grounded theory approach is good at refining and summarizing the students learning experiences because grounded theory describes and conceptualizes respondents perspectives behaviors and lived experiences in the context of their lives it ensures a participantcentered understanding 34 third the nature and formation mechanism of classroom silence among chinese undergraduates majoring in education have not been thoroughly studied and grounded theory has important applications when theory and research are underdeveloped and underdefined 35 fourth based on research in other contexts the nature and mechanisms of silence in the classroom are complex and involve a variety of relevant factors which is where grounded theory can be useful grounded theory is defined as the discovery of theory from data systematically obtained and analyzed in social research 32 and is a method that better reflects social psychological processes the use of grounded theory as a methodology can help to reveal the formation mechanism of classroom silence among university students majoring in education in china procedure the grounded theory research procedure is characterized by the integrated nature of data collection and data analysis therefore the data collection for this study was based on the principles of theoretical sampling 36 it adopted a strategy of mutual facilitation and dynamic generation and was conducted in three stages with semistructured interviews theoretical sampling is a sampling that builds on concepts that have proven theoretical relevance in the developing theory 36 the principle of sampling is to keep adding to the sample as needed for theory development until each category in the data reaches theoretical saturation 32 data reaches theoretical saturation 32 stage 1 this stage focused on building a preliminary interview system and coding system first an initial interview outline was prepared based on the purpose of the study based on this the researchers selected 87 participants from the 156 participants recruited in march 2019 as a preliminary sample including 5 freshmen 18 sophomores 57 juniors and 7 seniors these students not only had classroom silence in their professional classes but also had many views about it through which they could help the researchers to better identify the characteristics of classroom silence and students attitudes in education major classes researchers conducted oneonone semistructured interviews with the participants the interview locations were set in empty classrooms or the school cafeteria according to the interviewees preference although the researchers designed the interview outline in advance the actual interview was followed up when the researchers found new and more valuable information at the right time the interview questions were based on the interview outline and focused on the current state of silence in the professional classes experienced by the participants and the reasons for their silence starting with an understanding of classroom silence the participants were allowed to share autobiographical accounts of themselves and their experiences in class 39 questions were then directed to the respondents perceptions and attributions of the silencing phenomenon in the professional classroom strategies to improve it and to pursue new questions that arose once all interviews were completed two researchers simultaneously coded these 87 interview texts for independent analysis and then the four researchers discussed the coding rationale and further interview questions together to enrich the prototype coding system the researchers continued to select 57 participants from the remaining participants for oneonone semistructured interviews and repeated the coding procedure above this round of interviews further uncovered the reasons for the stage 1 this stage focused on building a preliminary interview system and coding system first an initial interview outline was prepared based on the purpose of the study based on this the researchers selected 87 participants from the 156 participants recruited in march 2019 as a preliminary sample including 5 freshmen 18 sophomores 57 juniors and 7 seniors these students not only had classroom silence in their professional classes but also had many views about it through which they could help the researchers to better identify the characteristics of classroom silence and students attitudes in education major classes researchers conducted oneonone semistructured interviews with the participants the interview locations were set in empty classrooms or the school cafeteria according to the interviewees preference although the researchers designed the interview outline in advance the actual interview was followed up when the researchers found new and more valuable information at the right time the interview questions were based on the interview outline and focused on the current state of silence in the professional classes experienced by the participants and the reasons for their silence starting with an understanding of classroom silence the participants were allowed to share autobiographical accounts of themselves and their experiences in class 39 questions were then directed to the respondents perceptions and attributions of the silencing phenomenon in the professional classroom strategies to improve it and to pursue new questions that arose once all interviews were completed two researchers simultaneously coded these 87 interview texts for independent analysis and then the four researchers discussed the coding rationale and further interview questions together to enrich the prototype coding system the researchers continued to select 57 participants from the remaining participants for oneonone semistructured interviews and repeated the coding procedure above this round of interviews further uncovered the reasons for the participants classroom silence subsequently researchers conducted a focus group interview with the remaining 12 participants to confirm the developed coding system to avoid participants nervousness the researchers chose a smart classroom with a cozy environment and tables and chairs that could swing freely arranged the tables and chairs in a ring shape in advance informed and invited 12 participants to come to the interview at a uniform time with researcher 2 and researcher 3 acting as the moderator and recorder respectively questions were set up mainly around the interview outline and the results of the previous two rounds of interviews and were adjusted according to the onsite conversation for example asking the participants to talk about their perceptions of professional classroom silence based on their professional knowledge and experience to obtain more information for the study the fieldwork was organized in a way that allowed data collection and preliminary analysis to occur simultaneously 40 this stage focused on further validation and refinement of the coding system developed in the first phase only online interviews were used in this phase because students were learning online due to the epidemic 78 participants were randomly selected from the 131 participants recruited in march 2020 and onetoone semistructured interviews were still conducted by the researchers with the participants after that the researchers selected 43 participants for oneonone indepth interviews and conducted a focus group interview for the remaining 10 participants the specific process was similar to the first stage and will not be repeated here this round of interviews was dedicated to fulfilling the attributes and dimensions of the emerged categories on the one hand and to discovering new elements on the other 41 pp 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 after this round of interviews four researchers continued to follow the first phase of independent coding followed by a consultative workshop at this stage the existing categories were further enriched the relationship between these categories was clarified through the paradigm model of axial coding based on this the researchers established the core category through selective coding and formed a theoretical model about the formation and development mechanism of the phenomenon of silence in the professional courses of chinese undergraduates majoring in education stage 3 this phase focused on confirming or revising the theoretical model developed in phase 2 52 of the 107 subjects recruited in march 2021 were selected by the researchers for oneonone semistructured interviews the remaining 55 participants were divided equally into five separate groups for focus group interviews the focus group interviews were conducted in empty classrooms at the university and each focus group interview consisted of 2 researchers and 11 participants one researcher was responsible for indepth interaction with the 11 participants and the other researcher was recording the interview after this round of interviews researchers found that no new categories or attributes emerged and the theoretical model of the representation and formation mechanism of the phenomenon of the professional classroom silence of chinese undergraduates majoring in education developed in the second round was further confirmed here this meant that this study had achieved theoretical saturation at this point and no new information needed to be collected 3641 data analysis coding is the key to generating theory from empirical data and thus is the core strategy for data analysis in this study the open codingaxial codingselective coding strategy invented by strauss and corbin 36 is widely accepted in this study this coding strategy was chosen and the interview data were analyzed level by level with the help of nvivo12 software open coding occurred mainly in the first stage of data collection and analysis and was centered on decomposing comparing labeling conceptualizing and categorizing data through linebyline analysis for example the label attitude was assigned to the statement silence in the classroom has become a common phenomenon in professional classrooms nowadays and for me this is a bad phenomenon with the emergence of the new label harm from the supplementary interview a new related concept subjective perception could be created on top of the two and further developed into the category silence cognition through this inductive and continuous comparison approach five major categories were established at this stage the axial coding occurred mainly in the second phase of data collection and analysis which centered on the establishment of a paradigm model and the determination of the relationships among the major categories a paradigm model is an analytical model for linking categories and subcategories in a set of relationships at a higher level of abstraction 42 in this study the analysis of the five categories relationships clarified the status of the main category classroom silence the core of the selective coding was to write a story line select the core category and complete the theoretical construction of the specific representation of classroom silence and its formation mechanisms among chinese education major undergraduates the selective coding was initially achieved in the second phase of the research process and the rationality and credibility of the coding were further verified in the third stage theoretical saturation test the grounded theory approach requires researchers to continuously collect and analyze data and to continuously supplement and improve emerging concepts and categories 38 when the newly collected data cannot be classified in new ways this indicates that the theory has reached saturation 43 after the first phase was completed we organized the second phase of data collection and analysis to confirm whether new categories or concepts would be generated and found that new concepts and categories were indeed generated in the second phase for which we organized the third phase the third phase generated no new theoretical elements and further validated the previously coded logical relationships this indicated that the previously constructed theoretical model was saturated in addition we fed back the categories and models generated by the coding to the professional course instructors and some of the interviewees they confirmed that the model was consistent with reality and no more new categories were needed the collection of new data was stopped because of the clarity and robustness of the extracted major class genera initial class genera and relationship descriptions rigor the credibility of research starts from the data the depth and scope of the data are very important research that generates data with rich area of coverage rich content and relevant information is exceptional 44 pp 24 25 in this sense the larger the sample size of a qualitative study the more representative the analysis of the sample will be of the population however the qualitative research process is more complex and depthoriented and it is not possible to select a very large sample as in quantitative research so the sample size of common grounded theory studies is usually less than 100 3342 thus it is clear that this study is rich and substantial in terms of both sample size and interview data while following the principles of theoretical sampling in addition it is particularly important to consider how to enhance selfreflexivity throughout the study 45 to this end the researchers used memos and reflections after each interview and during data analysis the researchers wrote memos about interview elements or illuminating data based on professional experience at the same time the researchers considered the possible impact of these ideas on the interview and analysis process through workshops and reflections and reevaluated the process of interviewing and analyzing the data results and theory through theoretical sampling and a rigorous threelevel coding procedure this study focused on the basic situation of silence in the professional classroom of chinese undergraduates majoring in education and the real perceptions and explanations of students involved in the silence in the professional classroom responses to these questions formed the basis of the grounded theory of the formation and development of classroom silence within the professional course context this section will use the threelevel coding as providing clues to drive the analysis deeper layer by layer until the theory is generated open coding the purpose of open coding is to develop a large number of codes to describe name or classify events 32 detailed information about these categories and concepts will be specified in section 33 of this study learning adjustment p107 the longtime habit from elementary school to high school causes students to maintain their original listening habits and gradually develop classroom silence when they enter the university classroom learning habits p35 basic education establishes the image of teacher authority and knowledge authority which leads students to be afraid to challenge teachers and textbooks authority awareness p2 the strict entry and lenient exit of domestic universities also give students the capital to ignore the classroom management system university environment p24 the free and diffuse atmosphere of the university campus somewhat undermines students motivation to perform in class learning atmosphere p8 most students simply require that they do not fail the exams in each course selfdevelopment learning motivation p2 because of the different levels of attention university students are generally scattered and not motivated to study so it makes sense that they are silent in class learning emphasis axial coding axial coding is the use of a combination of inductive and deductive reasoning to connect codes 46 following strauss and corbins paradigm model this paper regrouped categories and attributes from the open coding by analyzing the causal conditions phenomenon context intervening conditions actioninteraction and consequences of the phenomenon the major categories and subcategories were distinguished figure 3 showed the results of the axial coding int j environ res public health 2022 19 x for peer review 11 of 22 axial coding is the use of a combination of inductive and deductive reasoning to connect codes 46 following strauss and corbins paradigm model this paper regrouped categories and attributes from the open coding by analyzing the causal conditions phenomenon context intervening conditions actioninteraction and consequences of the phenomenon the major categories and subcategories were distinguished figure 3 showed the results of the axial coding as can be seen from figure 3 classroom silence is the main category of the study and the open coding of silence cognition silent behavior personality characteristics classroom experience and learning adjustment are all subcategories for further understanding and interpretation of this main category through the paradigm model the story context of silence in education professional courses among chinese undergraduates becomes clear the phenomenon of silence in education courses emerges among students majoring in education triggered by personality psychological characteristics such as introversion and fear in turn under the external conditions of inconvenient interaction peer pressure and a strict entry and loose exit free and relaxing university environment chinese education major students adopt learning adjustment strategies such as lowering selfrequirement or maintaining passive learning habits mediated by students silence perceptions and basic education experiences ultimately leading to the continuation of silent behaviors in education professional courses selective coding selective coding is the process of systematically selecting categories to find the core category by exploring the deeper relationships among the main categories this paper described the relationship of each sequence using selective coding focusing on the story as can be seen from figure 3 classroom silence is the main category of the study and the open coding of silence cognition silent behavior personality characteristics classroom experience and learning adjustment are all subcategories for further understanding and interpretation of this main category through the paradigm model the story context of silence in education professional courses among chinese undergraduates becomes clear the phenomenon of silence in education courses emerges among students majoring in education triggered by personality psychological characteristics such as introversion and fear in turn under the external conditions of inconvenient interaction peer pressure and a strict entry and loose exit free and relaxing university environment chinese education major students adopt learning adjustment strategies such as lowering selfrequirement or maintaining passive learning habits mediated by students silence perceptions and basic education experiences ultimately leading to the continuation of silent behaviors in education professional courses selective coding selective coding is the process of systematically selecting categories to find the core category by exploring the deeper relationships among the main categories this paper described the relationship of each sequence using selective coding focusing on the storyline reasons for classroom silence in professional courses of university students majoring in education this section begins with a detailed description of the meaning of each category and the subcategories it contains and cites the original data in which they are grounded when necessary silence cognition silence cognition was the subjective awareness and objective cognition of chinese undergraduates majoring in education about the phenomenon of silence in the professional classroom it mainly included two categories of status quo perception and subjective cognition subjective awareness this referred to the participants perception of silence in the professional classroom and contained three aspects the participants attitude judgment on the nature of classroom silence and the impact analysis firstly almost all participants had a negative attitude toward silence in the professional classroom they believed that silence in the professional classroom was a very bad phenomenon and a persistent problem in the university classroom and expressed their disagreement with it secondly one of the basic judgments given by the participants about the nature of classroom silence was that classroom silence was the opposite of classroom dialogue which alienated the potential twoway constructive activity in which both teachers and students participated into a oneway activity on the teachers side with no place for the students subjectivity to manifest finally the participants provided a professional analysis of the harm of classroom silence participating students pointed out that this phenomenon not only limited multiple aspects of their development but also led to a vicious circle in which teachers lost the enthusiasm to teach and students lost the desire to learn objective perception this category was concerned with the objective description of the current situation of classroom silence by the participants according to the general descriptions of the frequency extent and scope of classroom silence in professional classes by the interviewees classroom silence was frequent and serious in such courses classroom silence has become a normal for university students classroom learning silent behavior silent behavior was a silent activity of nonparticipation exhibited by students in the classroom as evidenced by circumstances of speaking up and concentration on the course speaking situation according to the descriptions of the participants the positive and initiative level in classroom interaction among university students today was not high contemporary university students are always poorly motivated or engaged in the university classroom which was a deep obstacle to classroom interaction even when there was a break in classroom silence it was a passive choice forced by the final assessment some students classroom participation would be significantly higher if the instructor made it clear that classroom presentations would be recorded in the overall final grade course concentration students attention was not focused on the classroom and they appeared to sleep indulge in temptations wander and do other assignments modern technological products made learning activities a little bit tedious and long and created a great temptation for students who lacked a clear goal and a strong will indulging in various digital temptations had become a prominent manifestation of silence in the university classroom personality characteristics students personality traits were individual factors of their silence in professional classes and its perpetuation the results of the interviews and analyses showed that students silent orientation was closely related to their selfconfidence disposition and speaking mentality selfconfidence this study found that students selfconfidence had a profound effect on their silent behavior in the classroom first a lack of selfefficacy caused students to lose the courage to answer questions students were often afraid to be the first speaker because if they dont speak well they will look reckless and stupid second speaking competency influenced students decisions about whether to speak in class many students worry that they will not be able to give the right answer because they lack effective preparation or lack the ability to organize their thoughts and language in a short time thus they chose not to respond disposition according to the descriptions of the participating subjects there was an important connection between individual students disposition and their classroom performance first introverted students had a natural tendency to remain silent for students who are introverted or timid silence may happen on any occasion second students who emphasized modesty and selfesteem would not express or present themselves in front of groups either keeping face and remaining a low profile as well as humble attitude will reduce the frequency they speak or show in public it is important to note that the determination of personality in this study was based on the selfreports of the participants and combined with the descriptions of the classroom instructors as well as the daily observations of the researchers this is consistent with the basic requirements of grounded theory and has a basis in reality speaking mentality this was a factor that was relatively controllable by the individuals themselves and included fear willingness to speak and speaking needs most of the participating subjects expressed their fear of speaking in class which could be categorized into three specific situations fear of speaking fear of being criticized by the teacher and fear of being ridiculed or excluded by their classmates students might be afraid to speak up because they were afraid of being blamed and criticized by the teacher for saying something wrong or afraid of being ridiculed by their classmates for incorrect comments another direct cause of classroom silence as noted by some of the participants was the lack of willingness to participate in class some university teachers just read the content from a powerpoint causing students to lose interest in interacting with the teacher some of the participants indicated that speaking was unnecessary for classroom learning so there was no need for speaking classroom experience the classroom experience was the subjective feelings of the participating subjects about classroom learning in professional courses and the contextual factors of classroom silence in professional courses which mainly included three subcategories of course attractiveness peer influence and interaction convenience course attractiveness course attractiveness often determined the extent to which students were willing to engage in the course and it could be reflected in the teaching situation studentteacher relationships personal attributes of the instructor score incentive and classroom interest according to the narratives of the participants students did not participate in classroom interactions when the content was outdated boring or too abstruse the teaching style was single questions from the teacher were too difficult too empty or too grand there is rejection written all over the teachers face the teacherstudent relationship was indifferent there was a lack of score incentives and they were not interested in the course peer influence the classroom was a collective and students performance was often influenced and even pressured by other students when it becomes clear that no one is interacting with the teacher students are reluctant to be the first to communicate for fear of being alienated by group another scenario of peer influence was if the number of students who were afraid to express their inner thoughts increased in the classroom it would create a more serious classroom atmosphere those who were usually willing to speak were more likely to remain silent due to the collective silence of the majority which was called contagious silence interaction convenience the ease of interaction reflected how easy or convenient it was for students to interact with the instructor and was primarily influenced by seating distribution class size and classroom equipment the teacherstudent relationship was alienated by the unreasonable layout of seating space and the general classroom seating arrangement does not facilitate discussion between the teacher and students and overemphasizes the teachers authoritative position in addition the excessive class size and poorly equipped instructional equipment also impacted students participation in the classroom learning adjustment learning adjustment reflected the psychological and behavioral transformation of students from basic education featuring highintensity pressure to higher education featuring freedom and ease it was another important realistic factor related to the subjects professional classroom silence mainly in terms of educational experience university environment and learning motivation educational experience educational experience referred to the schooling experience of the participating subjects before they entered university and was a historical factor that included educational inertia study habits and authority awareness most of the participants indicated that silence in class began to appear in primary and secondary schools and gradually intensified with the increase of school years the longstanding indoctrination teaching examoriented education and highintensity pressure learning atmosphere had cultivated a learning habit of passive acceptance for students and fostered thinking inertia the image of authority established by teachers in basic education also led students to be afraid to show their differences therefore the silence of the professional classroom in higher education was a natural extension of the silence of the basic education classroom university environment universities were the learning environment and living space of university students and the management system and learning atmosphere of universities were the realistic factors for the silence in professional courses of the participants on the one hand the entry and exit mechanism and assessment system of universities inhibited students enthusiasm for selfexpression the strict entry and lenient exit together with the resultoriented and quantityoriented assessment system of universities gave university students the capital to ignore the classroom on the other hand the free and undisciplined learning atmosphere of universities made it easy for students to let themselves go excessive free time and loose requirements from parents and teachers made students free to indulge in their respective worlds and appear silent in the classroom learning motivation the majority of participants reported that due to the stark differences between the two educational systems their demands for themselves and the emphasis on learning generally decreased after they entered university most students adjusted their learning goals from high scores to not failing the exam with the lowering of learning goals students enthusiasm for classroom participation gradually disappeared and thus classroom silence happened university students in a relaxed environment had a lax learning mindset they were less committed to learning so they lost the prerequisite for classroom interaction considering this the silence in class was reasonable from the analysis above it was clear that the chinese undergraduates majoring in education had a profound understanding of the nature and the harm of classroom silence in professional courses at the same time they perpetuated classroom silence that was barely recognized by themselves under the combined influence of multiple factors as a result the core category of the study emerged namely the separation of cognition and practice in the professional classroom silence of chinese undergraduates majoring in education based on this the researcher further clarified the attributes and dimensions of this core category core category attribute dimension separation of cognition and practice cognitive level highlow behavior state speakingno speaking through indepth analysis of the core category the study found four variants of the undergraduates cognition and practice of classroom silence in their professional courses through indepth analysis of the core category the study found four variants of the undergraduates cognition and practice of classroom silence in their professional courses the theoretical model of the formation and development of the phenomenon of professional classroom silence for chinese undergraduates majoring in education the analysis above showed that the classroom silence of these students in professional classes featured the separation of cognition and speaking practice which was manifested as high cognition and low practice that was students had professional cognition of silences hazards and disapproved of silence but remained silent practically to deeply explain the mechanism of this phenomenon this study constructed a theoretical model of the formation and development of cognition and practice separation in the classroom silence of chinese undergraduates majoring in education the theoretical model of the formation and development of the phenomenon of professional classroom silence for chinese undergraduates majoring in education the analysis above showed that the classroom silence of these students in professional classes featured the separation of cognition and speaking practice which was manifested as high cognition and low practice that was students had professional cognition of silences hazards and disapproved of silence but remained silent practically to deeply explain the mechanism of this phenomenon this study constructed a theoretical model of the formation and development of cognition and practice separation in the classroom silence of chinese undergraduates majoring in education figure 5 is the visualization of the formation mechanism of high cognition low practice sional classes featured the separation of cognition and speaking practice which was manifested as high cognition and low practice that was students had professional cognition of silences hazards and disapproved of silence but remained silent practically to deeply explain the mechanism of this phenomenon this study constructed a theoretical model of the formation and development of cognition and practice separation in the classroom silence of chinese undergraduates majoring in education figure 5 is the visualization of the formation mechanism of high cognition low practice chinese undergraduates majoring in education had a professional judgment about classroom silence due to their professional background for example they were able to recognize that students silent behavior in professional classes transformed teaching as a bilateral activity between teachers and students into a oneway activity on the teachers side and pointed out that the greatest harm was the formation of a vicious circle in which chinese undergraduates majoring in education had a professional judgment about classroom silence due to their professional background for example they were able to recognize that students silent behavior in professional classes transformed teaching as a bilateral activity between teachers and students into a oneway activity on the teachers side and pointed out that the greatest harm was the formation of a vicious circle in which teachers do not want to teach and students do not want to learn through the interviews we found that the judgment and reflection of education major students on classroom silence reflected strong professionalism which was manifested in the terminology of expressions such as unilateral activity alienation and the sequela of basic education this is one of the characteristics that distinguish this study from other studies despite a high degree of professional awareness they continued to behave as contributors to the phenomenon of silence in the professional classroom this study found multiple causes for this phenomenon through an inductive analysis of data grounded in student interviews the primary causes were students personality characteristics such as lack of confidence introversion and a mentality that hindered speaking among them speaking mentality was the most direct cause of the silent behavior the speaking mentality was not innate some deeper causes could be further traced for example individual psychological characteristics of students classroom experiences the university environment and the learning adjustments that occurred after students enter university some of these factors were situational some were cultural some were historical and some were personalized it was the interaction and joint influence of these factors that shaped students silent behavior in the classroom 47 at the same time this validated the paradigm model proposed at the phase of axial coding in other words the speaking mentality was a direct cause of students maintaining silence in the professional classroom and this relied on contexts such as the classroom experience and the university environment and it acted through mediating conditions such as silence cognition and educational experiences specifically the fear of speaking was closely related to students psychological characteristics of lack of selfefficacy or introversion and was also rooted in their educational experiences especially their personal experience of being criticized for wrong answers in basic education some students were afraid to speak because of their lack of speaking competency which was closely related to their lack of knowledge reserves the root cause was the loose study habits and negative study motivation of university students the reluctance to speak was largely due to the students poor classroom experience especially their low interest in course content or interactive topics at the same time peer pressure in the classroom experience might also weaken students willingness to speak for fear of being embarrassed perceived as being strangely or excluded this depended in part on the lax management and inappropriate evaluation of teachers and students in universities and also affected students adjustment to the university environment the lack of need to speak was mainly due to the oneway input learning habits developed in the indoctrination classroom mode of basic education which hindered the development of students thinking and expression skills in other words the inappropriate learning adjustment that occurred after students entered the relaxed environment of universities was the root cause of students lack of speaking needs the underlying causes were both relatively independent and interrelated on the one hand personality and psychological characteristics classroom experience and learning adjustment each constituted relatively independent influencing factors on the silence maintenance of the undergraduates in their major courses on the other hand the great contrast between the highintensity pressure learning environment in basic education and the free and easy learning atmosphere in higher education generated learning adjustment behaviors which interacted with their classroom experience through the influence of students psychological characteristics discussion summary and discussion this study proposed a dynamic theoretical model of the formation and development of silence in the professional classroom of chinese undergraduates with an education major by grounding in interview data the main contribution of the study is to reveal the phenomenon of the separation of cognition and practice in the professional classroom silence among chinese undergraduates majoring in education and to further investigate the mechanisms of this phenomenon the main findings of this study will be discussed in further depth in comparison with related existing research first this study found that not only the silence in the professional classroom was very common and serious among chinese university students who majored in education but there was also a separation of cognition and practice in which students had high cognition and low practice of speaking in the professional classroom on the one hand both the researchers informal classroom observations and the researchers indepth interviews with the participants suggested that classroom silence was normal for university students silence in the classroom was still widespread among chinese university students even in professional classes at domestic universities where the native language was the medium of communication which formed a mutually corroborating relationship with existing research on silence in overseas classrooms and second language classrooms in local universities 1113 17 18 19 2122 on the other hand all participants in the interviews had a negative attitude toward classroom reticence and made a more professional analysis of silence in the professional classroom but at the same time took no measures to improve it so that silence continued to occur or even gradually increased zhou 24 and hsu 14 revealed in their study that there was a clear contradiction between chinese university students perceptions of oral participation in university english classes and their actual behaviors although students valued classroom oral participation and did not wish to be passive learners their overall level of participation remained low chengs 48 study focused on the reasons why some asian eslefl learners continued to fail to take an active role in the classroom although they might have a strong desire to speak the research above identified some mutual evidence with the finding of this study that there was a separation of cognition and practice among chinese university students regarding classroom silence in contrast this study not only directly addressed chinese university students perceptions of classroom silence but also explored the mechanisms that generated the cognitionpractice gap of classroom reticence among chinese university students in their native language classrooms at domestic universities correspondingly low cognition low practice was observed in research on asian students classroom reticence silence was a positive strategy for asian students to save face and show respect and courtesy 4950 as well as maintain harmony in the social order 51 as a result they often chose to be reticent for the sake of these positive functions of reticence both in domestic and foreign classrooms a certain explanation of this interpretation difference might be that relevant studies tended to reveal the positive meaning of silence from the perspective of understanding silence or the cultural identity of the participants while this study was not limited by a specific theoretical perspective due to the education professional background of participants the analysis based on the interviews with these students inevitably reflected the disciplinary characteristics of education ie showing the understanding of the essence of teaching and learning and paying more attention to the problems of education itself second the reasons why students remained silent in the classroom were systematic and diverse this study found that students classroom silence in specific contexts was facilitated by a combination of factors many of these factors extended beyond the specific classroom context and were linked to the learning environment and its changes as well as the learners learning adaptations although the outwardly observable manifestations of silent behaviors such as students not taking initiative not actively speaking and doing things unrelated to the classroom were similar the reasons behind them were not the same moreover the combination of these factors could make students tendency to be silent more stable making it difficult for students to induce changes in their actions even when they were highly aware of the dangers of classroom silence relevant research had also explored the causes of students refusal to participate orally in class from multiple perspectives 5131425 52 53 54 55 56 for example king 5 from the perspective of dynamic system theory pointed out that the state of silence prevalent in japanese second language classrooms was built on many pillars even within a single lesson there might be multiple interrelated reasons behind students silence these reasons included both dynamically changing external factors as well as internal characteristics of learners this systematic perspective was highly compatible with the model ultimately constructed in this study with the difference that kings 5 study used dynamic system theory as a prior research perspective while this study generalized the findings by grounding them in the interview texts in addition this study did not stop at displaying the influential factors behind students persistently silent behavior in professional classes but further subdivided the factors into direct and deep causes then the interrelationships among the causes were clarified to build a systematic hierarchy of the causes of persistent silence in professional classes among chinese undergraduates majoring in education finally this study further confirmed some of the common factors that had been studied and also revealed some factors that had not received sufficient attention in relevant studies for example some of the influential factors summarized in this study such as individual psychological factors such as selfconfidence personality speaking mentality and classroom contextual factors were consistent with factors concluded from studies of jia et al 57 wang et al 58 ai 21 flowerdew and miller 10 eddyu 13 hsu 14 liu and littlewood 12 sedova and navratilova 59 these factors constituted the general reasons for chinese students silence in different types and contexts of university classrooms at the same time this study also highlighted some new factors this study found that the learning adjustment that occurred after students moved from basic education to higher education was both a cause of their professional classroom silence and a consolidating factor in their continued classroom silence despite their disapproval of silent behavior these factors had not received the attention they deserved in related studies as mentioned earlier basic education not only helped students develop a passive acceptance of learning inertia but its excessive emphasis on scores and standard answers also imposed limitations on the development of students thinking and expression skills as one study revealed chinese students classroom silence was essentially a learned behavior as they began to learn to be silent in elementary school 60 even in conversational contexts teachers questions were usually not used to elicit reasoning or probe students understanding but rather to check students memory 61 and unskilled questioning left students with very limited opportunities for inquiry and discussion in the classroom 576263 in the absence of any external intervention these factors which the participants called the aftereffects of basic education would accompany students to the university and became an important historical source of silence in the university professional classes most students entered chinese universities with a change in their learning mindset and behavior as a result of changes in the learning environment which manifested itself in the form of lowered attention to learning relaxed selfrequirement and indulgence in external temptations these factors were accompanied by a lack of knowledge and a scattered state of learning in the classroom resulting in students losing the prerequisites for interaction in the dialogue situations of professional classes due to a lack of ideas or the absence of concentration the results of this study have important implications for countries or regions where university classroom silence also exists such as australia 50 the united kingdom 58 and south africa 64 and east asian countries such as japan and south korea 12 which share a similar culture and educational context as china generally speaking improving silent behavior in the classroom requires dealing with factors such as classroom experience and learning adaptation to achieve consistency in university students cognition and practice first educators should focus on fostering an encouraging positive classroom atmosphere and arranging openended discussions to increase student friendship and teamwork which means a nonthreatening environment second educational administrators should pay attention to students adaptation problems during the educational phase transition and adopt a combination of centralized preaching and individual counseling to help students make a smooth transition third students should be guided to continuously increase their knowledge base and keep the classroom progressively active in the beginning students are invited to express ideas as a group rather than as individuals then they are encouraged to express ideas as individuals eventually they will be able to actively share their views limitations this study focused on students majoring in education so the results obtained might be influenced by the professional attributes of the participants the results of this study showed that the core feature of the silencing phenomenon in professional courses in chinese universities was the separation of cognition and speaking practice among university students which was characterized by high cognition and low practice the high cognition might be related to the professionalism and sensitivity of such a student group due to the contextual limitations of the substantive theory of cognition and practice separation of chinese education undergraduates professional course silence whether the findings of this study can apply to those from different majors should be further discussed therefore subsequent studies need to expand the professional dimension by conducting research on classroom silence in different types of professional courses to explore whether the high cognition low practice model of classroom silence formation and development can explain classroom silence for other majors outside of education in chinese universities in terms of sampling future research needs to include the classroom silence and participation of junior students in various categories of majors at representative comprehensive universities to develop or revise the findings of this study from the perspective of seeking contextual variables to increase the density and explanatory power of the theory future research should focus on whether there is a unity between cognition and practice of high cognition high practice or low cognition low practice in chinese university students professional course learning and a new separation between cognition and practice of low cognition high practice due to the use of a qualitative research method based on grounded theory the findings obtained in this study lacked largescale quantitative validation therefore using quantitative research methods and statistical analysis to validate the findings of this study and further explore the effects of other factors such as age gender socioeconomic status career prospects and academic achievement on chinese university students silent behavior in the classroom are also our next directions conclusions to investigate the phenomenon of silence in the professional classroom among chinese undergraduates this study used a grounded theory approach to conduct indepth interviews and coding analysis with 394 chinese undergraduates majoring in education who had experiences of silence in the professional classroom the study found that students maintained silence while holding negative attitudes toward the phenomenon of classroom silence in professional classes this finding further reinforces the relevant findings of existing studies however the outstanding contribution of this study is not only to show the existence of this phenomenon but also to reveal the formation mechanism of the cognitionpractice mismatch of students silence in the professional classroom with the help of the grounded theory approach in terms of high cognition of classroom silence the students background in education gives them a certain professional advantage in analyzing educational and learning issues this insight further influences their attitudes toward silent behavior in the professional classroom in terms of the low practice of classroom speech speaking mentality is the direct cause in contrast personality and psychological characteristics classroom experiences and learning adjustment as deeper causes jointly influence students speaking impediments thus indirectly contributing to the persistence of silent behavior in students professional classes in addition this study provides some new insights based on reaffirming and deepening the relevant findings of existing studies for example this study finds that learning adjustment contributes equally importantly to chinese university students classroom silence but these factors have not received enough attention in existing research data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to privacy institutional review board statement ethical review and approval were waived for this study due to that the research does not deal with vulnerable groups or sensitive issues informed consent statement informed consent was obtained from all subjects involved in the study	classroom silence is a negative form of classroom performance that is particularly prominent in the chinese learner population existing research has mainly explored the silence phenomenon among chinese university students in two types of learning contexts overseas university classrooms and foreign language classrooms at local universities without focusing on the chinese undergraduates reticence in courses mediated by native language at domestic universities however the last type is the most common habitat for chinese university students learning in higher education therefore a sample of chinese undergraduates majoring in education n 394 was recruited to determine the mechanisms of silence formation in professional classrooms this study was based on grounded theory and indepth interviews and the recorded material was processed using nvivo 12 after a series of steps including open coding axial coding selective coding and theoretical saturation testing the core feature of the phenomenon of silence in professional classrooms of chinese university students majoring in education was found to be the separation of students cognition and speaking practice then a theoretical model of the formation and development of the phenomenon of classroom silence in professional classrooms of these undergraduates was constructed the study showed that these university students had professional perceptions of classroom silence and displayed strong opposition to it but they continued to maintain silent classroom behavior under the combined influence of individual characteristics classroom experience and learning adjustment following this implications for existing research and suggestions for future practice are discussed
introduction employment is vital for financial stability in the lives of all people and when it comes to people with disabilities it becomes even more essential to increase job quality to ensure their financial stability in particular bullying might become an issue for people with mild intellectual disabilities as they interact with supervisors and fellow employees in the workplace espelage and swearer defined bullying as physical and verbal aggression that happens repeatedly from individuals or groups to achieve a goal the issue of bullying in the workplace for workers with disabilities is rarely discussed in saudi arabian empirical studies therefore the needs of people with disabilities in the workplace must be addressed to increase overall workplace quality in 2000 the saudi government enacted the disability welfare law which supports people with disabilities in all life aspects including employment services to find jobs with their typically developing peers this law guarantees the basic rights of people with disabilities to protect and increase their quality of life also the united states of america passed the americans with disabilities act to protect the rights of people with disabilities in all aspects of life this law prevents discrimination against people with disabilities in all activities of life it also ensures that people with disabilities have the same access and opportunities as their typically developing peers in areas such as employment and services these laws clearly affirm that people with disabilities need protection of their rights in everyday activities just as the rights of their typically developing peers are protected thus people with disabilities need more attention not only regarding their employment rights but also their right to a safe environment in their workplaces this involves a clear policy and more awareness about workplace bullying and how employees are protected the current study focused on the variables of age education level gender years of work experience and the employment positions of assistant supervisor assistant manager area manager and coworker these variables are important since age education level and years of work experience could determine why some workers with intellectual disabilities have faced bullying or not education level is also important because workers with intellectual disabilities with less education might face more bullying it is also important to find out how gender affects levels of bullying in the workplace i also included important employment position variables to determine the extent to which these variables are linked with bullying and therefore limiting workplace quality for workers with intellectual disabilities løvvik et al conducted a study about bullying in the workplace and found that 36 of their participantsw experienced workplace bullying thus it is important to study this issue among people with intellectual disabilities to potentially improve the quality of workplace for these individuals vickers noted that not many studies have addressed the issue of bullying for people with disabilities compared to studies of bullying issues for typical people thus bullying is a critical issue for any organization and it becomes more of a concern to people with disabilities in their workplaces as they might be unable to defend their rights or even recognize bullying when it occurs there are few studies on bullying against people with intellectual disabilities in the field to help stakeholders improve workplace quality for people with disabilities and learn how to prevent workplace bullying the objective of this study was to determine which groups have had more experience with bullying based on demographic variables to assist stakeholders in improving workplace quality by decreasing bullying incidents that might occur for people with intellectual disabilities this studys hypothesis was that there is an association between the variables identified in this study and workplace bullying of people with intellectual disabilities this study is essential for the field of disabilities as we strive to support people with disabilities by preventing in workplace bullying workplace bullying in related fields bullying is an issue that people with disabilities face in the workplace jones et al studied workplace discrimination and harassment among workers with disabilities and found that 184 of the sample reported harassment in the past 2 years in their jobs workers with disabilities faced higher levels of harassment compared with workers without disabilities also women with disabilities experienced higher levels of workplace harassment than men and younger workers faced lower levels of harassment than older workers jones and his colleagues found that about 8 of their sample with disabilities had faced discrimination in the workplace in the past 2 years also workers with disabilities faced higher levels of discrimination than workers without disabilities workplace discrimination levels were similar for men and women and discrimination levels were lower for younger workers than for older ones these results imply that people with disabilities face more workplace discrimination than their typically developing peers because of their disabilities another study by gardner et al indicated that 15 of their sample had experienced bullying in new zealand workplaces and 28 faced cyberbullying in the workplace women experienced more workplace bullying than men and women had worse physical health more emotional strain and more destructive leadership and team conflicts in the workplace this study showed that people faced bullying of different types and at different levels in all workplaces that women might experience more workplace bullying than men and that workplace bullying might occur more frequently for workers with disabilities than for their typically developing peers also organization strategies were less effective in the workplace gardner et als participants selfidentified workplace bullying vs cyberbullying and 1679 indicated they experienced bullying either as workplace bullying or cyberbullying 17 of the sample said they faced bullying several times a week or even daily and 31 of the sample experienced bullying from supervisors employers or managers 48 experienced bullying from their peers 17 experienced bullying from subordinates and 17 mentioned they experienced bullying from clients workplace bullying is an issue in any workplace etienne stated that 48 of nurse participants experienced bullying in their workplaces and the most bullying acts they faced involved being ignored or excluded in their workplaces in another study report discussing bullying in saudi arabia basfr et al noted that 903 of nurses in saudi arabia experienced bullying in their workplaces and 577 faced physical and verbal abuse the majority of them attributed the stress or anxiety resulting from that bullying to lack of support for these nurses in their workplaces also islam and chaudhary found that bullying in the workplace was related to emotional exhaustion and workers knowledge hiding in the health sector they also found that friendship in the workplace was key to reducing bullying and knowledge hiding workplaces should attempt to prevent bullying by improving their organization systems and training their staff members however ekici and beder studied workplace bullying among nurses and found that 82 of nurses and 74 of physicians had faced workplace bullying at least once in the past year and 12 of nurses and 11 of physicians had experienced intentional bullying at least once in the past year the most common type of bullying among them was aggression related to their professional positions and their personalities islam and his colleagues studied the impact of workplace bullying among health care workers and found that the negative impact of workplace bullying caused burnout in nurses and that passive avoidant leadership was one of the variables that reinforced workplace bullying and the resulting burnout these findings show that bullying occurs in many workplaces at different levels based on these findings we need more interventions to establish healthier and more stable work environments for people with disabilities in addition sveinsdttir et al indicated that 66 of their participants experienced bullying 39 faced violence and 53 cited psychological distress as common health issues women had more mental health and physical issues than men bullying is a serious issue in all places especially in workplaces because bullying may cause serious health issues over time lindsay and mcpherson studied bullying and exclusion among students with disabilities and their results indicated that teachers attitudes impacted social exclusion and that social exclusion of and bullying toward students with disabilities appeared to be verbal and physical marraccini et al also studied bullying at the college level and found that 51 of their participants had witnessed other students being bullied by staff members at least once 18 of their sample had experienced bullying by staff members at least once 44 had experienced bullying in high middle or elementary school most of sample had witnessed bullying by their peers in college at least once and 33 had faced bullying by their peers in college marraccini et al also reported that 47 of their female participants indicated that they had been bullied by teachers before they entered college and 34 of their male participants mentioned that they had faced bullying by teachers 21 of the female students had experienced bullying by staff members at least once 9 of the male students had also faced bullying by staff members 75 of students with disabilities indicated that they had faced bullying by teachers before they entered college compared to the 42 of students without disabilities and 50 of students with disabilities were bullied by staff members in college compared to 16 of students without disabilities the studies discussed here stated clearly that bullying occurred verbally and physically that females were more likely to experience bullying than males and that students with disabilities faced bullying more than their typically developing peers did bullying might occur more often for individuals with disabilities because of lack of awareness and effective policy in the workplace robert found that bullying in the workplace had no impact on job stress and job performance however bullying might cause serious physical and health issues among workers who are impacted by bullying however khubchandani and price studied harassment and morbidity in the workplace among us adults and results indicated that 81 of their participants had experienced harassment in the workplace in the past year and women reported higher levels of harassment especially those women who were divorced or separated compared to their nondivorced or nonseparated peers khubchandani and price also reported that workers who worked with local government on night shifts or who were paid by the hour for their work were more likely to face harassment in the workplace compared to other working peers also individuals who reported harassment had more health issues less sleep more asthma attacks and smoked every day fattori and his colleagues also studied workplace bullying and their results showed that 163 of their participants were victims of bullying in the workplace and that older participants were more experienced with bullying also 30 of their participants mentioned that they had experienced depression after bullying occurred and there was a strong relation between sick leave and workplace bullying fattori et al also indicated that worse healthrelated quality of life was linked with workplace bullying and those who already had medical conditions were more adversely affected by bullying workers who have experienced bullying in the workplace may experience health issues and other medical conditions as noted previous studies have indicated that bullying may cause physical or health issues or depression which emphasizes the importance of the current study because without studying bullying which might cause other health issues we cannot develop interventions and policies that could prevent workplace bullying and thus enhance the work environment ahmad and his colleagues studied how to provide a new perspective on how to limit bullying in workplace and they found that perceived servant leadership assists in reducing the number of workers experiencing bullying in the workplace by supporting them with compassion chaudhary and islam studied how despotic leadership affects workers psychological suffering as bullying was a mediating mechanism they found that despotic leadership might impact workers psychological suffering these studies emphasize the notion that some leadership styles might be contributing causes of bullying as some leaders do not take on their roles to decrease and ensure by effective policies how to manage and prevent bullying behavior in their workplaces workplace bullying toward people with disabilities people with disabilities face bullying in the workplace which often causes them to quit their jobs chiu and chan found discriminatory behavior against people with mental illness in the health care employment and family domains thus discrimination and bullying may occur intentionally or unintentionally in any workplace toward people with health issues or people with disabilities gunderson and lee found that people with disabilities were paid 10 less than their peer workers without disabilities these results imply that even if physical or verbal bullying does not occur in a workplace it might be perpetrated by administrators using policies and other authorities to not pay or respect the workplace rights of employees with disabilities as they do those of workers without disabilities mann and wittenburg 214 improve the employability and wages of people with disabilities thus workplaces need to be inclusive of people with disabilities and decisionmakers need to be aware of bullying that might occur in the workplace and find ways to improve the workplace for all workers with disabilities mitra and kruse found that people with disabilities of both genders in the us were more likely to be replaced than people without disabilities by 75 to 89 and they were more likely to lose their jobs involuntarily compared to people without disabilities these findings show how interventions can be implemented by using laws to enhance and improve the workplace for employees with disabilities prompting the exercise of their rights as others without disabilities exercise theirs fevre et al found that workers with disabilities and other longterm health conditions are most likely to experience and suffer from ill treatment in the workplace their results also showed that workers with disabilities blamed for their ill treatment as why they believed the ill treatment happened in workplace this means that workplace bullying might occur toward people with disabilities and other health issues as these individuals appear weak to speak about their rights as workers they may be afraid to lose their jobs if they speak out and they need to work to live also their managers might exert more control over them seeing them as workers with disabilities who are weak and lacking power in another study maroto and pettinicchio found that people with disabilities faced work segregation which limited their earning capacity and workers with disabilities also worked in workplaces that required fewer skills and fewer chances to access education and experiences to improve their skills in other words these people with disabilities were neglected because the people in charge didnt give them a chance to improve their skills needed for other jobs that suited their abilities by training and educating them like their typically developing peers also snyder et al stated that workers with disabilities experienced higher levels of discrimination overtly and subtlety targeting people with disabilities with low job satisfaction levels in summary employees with disabilities experience more workplace bullying through injustice and ill treatment compared to their typically developing peers statement of the problem i have witnessed bullying during my work in the field as a researcher working with people with disabilities to rehabilitate them to be able to work in keeping with their abilities and needs this experience has prompted me to conduct research about the bullying issue in my country few studies have addressed the issue of bullying toward people with mild intellectual disabilities bullying is a pervasive issue that workers with disabilities face and experience and its effects might cause serious health issues this study addresses this issue and supports decisionmakers in increasing the quality of workplaces for individuals with disabilities as they need more attention not only regarding their employment rights but also their right to safe work environments and to clear and effective policies that build more awareness about workplace bullying and how to be protected from it there are not many existing studies about bullying against people with intellectual disabilities that can help stakeholders improve the quality of workplaces for people with disabilities and learn how to prevent workplace bullying this study is also important for the workplaces that people with disabilities work in it as employers need to be aware that bullying might be occurring intentionally and unintentionally in their workplaces toward people with disabilities this studys results may also prompt decisionmakers to improve workplaces for people with disabilities by preventing bullying this study might also bring attention to the phenomenon of bullying to protect people with disabilities from it vol 13 no 5 september 2023 215 5 method sample and procedure employees with mild intellectual disabilities in saudi arabia comprised this studys sample believed to be appropriate survey respondents to share their opinions about workplace bullying several factors affected my investigation into this group of people as respondents to the workplace psychologically violent behaviors instrument sharing their views and opinions to contribute to this study this population of employees with disabilities could help policymakers at the government level company level or other workplaces to improve workplace conditions for all employees with disabilities the ethics committee at qassim university approved the study i based the sample selection on eligibility of having mild intellectual disabilities and 1 year of work experience and used a random sample technique to provide equal opportunity to the whole sample i obtained email addresses of companies who had workers with mild intellectual disabilities and then sent the surveys link through the companies email the employers then sent my invitation to participate in this study to about 350 workers with mild intellectual disabilities the invitation included an informed consent letter with an explanation of participants rights and assurance that participants would remain anonymous participants had 2 weeks to complete the survey the response rate was roughly 40 of the sample measures this study was designed to determine the relation between the independent variables and the dependent variable using a quantitative research approach with multiple regression i also used descriptive statistics for each dimension of the wpvb to collect means standard deviations skewness and kurtosis data to estimate the normality of distribution the ivs were age education level gender and years of work experience the dependent variable was workplace bullying toward people with mild intellectual disabilities in saudi arabia across four dimensions to determine which of the ivs might predict bullying against workers with mild intellectual disabilities in their workplaces i also used work positions of assistant supervisor assistant manager area manager and coworker as independent variables and the wpvb dimensions as dependent variables to determine which of these variables might predict bullying against workers with mild intellectual disabilities in their workplaces i conducted multiple regression analysis to reveal the correlation between variables to predict the best group of two or more independent variables by using dummy coding of variables and how that affected the dependent variables specifically this study identifies factors associated with workplace bullying toward people with mild intellectual disabilities in saudi arabia to address the research question that guided this study what work factors are associated with workplace bullying toward people with mild intellectual disabilities in saudi arabia with permission from the authors i used the wpvb to collect data from the participating workers with disabilities the first part of the data collection tool was a researcherdeveloped demographic questionnaire designed to gather information about the sample on the variables of age education level gender years of work experience and the positions of assistant supervisor assistant manager area manager and coworker the second part was the wpvb instrument used to collect data from the participants with mild intellectual disabilities who worked currently or previously the wpvb includes 33 items with four categories attack on personality attack on professional status isolation and direct negative behaviors the wpvb uses a sixpoint rating scale i have never faced i have faced once i face this sometimes i have faced several times i frequently face this i constantly face this dilek and aytolan reported that the wpvb has a high reliability measurement by cronbachs alpha vol 13 no 5 september 2023 216 internal consistency value also the cronbachs alpha of the arabic version of the wpvb indicated high reliability pilot study the pilot for this study was conducted in two phases first i translated the wpvb survey from english to arabic after obtaining permission from the original authors and then gave it to another colleague in the field of special education who holds a phd degree to backtranslate the survey from arabic to english to ensure accuracy next i asked 10 faculty members to review the survey and provide comments and feedback to ensure the survey was ready for collecting data from the target sample results this part of this study report is organized according to descriptive statistics as well as multiple regression analysis results relevant to workplace bullying toward workers with mild intellectual disabilities in saudi arabia demographic characteristics of the sample the demographic characteristics of this studys sample include gender education level years of work experience and age see table 1 multiple linear regression results this study used multiple linear regression analysis to predict bullying toward workers with mild intellectual disabilities in saudi arabia workplaces with the ivs of age education level gender and years of work experience results of the linear regression analysis include a model summary of coefficients for each independent variable and each of the four dimensions of the wpvb as presented in tables 3456 additionally with the wpvb dimensions as the dependent variables i used the work positions of assistant supervisor assistant manager area manager and coworker to determine which of these variables might predict bullying against workers with mild intellectual disabilities in their workplaces results of this analysis are presented in table 7 the results of regression analyses show that the dimension of isolation explains 26 of variance and the best predictors were high school diploma years of work experience from 11 to 15 age from 18 to 25 and age from 26 to 33 the coefficient of the high school variable was 157 indicating that workers with mild intellectual disabilities in saudi arabia who held high school diplomas showed lower levels of workplace bullying on the isolation dimension by 157 points also the coefficient of the diploma variable was 121 indicating that workers with mild intellectual disabilities in saudi arabia who held diplomas showed lower levels of workplace bullying on the isolation dimension by 121 points the coefficients of the years of work experience from 11 to 15 age from 18 to 25 and age from 26 to 33 variables were 157 173 and 222 respectively indicating that workers with mild intellectual disabilities in saudi arabia who had 1115 years of work experience or were 1825 or 2633 years old showed higher levels of workplace bullying on the isolation dimension by 157 173 and 222 points respectively see table 3 for a summary of the model 218 regression analyses results show that the dimension of attack on professional status explained 29 of variance and the best predictors were high school 1115 years of work experience age from 26 to 33 and age from 34 to 43 the coefficient of the high school variable was 172 indicating that workers with mild intellectual disabilities in saudi arabia who had completed high school showed lower levels of workplace bullying on the attack on professional status dimension by 172 points also the coefficients of the 1115 years of work experience age from 26 to 33 years and age from 34 to 43 years variables were 121 127 and 99 respectively indicating that workers with mild intellectual disabilities in saudi arabia with 1115 years of work experience age 26 to 33 years and age 34 to 43 years showed higher levels of workplace bullying on the attack on professional status dimension by 121 127 and 99 points respectively see table 4 for a summary of the model the results of regression analyses show that the dimension of attack on personality explained 26 of variance and the best predictors were high school and 1115 years of work experience the coefficient of the high school variable was 113 indicating that workers with mild intellectual disabilities in saudi arabia who had completed high school showed lower levels of workplace bullying on the attack on personality dimension by 113 points also results show that saudi arabia workers with mild intellectual disabilities who had 1115 years of work experience showed higher levels of workplace bullying on the attack on personality dimension by 107 points see table 5 for a summary of the model 219 regression analyses results show that the dimension of direct negative behaviors explained 71 of variance and the best predictor was age from 26 to 33 years the coefficient of the age from 26 to 33 years variable was 64 indicating that workers with intellectual disabilities in saudi arabia who were 2633 years old showed higher levels of workplace bullying on the direct negative behaviors dimension by 64 points see table 6 for a summary of the model the results of regression analyses show that the wpvb dimensions explained 47 of variance and the best predictors of workplace bullying were the positions of assistant manager area manager and coworkers the coefficient of the assistant manager area manager and coworkers variables were 232 355 and 341 respectively indicating that workplace bullying toward workers with mild intellectual disabilities in saudi arabia occurred at higher levels of frequency by assistant managers area managers and coworkers by 232 355 and 341 points respectively see table 7 for a summary of the model discussion and interpretation this study focused on predicting the relation between a group of independent variables and bullying toward workers with mild intellectual disabilities in saudi arabia workplaces results showed an association between high school completion and three dimensions of the wpvb isolation attack on professional status and attack on personality which means participants who had completed high school experienced lower levels of bullying on three dimensions isolation attack on professional status and attack on personality this might be because these workers who had only completed high vol 13 no 5 september 2023 220 school and had mild intellectual disabilities might not have known the meaning of bullying or been able to recognize its occurrence in their workplaces because their mild intellectual disabilities may have limited their ability to recognize workplace bullying thus they reported low levels of bullying experience this finding opposes that of marraccini et al who found that 51 of their participating students had witnessed other students being bullied by staff members and 18 of their sample had experienced bullying by staff members at least once also the current study revealed that holding a diploma was associated only with the isolation dimension and lower levels of bullying this result differs from fattori and colleagues finding that 163 of their participants were victims of workplace bullying and that older participants were more experienced with bullying thus the current studys finding of low bullying levels in workers with intellectual disabilities who finished high school or held dip lomas might be due to their unwillingness to admit to experiencing bullying so as not to negatively impact their work and for fear that their managers might fire them islam and chaudhary found that workplace bullying was related toemotional exhaustion and knowledge hiding in workers in the health sector thus workplace bullying occurs and workers with intellectual disabilities might not be aware of the resulting emotional exhaustion and knowledge hiding and are not reporting the workplace bullying that might be happening to them the current study on workplace bullying toward workers with mild intellectual disabilities in saudi arabia found that the variable of 11 to 15 years of work experience was associated with high levels of bullying on three dimensions isolation attack on professional status and attack on personality this studys results are supported by sveinsdttir et al who indicated that 66 of their participants experienced bullying 39 faced violence and 53 cited psychological distress as a common health issue among them also etiennes results were similar to the current findings as etienne reported that 48 of nurse participants experienced bullying in their workplaces and that most bullying acts they faced involved being ignored or excluded in their workplaces in the current study workers with mild intellectual disabilities experienced bullying in the workplace on the dimensions of isolation attack on professional status and attack on personality by other workers in the workplace this finding is supported by maroto and pettinicchio who found that people with disabilities faced work segregation which limited their earning capacity workers with disabilities also worked in workplaces that required fewer skills and afforded them fewer chances to access education and experiences to improve their skills in the current study workers with mild intellectual disabilities who had more than 10 years of work experience faced higher levels of bullying in the workplace as they became more familiar with bullying and could recognize when it happened to them another study that supported the current studys results was conducted by løvvik et al who found that 36 of their participants experienced bullying in their workplaces the current study found that higher levels of workplace bullying toward workers with mild intellectual disabilities in saudi arabia were related to workers aged between 18 and 43 years across three dimensions isolation attack on professional status and direct negative behaviors this finding aligns that of jones and colleagues who found that younger workers experienced lower rates of discrimination compared to older workers thus it might be that workers with mild intellectual disabilities experience higher levels or different types of bullying as they get older and become more aware that bullying might occur against them in the workplace another study supported the current results as that study found that 163 of their participants were victims of bullying in the workplace and that older participants were more experienced with bullying thus as workers get older they may become more aware that bullying might happen in their workplaces also islam and his colleagues found that workplace bullying had a negative impact on nurses and this negative impact caused burnout in their workplaces likewise the current studys workers with mild intellectual disabilities might experience the negative impact of bullying in their workplaces with potential resulting burnout the current study also found that bullying toward workers with mild intellectual disabilities in the workplace is associated with various work positions this study found three positions were related to higher levels of workplace bullying against workers with mild intellectual disabilities this result is supported by gardner et al who found that 31 of their participants experienced bullying by their supervisors employers or managers 48 experienced bullying by their typically developing peers and 17 experienced bullying by subordinates thus workers with mild intellectual disabilities may face workplace bullying by their managers and typically developing peer workers this type of bullying might target individuals with disabilities because the bullies assume they cannot defend themselves this finding is supported by snyder et al who stated that workers with disabilities experienced higher levels of discrimination overtly and subtlety targeting people with disabilities chaudhary and islam found that despotic leadership might impact workers psychological suffering through bullying behavior thus leadership styles might negatively affect workers as they face bullying behavior without their managers preventing or reducing it in the workplace the current study revealed that workers with mild intellectual disabilities faced bullying by their managers which may imply that leadership style plays a major role in increasing or decreasing workplace bullying implications and recommendations based on this studys results i recommend including more disabilities specialists when hiring people with disabilities in any workplace in order to determine the appropriate jobs for them based on their needs and skills moreover i recommend that each workplace with workers with disabilities have a clear policy on bullying and explicit procedures on how to report it i also recommend more workshops and training sessions about disabilities as intervention for managers and coworkers to teach them how to support their employees and peers with disabilities also people with disabilities should attend workshops and training sessions with their families as effective intervention in their first week of work so that they know their rights in the workplace and the meaning and types of bullying behaviors that might occur and so they can be aware of the employers policy on bullying and the procedures to follow for reporting bullying lastly i recommend that each workplace encourage their department of human resources to improve their policy on bullying prevention and to hire staff members who have degrees in the field of disabilities to assist employers in supporting people with disabilities in all aspects of the workplace enhancing and improving the workplace environment conclusion employees with disabilities face workplace bullying and this study examined the relations among factors that might predict bullying on specific dimensions of the wpvb tool this study found an association between workers with mild intellectual disabilities who had completed high school and lower levels of workplace bullying across three dimensions isolation attack on professional status attack on personality workers who held diplomas were associated with lower levels of workplace bullying only on the isolation dimension the current study found that years of work experience from 11 to 15 were associated with higher levels of workplace bullying toward people with mild intellectual disabilities across three dimensions isolation attack on professional status and attack on personality the variable of age between 18 to 43 was associated with higher levels of workplace bullying toward people with mild intellectual disabilities across three dimensions isolation attack on professional status and direct negative behaviors the current study also found that three work positions were related to higher levels of workplace bullying against workers with mild intellectual disabilities this finding is supported by several studies concluding that worker with disabilities faced more bullying and unjust treatment compared to their typically developing peers 222 limitation of this study was that some of the participants had problems understanding some questions because they had mild intellectual disabilities and therefore required some help from family members who explained the questions to them so that they were able to accurately answer questions based on their experience future research might consider other variables which could also influence bullying behaviors the size of the company cultural background training and mentoring assistant in workplace families support cyberbullying and types of coworkers such as local workers and international workers	the purpose of this study was to examine the association between bullying in the workplace toward people with mild intellectual disabilities in saudi arabia and demographic factors ie variables such as age education levels gender years of work experience and the employment positions of assistant supervisor assistant manager area manager and coworker this study utilized the workplace psychologically violent behaviors tool and multiple regression analysis results found a significant relation between high school and lower bullying levels among three dimensions isolation attack on professional status and attack on personality also the study found that 11 to 15 years of work experience was associated with high levels of bullying among three dimensions isolation attack on professional status and attack on personality the variable of age 18 to 43 was associated with a high level of bullying among three dimensions isolation attack on professional status and direct negative behaviors in the workplace toward people with intellectual disabilities in addition findings showed that three employment positions ie assistant manager area manager and coworkers were related to bullying against workers with intellectual disabilities these findings prompt the recommendation that human resources personnel pay attention to work policies on bullying prevention and that every workplace hire specialists to assist companies in supporting workers with disabilities
u nderstanding the pattern of human activities has been received growing attention due to its important practical applications from traffic management to epidemic control 1 2 3 4 several mechanisms with individual activities have been discovered based on statistics of huge amounts of data on human behaviors such as queueing theory and adaptive interest 5 6 7 however mechanisms behind human activities with interacting individuals are far from well understood because of complex population structures which can be described by complex networks 8 9 10 apart from the statistic characteristics of human dynamics in space and time interval abundant researches have focused on comprehending human activities in social networks such as making friends where people in the same class with similar feature are more likely to be friends there are also common phenomena of seeking social partners belonging two classes in bipartite populations 1112 such as mate choosing between men and women commercial trading between buyers and sellers the seeking processes which may be the base of building many social relationships can be described by matching model 13 individuals are generally divided into two classes according to their natural status then they observe features of others belonging to the other class and finally decide whether select the individual as a social partner although characters of individuals are too complex to be quantitatively described in bidirectional selection systems personal quality and economic status can be viewed as the main characters of individuals 1415 zhang and his collaborators solve the bipartite matching problem in the framework of economic markets finding that partial information and bounded rationality contribute to satisfied and stable matches 1617 besides characters of individuals the matching processes is also affected by structure of social networks 18 19 20 since social networks have emerged some common characteristics such as smallworld phenomena scalefree properties with powerlaw degree distributions 2122 questions naturally arise how properties of social networks affect matching processes and what kind of the property improves the matching performance of networks to answer these questions a bipartite network is reconstructed from the original networks 23 24 25 where only connected nodes satisfying successfully matching conditions and their links are reserved this allows us to investigate the bidirectional matching processes with mathematical analysis and computer simulation in this paper we researched the matching problem of two classes in the framework of complex networks the analytical solution for the rate of successfully matching rate is presented which is consistent with our simulation results of matching processes on social networks it is observed that properties of networks greatly impact matching performance of networks and the smallworld effect improve rate of successfully matching more than scalefree properties in addition the smallworld effect on matching performance of networks was quantitatively investigated with different rewiring rate in the small world network results for the given network m nodes belong to the class a and n nodes belong to the class b after the characteristic state of each node is determined for a node in the given network only the neighbor nodes which can successfully match with the node are valuable to the node thus the original network is reconstructed as a bipartite network where only connected nodes satisfying successfully matching conditions and their links are reserved as shown in top panels of fig 1 in this way we get a new bipartite network with m nodes belonging to the class a and n nodes belonging to class b where any two connected nodes satisfy conditions of successfully matching in the new bipartite network k i is the degree of the ith node in class a and k h denotes the degree of the hth node in class b connected to the ith node of class a in order to get the probability on successfully matching of the ith node we can firstly calculate the probability on unsuccessfully matching of the ith node because the degree of the hth node in class b is k h the probability that the hth node can successfully match with the ith node is 1k h therefore the probability that the hth node can unsuccessfully match with the ith node is 1 2 1k h so the probability that the ith node in class a can not successfully match with all neighbor nodes is p k i h 1 1 1 k h ð1þ the probability that the ith node in class a can be successfully matched is 1 p ki h 1 1 1 k h ð2þ if k i denotes the degree of node i in class b k h presents the degree of hth node in class a connected to the i node of class b and above equations also describe nodes in class b as shown in fig 1 the the probability that node i can not match with its neighbors is 00 for node a 1 of class a 05 for node b 1 of class b and 05 for node b 2 of class b if there are m nodes belonging to the class a the expectation e of the total number of nodes in domain a matched successfully is e mnm ð þ a m x m i 1 p ki h 1 1 1 k h ð3þ where the m denotes the number of types for nodes characters similarly the expectation e of the total number of nodes in class b matched successfully is e mnm ð þ b n x n j 1 p kj h 1 1 1 k h ð4þ because the matching between the two classes is onetoone e a 5 e b therefore for a given network with m n and m the expectation e about the total number of successfully matching pairs in the model is e mnm ð þ m x m i 1 p ki h 1 1 1 k h n x n j 1 p kj h 1 1 1 k h ð5þ according to we can get 2e mnm ð þ m x m i 1 p ki h 1 1 1 k h zn x n j 1 p kj h 1 1 1 k h ð6þ further we define the average successful matching rate of networks from the equation e b n x n i 1 p ki h 1 1 1 k h 10 l 2 e mnm ð þ mzn m p m i 1 p ki h 1 1 1 k h zn p n j 1 p ki h 1 1 1 k h mzn ð7þ where m 1 n represents the total population of two classes in the network and the range of l is from 0 to 1 therefore l can quantify the matching performance of a network and the large value of l reflects high matching performance of the network to investigate the effects of population structures on the matching rates of networks analytical results are performed from above equations as shown in top panels of fig 2 without loss of generality m is fixed as 2 in the analysis and four types of networks are applied to model different structured population one can find that there exists an optimal value of a to enhance matching performance of networks revealing that balanced population between class a and b plays an important role in matching performance for the four networks in addition the average degree of networks k affects l greatly nearby the a o and a larger average degree of networks induces better matching performance of networks to confirm analytical results we performed simulations of matching process on regular networks smallworld networks random networks and scalefree networks respectively as shown in the bottom panels of fig 2 in simulation firstly of all nodes are divided to the class a with probability a and with probability 1 2 a belong to class b then the state of each node is randomly assigned a kind of character from v following the uniform distribution and m is also fixed as 2 in the simulation for example the characters of node i are labeled as where c ai is node is own character and s ai represents the character the node i attempts to select it is found that our simulation results are consistent with analysis and both results show peaks of the l all appearing at around a 5 05 where the peak of l on the scalefree network is the lowest we therefor focus on the matching performance of different average degree k at a 5 05 fig 3 indicates the rate of successfully matching increases with enhancing of average degree of networks and the l value of scalefree network is minimum at the same value of the average degree k compared to other networks on the other hand the successfully matching rate l of smallworld networks is the maximum reflecting that structures of smallworld are more conducive to matching process than structures of scalefree networks since structures of smallworld networks enhance the matching performance of networks greatly we focused on the matching process on smallworld networks with different rewiring probability b as shown in fig 4 it is found that l monotonously decreases with increasing of b in the condition of a 5 01 where individuals in class b are much more than that of class a when the balanced population between class a and class b is achieved ie the value of a is nearby 05 there exists an optimal value of rewiring rate b to induce the highest rate of successfully matching for smallworld networks such as in order to study effects of population size on the rate of successfully matching we conducted simulation of matching processes on random networks with the average degree of k 5 1 k 5 2 k 5 3 and k 5 4 respectively as shown in fig 5 in the case of k 5 1 with m 5 n 5 1 the probability of successfully matching between the two connected nodes belonging two classes is about 0125 which is consistent with the mathematical analysis result if the two connected nodes match with each other successfully they must simultaneously satisfy the two conditions firstly the two connected nodes belong to different classes a and b the second c ai sbj and s ai cbj where i and j represent the two connected nodes the probability of satisfying the first condition is 12 and the probability of satisfying the second condition is 14 so the probability of successfully matching between the two connected nodes is 18 limited by average degree of networks the number of total populations in the four case of k 5 1 k 5 2 k 5 3 and k 5 4 starts from 2 3 4 and 5 respectively one can find that successfully matching rate l decrease with increasing of m 1 n when the number of total populations is lower than 10 while the value of l tends to a stable value for m 1 n 10 discussion although our results are obtained from mathematical analysis and computer simulation there are some human subject experiments which support our conclusions for example in experiments on matching behavior 20 human subjects are connected on virtual complex networks with the interface of computers including preferential attachment and smallworld networks different from our model where all individuals are divided into two classes participants in their experiments belong to one class to march as a single pair in particularly subjects in the human experiments are able to propose to match with a neighbor and accept a proposal from a neighbor which is similar to matching process of our model the experimental results show that the matching performance of smallworld networks is better than that of preferential attachment networks which are consistent with our conclusions in addition the similar observation is also obtained from the experimental data of the coloring games performed by kearns et al 18 where preferential attachment networks lead to worse performance than smallworlds networks it is worth mentioning that our approach is also suitable for the condition of fully connected networks where the average degree of networks depends on the size of networks in this case the matching performance is determined by the size of networks and the larger networks lead to the higher successfully matching rate which is consistent with the result of real data 13 compared to the previous work 13 the current model and analytical solutions can be used to solve the matching problem in complex networks thus the illustrations of matching processes has been extended in more general situations in particularly the matching process on smallworld networks with different rewiring probability was studied in details because the structures of smallworld networks obviously enhance the matching performance of networks summarizing we have studied the bidirectional selection system on complex networks where nodes are occupied by individuals in two classes the average matching rate is proposed to evaluate the successfully matching performance of networks it found that high average degree of nodes and balanced population between the two classes contributes to enhance the matching performance of networks and our analysis is consistent with the simulation results we also observed that the smallworld networks perform better than scalefree networks at a given average degree our approach to restructure the bipartite network may be also applied to spreading dynamics of information and diseases in bipartite populations 26 27 28 where some social partners would be successful in matching but others not there are also future application of our research in covolution of matching dynamics and social network structures 2930 methods the matching model in structured population to model the structure of population regular networks smallworld networks random network and scalefree networks are conducted as follows 1 regular networks starting from a regular ring lattice with m 1 n vertices with k edges per vertex each vertex connected to its k nearest neighbors by undirected links 21 2 small world network starting from regular network with degree of k we randomly choose a vertex and its edge then rewiring the link to an randomly selected node with probability b until each edge in the original regular networks has been considered once 21 3 random network starting from a regular network with m 1 n nodes we connect any two nodes with the probability k where the k is the average degree of network 31 4 scalefree network first of all a globally coupled network with k 1 1 nodes is built where k is the average degree of a network 22 then the network grows with preferential attachment process with the probability that a new node will be connected to the node i is proportional to the degree of the node the network keep growing until the size of the network is up to m 1 n simulations for a given network in the simulation trial of the model nodes belong to the class a with probability a and belong to class b with probability 1 2 a the number of nodes in class a and class b are m and n respectively therefore there are m 1 n nodes in the network for the characters of each node the c ai s ai c bj s bj are randomly assigned a kind of character from set v with m types of characters a bipartite network is reconstructed from the given network where only the matched nodes and links of matched nodes are reserved then a new bipartite network is generated with m nodes belonging to class a and n nodes belonging to class b in the new bipartite network a node and one of its neighboring nodes are randomly chosen the two nodes are determined as a pair meaning the two nodes are matched successfully every node can be only chosen one time at most the matching process is repeated until no pair can be determined any more in this way we can calculate how many nodes are matched successfully and get the rate of successfully matching for the whole population additional information competing financial interests the authors declare no competing financial interests	the bidirectional selection between two classes widely emerges in various social lives such as commercial trading and mate choosing until now the discussions on bidirectional selection in structured human society are quite limited we demonstrated theoretically that the rate of successfully matching is affected greatly by individuals neighborhoods in social networks regardless of the type of networks furthermore it is found that the high average degree of networks contributes to increasing rates of successful matches the matching performance in different types of networks has been quantitatively investigated revealing that the smallworld networks reinforces the matching rate more than scalefree networks at given average degree in addition our analysis is consistent with the modeling result which provides the theoretical understanding of underlying mechanisms of matching in complex networks
introduction noncommunicable diseases are the leading cause of mortality worldwide with nearly three quarters of ncdrelated deaths occurring in lowand middleincome countries 1 in addition many lmics are experiencing a double burden of disease with high prevalence of both ncds and infectious diseases that stretch the priorities and funding of limited health systems 2 these challenges are compounded when considering refugee populations humanitarian crises can cause disruptions in previously available health services further weaken fragile health systems and divert resources away from chronic disease management 2 as a result research has shown an increase in ncd complications in conflict settings 23 as the prevalence of ncds continues to rise and humanitarian crises persist countries and organizations responding to humanitarian crises have an obligation to address longterm management of ncds 4 in the middle eastern region gaps seen with ncd treatment in refugee settings tend to mirror overall challenges and weaknesses within national health systems 5 data on ncd care in refugee settlements in subsaharan africa is much more sparse a national prevalence survey in uganda estimated 265 of adults had hypertension 6 and 14 had diabetes 7 and the majority were unaware of their underlying medical condition 67 highlighting the importance of expanding access to screening for ncds only 80 of ugandan health facilities offered blood glucose testing and 34 offered diabetes management in 2013 8 rural clinics in uganda continue to face challenges in training health workers and providing continuous support for diabetes care 9 additionally the ugandan essential medicines list includes medications for hypertension and diabetes management 1011 but there is limited availability of essential medicines throughout uganda and there are disparities related to less access at public hospitals compared to private forprofit hospitals 5 in refugee settlements in uganda the burden of disease and degree to which there are unmet medical needs is unclear improved understanding could help identify unmet medical needs inform public health policies and goals and inform medical resource allocation for this vulnerable population to assess the ncd burden within nakivale refugee settlement in southwestern uganda we leveraged existing infrastructure for patients presenting to health centers and screened them for hypertension and diabetes methods setting this research was conducted in nakivale refugee settlement in southwestern uganda over 100000 refugees live in the settlement the majority of refugees are from the democratic republic of the congo rwanda somalia and burundi and a small minority are from other nearby subsaharan african countries this research was conducted at three health centers in the settlement nakivale health center kibengo health center and juru health center there is a fourth health center in the settlement but it was not an enrollment site given its remote location and difficult access compared to the other sites refugees and ugandan nationals can access clinical services free of charge at health centers in nakivale including free prescription medications for diabetes hypertension and hiv when indicated study population and procedures these ncd data were collected as a part of a larger study on linkage to hiv care in nakivale refugee settlement prior to initiation of the ncd component of this work our research team met with the local implementing partner leadership team to ensure there was sufficient capacity to accommodate people newly diagnosed with hypertension and diabetes we worked with these partners to create a referral protocol that specified who to refer and the expected timeline for medical followup multilingual research assistants were trained in blood pressure and glucose measurement techniques prior to study initiation adults presenting for hiv testing were recruited from the outpatient department waiting areas at nakivale juru and kibengo health centers inclusion criteria were 1 18 years of age or older 2 willingness to participate in routine clinicbased hiv testing 3 not previously diagnosed with hiv 4 no prior participation in the study in the preceding 3 months and 5 able to understand the consent process and study procedures in kiswahili kinyarwanda runyankore or english after giving written consent participants verbally completed a questionnaire which was read to them by a research assistant who directly entered information into an electronic database data collected included sociodemographic information medical history and ongoing diabetes and hypertension treatment research assistants then measured participants height weight blood glucose using the freestyle optium neo blood glucose and ketone monitoring system and blood pressure prior to conducting hiv testing for blood pressure measurements participants were seated for 1 min before the measurement was taken using a stethoscope for auscultation and a veridian healthcare pro kit sphygmomanometer for those with an elevated blood pressure the measurement was repeated two additional times 5 min apart for each additional measurement according to ministry of health guidelines 12 research assistants then conducted pointofcare blood glucose and hiv testing all participants included in these analyses were enrolled between january 16 2019 through january 13 2020 definition of endpoints endpoints were established using uganda ministry of health guidelines 12 we defined diabetes as a random blood glucose ≥111 mmoll with selfreported frequent urination or thirst or fasting blood glucose ≥70 mmoll regardless of symptoms 12 we used the lowest systolic and diastolic blood pressures to ascertain hypertension and defined it as both a binary and categorical outcome according to local guidelines 12 in contrast to world health organization guidelines all measurements were taken on the same day we used standard definitions of body mass index 185 kgm 2 for underweight 185 ≤ bmi 250 kgm 2 for normal weight and bmi ≥250 kgm 2 for overweightobese 13 statistical analyses we tested for differences in descriptive statistics and study outcomes by refugee status using χsquare or fishers exact test for categorical variables and students ttest for continuous variables we used the agresticoull method to calculate 95 confidence intervals for the prevalence of diabetes and hypertension 14 we also estimated the period prevalence of diabetes by including participants who met the criteria for diabetes or reported a prior diabetes diagnosis in the numerator we estimated the number needed to screen as 1prevalence we used logbinomial regression models or poisson regression with robust standard errors if the model failed to converge 1516 to estimate the associations of immigration status and country of origin respectively with hypertension and diabetes while controlling for age sex education level and bmi we performed statistical analyses using sas version 94 results study population of the 2137 participants enrolled since ncd testing was introduced 2127 received blood glucose testing and blood pressure measurement among these 1379 were refugees or asylum seekers and 748 were ugandan nationals ugandan nationals were more likely to be female and older compared to refugees and asylum seekers after uganda the most commonly reported countries of origin were the drc kenya and burundi somalia sudan south sudan and other were also reported hypertension overall 1067 of participants met criteria for prehypertension at the time of their clinic visit and 187 met criteria for hypertension the number needed to screen to identify one new instance of hypertension was 153 people and did not vary substantially by refugee status or country of origin among those with hypertension 129 were stage 1 48 were stage 2 and 9 were stage 2 severe at the time of screening 112 of participants reported a prior diagnosis of hypertension among the 112 participants reporting previously diagnosed with hypertension 48 were hypertensive at the time of screening reflecting uncontrolled hypertension and this did not differ by refugee status sustained antihypertensive treatment was uncommon with 31 reporting use of prescribed antihypertensive drugs in the past 2 weeks and 15 using traditional remedies use of a prescribed antihypertensive drug among those with a prior diagnosis did not vary by the presence of hypertension at the time of screening diabetes overall 32 participants met the criteria for diabetes the number needed to screen to identify one new case of diabetes was 787 persons the large majority did not report a prior diabetes diagnosis and this did not vary substantially by refugee status there were no significant differences in previously reported or new diagnosis of diabetes by refugee status or country of origin overweight and obesity were more common among participants with diabetes than those without diabetes though this was not statistically significant the period prevalence was 23 among the 21 participants who reported a prior diagnosis of diabetes 15 reported taking prescribed diabetes drugs within the prior 2 weeks 10 reported ever visiting a traditional healer for diabetes and 9 reported current use of herbal or traditional remedies for diabetes there were 5 individuals who reported a prior diabetes diagnosis and met the criteria for diabetes at the time of screening all of whom multimorbidity a total of 116 participants tested positive for hiv infection few participants had multimorbidity in multivariable models diabetes and hypertension were associated with age but not refugee status or country of origin discussion among 2127 adults presenting for routine hiv testing at health clinics in nakivale refugee settlement the prevalence of prehypertension and hypertension were high while the prevalence of diabetes was low the burden of hypertension and diabetes were similar across refugee status and country of origin the majority of participants did not suffer from multimorbidity studies of ncd prevalence and interventions among refugee populations have overwhelmingly focused on the middle east geographically 2481017 there health services are provided to those in refugee settlements through the existing urban health infrastructure of the host country our data showed that in nakivale refugee settlement the opposite is happening 35 of participants were ugandan nationals integrated into the refugee health system inadequate treatment for those with known conditions has also been observed previously 317 among syrian refugees in jordan hypertension and diabetes were the most prevalent ncds and observed at similar frequencies as in the general jordanian population 1718 similarly we found no significant difference in burden of disease between refugee and ugandan nationals the period prevalence of 23 is higher than a 2014 national prevalence estimate of 14 possibly due to higher diabetes prevalence in the countries of origin 7 interestingly the prevalence of hypertension at these refugee clinics is considerably lower than the national prevalence estimate of 265 6 blood pressure screening for prehypertension or hypertension in this population could be feasible and would have a high yield a blood pressure test is noninvasive low cost and requires minimal training and infrastructure to administer there is a strong association between hypertension and cardiac disease as well as mortality 19 although technically the diagnosis of hypertension requires two or three high blood pressure measures at least one week apart the ability to screen patients with a single visit in order to direct them to further care could have a large impact in diagnosing hypertension for earlier intervention and decreasing disease complications immigration status and country of origin were not significant predictors of hypertension indicating screening could be broadly implemented at all health centers in the refugee settlement outreach to better understand and address barriers to care faced by vulnerable and underserved populations such as somali nationals who are underrepresented in these data could increase the impact of the program increasing screening will inevitably place a greater burden on the health system to provide medications and clinic visits to more individuals this will put additional stress on an already underperforming system 89 however leveraging preexisting hiv infrastructure as was done in this study already has been shown to be feasible and costeffective when tailored to the appropriate population 2021 task shifting by using community health workers or peers can also be a costeffective way to provide hypertension and diabetes care 22 23 24 community health workers can provide a variety of services including questionnairebased screenings and referrals for testing education around nonpharmaceutical disease management and developing client selfefficacy for medication adherence and homebased disease management 22 23 24 25 such a program would need to be wellmanaged provide ongoing training and salary support for the community health workers and be developed in the context of broader health systems strengthening programs 2526 additionally médecins sans frontières demonstrated the feasibility and effectiveness of providing hypertension and diabetes treatment for refugees and vulnerable host communities within a camp by conducting a clinical consult lab draws and drug delivery at the same visit 3 diabetes screening in this setting will need to be carefully considered given the large number needed to screen and the considerable resources required diabetes testing is complex requiring a multistep testing process and advanced laboratory capabilities additionally established screening methods may not be as effective in this population for example thirst is a wellestablished symptom of diabetes but may not perform well in this highly resourceconstrained setting additional research is needed to identify subpopulations most at risk of diabetes and possibly develop modified screening guidelines in order to target diabetes testing for those most likely to benefit from treatment although not statistically significant in our data there was a higher prevalence of diabetes among overweight or obese individuals which could be an appropriate subpopulation to screen approximately three quarters of patients previously diagnosed with diabetes had access to prescription diabetes drugs and did not have elevated blood glucose at the time of their clinic visit suggesting successful pharmacologic disease management for the majority of cases notably all five previously diagnosed participants with continued elevated blood glucose at the time of their clinic visit also reported recent medication use indicating a role for more intensive diabetes management in select cases it may be that refugees with complex medical needs should be considered for more urgent resettlement so they can better care for their health needs our study has several strengths we are among the first to estimate the burden of hypertension and diabetes in a vulnerable refugee population in a settlement we have a large sample size we also have good ascertainment of hypertension using three consecutive measurements our study also has several limitations we had a small number of diabetes cases despite our large sample size which likely limited our ability to detect an association between bmi and diabetes in multivariable analysis additionally diabetes is difficult to test for and we could not confirm hyperglycemia with a repeat glucose test or followup hba 1c testing as recommended 12 so the true prevalence is likely lower than estimated conversely relying on blood pressure measurements all taken on the same day instead of the recommended 2 days may overestimate hypertension prevalence 27 utilizing local criteria rather than the more stringent who criteria makes generalizing these findings to other contexts difficult furthermore adults presenting for hiv testing at an outpatient clinic may not be a representative sample of the local population those presenting for care are either sicker or more healthconscious and therefore more or less likely to screen in for hypertension or diabetes than those not presenting to the health center to the extent that hiv infection and antiretroviral therapies increase the risk of diabetes and that hiv is prevalent in the community our estimate of diabetes which excludes people with a prior hiv diagnosis may underestimate the true overall prevalence 27 28 29 30 31 lastly given stigma around hiv testing and the fact this study was nested in an hiv study some of the population was not screened and hence underrepresented for instance there were only three somalis involved in our study while the population of somalis in nakivale was 13397 demonstrating the lack of true representation for this specific group of refugees individual or focus group discussions with community leaders and members could help identify barriers to care in this setting as a first step towards designing targeted interventions conclusions at health centers in nakivale refugee settlement in uganda attended by refugees and ugandan nationals elevated blood pressure was common and frequently unknown or uncontrolled testing could be incorporated into the clinic visit flow and if sustained monitoring and treatment is provided could improve longterm health outcomes diabetes prevalence was low given the challenges associated with diabetes screening and high frequency of severe outcomes associated with this disease focused screening of higher risk individuals should be considered in this setting competing interests the authors declare that they have no competing interests	background diabetes and hypertension are increasingly prevalent in low and middle income countries but they are not well documented in refugee settlements in these settings we sought to estimate the prevalence and associated characteristics of diabetes and hypertension among adults presenting for clinicbased hiv testing in nakivale refugee settlement in uganda methods hivnegative adults presenting to outpatient clinics for hiv testing at three health centers in nakivale refugee settlement were enrolled from january 2019 through january 2020 multilingual research assistants administered questionnaires aloud to ascertain medical history and sociodemographic information the research assistants used standardized procedures to measure participants blood pressure to detect hypertension systolic blood pressure ≥ 140 mmhg or diastolic blood pressure ≥ 90 mmhg and conduct a pointofcare blood glucose test for diabetes random blood glucose ≥111 mmoll with selfreported frequent urination or thirst or fasting blood glucose ≥70 mmoll regardless of symptoms as per uganda ministry of health guidelines we used χsquare or fishers exact test to test for differences in disease prevalence by refugee status and logbinomial or poisson regression models to estimate associations of immigration status and country of origin respectively with hypertension and diabetes while controlling for age sex education level and body mass index results among 2127 participants 1379 65 were refugees or asylum seekers and 748 35 were ugandan nationals overall 32 participants met criteria for diabetes 15 95 ci 1121 and the period prevalence was 23 95 ci 1730 there were 1067 50 95 ci 480522 who met the criteria for prehypertension and 189 9 95 ci 77101 for hypertension these proportions did not vary by immigration status or country of origin in univariate tests or multivariable regression models
introduction the covid19 pandemic has proven how social media can quickly create a parallel infodemic impacting the health and wellbeing of global citizens and posing a challenge for the delivery of public health services worldwide 1 the world health organization defines the term infodemic as an overabundance of information some of which is accurate and some not which makes it difficult for citizens to identify trustworthy sources of information and reliable guidance 2 at the start of the pandemic citizens consumption of news increased by 62 3 with many being exposed to mass amounts of misinformation and fake news as they searched for information relating to covid19 45 an infodemic typically includes the dissemination of unclear and unreliable messages rumors and fake news which affects the penetration of public health communication and causes mass anxiety and social panic ultimately impeding effective crisis management 6 7 8 in china in the early stage of the pandemic false information spread rapidly on social media 9 causing serious difficulties in managing the disease 10 combating covid19 requires the combined efforts of multiple stakeholders who disseminate accurate and authoritative information through different media channels in a timely manner 1112 for example governments and public health agencies should provide uptodate reliable information on covid19 and emotional support to citizens in order to reduce public anxiety and uncertainty 13 there is a societal need for accurate information to be corroborated quickly to prevent the spread of misinformation resulting in mass panic 14 official social media accounts such as those managed by governments serve as an ideal medium for facilitating communication between official sources and citizens during public health crises 15 but their strict control invalidating and disseminating information may inhibit fast and effective dissemination and lead to public distrust towards such organizations 16 many scholars have noted the widespread adoption of the term infodemic by the research community 17 however the term still requires some clarification especially in terms of how it is measured which is still not fully understood to address this shortcoming this study provides a measurement for the current and future infodemic previous infodemic studies have focused predominantly on how to control them such as minimizing the spread of fake news misinformation and rumors as well as controlling their impact on citizens psychological health 1819 however a critical question remains how do official social media accounts affect the infodemic the aim of this study therefore is multifold first we aim to create a conceptual framework and provide practical implications for reducing the severity of an infodemic and second we aim to explore the possible relationship between official social media accounts and the infodemic in the context of public health crises by doing so this study contributes to both the processing of health information on official social media accounts and the understanding of how to respond to an infodemic literature review and hypotheses theoretical basis the socialmediated crisis communication model is widely used to study how and why citizens communicate about crises especially in terms of how different sources and forms of initial crisis information are exposed and affect followup crisis communication similarly it describes the relationships between organizations citizens social media and traditional media during and after crises have occurred 20 some researchers have used the smcc model to explore how citizens cope with risk information disseminated by governments such as their information processing behaviors changes in emotions and protective behaviors 21 the smcc model focuses on the format and sources of information and social media effectiveness to improve social resilience further it suggests that citizens use social media to meet their untapped social needs such as to vent socialize with friends and family seek information and to obtain emotional support 22 the emotional support provided to citizens through different media sources can directly affect their feelings and their responses 23 and one important factor of socialization is communication through social media 24 the smcc model categorizes information sources into either official or a third party 25 information posted by official sources that has been verified is key to establishing credibility and trust among citizens 26 but the covid19 infodemic resulted in the frequent sharing of misleading information and false claims such as the sharing of pseudoscientific therapies and discussions about the origin and spread of the disease 27 these activities can undermine public trust in governments a previous study in india found that focusing on twitter sentiment was an important crisis management strategy 28 therefore to reduce the harm caused by public health crises government agencies and public health organizations can use social media to help deal with the dissemination of crisis information 29 extant research shows that government social media accounts are an important information source for promoting citizen engagement during covid19 30 we posit therefore that official social media accounts are a key facilitator in successfully communicating with citizens and act as an important information source and provider of emotional support during the first wave of the covid19 pandemic in china citizens knew very little about the disease causing mass panic and anxiety if an information source is unofficial with low information quality it can affect the emotions of citizens and lead to an infodemic which is shown as important variables in the theoretical model however the smcc model does not mention the variable of information cascades when citizens know little about a crisis information cascades can easily occur during the initial stage of the pandemic citizens knew very little about covid19 so we have therefore introduced the variable information cascades into our theoretical model based on the smcc model social media in public health crises and the infodemic during the covid19 pandemic governments imposed frequent lockdowns with the aim of controlling the spread of the covid19 disease during these times citizens used social media more frequently than usual 3132 becoming compulsive and often demonstrating an addictive behavior 33 the information posted on social media acted as a doubleedged sword first verified information relieved citizens panic and anxiety and motivated them in the fight against covid19 34 secondly however as the amount of information available grew citizens became unsure about whether the information they were viewing was in fact true 35 throughout the lockdowns social media and the internet acted as a main source of information for citizens 3637 with social media use rapidly increasing during the crisis 38 communication during the pandemic was characterized by knowledge communities organized into hierarchies of subgroups with clear geopolitical and ideological characteristics 39 citizens used social media to obtain healthrelated information such as to learn about necessary control measures disseminate the latest information about the pandemic and listen to critical announcements 40 however content posted to social media was not always censored like the statecontrolled media 41 this ultimately affected the spread of anxiety and fear among citizens 42 as the pandemic evolved information related to covid19 received far greater attention than noncovid19 information on commercial social media platforms 43 the infodemic started to portray the characteristics of repeated fluctuations 4445 resulting in vast amounts of misinformation and fake news demonstrating different types of reconfigured and fabricated content and dubious ideas 46 the emergence of new mobile platforms heightened the infodemic during the pandemic 47 media coverage also affected citizens psychological state 48 while information exposure affected citizens trust in governments especially their experiences of lockdown measures 49 during the initial stage of the pandemic official social media accounts played an important role in disseminating authoritative information about covid19 which resulted in a reduction in uncertainty based on this we propose the following hypothesis hypothesis 1 the information quality of official social media accounts has a significant negative effect on the infodemic information cascades and the infodemic as rumors and false information started to spread on social media citizens imitation behaviors began to influence information diffusion similarly it triggered uncertainty and fluctuation 50 resulting in information cascades individuals with limited official information become reliant on the collective opinions of others as a reference to making their own decisions 19 information dissemination therefore quickly becomes a dynamic process in which one group imposes their ideas on another group and maintains them stereotyping the negative characteristics of the group and thus covering up the other characteristics when negative messages conveyed by earlier rejection begin to down cascade a person may become stigmatized 51 disturbances experienced during the initial stage of anxietyrelated information processing may lead to subsequent cascades of processing biases 52 peer rejection and information processing problems may also have interactive influence which can lead to intentions to spread rumors 53 among investors with a public profile information cascades increase the offer appeal to earlystage investors who in turn attract laterstage investors 54 internet users usually imitate other users behaviors online regardless of their own messages 55 which is what happened during the initial stage of the pandemic based on this we propose the following hypotheses hypothesis 2 information cascades have a significant positive effect on the infodemic hypothesis 3 information cascades have a mediation effect on the relationship between iq and the infodemic social support and the infodemic the level of social support experienced by citizens affects their mental health far more than the actual structure of personal networks 56 social support refers to the feeling of being valued and cared for by a network 57 and is described as the support an individual receives through social connections with other individuals groups and the larger community 58 which in turn reduces anxiety and panic 59 adolescents suffering from severe mental health problems often experience low to medium levels of social support 60 during the covid19 pandemic citizens who selfisolated experienced significantly higher rates of loneliness and depression than those who did not with some studies finding that social support is significantly associated with poorer sleep quality and an increased risk of depression 61 during the outbreak of covid19 citizens experienced severe lockdown measures which limited their social contact with others as a result the rates of loneliness stress worry and anxiety grew rapidly 62 which necessitated increased social support this resulted in some citizens sharing fake news online for different reasons for example to seek social support to reduce anxiety 63 based on this we propose the following hypotheses hypothesis 4 social support has a significant negative effect on the infodemic hypothesis 5 social support has a mediation effect on the relationship between iq and the infodemic mediation and moderation variables and the infodemic social media use low ehealth literacy and rapid publishing processes are cited as major contributors to the covid19 infodemic 1 citizens that frequently use social media can experience information overload which has a significant effect on their mental health 1864 excessive use of social media to seek covid19 information may also lead to depression and anxiety 59 some people experience difficulties in finding and evaluating information 36 which becomes more serious during public health crises ultimately the covid19 infodemic highlighted the poor health literacy of global citizens which is defined as the cognitive ability of people during the pandemic health literacy was perceived as important for preventing covid19 with governments investing heavily in education and improved communication 65 the perceived threat of covid19 lower levels of digital health literacy and rejection of official government social media led to higher levels of covid19 misinformation 66 in this regard it is understood that health literacy and private social media use may indirectly affect the infodemic based on this we propose the following hypotheses hypothesis 6 private social media use moderates the relationship between iq and the infodemic hypothesis 7 health literacy moderates the relationship between iq and the infodemic based on these hypotheses this study aims to examine the effect of official social media accounts on the infodemic during the first wave of covid19 in china figure 1 presents our theoretical model specifically we aim to understand how information cascades and social support mediate the relationship between official social media accounts and the infodemic moreover how do health literacy and private social media use moderate the relationship between official social media accounts and the infodemic hypothesis 6 private social media use moderates the relationship between iq and the infodemic hypothesis 7 health literacy moderates the relationship between iq and the infodemic based on these hypotheses this study aims to examine the effect of official social media accounts on the infodemic during the first wave of covid19 in china figure 1 presents our theoretical model specifically we aim to understand how information cascades and social support mediate the relationship between official social media accounts and the infodemic moreover how do health literacy and private social media use moderate the relationship between official social media accounts and the infodemic methods questionnaire and samples a questionnaire was written in chinese and composed of three sections the first section explained that the survey was to be completed anonymously and that the data collected would be used for scientific research purposes only the second section collected participants perceptions about the variables amended from many references including information quality social support information cascades and the infodemic the measurement items are shown in the measures section and the modified items of this section were reviewed by a panel of experts including a professor who studies government social media one public health expert and one data analyst the third section collected sociodemographic information about participants their social media use frequency and their health literacy level such as gender age education level and household income as shown in table 1 as most citizens were isolated at home during the covid19 pandemic survey invitations were sent electronically with responses being solicited online the survey was carried out from march to april 2020 with 4152 citizens over the age of 18 years old being randomly invited including those who have different levels of education and income as shown in table 1 responses were collected anonymously using wechat and tencent qq both leading chinese social media platforms a random sampling strategy focused on recruiting residents in the covid19 outbreak regions of mainland china was used in the beginning a pilot study was conducted to test the reliability and validity of the constructs the cronbachs α values and kmo values showed good reliability and validity in the preliminary study then we sent our methods questionnaire and samples a questionnaire was written in chinese and composed of three sections the first section explained that the survey was to be completed anonymously and that the data collected would be used for scientific research purposes only the second section collected participants perceptions about the variables amended from many references including information quality social support information cascades and the infodemic the measurement items are shown in the measures section and the modified items of this section were reviewed by a panel of experts including a professor who studies government social media one public health expert and one data analyst the third section collected sociodemographic information about participants their social media use frequency and their health literacy level such as gender age education level and household income as shown in table 1 as most citizens were isolated at home during the covid19 pandemic survey invitations were sent electronically with responses being solicited online the survey was carried out from march to april 2020 with 4152 citizens over the age of 18 years old being randomly invited including those who have different levels of education and income as shown in table 1 responses were collected anonymously using wechat and tencent qq both leading chinese social media platforms a random sampling strategy focused on recruiting residents in the covid19 outbreak regions of mainland china was used in the beginning a pilot study was conducted to test the reliability and validity of the constructs the cronbachs α values and kmo values showed good reliability and validity in the preliminary study then we sent our questionnaire to all citizens invited 1515 citizens completed the questionnaire however 117 were considered invalid responses in total 1398 valid responses were received that covered all provinces that experienced the first wave of the covid19 outbreak measures this study investigated the effects of the information quality of posts published by official social media accounts information cascades and the social support on the infodemic during the first wave of the covid19 pandemic in china all scale items were measured using a 5point likerttype scale where 1 strongly disagree and 5 strongly agree information quality of official social media content information quality is the degree to which information satisfies users based on their perception 67 in the context of covid19 the information quality of covid19related content was assessed based on its usability and reliability etc 68 in this study we propose an information quality evaluation index for official social media based on user subject cognition including information expression level information content and information utility level the information quality of covid19related content on social media should be comprehensive and authoritative 69 uptodate 70 and easy to access and read 65 the measurement of iq was completed using a 5point likert scale where the authors asked participants about their perceptions toward the information quality of covid19 content posted by official social media accounts five statements were used to measure participants perceptions including their agreement toward the following characteristics authoritative timeliness comprehensive accessibility and usefulness 71 72 73 74 the iqeiosm had a high internal consistency as shown in table 2 the higher scores indicate higher quality of information posted by official social media social support social support is defined as the support accessible to individuals through their social ties with other individuals groups and the wider community 58 which affects their preventive health behavior and mental health 57 the multidimensional scale of perceived social support proposed by zimet et al 61 is a 12item measure of perceived adequacy of social support from three sources including friends family and a significant other based on prior research this study measures social support as a multidimensional concept including information support emotional support and peer support which citizens receive when obtaining covid19related health information from official social media accounts seven items were included to measure social support 7576 including i would rather visit official social media accounts for covid19related information than ask someone inperson on official social media accounts i have obtained information about preventing covid19 that i never knew from anywhere else i used the official social media account to deal with stress caused by the covid19 pandemic while visiting official social media accounts i felt i have fewer concerns the health information posted on official social media accounts alleviates my feeling of loneliness i used official social media accounts to understand others experience during the initial stage of covid19 and i shared the practical advice and suggestions about preventing covid19 found on official social media accounts with my friends and family the social support index had a high internal consistency as shown in table 2 where the higher scores indicate more social support information cascades information cascades occur when individuals observe and act on the behavior of others regardless of their own information as a result they follow the behavior of the preceding individual to reach an optimal state in this scenario cascades might cause individuals to make wrong decisions 77 because of the zerosum nature of attention the amount of information found on private social media accounts draws users attention away from official social media accounts some information is prevalent while the rest is ignored which is known as the typical and common longtail phenomenon on social media 78 information cascades are measured in the form of relational cascades and structural cascades 5079 four items were used to measure information cascades i relied on the opinions of others to process information related to covid19 i relied on the opinions of others to make preventative decisions about covid19 i relied on social norms to process information about covid19 and i relied on social norms to make preventative decisions about covid19 the information cascades index had a high internal consistency as shown in table 2 where the higher scores indicate higher levels of information cascades the covid19 infodemic the vicious circle of psychological problems and the spread of rumors were the main features of the covid19 infodemic 1 the measurement of the infodemic was mainly derived from previous studies five items were used to measure the covid19 infodemic 3480 namely during the covid19 pandemic the information i received exceeded my capacity to cope with it during the covid19 pandemic i felt panicky when i saw the amount of information about covid19 from different sources during the covid19 pandemic i constantly sought information about covid19 because of my excessive information seeking on different media channels i often forgot to respond to other important messages and during the covid19 pandemic i found it difficult to obtain reliable information when i needed help the infodemic index had a high internal consistency as shown in table 2 where the higher scores indicate higher levels of the infodemic partial least squares structural equation modeling plssem is used to estimate complex models with many constructs indicator variables and structural paths without making distributional assumptions about the data which is useful for exploratory research when examining a developing or less developed theory 81 similarly it can deal with multicollinearity problems we used plssem to examine the effects of the information quality of official social media information cascades and social support on the infodemic using smartpls 337 software for two reasons first based on the smcc theory we added two variables to explain the underlying mechanisms of the relationship between official social media accounts and the infodemic which can be seen as a less developed theory second plssem can report the r 2 values of each endogenous latent variable results the measurement model this study conducted the internal consistency test using smartpls 337 statistical software composite reliability values were calculated to test the reliability and internal consistency of the scale the cronbachs α is another measurement of internal consistency reliability which is a less precise measure than cr rhoa lies between cronbachs α and cr which may represent a good compromise 82 average variance extracted is used to assess the convergent validity of each constructs measure the cranachs α of each subscale was 06 which indicates that the survey data were highly reliable the outer loadings ranged from 0637 to 0812 as shown in figure 2 which exceeds the minimum value of 060 the cronbachs α values ranged from 0732 to 0880 which showed a satisfactory internal consistency level the cr values ranged from 0833 to 0907 with satisfactory to good indicating the instrument had good internal consistency the ave values were higher than 050 which indicates that the four constructs explain more than 50 of the variance of their own items 83 further the range of the variance inflation factor was 1280 to 2068 as shown in table 2 and all were less than 5 which shows that there was no significant multicollinearity risk discriminant validity was completed using smartpls by the criterion provided by fronelllarcker 84 table 3 shows that the minimum square root values of the ave along the diagonal line were higher than the correlation values between latent constructs in each column which meets the above criterion and indicates that the measurement model had an acceptable discriminant validity level results show that plssem had an adequate fit since the models fit indicates that duls and dg were less than 095 srme was less than 008 and nfi index was 0893 the r 2 values of the infodemic information cascades and social support were 0753 0611 and 0741 respectively indicating that the model was moderate and had a substantial fit 85 the structural model our results show that the information quality of content posted by official social media accounts had a significant negative effect on the infodemic while information cascades had a significant positive effect on the infodemic social support had a significant negative effect on the infodemic thus hypotheses h1 h2 and h4 are supported approximately 753 of the variance in the covid19 infodemic was driven by the significant influence of information quality information cascades and social support the path coefficients tstatistics and pvalues of the hypotheses are shown in figure 2 and table 4 respectively all path coefficients are standardized enabling us to compare their absolute value the absolute value of social support is higher than information quality and information cascades indicating that social support has the greatest negative direct effect on the infodemic this means that the higher level of social support received the lower level of the infodemic the absolute value of information quality is lower than social support indicating a greater negative direct effect on the infodemic which means that the higher level of information quality the lower level of the infodemic however it should be noted that information cascades have a positive effect on the infodemic which means that the higher the level of information cascades the higher the level of the infodemic mediation analysis the two models have two mediation effects namely information quality → social support → infodemic and information quality → information cascades → infodemic to examine the significance of indirect effects the bootstrapping method was used with either data normality distribution or not 86 since the results show that official social media accounts were the key factor in controlling the infodemic the underlying mechanisms of this factor are further explored through meditation analysis using smartpls and bootstrapping with 5000 subsamples the bootstrap method was used to examine the hypothesized relationships and sampling distribution as a measure of accuracy using random sampling methods to ensure consistency in results 81 mediation analysis was conducted to better understand the relationship between the information quality of official social media accounts and the infodemic and the mediation effects of information cascades and social support were shown with 95 confidence intervals our results revealed that with 95 ci if information cascades were taken as the mediator variable the mediation effect was significant if social support was taken as the mediator variable the mediation effect was significant in general the information quality of content posted by official social media accounts has both a direct and indirect effect on the infodemic and mediation through both information cascades and social support this indicates that official social media accounts contained the covid19 infodemic and therefore hypotheses h3 and h5 are supported moderating analysis the twofactor analysis of anova with interaction was used to conduct a moderationinteraction effect analysis with visualization 87 the results of the moderation effect are shown in figures 3 and4 to further examine the effect of information posted by official social media accounts on the infodemic under different conditions this study coded the official social media information quality into two groups similarly private social media use was coded into two groups as shown in figure 3 then a 2 × 2 off our groups anova was performed taking different levels of information quality perceptions and private social media use as independent variables and the infodemic as the dependent variable the main effect of both information quality and private social media use were significant the interaction effect of information quality and private social media use was also significant the line of high usage and the line of low usage of private social media intersected and the slope of high usage was greater than the low usage this finding indicates that private social media usage positively moderated the relationship between information quality and the infodemic acy of four groups anova was performed taking different levels formation quality perceptions and health literacy as independent variables an infodemic as the dependent variable the main effect of information quality was significant however the main effect of health literacy was not sign it is wellknown that the significance of moderating effects can judged by simply relying on the significance of the product terms it should be ju comprehensively by whether they have interaction points in the interaction graph o therefore the interaction graphs were drawn as shown in figure 4 with results r ing that the line of two levels of health literacy had an intersection while the slope high level is smaller than the low level this indicates that health literacy nega moderated the relationship between information quality and the infodemic and fore hypotheses h6 and h7 are supported at the same time health literacy was coded into two groups as shown in figure 4 then a 2 × 2 of four groups anova was performed taking different levels of information quality perceptions and health literacy as independent variables and the infodemic as the dependent variable the main effect of information quality was significant however the main effect of health literacy was not significant it is wellknown that the significance of moderating effects cannot be judged by simply relying on the significance of the product terms it should be judged comprehensively by whether they have interaction points in the interaction graph or not therefore the interaction graphs were drawn as shown in figure 4 with results revealing that the line of two levels of health literacy had an intersection while the slope of the high level is smaller than the low level this indicates that health literacy negatively moderated the relationship between information quality and the infodemic and therefore hypotheses h6 and h7 are supported predict partial least squares model the pls predict algorithm uses training and hold out samples to generate and evaluate predictions from pls path model estimations which means it combines aspects of outofsample prediction and insample explanatory power 88 the pls predict results are shown in table 5 the q 2 predict statistic values of plssem outperform most lm benchmarks 89 meanwhile only in addition to the indicator of read experience the other indicators in the plssem analysis have lower rmse and mae values compared to the lm benchmark 85 which indicates that the structural model has higher explanatory power and predictive power discussion this study provides valuable insights into the effects of official social media accounts on the infodemic during the initial stage of covid19 recent studies have focused their efforts on examining the effects of the infodemic on citizens psychological issues and mental health 634 and how private social media use has affected the infodemic 11245 for example some studies have found that commercial media positively affects psychological anxiety but that official government media has no effect on psychological anxiety 90 however the underlying mechanisms of how official social media accounts affect the infodemic have received little attention specifically during the pandemic it has not previously been understood how official social media accounts affect the infodemic by the mediation effects of information cascades and social support and the moderation effects of private social media use and health literacy our results show that the information quality of content posted by official social media accounts and the social support provided have a significant negative effect on the infodemic information cascades have a significant positive effect on the infodemic mediation analyses were conducted to explore the underlying mechanisms of the relationship between iq and the infodemic with results revealing that both information cascades and social support mediate the relationship between iq and the infodemic in addition moderation analyses were completed to explore the underlying mechanisms of the relationship between iq and the infodemic with results indicating that private social media use and health literacy moderate the relationship between iq and the infodemic these findings demonstrate the underlying mechanisms of the relationship between official social media accounts and the infodemic in the context of public health crises citizens tend to seek information to alleviate uncertainty 91 our findings show that official social media accounts have controlled the infodemic and have increased the social support provided to citizens in other words it has alleviated citizens uncertainty regarding covid19 it is noted however that it is necessary to guide citizens in using and promoting the use of official public health organizations websites and official social media accounts when seeking health information related to covid19 92 on the other hand the rational use of official social media should be promoted to prevent the dissemination of misinformation similarly social media users should be trained to identify misinformation by using official information sources only and scientific digital health literacy cultivation 36 information cascades and social support were found to be important mediation variables in explaining how official social media accounts affected the infodemic during the first wave of covid19 when citizens were exposed to excessive information related to covid19 they tended to choose information that was useful to themselves meanwhile they often sought social support to alleviate the uncertainty experienced if citizens made decisions by relying on the opinions of others or social norms it indicates that information cascades have occurred during the first wave of covid19 commercial media circulated an overload of information with epidemic information being pushed to users continuously 90 with reliable and authoritative information being important for designing and conducting preventive measures to raise healthprotective awareness 14 this study shows that official social media can provide highquality epidemic information to citizens which can increase social support and reduce information cascades this study also confirmed that the greater use of social media can lead to more social support 19 different information sources were shown to have different effects on the infodemic 90 private social media use is found to be a doubleedged sword which was found to be a major source of rumors or misinformation during emergencies in prior studies on the other hand it also plays a key role in communicating health information 93 this finding shows that private social media use positively moderates the relationship between iq and the infodemic indicating that excessive use of private social media increases public anxiety and leads to an infodemic 19 therefore this finding proves that citizens should take a break from private social media and rationality use both official social media and private social media during public health crises health literacy was also found to negatively moderate the relationship between iq and the infodemic when citizens are faced with uncertainty they are in a state of anxiety and depression and their health literacy provides little help in identifying valid health information theoretical and practical implications this study constructed a theoretical model to uncover the underlying mechanisms of the relationship between official social media accounts and the infodemic during the first wave of covid19 in mainland china the proposed model made several contributions to previous studies by integrating two further variables to investigate the infodemic problem ongoing with the covid19 pandemic we treated official social media accounts as a cue to controlling the infodemic while information cascades and social support were used as the mediation variables which as we know have not been proven in prior research similarly we considered the moderation effects of private social media use and health literacy thus this paper calls for more research into the underlying mechanisms of the determinants of the infodemic policy implications can also be derived from this study to develop strategies for controlling future infodemics during public health crises the outbreak of covid19 was accompanied by the mass dissemination of unvalidated information by private social media accounts if authoritative information about covid19 was not published in a timely fashion it may have caused the further dissemination of false information this study provides evidencebased implications to control the covid19 infodemic first the public agencies that manage official social media accounts should improve the usefulness timeliness availability and authoritative nature of the information provided through enhancing the professionalism of practitioners public agencies should also establish a release system to control information quality and use social media and the internet rationally to encourage citizens to interact with public agencies 94 and to pay greater attention to credible and authoritative sources and factcheckers about the covid19 pandemic 95 secondly official social media accounts should set an example for private social media users and commercial media accounts such as forging a usercentered factbased and collaborative response to the pandemic official social media accounts not only alleviate citizens anxiety and uncertainty through the dissemination of authoritative reports but also carry out useful preventive measures and touching epidemic stories to increase social support inspiring citizens to fight against covid19 together in special official social media accounts should establish information communication mechanisms for sharing pandemic information resources between official social media accounts and big individual private social media accounts therefore official social media accounts can help manage citizens stress and health risks and should therefore convey information to citizens with empathy scientific and rational evidence and personal experience and encourage them to share the content with friends family and peers etc so as to increase the social support and reduce potential information cascades thirdly when faced with large amounts of media and healthrelated information local governments should formulate rules to regulate the dissemination of pandemic information by private social media accounts health literacy may also help citizens better understand the reasons behind governments and public health agencies preventive recommendations and make protective and preventive actions quickly in the later stages of covid19 citizens showed a good level of knowledge about the disease 96 but in the initial stages citizens almost knew nothing about it hence local governments and public health agencies should popularize common health knowledge while citizens should enhance their health literacy to enable largerscale psychological prevention of fake news 97 meanwhile local governments should encourage citizens to take social responsibility and encourage people to take the initiative in pandemic prevention limitations and future studies this study has several limitations first the survey was administered during the first wave of the covid19 pandemic in mainland china which relied on respondents selfreporting data online it lacked indepth interviews with participants which could help deepen cognition and the importance of official social media accounts and how they helped control the infodemic during the pandemic second in most cases information cascades were calculated using big data with the study measuring it using four items future research may mine public comments from official social media accounts and calculate their forwarding interaction and liking behaviors similarly studies can analyze their emotional tendency to estimate what support is provided to citizens and uncover how official social media accounts affect citizens emotions third only one round of the online survey was conducted fourth some respondents might have been relatively calm and objective to participate in the survey but some might have felt very anxious and uncomfortable when completing the questionnaire fifth we only examined the effect of information quality of official social media accounts on the infodemic future study will try to examine the impact of official social media accounts response strategies on the infodemic finally there have been several subsequent waves of covid19 outbreaks in china since the survey was conducted and therefore longitudinal and comparative studies can be conducted in the future conclusions this study provided empirical evidence on the effects of official social media accounts on the covid19 infodemic and gave insights for uncovering the underlying mechanisms of the infodemic by analyzing the essential roles of the information quality of official social media accounts the mediation effects of information cascades and social support and the moderation effects of private social media use and health literacy our findings provide policy implications for controlling future infodemics and can help public health agencies that manage official social media accounts improve their information quality increase social support and decrease information cascades data availability statement the raw data presented in this paper are available from the authors without undue reservation author contributions hl was responsible for conceptualizing and designing the study acquisition analysis and interpretation of data and writing and reviewing of the manuscript qc provided guidance about the research methods and reviewed the manuscript re reviewed and edited the manuscript all authors have read and agreed to the published version of the manuscript funding this research was funded by the national social science fund of china the information presented in this paper is the responsibility of the authors and does not necessarily represent the views of the national office for philosophy and social sciences institutional review board statement ethical approval was received from the biomedical ethics committee of the school of medicine at xian jiaotong university all participants andor their legal guardians gave informed consent prior to the collection of data informed consent statement not applicable	how official social media affected the infodemic among adults during the first wave of covid19 in china
introduction obesity is a major public health concern particularly as it leads to increased risk for premature mortality and chronic diseases including type 2 diabetes cardiovascular disease hypertension stroke some cancers as well as soaring healthcare costs 1 2 3 4 emotional eating which refers to the tendency to overeat in response to negative emotions has been studied extensively over the last decades as a risk factor for obesity and an impediment to weight loss 5 6 7 8 9 10 studies have employed various research methods to demonstrate how negative emotions including sadness anxiety stress or anger are related to the urge to overeat for example laboratory studies indicate that priming a negative affect among obese binge eaters via exposure to a sad film induces overeating 11 and a metaanalysis of 36 ecological momentary field studies 12 confirmed an increase in negative emotions prior to binge eating episodes a seminal study by kaplan and kaplan focusing on the psychosomatic interpretation of obesity posits that eating in response to negative emotions is a learned behavior that aims to diminish the negative state that one is in 13 furthermore research has found a link between emotional eating and weight gain 14 and that enhancing emotional regulation skills should be the focus of interventions aimed at weight loss rather than caloric restriction alone 15 hence it is important to describe the prevalence of emotional eating at a national level factors predicting it as well as its corollaries particularly as emotional eating has been linked to adverse health outcomes 1016 in this study we describe emotional eating among a large us sample of adults by individual and socioeconomic factors health behaviors and a key indicator of selfregulatory performance namely temporal discounting 17 findings help to elucidate factors that are related to emotional eating and might therefore inform future intervention programs focused on emotional regulation while eating materials and methods the current study crosssectionally examines the relationship of sociodemographic factors lifestyle behaviors and selfregulation with emotional eating this is explored using data collected in 2011 from the family health habits survey which is described elsewhere 18 briefly households from the nielseninformation resources inc consumer panel were asked to participate in an internetbased survey which aimed to assess obesity and lifestyle behaviors in families 18 in the present study we utilize individuallevel data on 5863 adults aged 21 years and above from the fhhs with information pertaining to the independent and dependent variables the current study received ethics approval from the university of haifa institutional review board as well as exempt status from the morehouse school of medicine irb individual and socioeconomic variables consist of age raceethnicity annual household income household size college education marital status and selfreported health status in addition body mass index was computed using the standard formula based on reported weight and height bmi was then dichotomized based on obesity yesno 4 additionally participants sex was missing for a large proportion of participants 19 consequently a multipleimputation approach where the covariates along with participants height are considered was used to impute the missing sex variable 20 this approach is consistent with a previous fhhs study 19 the physical activity measure is described elsewhere 21 briefly this measure is adapted from the international physical activity questionnaire 22 where the metabolic equivalent for task minutes per week are computed based on the frequency intensity and duration of the activity 21 met minweek were then dichotomized according to the health and human services physical activity guidelines yesno 23 in addition the frequency of fastfood consumption was based on the reported times per week frequenting these establishments 24 participants were also queried regarding the frequency of eating at sitdown restaurants both variables were categorized into the following three groups for consistency with previous research 01 23 and ≥4 times per week 19 we used an established proxy of selfregulatory performance namely delay discounting 1725 delay discounting measures assess the ability to exert patiencethe extent to which one is willing to forego a smaller more immediate reward for a larger but later reward thus delay discounting measures gauge the ability to suppress presentmoment impulse in the service of valued longerterm goals with higher patience indicating higher selfregulatory performance 2627 in this study we utilized a survey question on monetary tradeoffs related to delayed discounting specifically participants were asked whether they would prefer to receive 10 in 30 days or larger monetary sums in 60 days 19 based on responses we calculated delta values indicative of ones ability to delay immediate gratification using the standard exponential discount model 2829 as described elsewhere 29 delta values computed by dividing 10 by the lowest monetary sum one is willing to receive in 60 days were grouped into three categories patience medium patience and impatience whereas patience served as the reference group the medium patience and impatience categories referred to varying levels of ones ability to delay gratification participants were asked to state the frequency with which they feel the desire to eat when emotionally upset or stressed this question was adapted from the emotional eating scale of the dutch eating behavior questionnaire 30 specifically participants were asked when you are emotionally upset or stressed how often do you feel the desire to eat they were then asked to choose one of the following verbal expressions of frequency 31 never rarely sometimes often and very often due to its ordinal nature this variable was entered into ordered logistic regression models as the dependent variable the relationship among socioeconomic factors selfregulation lifestyle behaviors and emotional eating is examined utilizing two ordered logistic regression models the first model includes socioeconomic variables and selfregulation as independent variables and emotional eating as the dependent variable the second model adjusts for variables in the first model with the addition of health and lifestyle behavior variables in both models the ordered regression is indicative of the odds of reaching a higher emotional eating score versus remaining in the same score according to the independent variables odds ratios and 95 confidence intervals were computed stata version 151 was utilized for the analyses with alpha below 005 regarded as statistically significant results participants baseline characteristics are described in table 1 briefly 592 of individuals were aged 50 years and older with the largest racialethnic group being nonhispanic white followed by nonhispanic black and hispanic less than half were college educated and 627 earned an annual household salary of below 70000 regarding participants lifestyle variables 336 were obese 215 met physical activity guidelines and 259 frequented fastfood establishments twice a week or more moreover 271 were regarded as being impatient that is having difficulties in delaying immediate gratification finally 205 of participants indicated a tendency for emotional eating often or very often figure 1 depicts the relationship between socioeconomic factors and selfregulation to emotional eating analysis reveals that being female nonhispanic white and of younger age were all related to a higher likelihood of emotional eating for example nonhispanic blacks and hispanics were less likely to report higher emotional eating rates than their nonhispanic white counterparts further having a college education was significantly associated with emotional eating additionally those who were impatient and had medium levels of patience were 19 and 18 respectively more likely to have higher emotional eating scores marital status and annual household income however were not significantly related to emotional eating 105133 respectively more likely to have higher emotional eating scores marital status and annual household income however were not significantly related to emotional eating figure 2 presents the association between lifestyle behavior variables and emotional eating while adjusting for covariables analysis reveals that more frequent fastfood consumption and obesity were each significantly related to emotional eating for example those frequenting fastfood establishments 23 times a week were 24 more likely to have a higher emotional eating score in comparison to those with a fastfood consumption of 01 times weekly fullservice restaurant consumption and physical activity as well as selfrated health were not related to emotional eating figure 2 presents the association between lifestyle behavior variables and emotional eating while adjusting for covariables analysis reveals that more frequent fastfood consumption and obesity were each significantly related to emotional eating for example those frequenting fastfood establishments 23 times a week were 24 more likely to have a higher emotional eating score in comparison to those with a fastfood consumption of 01 times weekly fullservice restaurant consumption and physical activity as well as selfrated health were not related to emotional eating b the model adjusts for age sex raceethnicity marital status annual household income education household size and selfregulation discussion obesity is a risk factor for chronic diseases and premature mortality 4 emotional eating the tendency to eat in excess when experiencing negative emotions is related to weight gain and thus obesity risk 14 emotional eating also hinders weight loss and weight maintenance 5 6 7 8 9 10 in the current study we seek to describe rates of emotional eating among a national sample of adults while illuminating potential contributing factors to this phenomenon findings suggest that approximately onefifth of adults reported a tendency for emotional eating often or very often thereby potentially contributing to the obesity epidemic in the us 115 it should be noted that emotional eating was determined via a single survey item assessing the desire to eat when upset or stressed while it might have been preferable to utilize the complete 13item emotionaleating subscale of the dutch eating behavior questionnaire 30 this information was not available in the dataset beyond describing prevalence rates the present study explores sociodemographic factors related to emotional eating specifically multivariable analysis indicates that younger adults were markedly more likely to be emotional eaters one possible explanation for this finding is that older adults might have a tendency to adhere to routine meal schedules 32 which facilitates meal planning and enhances eating selfefficacy in social situations moreover eating disorders are more prevalent among younger rather than older adults 33 notably nonhispanic blacks and hispanics reported lower emotionaleating rates than their nonhispanic white counterparts did these findings are supported by research suggesting that despite a high prevalence of obesity among african americans and hispanics 34 the prevalence of disordered eating behaviors among these minority groups is relatively low 35 36 37 scant research however has specifically examined the underlying mechanisms as to why the prevalence of emotional eating might differ by raceethnicity diggins and colleagues for example examined the relationship between stress and emotional eating among africanamerican female college students discussion obesity is a risk factor for chronic diseases and premature mortality 4 emotional eating the tendency to eat in excess when experiencing negative emotions is related to weight gain and thus obesity risk 14 emotional eating also hinders weight loss and weight maintenance 5 6 7 8 9 10 in the current study we seek to describe rates of emotional eating among a national sample of adults while illuminating potential contributing factors to this phenomenon findings suggest that approximately onefifth of adults reported a tendency for emotional eating often or very often thereby potentially contributing to the obesity epidemic in the us 115 it should be noted that emotional eating was determined via a single survey item assessing the desire to eat when upset or stressed while it might have been preferable to utilize the complete 13item emotionaleating subscale of the dutch eating behavior questionnaire 30 this information was not available in the dataset beyond describing prevalence rates the present study explores sociodemographic factors related to emotional eating specifically multivariable analysis indicates that younger adults were markedly more likely to be emotional eaters one possible explanation for this finding is that older adults might have a tendency to adhere to routine meal schedules 32 which facilitates meal planning and enhances eating selfefficacy in social situations moreover eating disorders are more prevalent among younger rather than older adults 33 notably nonhispanic blacks and hispanics reported lower emotionaleating rates than their nonhispanic white counterparts did these findings are supported by research suggesting that despite a high prevalence of obesity among african americans and hispanics 34 the prevalence of disordered eating behaviors among these minority groups is relatively low 35 36 37 scant research however has specifically examined the underlying mechanisms as to why the prevalence of emotional eating might differ by raceethnicity diggins and colleagues for example examined the relationship between stress and emotional eating among africanamerican female college students 38 they did not explore however how stress might have differentially impacted emotional eating among whites or hispanics it could be plausible that ethnic minorities are more resilient to life stressors 39 and thus less prone to emotional eating in comparison to their ethnic majority counterparts this supposition however warrants future empirical research in addition we examined the relationship between emotional eating and lifestyle behaviors such as fastfood consumption and physical activity study findings indicate that unhealthy lifestyle behaviors are related to emotional eating while more healthful behaviors are not prior evidence suggests that low distress tolerance is related to emotional eating 40 moreover the link found between fast food and emotional eating is consistent with previous studies showing that emotional eaters often have a preference for energydense foods with abundant saturated fat 4142 with regard to physical activity our findings corroborate a study by koenders among 1562 us adults observing no significant association between emotional eating and exercise 14 thus while emotional eating and lack of insufficient physical activity are each related to weight gain and maintenance 1043 they appear not to be directly linked to each other furthermore current study findings underscore the independent and significant relationship between patience time preferences and emotional eating that is those who had difficulties delaying immediate gratification for a larger delayed reward were markedly more likely to eat when emotional than their more patient counterparts were this finding is consistent with psychological research linking emotional eating behaviors to impulsiveness and selfcontrol 4445 these studies however measured selfcontrol via a selfreport instrument asking participants to rate their ability to resist temptation 46 which might be influenced by conscious or unconscious factors to reinforce selfimage 27 while this approach is widely accepted eliciting selfcontrol through assigning an objective task such as in psychological experiments 47 or multiple list price methodology will likely yield a more valid assessment 48 hence in the present study we utilize the latter approach which provides a more robust assessment of selfregulation 49 the current study has several limitations that should be noted its design is crosssectional therefore a temporal relationship between the independent variables and dependent variable cannot be substantiated thus subsequent longitudinal research is needed to establish a causeeffect relationship moreover study variables such as lifestyle behaviors and emotional eating were selfreported thus under or over reporting could have occurred due to social desirability 50 nonetheless since standard measures were used to collect information from participants nondifferential misclassification could have occurred which causes a bias of the point estimates toward the null 51 in addition the sex variable was missing for a large proportion of the sample thus we utilized a multipleimputation approach to address this limitation finally the data were derived from a us survey that is not nationally representative and the racialethnic minority composition in this sample is lower than that in the us population at large conclusions the current study significantly contributes to the literature by determining the prevalence of emotional eating among a national sample of us adults and examining predictive factors of this behavior findings reveal that approximately onefifth of us adults report emotional eating behavior often or very often and it is more common among younger adults nonhispanic whites those with a college degree and with difficulty delaying immediate gratification furthermore an emotional eater might have an increased tendency for obesity and to eat at fastfood establishments more often future longitudinal research among large samples is clearly warranted to determine causeeffect relationships moreover as emotional eating is related to obesity and other unhealthy behaviors program planners might need to develop targeted interventions aimed at addressing these maladaptive health behaviors alongside improving emotionalregulation skills with the goal of obesity prevention and chronic disease prevention data availability statement the data used for this study are not publicly available for data requests please contact the nielsen consumer panel author contributions reb and ks led the writing conceived and designed the study contributed to the analytic approach as well as interpretation of the study findings ql contributed to the analytic approach and led the statistical analyses ql ro jd aly bmf and mh participated in the study design interpretation of results as well as critical revisions of the manuscript drafts all authors have read and agreed to the published version of the manuscript funding the current study did not receive funding data collection efforts were supported by grant 69294 from the robert wood johnson foundation through its healthy eating research program institutional review board statement the current study received ethics approval from the university of haifa irb and exempt status from the morehouse school of medicine irb informed consent statement study participants are from the nielsen consumer panel for which participation is voluntary individuals optin in order to participate in the panel more detailed information on privacy data use policy and consent appear here legalprivacystatementprivacypolicytvonly	background emotional eating the tendency to overeat in response to negative emotions has been linked to weight gain however scant evidence exists examining the prevalence and correlates of emotional eating among large samples of adults in the united states us hence we examine the relationship among individual and socioeconomic factors health behaviors and selfregulation with emotional eating patterns among us adults methods crosssectional analysis of 5863 family health habits survey participants multivariable ordered logistic regression was employed to examine the relationship between the frequency of the desire to eat when emotionally upset never rarely sometimes often and very often and the independent variables results analysis reveals that 205 of the sample tended to emotionally eat often or very often being female nonhispanic white and of younger age were all related to a higher likelihood of emotional eating additionally inability to delay gratification impatience was related to an 18 increased likelihood 95 confidence interval ci 105133 for emotional eating finally emotional eating was significantly related to more frequent fastfood consumption conclusions program planners might need to develop targeted interventions aimed at enhancing emotional regulation skills while addressing these less healthful behaviors eg fastfood intake with the goal of obesity and chronic disease prevention
introduction aggression in high school students is a problem in many countries 1 2 3 4 5 6 7 8 and adolescents are especially vulnerable to its consequences 9 bullying victimization and fighting illustrate different types of involvement in violence during adolescence bullying involves negative physical or verbal action that has hostile intent causes distress to the victim and includes a power differential between bullies and their victims 6 according to olweus it is also bullying when a person is teased repeatedly in a way heshe does not like victimization by bullying occurs when a person is made the recipient of aggressive behavior 10 typically it is someone less powerful than the perpetrator fighting is an aggressive behavior and in most cases the people involved are of a similar age and equal strength demographic social academic achievement and substance use have shown association with violent behavior in adolescents 1112 according to a report released in 2016 the prevalence of fighting among adolescents aged 15 from europe and north america varies between 22 and 69 in boys and between 9 and 25 in girls 13 physical fighting was strongly associated with alcohol consumption and drug use 14 15 16 the social developmental model states that the youth behavior is learned through a continuous process starting from childhood the social agents that play an important role in their behavioral development are families schools peers communities 17 18 19 adolescents who maintain a stronger healthier relationship with their families and their education are less likely to participate in unacceptable behaviors such as violence 2021 the relationship with parents including poor parental monitoring and low parental support has also been mentioned as risk factors for violent behavior among adolescents 2223 physical fighting has also been associated with poor peer relationships 2425 one of the most important factors in sculpting and defining the adolescent behavior represents the time they spend with their peers and the relationships they establish with them numerous studies have shown that adolescents tend to engage in similar behaviors as their peers 26 27 28 many adolescents have at least one friend that uses substances but when most of their peers engage in behaviors such as drinking smoking or even illegal activities the risk of them doing the same increases while engagement in peer group activity is normative for adolescents it is when a person has high support from peers and low support from parents that substance use is particularly elevated 28 beside the immediate effects bullying victimization and fighting have longterm negative consequences for the bullies victims fighters and those who observe the interaction 2930 some studies have shown that children who are bullies tend to still be bullies as adults additionally an interesting observation is that adult bullies with children of their own tend to raise them as bullies 30 because it relates to students school violence has received substantial media research and political attention 31 in romania no systematic studies on aggressive behavior among high school students have been published so far according to the health behaviour in schoolaged children study conducted in romania between 2005 and 2006 32 6 of the girls and 24 of the boys aged 15 have been involved in a physical fight at least three times in the last 12 months another survey performed by hbsc between 2009 and 2010 33 found that 4 of the girls and 19 of the boys aged 15 have been involved in a physical fight at least three times in the last 12 months however there is increased concern about violent behaviors amongst adolescents in the school setting and on the community level hospital primary health care and ambulatory data shows increased numbers for adolescent victims of aggressive behaviors 3435 the 2007 36 and 2011 37 european school survey project on alcohol and other drugs which examined 35 and 36 european countries respectively including romania provided an opportunity to study aggressive behavior in a large national sample the first aim of this paper is to examine patterns of aggressive behavior of 1516year old high school students in romania and compare the collected data in two national representative samples from 2007 and 2011 the second aim of the study is to identify factors associated with physical fights in adolescents in romania we hypothesized that physical fighting is associated with different types of factors such as demographic social school performance problem behavior and substance use materials and methods population sampling design and representativeness the espad target population is defined as regular students who turn 16 during the calendar year of the survey and are present in the classroom on the day of the survey 3637 this definition includes students who are enrolled in regular vocational general or academic studies but excludes those enrolled in either special schools or special classes for students with learning disorders or severe physical handicaps parttime and evening students and military high schools were also excluded sampling in the espad project is based on the class as the final sampling unit a total of 104828 students participated in the 2007 espad study and 103076 students in the 2011 study more details about methodology are available in the espad reports 3637 among all romanian inhabitants born in 1991 and 1995 roughly 87 and 94 respectively were still enrolled in regular schools the remaining students were enrolled in either a vocational theological or military school or in schools where the teaching language is not romanian the romanian sampling frame included 9th and 10th graders and covered approximately 99 of the espad target population the sampling frame was nationally representative for students from regular schools and covered all 42 counties a simple random sampling procedure was applied to a list of 1459 schools in 2007 and 1499 schools in 2011 in order to obtain an adequate geographical distribution both lists were provided by the ministry of education these lists did not include information about school size meaning that all schools had the same probability of being sampled from these schools one class per grade was randomly selected to participate without class size being considered the samples are representative for romanian students born in 1991 and 1995 enrolled in grades 9 and 10 at regular schools using the detailed information about school and class size provided by the schools contacted a weight has been introduced to adjust for school size organization of the study once classes had been selected the parents received information about the study in order to give their active consent the schools received a folder with methodological information and the headmasters were asked to make plans for the datacollection procedure the questionnaires and response envelopes were distributed by ordinary post to the research assistants research assistants collected data in the classrooms where the students answered the questionnaires anonymously they received standard instructions and individual sealable response envelopes to put their questionnaires in the completed questionnaires were brought by the research assistants to the county center where the data were entered this study was approved by the research ethics committee of victor babes university of medicine and pharmacy school and student participation students and schools were informed that participation in the survey was voluntary the overall response rate was 84 in 2007 and 79 in 2011 only 2 of the research assistants experienced that some of the students found the questionnaire difficult to complete a total of 2289 romanian students were included in the final database in 2007 and 2770 in the 2011 database instrument measurement and data processing the translation of the questionnaire was made by a team of professional translators after which it was backtranslated and reviewed by a psychiatrist and publichealth specialists the questionnaire was pretested at ten schools which led to some modifications cronbachs alpha reliability coefficient was determined for the main parts of the questionnaire investigating social support substance use violence etc results ranging from 077 to 081 were found indicating that participants responded consistently to questionnaire items aggressive behaviors were assessed through the following questions how many times during the last 12 months heshe had experienced a physical fight hit one of the teachers got mixed into a fight at school or at work took part in a fight where a group of friends were against another group hurt somebody badly enough to need bandages or a doctor used any kind of weapon to get something from a person participated in a group teasing an individual participated in a group bruising an individual participated in a group starting a fight with another group started a fight with another individual victimization was assessed through questions like how many times during the past 12 months have you been individually teased by a whole group of people bruised by a whole group of people in a group that was attacked by another group or individually involved in a fight started by someone else the use of tobacco alcohol and illicit drugs was assessed through questions that aimed to establish whether these substances have ever been used by the participants age of first use and the possibility of consumption during the past 30 days binge drinking was assessed by asking how many days out of the last 30 the respondent had five or more drinks in a row the answers for all the question from above were dichotomized to not at all and once or more times relationship with parents and perceived parental behavior were assessed as follows relationships with parents family control was assessed by the questions do your parent set definite rules about what you can do at home do your parent set definite rules about what you can do outside the home do your parent know whom you are spending your evenings with do your parent know where you are in the evenings do your parent know where you spend saturday nights emotional support and caring from mother andor father one item analyzed relationship with friends and two items assessed emotional support and caring from best friend students were also asked about their school performance mainly their grades at the end of the last term and about absenteeism during last 30 days the variable how often during the last 12 months have you experienced physical fight was dichotomized and the new variable was grouped as follows neverone or more physical fights during the past 12 months this question was introduced for the first time in the 2011 survey the data were entered manually in each county during a fiveweek period and then centrally merged by the national school of public health management and professional development bucharest romania statistical analysis all analyses were performed on weighted data the results are presented as absolute and relative frequencies all analyses were conducted with stata 92 using the svy commands descriptive statistics were conducted using frequencies and proportions chisquare tests were performed to compare values between 2007 and 2011 a logistic regression analysis was used to estimate factors associated with physical fight experienced during previous 12 months a p 005 was considered statistically significant and odds ratios with their respective 95 confidence interval were calculated results a total of 2289 students were included in the survey in 2007 and 2770 students in 2011 the present study revealed that 1000 students had experienced a physical fight during the previous 12 months univariate analysis showed important differences between students who experienced physical fight and those who did not the following variables were significant factors associated with physical fighting male gender poor relationships with mother and father parent do not know where adolescents spend their saturday nights parent do not know where and with whom the adolescents spend their evenings poor caring and emotional support from parent serious problems with parents poor caring and emotional support from best friend serious problems with friends low school grades high truancy marijuana lifetime use current smoking and binge drinking during the previous 30 days we did not find any association between physical fight experienced during the last 12 months and definite rules set by parent regarding what adolescents can do at home and outside home using stepwise logistic regression the most parsimonious multivariate logistic model was produced for factors associated with physical fight experienced during the last 12 months the following factors associated with physical fight remained male gender parent do not know where and with whom the adolescents spend their evenings poor parental caring serious problems with friends low school grades high truancy and binge drinking during the previous 30 days a decrease in almost all aggressive behaviors was noticed in 2011 compared to 2007 statistically significant differences were observed for taking part in a fight where a group of friends went against another group participating in a group teasing an individual participating in a group starting a fight with another group starting a fight with another individual the only violent behavior that increased in 2011 compared to 2007 was using any kind of weapon to get something from a person but this was statistically significant only for females regarding victimization we also found a decrease of prevalence in 2011 compared to 2007 statistically significant differences were observed for being individually teased by a whole group of people being bruised by a whole group of people being in a group that was attacked by another group being individually involved in a fight started by someone else discussion the espad surveys among high school students provided us an opportunity to study aggressive behavior in two large national samples in 2007 and 2011 the present study revealed that 3587 of the students experienced physical fight during the previous 12 months this result was higher than the prevalence of physical fight for the entire european espad database 38 that was 3125 the lowest value being recorded in denmark and the highest in malta 37 the 2011 questionnaire included a new variable regarding the physical fighting experienced by the students during the previous 12 months we investigated different types of factors associated with physical fighting demographic social school performance and substance use the present study has demonstrated that the combination of male gender binge drinking during the previous 30 days having serious problems with friends parent who do not know where and with whom the adolescents spend their evenings poor parental caring low school grades and high truancy were predictive of physical fighting in this adolescent population however the results do not provide information about a causal relationship similar to other studies 16 39 40 41 42 43 physical fighting was more prevalent in boys than in girls boys usually engage in undisguised violence to gain influence money or power girls resort to relational aggression and may become violent when it comes to emotional situations such as peer andor romantic relationships family arguments or outsiders instigation 44 45 46 according to our findings students with poor school performance were the most exposed to experience physical fighting compared to the highest school performance the multivariate analysis showed they were three times more likely to engage in physical fight this is similar to other studies findings 4748 absenteeism has also been found to be associated with youth violence 144950 in our logistic regression model students who have been missing 56 days from school in the last 30 days were almost seven times more likely to engage in physical fighting the development of bullying and victimization might be influenced by individual and family factors aggressive behavior research has shown that childrens socialization experiences within the family have a major role in aggressive behaviors development 36 the following family influences on the development of aggression have been studied family demographics parenting techniques and relationships between parent and child 37 we found that the adolescents who are more likely to experience physical fights usually have parents who rarely know with whom their children spend their evenings poor parental care and serious problems with friends were another two important predictors in our model certainly a wide variety of factors contribute to todays adolescents exposure to violent behaviors including family structure social environment and peer behavior two of the most common correlates of violent behavior are alcohol and drug use 5152 for example alcohol may suppress inhibitions against violent behavior or may affect the brain in such a way as to produce aggressive behaviors 5354 a competing theory proposes the reverse causal relationship ie people who plan on being violent may drink to give themselves courage or an excuse for the violence 55 56 57 finally a third theory states that drug use alcohol use and violence are all outcomes of an unobserved third factor for example a risktaking personality 395158 risk taking is frequent during adolescence and is associated with adverse outcomes including substance use it is likely to be influenced by an individuals cognitive development social development and experiences with dangerous situations 59 the inability to recognize warning signs in dangerous situations can make drinkers easy targets for perpetrators 52 our study showed that alcohol consumption and drug use is a significant predictor for developing an aggressive behavior we observed declines in almost all aggressive behaviors in 2011 compared to 2007 this trend is also confirmed by the two hbsc studies that took place in the same periods in romania 3233 after gaining access to the eu in january 2007 new legislation has been enacted and previous rules have been reinforced in areas related to youth violence for instance the romanian parliament adopted two laws on improving safety in schools law no 35 6061 this new legislation may have played a role in reducing violence but there is no proof of causality strengths and limitations of the study there are certain limitations of this study that must be considered when interpreting the results first the findings reported here are only relevant to high school students from romania who turn 16 in the calendar year of the survey and may not be generalized to other adolescents in the same age group that are not included in scholastic institutions second survey methods are frequently criticized because they rely on the validity of selfreporting of sensitive and highly stigmatized behavior thus error based on selfreported behavior might have been generated third adolescents who were not available to complete the questionnaire due to truancy or dropout are likely to be at higher risk for aggressive behavior and other risk behaviors despite the limitations mentioned above the study has strengths we used a standardized questionnaire employed in other european countries in similar settings the prevalence estimates we obtained are likely to closely represent the aggressive behavior prevalence amongst adolescents going to school as we used probability methods for selecting the sample conclusions physical fighting amongst the young adolescents that we evaluated was higher than the prevalence of physical fighting for the entire european espad database 38 and was associated with several factors a combination between male gender binge drinking problematic relationships with friends and family members low school grades absenteeism was found to be associated to the violent behaviors of adolescents the development of a theoretical model which separates problem behaviors from adolescent experimental or risktaking behaviors might be useful for future evaluations the novelty of this study lies in analyzing patterns of associations using a large sample with national representation these findings may be useful to support and guide policy makers regarding the improvement and implementation of strategies to further prevent aggressive behaviors in teenagers as in other european countries romania managed to reduce aggressive behaviors among high school students new legislation may have played a role in reducing violence but there is no proof of causality the ministry of education encouraged the development of partnerships between representatives of the county school inspectorates and the county police inspectorates to fight against violence in schools in addition the increase of alcohol excise played an important role especially for children with limited access to their parents funds this was coupled with the banning of alcohol advertising and clear rules for tv content for children and youth concomitantly various guides concerning violence prevention in school were published a school intervention strategy must provide a detailed presentation of the objectives pursued including the expected results the activities to be carried out the actors involved and their responsibilities the time horizon the necessary resources monitoring and evaluation modalities these interventions should provide students and teachers information about violence change the way adolescents feel and think about it and teach nonviolent skills in order to resolve disputes skill enhancement training with parents could be an important factor in controlling violence and creating a stronger family bond parentskill and familyrelationship approaches providing caregivers with support and teaching communication skills might offer problemsolving techniques and behaviormanagement skills additionally the school psychologists should provide therapy sessions for students in order to strengthen their problemsolving skills and resistance to negative peer influence	the aim of this paper is to examine aggressive behaviors among romanian high school students between 15 and 16 years old to compare data in two national representative samples and to identify factors associated with physical fighting this study investigates the association of selected factors social school performance and substance use with physical fighting a total of 2289 romanian students were included in the 2007 database and 2770 in the 2011 database this study revealed that 3587 of the teenagers have taken part in a physical fight during the previous 12 months as compared with the european average of 315 romania has the highest prevalence of violent behavior by participating in a group bruising of an individual in both surveys 2007 and 2011 a logistic regression analysis performed for the 2011 study revealed the following factors associated with physical fighting binge drinking during the previous 30 days male gender serious problems with friends parent s who do not know where and with whom the adolescents spend their evenings poor parental caring low school grades and high truancy a decrease in almost all aggressive behaviors was noticed in 2011 compared to 2007 these findings may be useful to support and guide policy makers regarding improvement and implementation of strategies to further prevent aggressive behaviors in teenagers
introduction my first experience with a tattoo artist was back in 1995 i was a teenager and tattoo studios or parlors were rare in mexico city and expensive in my childhood neighborhood of villa coapa located in the south however i had a friend who claimed to be a tattoo artist and inked people at his home his nickname was lua he was a punk rocker a selftaught tattoo artist who learned his trade from magazines and his experience practicing daily with his clients he may not have been the best artist in town but he was dedicated and offered an option to individuals who did not have the resources to get a proper tattoo in the expensive parlors i got my first two tattoos with him paying a symbolic fare most of my friends followed suit and got their tattoos with him too suffice it to say that over time my tattoos did not look great and finally in 2010 and 2014 i got them covered i lost contact with lua in the early 2000s however when i walk through my old neighborhood on a hot spring day i can spot some people my age or older still showing some tattoos made by lua in the 1990s which have resisted the passing of time i tell this story because the situation today in mexico but also in many cities of the world is very different tattoo parlors and artists abound and compete in a saturated market in mexico city new studios open their doors every year and some close or merge with others the tattoo culture in mexico has grown exponentially in the last decade and it has turned into a hierarchical community marked by status elitism and exclusion mirroring the stratified configuration of mexican society on the one hand there are famous artists with peculiar nicknames like dr lakra1 piraña chanok and wilson posada who were members of the collective dermafilia in the middle of the 1990s and who have a long trajectory and influence in the mexican tattoo scene even if some of them do not live permanently in mexico like posada on the other hand some artists have their studios in their homes in middleclass and lowerclass neighborhoods and many more do not work fulltime as tattoo artists or have just started tattooing recently it is difficult to give a detailed account of the tattoo community in mexico and even the concept of community is debatable as the limits of what constitutes it are not clear it involves artists tattooed persons and owners of magazines and supplies all are part of this subculture but it is by no means homogenous however despite the differences and divisions a sense of solidarity and communion exists between artists and consumers of tattoos still the history and anthropology of tattoos in mexico are a work in progress in this article i focus mainly on the apprenticeship process of tattoo artists in mexico my interest centers on how they learned their art got their knowledge about tattooing and perfected their craft in essence this article addresses the question of how a person becomes an expert through practice and how they transmit and share their knowledge with aspiring tattoo artists basic anthropological inquiries appear here like the conformation of a tradition the accumulation of knowledge and techniques the visual and sensual appeal of the body the experience of pain and the mystical and spiritual connotations of tattoos my theoretical approach is based on the anthropology of ritual experience and performance of embodied practices popularized by authors like victor turner paul stoller thomas csordas and david le breton the framework of what could be called an anthropology of skills and embodied knowledge also benefits from the insights developed by tim ingold in this sense experience skills and embodied practices appear under a phenomenological perspective which attempts to show the importance and meaning of tattoos in culture beyond a sociological simplified explanation the methodology implemented in this article draws on my longterm involvement in the tattoo scene in mexico for more than twelve years it is based on my participation in tattoo conventions multiple tattoo sessions with artists as a client and following the lives of tattoo artists for more than ten years longterm fieldwork in urban settings of your own culture allows developing a different kind of awareness of cultural practices a slowknowledge approach that takes years to assimilate and understand as paul stoller has argued recently but which provides a more indepth approach to the development of anthropological insights about embodied practices the perspective of the artists presented here is by no means representative of all the tattoo culture in mexico it offers only a window to what anthropologists like clifford geertz have referred to as the natives point of view this methodological strategy is inspired by the works of victor turner on ritual paul stoller and the embodied study of charismatic healers by thomas csordas it is through practice participant observation and commitment to the artist´s perspective that it is possible to draw an ethnographically driven theoretical approach from the bottom up and not the other way around it is important to mention that anthropological works on tattoos tend to focus on the clients perspective sociological and communication science works have followed this trend by trying to delve into the causes meanings and symbolism of certain tattoos that people have although the clients perspective is relevant i argue that the view of the artist is also essential in getting an understanding of the tattoo culture today in this sense the artistclient relationship becomes an indissoluble pair that signals the process of ephemeral interactions that culminate in intimate fluid body biographies2 i argue that these inked biographies become a roadmap for the self the first section of the article describes general aspects of the anthropology of tattooing the history of this art and the development of the tattoo culture in mexico the second section deals with the process of apprenticeship of tattooing as part of an embodied experiential practice where tattoo sessions represent performative public acts and painful rites of passage for clients and moments of innovation for the artists the third section connects the process of apprenticeship of tattoo artists with their experiences with their clients and how a bodily biography emerges from this relationship the fourth and final section focuses on the commercial side of the tattoo culture and the fierce competition artists face in a saturated market the art of tattooing the practice of tattooing according to aaron deterwolf and lars krutak appears in numerous archaeological records they argue that tattooing as a decoration dates back to the fourth millennium therefore it is an ancient practice that has existed all over the planet it is not exclusive to a region or a particular culture and there is not one exclusive place of origin archaeological evidence is based on skin remains in mummified human remains in skin preservation in graphically documented records and in the tools discovered to make tattoos there is always the question of why cultures practice tattooing as decoration or as a religious or political symbol of power and social identification there is no simple explanation and no such thing as a unilinear historical or evolutionary development of tattoos in the social imaginary of modernity we could portray a development from ancient cultures passing through indigenous and tribal people and finally arriving in the tattoo practices in the west today this is a fictional narrative that does not correspond with reality there is no such thing as a history of tattoos multiple overlapping histories exist some of the narratives about tattoos are told to justify a new tradition for a community for instance in her work bodies of inscription margo demello argues that the development of specific tattoo representations in the culture of the united states operates under the narrative of an evolutionary process that goes from tribal nonwestern societies to the appropriation of tattoos in america in the early twentieth century she says in the case of nonnative american tattooing the tradition first came from the islands of polynesia within the context of colonialism then was adapted by various subcultures within the working class and was once more reinvented in the 1980s primarily by middleclass artists and wearers through each step of this evolution and reinvention the participants must rework the tradition to make it fit the sensibilities of the new community for demello the narratives of tattoo artists and clients correspond to recent developments of a cultural change that made tattoos more accessible and fashionable among the american middleclass since the 1980s however the evolutionary view of tattoos differs in europe gemma angel mentions that the european gaze on nonwestern tattoo practices unavoidably confronts its prejudices about otherness the tattoo collections in different museums like the wellcome collection in london one of the most important in the world contain the material culture of tattoos meaning the preserved skin of tattooed people and artifacts for the inking process however gemma angel points out the lack of archival information about tattoos at least in the nineteenth century just recently academics have been trying to overcome the exoticism of otherness in the analysis of tattoos and body decoration and have moved away from a straightforward unilinear historical narrative about this art today if it is possible to portray an evolution of tattoos this relates to techniques and tools this imaginary trajectory traces a line that goes from the use of single handpoke techniques popular in japan and other asian countries passing through coil machines and finally arriving in complex lightweight rotary systems like the stigma rotary machines invented in the first decade of the twentyfirst century3 techniques bring refinement and help tattoo artists however this doesnt mean that artists depend exclusively on advanced tools to perfect their craft the wide range of techniques used to create a particular tattoo style relate to multiple factors like prestige more authentic and ancestral methods and procedures the demands of clients and individual preferences in mexico academic tattoo research focuses less on its indigenous prehispanic origins and more on its urban development in the nineteenth and twentieth centuries although there is archaeological evidence of the uses of body paint and tattoos in human remains found in oaxaca and the yucatán peninsula archaeologists like enrique vela argue that the evidence is scant and more work needs to be done particularly in the analysis of ceramic humanoid figures depicting lines and decoration in mural painting and stone engraving the anthropological and historical studies about tattoos in mexico havent attracted many specialists research interests lie with art historians journalists activists dermatologists doctors and tattoo artists themselves experts in criminalistic science and anatomy provided the first known works about tattoos in mexico according to álvaro rodríguez luévano the pioneering work of francisco martínez baca is perhaps the most known work he was a military physician who did research on prisons in the state of puebla and wrote the first book about tattoos in mexico in 1889 called tattoos a psychological and legalmedic study with criminals and the military martínez baca kept correspondence with the famous italian criminologist cesare lombroso who was the leading figure in tattoo research at the time according to rodríguez luevano martínez baca thought that through the analysis of tattoos in penitentiaries it was possible to deduce the degree of moral degradation of individuals for him tattoos belonged exclusively to the lower criminal classes and by making a registry of the tattooed people it was possible to guess their origins and association with gangs his theory got into methodological difficulties as tattoos also proliferated in the military there soldiers used tattoos as a form of identification and by no means did this translate into moral degradation martínez baca ended up creating spurious classifications of tattoos in both contexts the military and prisons related to the psychological character of individuals due to his prejudices he also did not delve into the tattoo artists themselves for him they were just rudimentary technicians with no skills prisoners who tattooed people just to kill time despite his shortcomings his classification also helped him to distinguish motives figures religious adscriptions and ethnic belonging through tattoos rodríguez luevano mentions that most of the tattoos registered by martínez baca were rudimentary with poor aesthetics and used lowquality materials martínez bacas book set a precedent for tattoo research in mexico however it inevitably contributed to the stigmatization and discrimination of tattooed persons this stigma hasnt completely disappeared and still exists in certain contexts of mexican society approximately twentyfive years ago more investigations in mexico carried out by anthropologists psychologists science communication experts and sociologists appeared which focused on contemporary urban tattoo culture at the same time more tattoo artists began to express their own views on tattoos in magazines narratives and interviews the interest in some of these works turns around the tattooed people their styles the use of tattoos as a form of social identity the psychological reasons for having inked art in their bodies and the impact of tattoos in society for instance samira rojas bolaños focuses on the notion of stigma and the psychological impact it has on tattooed people her research demonstrated that in certain professional occupations in mexico like doctors lawyers social workers and psychologists tattooed persons are still linked to criminality even more so if the tattoos lack quality melissa priego díaz on the other hand focuses on the gradual acceptance of tattoos and how artists have contributed to such acceptance she describes how tattoos become commodified as art in social media and the interventions of bodies can carry certain altruism like tattoos offered for free to women who have experienced breast cancer to cover their scars finally katia perdigón y bernardo robles analyze the tattoos related to the cult of the santa muerte in mexico city their research focuses on the different reasons people give to have tattoos of the santa muerte in visible parts of their bodies it shows that tattoos are part of a religious devotion that provides direct protection to individuals here tattooed images are seen as part of a global phenomenon of acceptance in society of the santa muerte cult which exists not only in mexico but also in many parts of the united states among tattoo artists who write about their profession in mexico topics range from the popularization of tattoos today to consumerism cultural appropriation and their own personal histories famous artists like dr lakra often give interviews in newspapers and have exhibited their artistic works as painters in different national and international galleries tattoo artists have become the main producers of discourses about tattoos today although these narratives do not derive strictly from academic publications how to learn a craft tattoos as embodied contemporary rituals although there is no evidence to claim an evolutionary approach to tattoos the division between the study of nonwestern and contemporary tattoos mirrors the classic distinctions between the primitive and the modern perceptions of the body on the one hand tattoos in indigenous settings like those studied by alfred gell or evoked by claude lévistrauss on the māori belong to cultures where tattoos or body decoration and modification are part of a collective enterprise and it is not a matter of individual choice there is a ritual and even religious component that signifies identity social belonging and change of status as david le breton has argued recently the oftenquoted remark of lévistrauss concerning the māori stress the value and power of the collective over the individual he says the purpose of maori tattooing is not only to imprint a drawing onto the flesh but also to stamp onto the mind all the traditions and philosophy of the group on the other hand tattoos in contemporary societies appear as a matter of personal choice often dislocated from a territory or place of origin and sometimes imprinted as a form of reappropriation of a lost tradition david le breton argues that the tattoo artist hovers above culture and becomes a shaman of modern times as he can connect through his art different settings and cultural traditions modifying the quote of lévistrauss mentioned above we could argue that a contemporary tattoo artist stamps in the mind of the tattooed a set of hybrid traditions selected from deterritorialized references pain is a quality inherent in tattoos it is inescapable and represents a temporary inner sacrifice it is localized singularly in the person therefore it is a highly individualized act in contemporary urban settings like mexico city the experience of pain is a choice that the tattooed accepts and it signifies a rite of passage pain is what makes the process of getting a tattoo a contemporary ritual art form as le breton mentions pain anticipates change a metamorphosis that the new tattoo brings to a person the artist understands pain as he or she has tattoos too it is very rare to find a tattooist who does not have tattoos therefore there is a shared body experience between the artist and his clients this momentary bond which lasts until the piece is done stays in the memory of the person getting the tattoo and for the artists it becomes a further development in their craft and proof of their expertise the process of getting a tattoo turns into a liminal experience intensified by localized pain as victor turner mentions liminality is an inbetween state marked by ambiguity social invisibility lack of status and camaraderie in the ritual process getting involved in a tattoo session means subjecting oneself to a liminal intense body experience where pain is predominant for some hours the subject is left in the hands of the artist so there must be mutual trust between the parties the artist on the other hand needs to be careful not to make mistakes so concentration is paramount if modern tattoos constitute personal neorituals then the tattoo artist symbolizes the role of the religious leader in initiation rituals he or she is the conveyor of knowledge transformation and permanence inscribed into others his role is like the charismatic healer described by thomas csordas where such a healer is a channel that controls the body experience of participants the cultural phenomenology of healing in religious settings has other kinds of connotations and motivations however tattoo artists sometimes heal other persons through tattoos covering scars signifying important moments of their lives and marking sometimes forever a memory in time through pain therefore there is a legitimate anthropological question about the cultural importance of tattoo artists how they have become skilled professionals whose craft has changed drastically in the last thirty years and whose work remains in high demand in mexico city the most famous tattooists have a background in arts graphic design or visual arts some are selftaught like dr lakra born in 1972 who says i started just drawing at school i liked to draw a lot i did comics and then i entered the friday workshop at gabriel orozcos house where he taught painting at the same time i started tattooing a friend started tattooing me and i saw that the machine was very easy to make then in the late 80s and early 90s i started tattooing other friends so since everything went a little hand in hand i was doing painting drawing comics tattoo i dont have it so separated wilson posada for instance began tattooing in 1994 when he joined the collective dermafilia he learned his craft with the people of the collective and his uncle taught him jewelry too in 2007 he moved to san francisco california apart from being a tattoo artist he is also a musician and won the legal battle to use the name dermafilia in his art collective chanok another of the most famous mexican artists in mexico city who started tattooing in the middle of the 1990s is also a selftaught person he said in an interview for the website tattoo life when i started i didnt know anything about tattoos i had seen it done and thought i could do it too since i knew how to draw…a lot of the punk iconography that we used came from the blue tattoo time we copied designs out of the few magazines we could get gangster stuff too street style images of the virgin skulls etc… getting books colors or even just some good advice was very difficult back then but conventions started happening in mexico and that began to open things up thats when we could meet other artists watch them work get tattooed and buy supplies 4interviews with other tattoo artists offer similar responses in the case of marco panké nicolat he transitioned from skateboarding to tattoos in an almost natural way he was part of a family of artists his deceased father was a famous painter who lived in oaxaca for many years and his two brothers were also artists and were interested in tattoos and mural painting marco told me he began learning about tattoos with his friend iván who had been living in berlin since the late nineties marco decided in 2007 that he wanted to learn for real about the art of tattooing so he could make a living from it as he was growing old and was piling injuries from skateboarding he tried his luck and decided to make berlin his home although he did not start his learning process in mexico he regularly traveled to his home country and there he got to know many tattoo artists in places like mexico city queretaro and guadalajara he owes his expertise to the help of iván who began tattooing in the late 1990s in mexico city in the case of alfredo chavarria he studied visual arts at the enap in the late 1990s he was always interested in drawings the culture of comics and design in an interview he gave for the youtube channel la casa del tatuador in march 2023 he mentions that he learned about tattoos from his friend rodrigo lópez de lara 6 through roys influence alfredo became involved and interested in tattoos from a creative perspective roy gave alfredo his first inked piece in 1998 a tribal design alfredo tried his luck in different graphic design firms where he worked as a freelancer illustrator until that work almost dried up and he had to do something else so he began working as a sales assistant and tattoo apprentice in tatuajes méxico at the trendy colonia roma neighborhood where his friend roy worked at the time tatuajes méxico was a studio and a shop that sold materials tools and designs and it was a place where artists went to buy products through this job alfredo got to know slowly the thriving community of tattoo artists and this studio allowed him to try out his first works as an apprentice these brief sample stories of tattoo artists who began tattooing in the middle of the 1990s and early 2000s show a cultural tradition in the making almost starting from scratch there was not much cultural background to rely on beyond the tattoo magazines and the trips that emerging artists with resources could make to the united states this is important for anthropology as the transmission of skills normally assumes that there is a corpus of ancestral knowledge on which the initiates depend for instance when victor turner asked about the meaning of symbols in ndembu rituals there were experts like muchona who gave detailed explanations to him about ritual procedures uses of colors rules and taboos even in socalled invented traditions there was a manipulation of cultural references used for political reasons and creative responses that depended on a set of cosmological innovations with tattoo artists in mexico in the 1990s and early 2000s their craft developed as a form of experimentation where their only solid ground was their artistic background in graphic design painting architecture or the simple curiosity they had however as tattoo artists say to work on human skin is very different it has a depth that challenges any drawing project it faces the resistance of another human being it also tests their endurance as tattoo sessions tend to be long and both artists and clients must remain seated in uncomfortable positions learning a craft for these emerging artists was not a case of an invention of tradition without any cultural authentic reference here it is important to remember the words of marshal sahlins about the importance of the specificities of cultural formations from what i know about culture then traditions are invented in the specific terms of the people who construct them in the case of emerging tattoo artists in mexico city they invented their tradition and craft by giving it motives themes images symbols and artistic techniques which came from their mexican traditional backgrounds in this way their development was quite unique they did not have a master tattoo artist to rely on and they worked with hybridizing techniques experimenting with tools and even learning from some selfmade tattoo artists in jail they would become experts years later and they would lead a new generation of emerging tattoo artists in the 2010s and the coming years it was at the beginning of the 2010s that the figure of the tattoo apprentice gained traction in studios and parlors all over mexico body biographies in mexico city today individuals learn about tattoos by working as apprentices with more experienced artists or by transitioning from other graphic or visual arts to tattooing what is true is that there is no institutionalized apprenticeship at a university or a specialized college where one can get a formal education in tattooing an artist becomes so by practicing and learning from others via the oral transmission of knowledge though advertisements about learning to tattoo online have grown in the last five years most artists are reluctant to use this form of learning today selftaught has its limits many reject the idea or even the possibility of learning to tattoo online to become an artist you must practice and be close to the studios and the people who know the craft and are more experienced besides famous artists are unwilling to share their trade secrets with people who know nothing about tattoos even less for free however these artists may offer seminars and tutorials for more experienced fellow artists sometimes online or during tattoo conventions to be a tattoo artist means to work with ink lines inscribed into the skin like many other arts like drawing sculpture calligraphy pottery and painting tattoos form lines and the artists creativity sparks from techniques and appliances on the body of such lines here it becomes inevitable to relate tattoos to the reflection on lines developed by tim ingold for ingold lines become essential to show human creativity and movement through history in his work he describes the process of writing by hand and drawing as experiments in innovation he highlights the importance of human movement as leaving linear traces on a surface as tantamount to a way of life for him writing goes beyond the modern association with inscription provided by typography in a computer or a mechanical device and to understand its value we need to appreciate it as a form of a drawing of lines which follows a trajectory traced by the artists hand on a surface surprisingly ingold does not make any direct reference to tattoos in his book i find this omission puzzling considering that other anthropologists like alfred gell have dedicated a substantial analysis of indigenous tattoos as art forms we can only take some of ingold´s references to lines and adapt them to the context of tattoos like the technological implementation of tools and the creative display of the artists as they develop their art as an unpredictable unfolding process in the case of gell indigenous tattoos among the māori form part of a particular artistic style which relates tattoo patterns to other forms of representations of culture inscribed in artifacts like ceramics shields canoe carving and face painting however tattoos are manufactured objects that convey agency gell mentions that manufactured objects are caused by their makers just as smoke is caused by fire hence manufactured objects are indexes of their makers the index as a manufactured object is in the patient position in a social relationship with its maker who is an agent and without whose agency it would not exist gell warns the reader that not all cultural objects appear to be manufactured by a human artist some are believed to be divinity creations sometimes the origin of such artifacts dissipates or is forgotten by people traditional indigenous tattoo art had religious and ritual motives and the tattoo artist did not always have to be remembered what was of relevance was that the tattoo offered protection to a person in the afterlife so maze tattoos for instance protected womens bodies when they died and guided them in the afterworld as documented in many parts of india however there are exceptions in other cultural contexts the importance of the tattoo artist was recognized and praised by people among the māori an artist got fame and prestige through his art where his skills and techniques were highly appreciated though their artistry was related to how well they could faithfully reproduce a particular cultural style and not about expressing their individual creativity for gell the limits of creativity imposed by what he called tradition differentiated tattoo art in indigenous settings from the west where tattoo art focuses on individual innovation although there are standardized styles in contemporary tattoo production these do not necessarily relate to the artists cultural milieu and are often borrowed or taken out of context from other cultures thus a mexican artist may become an expert in japanese imagery as is the case of dr lakra whose work is inspired by asian cultures or a german artist may become a specialist solely in the realism of horror hollywood movies the freedom of individual expression makes possible these types of cultural hybridization not all mexican tattoo artists work under a unique stylistic framework the majority use diverse techniques and patterns depending on the clients demand the question is how they develop their individuality through tattoos and how people assess their quality to begin with it is worth mentioning that most if not all tattoo artists have tattoos themselves made with a different array of fellow artists and friends their bodies become biographies and like with their clients they transform their bodies into vast canvases for experimentation where reciprocal links are constructed in what they argue is the karma they pay for being tattoo artists themselves they ink others but they need to be inked and experience the pain too the reciprocity of tattooing each other is a form of solidarity among artists it shows commitment trust and respect for others alfredo chavarria for instance has mentioned that artists and clients may become collectors of tattoos showing pieces of art from a wide diversity of creators in the tattoo world collected tattoos also add to the status of a person to show a tattoo made by a famous artist enhances the body representation of a person and the admiration of others for instance a tattoo made by dr lakra or chanok gives prestige to the tattooed person who wears it however it is rare to find a tattoo artist who has tattoos only from one colleague the body of the artist is a body biography that traces a trajectory in the tattoo environment and is a symbol of a life story it also affects how clients perceive them a heavily tattooed artist may bring more confidence to persons who decide to have their first tattoo as it shows passion and commitment to the art and the seriousness of the profession a committed artist also inspires apprentices to learn the intricacies of the trade artists continue learning after they master their trade in the case of the artists mentioned in the previous section the complexity of tattoos their history specialization and development of techniques demand ongoing actualization one never stops learning and experimenting artists sometimes foray into other arts like painting and photography to develop new skills learning new techniques involves getting acquainted with new technologies like social media particularly instagram it is through this last platform that tattoo artists advertise their work to the world i will describe the impact of social media in the next section to update their artistry tattoo artists invest a substantial amount of time in goodquality products updating their knowledge of ink brands and cartridges machines needles equipment in general and hygiene competition in a saturated market early tattoo artists in mexico initially did not know they could make a living tattooing people in the middle of the 1990s and early 2000s there was not much information available in mexico about tattoos only a couple of magazines existed mainly in english no widespread internet access was available and just a few tattoo parlors were around and few people got tattooed with time the tattoo culture in mexico expanded new companies like tatuajes mexico emerged which offered good quality products for the mexican market at a large scale and accessible prices new magazines in spanish began circulating and tattoo studios opened their doors all over the country in mexico city the tattoo scene grew because of the increasing demand and the social acceptability of tattoos in society more people in mexico are getting inked today than ever before many companies in the public and private sectors employ workers with tattoos in theory no employment agency should discriminate by advertising jobs explicitly banning tattoos nevertheless there is still a stigma in some sectors of society about tattoos particularly those that look poor in quality or are placed on the face head or hands however because of their acceptability they have acquired a high demand and have become a symbol of status dr lakra mentions that the popularity of tattoos today is mainly due to the hegemony of the visual culture over the written one the desire to create stronger bonds between people and as an act of social and individual memory preservation 7 nowadays more people are trying to make a living from tattoos not only as artists but also as business partners distributors and sellers of equipment in advertisements magazines consultancy and social media as influencers therefore there is much competition and the tattoo scene in mexico today has created a saturated market with a hierarchical structure where oldschool tattoo artists compete with the new generation who may have other interests and perspectives on tattoos there is a generational gap and to survive many tattoo artists organize themselves in collectives for instance dr lakra together with other artists from his generation opened the sigue sigue sputnik collective in 2016 located initially in the colonia guerrero and since september 2023 in the trendy colonia roma in the center of mexico city sss is a tattoo studio and art shop that also serves as an art gallery in a saturated market many anthropological issues arise how do we identify a true artist from a fake one price location and trends might not depict an artists quality therefore there are multiple factors to consider one is the history of the artist himherself particularly who taught himher and mentored himher second how long has heshe worked in the trade and in which studios third the quality of hisher portfolio fourth the recommendations heshe gets from other artists or clients even though it is still difficult to assess the real professionals from emerging artists and amateurs in this saturated market the creation of a persona on instagram and facebook is as important as the work of the artist itself how many followers the artists have how these artists interact with their virtual audience and how often they are under demand and on tour in other cities or countries are essential factors to consider in the world of tattoos the virtual persona adds a layer of legitimation to a tattoo artist being part of an influencer culture plays an important role too if a famous influencer talks about a particular artist or gets a tattoo from him or her it elevates the artists prestige and demand therefore today not only in mexico city but also in other cities tattoo artists depend on social media to get work and to advertise their products there is no escape from that and if they want to make a living from tattoos they need to have an active online presence at least on instagram artists like alfredo cahavarría mentioned that due to the saturated market in mexico established artists do not take apprentices too often either because of previous bad experiences because they do not want more competition or simply because they do not have the time these artists don´t share their knowledge with beginners less common even for artists is to share their knowledge without remuneration they may give courses seminars and tutorials for a fee but they will think twice before mentoring the uninitiated unless they are family members or people they genuinely trust as far as i know marco alfredo chanok and dr lakra do not have apprentices today mainly because they do not have the time to teach other tattoo artists from a younger generation i have met in mexico city and san luis potosí were more willing to have apprentices but in these cases they were their sentimental partners or people they had known for many years the reluctance to share knowledge may impact the tattoo culture in mexico city and beyond because tattoos are an art passed through oral transmission and practice the lack of proper guidance may have a negative influence on the quality of an artist new artists are impatient too and they are often very eager to start making a living from tattoos and rush the process without taking care of the proper development of their artistry a saturated market also impacts the remuneration an artist gets as more artists and studios are available some lower their prices in order to get clients quickly however alfredo and marco argue that professionals should always charge a fair fee depending on the characteristics of the tattoo still they shouldnt overcharge or sell their art cheaply normally low prices in a studio should be delegated to apprentices or people who are beginning their careers however what is true is that to get inked by artists from the old guard like chanok and dr lakra is usually expensive and they have a waiting list of many months to arrange a booking there are no census or statistics about how many tattoo studios exist in mexico city and less information about how many professional artists make a living from tattoos the closest one can get to surmising the dimensions of the tattoo scene is to attend one of the many tattoo conventions in mexico city and other cities it is at the conventions when artists get together to showcase their work studios use this opportunity to promote their business by handing out cards merchandise and stickers the conventions include tattoo exhibitions contests live music and quick tattoo sessions it is a place for artists to get to know people make connections and meet artists and suppliers from other regions although it shows the competitiveness of the trade the conventions also help promote tattoos as an art available to everybody to make them more accessible and acceptable to society in general8 conclusion the tattoo scene in mexico has changed substantially since i was first introduced to it in the middle of the 1990s today there are more professional tattoo artists than ever before in mexico what does it make an artist a professional this question lingers throughout the text and it has no simple answers as there are no formal institutions that legitimate professional tattoo artists nationally or internationally or even if they exist they are not universally recognized artists legitimate themselves through their work experience and time spent performing tattoos to know their trade means to learn from somebody willing to teach them the lucky ones like my friend alfredo learned when the tattoo scene was not so overcrowded and he had the support of his friend roy who introduced him and kindly taught him the basics of tattooing other artists were selftaught like marco and dr lakra who learned from different sources or got into tattoos by transferring previous skills learned in other arts like painting and graphic design for those who learned as apprentices the road to mastering a trade involves constant training being associated with studios and getting to know more established artists who may recommend their work the success of a career depends on the skills artists gain their gift and in some cases the development of a unique style selfdiscipline a businessoriented approach and their own personalities in the world of tattoos creativity is important and in mexico the creative skills of an artist may define his or her popularity the quality of the final product is also a determinant still the life paths of tattoo artists have not been easy and they currently face fierce competition in a saturated market despite the commodification of tattoos for many the experience of having one is still a rite of passage pain is unavoidable and tattoo artists inflict this pain for artistic purposes as artists see their craft as technical prowess sometimes if they are not too excited about the design a person wants if it is too repetitive or something they have tattooed many times their craft becomes mechanical a mastery that does not involve their full interest when an artist develops his or her own project or a tattoo that he or she considers aesthetically pleasant he or she will become more engaged and interact more with the client here the intensity of the experience involves both the artist and the tattooed the analysis of the apprenticeship experience of tattoo artists and the ritual of getting a tattoo are important aspects of the anthropology of embodied practices artists apprentices and clients form the core of the social relations that exist in a tattoo performance the body as a canvas for the experimentation of lines as tim ingold would say allows the artist to innovate and leave a mark as dr lakra mentions tattooing another persons skin and leaving a mark that will stay for the rest of his life is special it is not done in solitude but in coexistence and thats fun in this article i have focused mainly on the artists perspective the focus on the artists forms part of an anthropological strategy that considers the perspective of the experts as a vital component of human creativity like in ritual performance dance and a variety of social practices where the views of the experts form the core of the transmission of knowledge in tattoo contexts the artist embodies the craft of an art form by using lines like ingold correctly says an artist leaves an indelible impression on the bodies of others either for a short period or for the rest of ones life	based on the authors longterm fieldwork experience in mexico this article describes the apprenticeship experience of tattoo artists it deals with the learning process of a craft how artists develop skills and techniques and how they share their knowledge with others the text argues that the solidarity that the tattoo community creates passes not only through the relationship between artists and clients but also through the exchange and reciprocity between professionals through the mutual inking of their bodies in what the author calls body biographies the article also depicts the importance of social media in promoting an artists work and how a person becomes an expert or a professional finally it analyzes the growing popularity of tattoos in mexico and the saturated market it creates where artists compete for clients prestige and money
background selfperceived uselessness represents a negative evaluation of ones usefulness or importance to others and a general understanding about the aging process 1 2 3 4 5 selfperceived uselessness or its opposite usefulness is a major component of selfperceived aging for example it is one of five items of the attitude toward own aging subscale of the philadelphia geriatrics center morale scale 3 the feeling of uselessness shapes older adults thoughts and behaviors 1 2 3 4 5 6 7 8 9 10 11 12 which in turn influences psychological and physiological wellbeing 1213 empirical studies in both china and western societies have consistently reported that selfperceived uselessness a negative selfperception of aging is a robust predictor of high mortality risk 23511 13 14 15 16 17 18 and a wide range of poor health indicators such as functional impairment disability 13 10 19 20 chronic conditions 2122 lower rates of recovery from illness 23 poorer cognitive and mental health function 20 24 25 26 and lower rates of good selfrated health and life satisfaction 20 27 28 29 30 studies further indicate that older adults who have higher levels of selfreported uselessness tend to have lower levels of social engagement physical activity selfefficacy and selfesteem as well as higher levels of depression 1 2 3 4 lower levels of selfperceived uselessness with aging are associated with a greater likelihood of survival better functioning and good life satisfaction 3515 31 32 33 34 these studies have improved our understanding about the significant pathways through which selfperceived uselessness is associated with healthy longevity and successful aging 20 researchers have proposed several psychological physiological and behavioral pathways to explain the possible channels through which selfperceived uselessness affects health and mortality at older ages 1820 34 35 36 from a psychological perspective selfperceived uselessness could diminish beliefs about selfcontrol and selfefficacy that could lead to low resilience capacity and depression thus preventing psychological wellbeing 12 selfperceived usefulness by contrast could lead to a positive appraisal of ones capacity to deal with adversity or difficulties in daily life 2 from a physiological perspective selfperceived uselessness could lead to neuroendocrine and neurohumoral changes immune alterations autonomic and cardiovascular dysregulation or central neurotransmitter system dysfunction because of cardiovascular stress 3738 all these could contribute to cardiovascular diseases and subsequent symptoms and disabilities in older age 3639 from a behavioral perspective attitudes toward aging have the potential to influence responses to illness or physical experiences 31 selfperceived uselessness could lead to less optimal healthcare seeking behaviors 40 and less engagement in preventive and healthpromoting activities 41 subsequently influencing ones health or leading to more rapid declines in health 35 on the other hand positive perceptions of usefulness to families or others would help older adults adapt to agerelated changes 42 one inadequacy of the existing literature is that the majority of research is from nonwestern cultures 204344 with a couple of exceptions 1820 quantitative research on selfperceived usefulness or uselessness among older adults in china is almost nonexistent this is primarily due to lack of data on selfperceived uselessness despite several studies on selfperception of aging 12 45 46 47 it is also unclear whether the risk factors associated with selfperceived uselessness found in western societies still hold in nonwestern nations it has been argued that different cultures likely have different social views about aging because of different social norms about the social roles of older adults and their role in family systems which could alter patterns of selfperceived uselessness 48 the existing literature on selfperceptions of aging and usefulness is also limited by small datasets with a narrow range of age groups and covariates with a few exceptions 49 50 51 it is rare to analyze risk factors for the oldestold numerous empirical studies in other areas of aging have shown that the oldestold aged 80 or older including centenarians are likely to have a better capacity to cope with the adversities encountered in daily life 52 53 54 55 56 because those who live to advanced ages have had to adapt to many changes and challenges over time their selfperception of uselessness may differ from that of the youngold aged 6579 who have experienced fewer challenges comparative data from older adults at different levels of longevity may reveal important implications for achieving healthy longevity and successful aging across older ages 2052 furthermore most previous studies included relatively small sample sizes either from local or nonpopulationbased studies 53134 which limits the generalizability of the findings finally almost all existing studies only focus on one or two sets of factors no studies so far have investigated a wide range of theoretically motivated risk factors from a multidimensional perspective a more holistic understanding of risk factors would offer a large range of social demographic health and behavioral factors to identify older adults who are most likely to need intervention programs to address health problems related to selfperceived uselessness given the power of a single selfrated item like selfperceived uselessness to reflect a wide range of markers related to aging and health identifying its risk factors may have important implications for public health surveillance and health services research aimed at achieving successful aging and healthy longevity 20 a growing body of research has investigated factors associated with selfperceived uselessness and aging as reviewed above but there are several ways that new research can add to this literature to extend existing research in healthy longevity this study aims to investigate which socioeconomic resources social environments health statuses fixed attributes and health behaviors are associated with selfperceived uselessness among older adults in mainland china data come from the chinese longitudinal healthy longevity survey the largest ongoing nationallyrepresentative sample and the only nationwide survey in china that collects data on selfperceived uselessness in addition to demographics resources environmental factors and health status the focus on chinese older adults has profound significance in contemporary china around 20 of adults aged 65 years or older more than 25 million older adults feel useless always or often 20 about 5070 of older adults reported feelings of being a family burden getting older and falling behind social progress 20 this large population of older adults with a negative perception of usefulness is likely to experience higher mortality 18 higher risk of disability and cognitive impairment 20 and higher prevalence of depression and loneliness 5657 selfperceived uselessness is becoming a public health challenge for china a systematic investigation of factors that may be closely linked with selfperceived uselessness at older ages would help to identify risk factors and target appropriate interventions for subpopulations at highest risk in the next section we provide a brief review of risk factors for feeling useless at older ages organized with a new conceptual framework that guides the present study factors associated with uselessness and the rehab framework the existing literature on factors associated with selfperceived uselessness is very limited however there have been quite a few studies that have examined factors associated with selfperception of aging 474858 because selfperceived uselessness is a key component of selfperceived aging our review includes both selfperceived uselessness and selfperceived aging 310 overall empirical studies have shown that a number of factors are independently associated with selfperceptions of uselessness or aging 454858 we classified these factors as resources environments health fixed attributes and behaviors resource factors mainly include socioeconomic status environmental factors mostly refer to social environments that include familysocial supports and cultural factors health conditions could include various indicators measuring different dimensions of health fixed attributes mainly include age gender ethnicity predisposition and some biological components and behavioral or lifestyle factors usually consist of smoking drinking involvement in leisure activities and social participation accordingly we propose a conceptual framework named rehab to systemically examine how these sets of factors are associated with selfperceived uselessness we follow a conventional approach in the literature and begin with fixed attributes fixed attributes most studies have revealed that among older adults in various populations increasing age is associated with more negative perceptions of aging and uselessness 4749 59 60 61 however several studies have found that age is not associated with selfperception of aging 5862 even when health conditions are taken into account 63 gender differences are also inconclusive some studies have found that men tend to have a more positive perception about their own aging than women 5864 while others have found opposite results 65 and still others have found no gender differences 49 50 51 52 59 racial differences in selfperception of aging are welldocumented but such differences are largely due to cultural practices and norms 66 individual predispositions such as optimism and selfcontrol may help develop good skills to cope with daily challenges and promote social engagement 67 both optimism and selfcontrol are associated with positive perceptions of aging and usefulness 6468 resources ones selfperception of aging is contingent upon socioeconomic resources available to that person 68 studies have shown that lack of resources could lead to a negative selfperception about aging while adequate or sufficient resources could lead to positive perceptions about aging 67 this is because older adults with more resources have more opportunities to be involved in various social connections and feel useful to others wealthier people are also likely to feel more excited and hopeful about their lives ahead 69 however some studies have found no differences by resources such as education 4770 others have found that higher income and educational attainment are associated with less positive selfperceptions of aging because of relative losses perceived after retirement 475970 access to other resources such as greater medical care tended to be associated with more positive perceptions about aging 61 additional studies have revealed that there is a negative association between neighborhoodlevel socioeconomic development and selfperception of aging in more advanced societies due to increased individual independence and weakened multigenerational family structure that develop with industrialization and modernization 4571 the health environments selfperceived uselessness resources behaviors fixed attributes fig 1 conceptual framework for the multidimensional study of selfperceived uselessness note the underlined letter of each set of factors was used to name the framework rehab bold solid arrows represent possible linkages under study while grey dashed arrows represent possible linkages beyond the scope of this study socioeconomic resources of family members and significant others are also important factors influencing ones own resources physical health and quality of life 7273 environments social environments include familysocial support and cultural conditions the individual assessment of ones usefulness to others at older ages is a social process that reflects the internalization of culturally appropriate attributes 74 this social process could be influenced by family members that either reinforce or challenge previous perceptions thus affecting selfperceived aging or usefulness 75 social support social relations with family and friends are a central source of social support in later adulthood 58 selfperceptions of aging and usefulness may be influenced by social comparisons with network members surrounding older adults 46 the existence of strong social ties and support from others may bolster older individuals selfesteem positively influence their selfperception of aging and health 67 and make people aware of positive agerelated changes 76 older adults who are socially connected generally report more positive feelings about their aging process 77 the contact hypothesis posits that social contact and interactions could lead to a reduction in negative perceptions of aging and uselessness through improved communication and interaction with members in the network 78 studies have shown that fewer social ties and low frequency of interactions are associated with increased perceptions of uselessness 2147176 for older men marriage is an important basis of social support with spouses both sustaining health behaviors and facilitating physical care especially when there is a reduction in network size of family and friends 67 the socioemotional selectivity theory argues that social network sizes may decline in later ages but family ties remain important as older adults shift their focus to more emotionally meaningful intimate relationships 179 however when social support includes personal care the receipt of care services from spouses children family members or friends could increase negative selfperceptions of aging through intensified feelings of dependence on others which implies a loss of control and burden 80 studies on the association between social services and selfperception of aging are almost nonexistent culture cultural meanings are essential for selfperception of aging or usefulness 58 identity theory emphasizes the influence of society on individuals 78 because cultural systems shape ones views about aging 80 81 82 selfperception of aging is a product of societal beliefs 5 that differ across cultures 586482 scholars have argued that eastern cultures emphasize respect to ones elders 5076 for example societies influenced by confucian values and the practice of filial piety promote positive views of aging and usefulness in old age 5053 83 84 85 in contrast western societies hold more negative views about the aging process due to youthoriented value systems 4558828485 consequently selfperceptions of aging are more positive in confucian countries like china compared to western cultures 4584 however the societal attitude toward older adults in china is changing because of industrialization and rapid population aging 48 behaviors there is a consensus that healthy behaviors such as frequent participation in leisure activities exercise and social engagements could lead to positive perceptions of aging whereas low participation and inactivity may erode feelings of usefulness 4748 this is because activities imply regular commitments membership identity and integration 58 social engagements may also stimulate multiple body functions protect against cognitive decline 86 bolster active coping strategies and lower the risk of mortality these activities thus can be important contributors to feelings of meaningfulness purposefulness and usefulness in turn these feelings can reinforce individuals desires to maintain social connections and engagement 1 regular involvements in leisure and physical activities at late ages could buffer against the negative impacts of mishaps agerelated physical changes and life events and provide opportunities to successfully cope with these challenges and adversities in daily life 3458 meaningful social roles for older adults could promote the image of older adults at the societal level 58 on the other hand no participation in leisure and social activities could cause increased feelings of loneliness isolation abandonment distress and negative perception of aging health health can be considered the most important element in the selfassessment of aging and usefulness 5455884 declines in functioning and health status may prohibit older adults from providing meaningful services to others and thus negatively impact perceptions about their level of usefulness 2 better physical health can be associated with more positive feelings about aging 77 one recent study revealed that the presence of various health problems was associated with more negative perceptions of aging or uselessness 67 evidence further shows that physical health may play a more central role in selfperceptions of aging than cognitive function 45 psychological wellbeing could reduce disease disability and mortality through protective behaviors and thus eventually improve positive perceptions of aging 58 methods study sample we pooled four waves of the chinese longitudinal healthy longevity survey in 2005 20082009 20112012 and 2014 to increase the sample size to obtain more reliable results the pooled datasets were constructed longitudinally similar to some recent studies 20 three waves in 1998 2000 and the 2002 were not included in this analysis because many important variables were not available the clhls is conducted in a randomly selected half of the countiescities in 22 provinces where han is the majority ethnicity nine predominately minority provinces were excluded to avoid inaccuracy of agereporting at very old ages among minorities 87 the total population of these 22 provinces accounted for 82 of the total population of china in 2010 the analytical sample for this study consisted of 26624 respondents who contributed 48476 observations from 2005 to 2014 the sampling procedures and assessments of data quality of the clhls can be found elsewhere and thus are not detailed here 2087 measurements selfperceived uselessness the clhls designed a single question to collect data on selfperceived uselessness as you age do you feel more useless the wording is almost identical to the wording of the as you get older you are less useful item in the attitude toward own aging subscale of the philadelphia geriatrics center morale scale 310 there are six response categories for selfperceived uselessness based on frequency always often sometimes seldom almost never or never and unable to answer to obtain more reliable results we reclassified them into three levels of frequency plus one special category alwaysoften sometimes seldomnever and unable to answer the main purpose of keeping unable to answer as a response category was to keep original information intact and to better reflect true associations with levels of selfperception including being unable to assess due to poor health of the participants who selected unable to answer about 90 were unable to answer due to poor health 20 factors associated with selfperceived uselessness based on the rehab framework proposed above we modeled the following six sets of factors to examine whether they are associated with selfperceived uselessness resources environments health conditions fixed attributes and behaviors the fixed attributes included age sex ethnicity and two predisposition variables the variable age was grouped into 6579 8089 9099 and 100 optimism was measured by the question do you look on the bright side of things and selfcontrol was measured by the question do you have control over the things that happen to you both predisposition variables have six response categories always often sometimes seldom never and not able to answer we combined always and often into one category and combined sometimes seldom and never into another category for the respondents who were not able to answer the questions we imputed them into one of the five categories by assuming that their answers would be the same as those who answered the question if they had the same demographics resources familysocial support behaviors and health conditions resources were mainly measured by the respondents socioeconomic status that included residence years of schooling lifetime primary occupation economic independence and family economic conditions education of other family members including years of schooling of spouse coresident childrengrandchildren and father were also considered as ses factors around 1540 of the respondents did not provide information for educational attainment levels of other family members because they could not remember or the question was not applicable so we kept a category of missing to fully reflect the data considering urbanrural residence as an ses factor is a common practice in china due to significant ruralurban differences in economic development 88 social environmental factors were measured by familysocial support and cultural context the former included marital status most frequently contacted person most trusted person most helpful person availability of communitybased care services in the neighborhood and availability of communitybased social activities and entertainment services in the neighborhood proxy factors for culture included coresidence with children and match between expected living arrangements and actual living arrangements other measures of culturally expected support include receiving financial and instrumental support from children and giving financial and instrumental support to children in the literature on aging and social gerontology coresidence has been used either as a proxy of social connectedness and social support 89 or as a cultural tradition 90 91 92 93 94 95 96 many studies argue that the high prevalence of coresidence with adult children among older parents in china and other east asian countries is mainly due to the long history of confucianism 97 in the present study we considered coresidence as a cultural tradition behavioral factors were measured by currently smoking currently consuming alcohol regularly exercising and frequency of leisure activities and social participation levels of leisure activities were constructed from the sum of frequencies of six items including doing housework gardening raising domestic animals or poultry reading booksnewspapers watching tvlistening to radio and any other personal outdoor activities each item was measured on a fivepoint likertscale from never to almost daily the reliability coefficient of these seven items is 066 the tertile was applied to classify the sample into three equalsized groups low level moderate level and high level of leisure activity social participation was measured by two questions do you participate in social activities and do you play cardsmahjong we similarly classified the sample into three groups low level high level and moderate level health conditions included activities of daily living disability instrumental activities of daily living disability cognitive function chronic disease conditions and subjective wellbeing adl disability was measured by selfreported ability to perform six daily activities following the common practice in the field 18 we classified the respondents into two groups needing assistance in any one of the six tasks versus needing no assistance in any of the six tasks iadl was measured by selfreported ability to perform eight activities visiting neighbors shopping cooking washing clothes walking one kilometer lifting 5 kg crouching and standing up three times and taking public transportation in a similar vein we dichotomized the respondents into two groups needing help in performing any of these eight iadl items versus needing no help in performing any of the eight activities cognitive function was measured by a validated chinese version of the minimental state examination which included six domains of cognition with a total score of 30 87 we dichotomized the respondents into impaired and unimpaired based on the cutpoint commonly used in aging research 87 an alternative cutpoint score was also examined and yielded very similar results chronic disease condition was dichotomized into whether the respondent reported any disease at the time of survey from a list of more than twenty conditions versus none fewer than 5 of the respondents had 2 conditions and the prevalence of disease conditions was comparable to those found in other nationwide surveys 87 subjective wellbeing was measured by two variables do you feel lonely and do you feel as happy as you did when you were younger scoring for these variables is identical to optimism and selfcontrol the two predisposition variables analytical strategy because the outcome variable of selfperceived uselessness included four categories multinomial logistic regression models were employed to examine what factors were associated with frequency of selfperceived uselessness compared to the low level the results were reported as a relative risk ratio 98 results for unable to answer were not presented to better focus on the research objectives in order to obtain more robust and reliable results we pooled all four waves of the data together and adjusted for intrapersonal correlation across waves seven different models were analyzed including six models for each individual set of factors and one full model that included all sets of study factors because fixed attributes include demographics that are the most basic characteristics of respondents and because there are substantial differences in health and resources between demographic groups 87 fixed attributes were included in all seven models a variable reflecting survey year was also included in all models to account for possible trends over time with few exceptions that we noted above the proportions of missing values for other variables under study were less than 2 to minimize biases we used multiple imputation techniques to impute these missing values although the mode of each categorical variable produced very similar results sampling weights were not applied in the regression analysis because the clhls weight variable does not reflect the national population distributions with respect to variables other than age sex and urban or rural residence 99 weighted regressions could unnecessarily enlarge standard errors 100 so we chose to present the unweighted regression models that produce unbiased coefficients when including variables related to sample selection 101 we found that multicollinearity among variables was not a problem with all variance inflation factors less than 3 102103 all analyses were performed using stata version 131 98 derived from all observations although the distributions were similar if they were based on the number of respondents in the sample low frequency of selfperceived uselessness was most prevalent followed by moderate frequency and high frequency about 128 were not able to answer the question the weighted distribution of selfperceived uselessness was 192 for high frequency 340 for moderate frequency 438 for low frequency and 30 for unable to answer these weighted estimates suggest that about onefifth of older adults in contemporary china often or always feel useless the weighted percentage for high frequency was 22 for women and 16 for men results prevalence of selfperceived uselessness factors associated with selfperceived uselessness tables 2 and 3 present relative risk ratios from multinomial logistic regression models of rehab factors associated with high frequency and moderate frequency of selfperceived uselessness relative to low frequency we summarize several major findings below fixed attributes were strongly and consistently associated with selfperceived uselessness model i in table 2 shows that all fixed attribute factors are associated with risk of high frequency of selfperceived uselessness compared to younger ages 6579 octogenarians nonagenarians and centenarians experienced increased risk of high frequency of selfperceived uselessness relative to low frequency by 69 76 and 76 respectively these risk ratios were slightly attenuated in models ii through iv when resources and environmental factors were taken into account however when behavioral factors were considered these risk ratios were substantially reduced and nonsignificant for the centenarian group interestingly when health conditions were considered in the analysis octogenarians and centenarians tended to have 8 and 22 lower rrr for high frequency of selfperceived uselessness respectively these results were even more pronounced in the full model with reduced risks of 20 for nonagenarians and 35 for centenarians compared to youngold adults aged 6579 years old the reduced risk at oldest ages independent of health statuses and health behaviors was similar but weaker for moderate frequency versus low frequency male gender was associated with 1830 lower rrr for high frequency of selfperceived uselessness relative to low frequency compared to women when each set of factors was added individually however no gender difference was found when all sets of factors were simultaneously included in the model results for moderate frequency versus low frequency in table 3 were similar despite reduced rrrs participants of han ethnicity tended to have 3854 greater rrr for high frequency of selfperceived uselessness relative to low frequency compared to minority ethnicity no ethnic difference was found for moderate frequency versus low frequency high level of optimism and selfcontrol were associated with 4866 and 1129 lower rrr for high frequency relative to low frequency of selfperceived uselessness respectively although their rrrs were reduced when comparing moderate frequency with low frequency people with more resources tend to report low frequency of selfperceived uselessness model ii in table 2 shows that more socioeconomic resources were associated with lower rrr for high frequency of selfperceived uselessness relative to low frequency specifically compared to the zero years of schooling 16 years and 7 years of schooling were associated with 16 and 31 lower rrr for high frequency of selfperceived uselessness relative to low frequency respectively such rrrs were only mildly attenuated yet still significant in the full model higher educational levels of spouse and father were also independently associated with reduced rrr for reporting high frequency of selfperceived uselessness relative to low frequency but such associations were weaker compared to the respondents own educational level when predicting risk of moderate frequency selfperceived uselessness versus low frequency these rrrs were slightly attenuated living in an urban area whitecollar occupation economic independence and good family economic condition were associated with 1237 lower rrr for high frequency of selfperceived uselessness relative to low frequency compared to counterparts with lower levels of resources the reduced risk ratios for economic independence and good family economic status were moderately attenuated yet still significant in the full model while the urban residence and white collar occupation effects remained stable this is also the case in models ii and vii of table 3 when comparing moderate with low frequency of selfperceived uselessness risk of selfperceived uselessness was lower in supportive and culturally traditional social environments results in model iii in table 2 reveal that as a component of social environment familysocial support factors were significantly associated with selfperceived uselessness specifically married older adults had a decreased rrr for high frequency of selfperceived uselessness relative to low frequency by 18 compared to unmarried counterparts compared to having a family member as the most frequently contacted person having a friendrelative and having no one to contact were associated with 19 and 80 higher rrr for high frequency of selfperceived uselessness relative to low frequency respectively results for the most trusted person were marginally significant compared to having a family member as the most helpful person having a friendrelative as the most helpful person or having no one to ask for help was associated with 26 or 22 higher rrr for reporting high frequency of selfperceived uselessness relative to low frequency respectively having available communitybased services for social activities and entertainment but not for care was associated with 24 lower rrr for reporting high frequency of uselessness relative to low frequency however most of these rrrs were not significant when all other sets of factors were simultaneously controlled for in the model the findings in model iii in table 3 are similar to those in table 2 except that some of these variables were still significant in table 3 results in model iv represent cultural environmental factors that were associated with selfperceived uselessness coresidence with children was associated with 13 lower risk ratio for reporting high frequency of selfperceived uselessness relative to low frequency compared to noncoresidence with children concordant coresidence was associated with 11 lower rrr for high frequency of selfperceived uselessness relative to low frequency compared to those who did not fulfill their expectation of coresidence or were institutionalized giving financial and instrumental support to children was associated with 38 lower rrr for high frequency of selfperceived uselessness relative to low frequency compared to those who did not provide for children interestingly receiving financial and instrumental support from children was associated with greater rrr for high frequency of selfperceived uselessness relative to low frequency in model iv but this upward financial transfer was not significant in the full model the rrrs of moderate frequency relative to low frequency in table 3 were similar to those for high frequency relative to low frequency good behaviors were associated with reduced risk of selfperceived uselessness good health behaviors were associated with lower risk of high or moderate frequency of selfperceived uselessness independent of all other study factors specifically current consumption of alcohol regular exercise participation in leisure activities and social participation were associated with 1854 lower risk ratio for reporting high frequency of selfperceived uselessness relative to low frequency while smoking was associated with 10 higher risk ratio for high frequency versus low frequency with one exception for current smoking these rrrs were still significant in the full model despite attenuated associations slightly weaker associations were found for these health behaviors in the case of moderate frequency versus low frequency health conditions were most strongly related to selfperceived uselessness health conditions were all significantly associated with selfperceived uselessness even when controlling for all other factors in the rehab model adl and iadl disability cognitive impairment and having 1 chronic disease conditions were associated with increased rrr for high frequency of selfperceived uselessness relative to low frequency by 37120 and increased rrr of moderate frequency relative to low frequency by 1257 these rrrs were only attenuated to 2296 and to 2152 in the full model loneliness was associated with 7 times higher rrr for high frequency of selfperceived uselessness relative to low frequency and 2 times higher risk ratio for having moderate frequency relative to low frequency while high joyfulness reduced rrrs in both cases by half these effects were only mildly weakened in the full model in both cases no clear trend over time in selfperceived uselessness the year of survey was also significant in some cases yet without a clear trend over time overall the respondents in the 2014 wave had 2171 greater rrr for high frequency of selfperceived uselessness relative to low frequency compared to the 2005 wave no difference was found for the other waves compared to the 2005 wave however in the case of moderate frequency versus low frequency respondents in the 2014 wave had a 932 higher rrr than those in the 2005 wave and the 2008 wave tended to be associated with 518 lower rrr for highmoderate frequency of selfperceived uselessness compared to the 2005 wave the sample strategy was slightly different between waves so verification of such trends deserves a closer analysis discussion selfperceived uselessness ie individual assessment or perception about ones usefulness to others at older ages is a social process 1 2 3 4 5 58 that can be influenced by several types of factors based on a unique very large multiwave nationally representative dataset of older adults in china the present study developed the multidimensional rehab framework to examine factors that could be associated with selfperceived uselessness to our knowledge the present study is among the first to address calls to systematically examine predictors of selfperceived uselessness 182076 overall we found that a wide range of variables within the factors of socioeconomic resources environments health fixed attributes and behaviors were associated with selfperceived uselessness specifically high and moderate frequencies of selfperceived uselessness were more likely among individuals who were older women han ethnicity less optimistic less selfcontrolled in poor health and those who had fewer social supports fewer resources and unhealthy behaviors cultural factors such as coresidence with children and giving children instrumental support were associated with lower frequency of selfperceived uselessness one unique finding is the relationship between fixed attribute age and selfperceived uselessness we found that older age was associated with greater relative risk ratio for high or moderate frequency of selfperceived uselessness relative to low frequency which is in line with many previous studies 4749 59 60 61 the finding is justifiable because at older ages health tends to decline and activities tend to decrease leading to diminished opportunities to help others 48 because the moreover when health condition and other factors were taken into consideration the rrrs for older ages were reversed indicating that with wellbeing held constant the older the respondents were the less frequently they felt useless empirical evidence indicates that those who survive to oldestold ages are a very selected group compared to those who died or are in a poorer state of health in their cohort 49 the longlived persons have likely developed excellent coping skills to overcome health decline and daily challenges 52 as a result they may perceive any level of usefulness positively this is especially true in a confucian country where longlived persons are generally respected on the other hand when youngold adults experience new negative events like illness these problems can negatively impact their perceptions of usefulness in the absence of coping skills that develop over time 49 our findings for the fixed attribute of age are in line with one recent study that found no difference in selfperception of aging among the oldestold aged 80 or older as compared to older adults aged 6069 when health was controlled 51 the second important finding is the importance of socioeconomic resources not only the respondents own education but also the education of significant others in relation to selfperceived uselessness we found that compared to those with no schooling higher levels of education were associated with lower risk ratio for high and moderate frequency of selfperceived uselessness relative to low frequency this finding is in line with many other previous studies 4558 but contradicts one recent study of older adults in canada and japan that showed either a negative association or no association between education of the respondents and their selfperception of aging 70 this may be due to the lower overall level of educational attainment of the current cohorts of chinese older adults about twothirds of the respondents in the current study were illiterate whereas the proportion of respondents with 16 years of schooling was about 10 in the japanese sample and 38 in the canadian sample we additionally found that educational attainments of significant others were associated with respondents selfperceived uselessness especially when other sets of factors were not present the significant association of spouses education suggests that their knowledge and related attitudes and perceptions could play a role in the formation of respondents selfperception of uselessness at later ages 69 the significant role of fathers education implies that parental education could also have a direct or indirect influence on ones internalized perception of aging or usefulness from early life though old age however the roles of significant others diminished when all measured covariates were included particularly due to intergenerational similarity in ses within families in sum every family members education could matter for respondents selfperception of uselessness but the more proximate measure of their own education mattered most the third unique finding is the association between selfperceived uselessness and cultural environmental factors of coresidence and intergenerational transfer that are uniquely important in china coresidence with adult children and the concordance between expected and actual coresidence are associated with lower risk ratio for high or moderate frequency of selfperceived uselessness relative to low frequency because china is a confucian society having a large family and coresidence with children are considered as a tradition 93 most members of older generations consider family life good intergenerational relations and coresidence with children to be the most important parts of their daily lives 42 from the perspective of older adults coresidence with children is important to ensure communication contact and shared views and understanding with children thus improving family solidarity coresidence with children also reflects the cultural tradition which is important for older generations that is why those who expect to coreside with children and fulfill that expectation have the greatest reduction in rrrs for high or moderate frequency of selfperceived uselessness compared to those whose coresidence expectation was not met furthermore older parents can provide some assistance to coresiding adult children in terms of doing housework and taking care of grandchildren which could enhance older adults feelings of usefulness to the family 93 all of these processes would eventually benefit all domains of health and improve positive perceptions about aging among older adults a separate but related cultural norm receiving financial and instrumental support from children was associated with greater rrr for high frequency of selfperceived uselessness relative to low frequency this seemingly counterintuitive finding is interpretable needing financial or instrumental support from children may indicate difficulties in older adults financial condition poor health or other needs as such older adults may interpret receipt of transfers as a family burden 57104 and reinforce negative perceptions about their usefulness to the family taken together with the coresidence patterns we argue that emotional support of family members may be more important in influencing older adults perceptions about their usefulness than financial or instrumental support by contrast providing financial and instrumental support to children was associated with less frequent selfperceived uselessness this is likely because actively and capably helping children could increase older adults selfesteem and their perception of their value to family members 93105 additionally providing support to children represents frequent contact with family members that can help to avoid social isolation loneliness and unhealthy behaviors 58 in sum our findings related to cultural components imply that culturally normative family support is important to the formation of selfperceived usefulness in old age which further supports the importance of family members as central forms of social support 58 several other fixed attributes were important for example we found that womens greater rrrs for high frequency of selfperceived uselessness disappeared when health and all other factors were modeled this is consistent with several previous studies 4751 and is likely influenced by their traditional gender roles and their poor health compared to men 47 compared to respondents of minority ethnicity han older adults were more likely to report high frequency of selfperceived uselessness relative to low frequency but there was no ethnic difference between moderate and low frequency the results for optimism and selfcontrol are expected and consistent with the literature because optimism indicates that one is openminded hopeful and secure about the future which could help one to effectively cope with adversities and conflicts in daily life 58106 and because selfcontrol enables one to be actively engaged in healthpromoting behaviors which in turn develop a positive perception of aging 58 resources other than education were also important including urban residence white collar occupation economic independence and good economic condition this is possibly because the noneducation resources increase quality of life if people feel good about their life and living conditions at older ages they may be less likely to see themselves as useless in old age 69 older adults with more resources can also afford services and products and modifications to allow them to continue to contribute despite setbacks like poor health 58 and enjoy better services that could help them overcome difficulties or adversities faced in daily life these results are in line with previous findings that individuals who were well educated and had lower levels of economic hardship were significantly more likely to report greater levels of positive beliefs about aging 46 overall ones selfperception of aging is closely linked with resources available to that person 68 individuals with more resources are more likely to have positive attitudes views and perceptions about aging because they have more opportunities and expectations 69 associations between good health behaviors and lower likelihood of selfperceived uselessness independent of socioeconomic resources environments health conditions and fixed attributes were expected and consistent with previous studies 3458 regular involvements in or maintenance of health behaviors such as leisure activities exercise and social engagements could simulate body functions buffer against negative emotional or psychological distress develop daily coping skills and increase feelings of meaningfulness 47485874 our findings provide additional evidence emphasizing the potential role of healthy behaviors in preventing selfperceived uselessness previous research also suggests that health outcomes may be the factor that most strongly predicts selfperceptions of aging 45 among the most common health events associated with the aging process are those pertaining to functional health and disability 45 physical health conditions such as chronic disease functional disability sensory performance and number of sick days may form an underlying basis for selfevaluation of aging and health status 67 our findings confirm that health conditions might be possibly the most pronounced predictors of selfperceived uselessness and that loneliness and disability might be the most significant factors compared to other health outcomes given the subjective nature of selfperceived uselessness however it is important to acknowledge that selfperceptions are not only influenced by objective health indicators but also by psychological and social factors 67 our findings have important policy implications given chinas large size and the rapid growth of the elderly population 107 the fact that the onefifth of this population reports a high frequency of selfperceived uselessness is a great challenge for public health identification of factors associated with selfperceived uselessness provides a great opportunity to target interventions and influence the health and wellbeing of the elderly population our findings related to cultural and social support elements imply that intervention should be oriented to supporting awareness of the value of older adults the nature of the aging process and the importance of family support and healthy behaviors the intervention programs should also aim to increase dialogues between generations and different groups of people and eventually promote frequent intergenerational contacts and geographical proximity or coresidence findings related to behaviors suggest that it is crucial to develop volunteer programs that facilitate communitybased leisure and social engagements to promote and improve healthy behaviors associated with low frequency of selfperceived uselessness findings on resources and health imply that policies to support those with limited resources and poor health are also key to improve older adults selfperceived usefulness the united nations sustainable development goals set for years of 20162030 have provided us a global context to address aging issues the theme of the international day of older persons for the year of 2016 is taking a stand against ageism 108 one purpose is to draw global attention to challenging negative perceptions about aging we hope that programs and events like these which are consistent with the findings of this study will influence the chinese government to better address selfperception of aging this study has the following limitations first selfperceived uselessness was measured by a single item multiitem measures of uselessness would provide a more complete reflection of the concept of uselessness 11 but may be difficult to implement in largescale epidemiological studies we encourage additional studies to investigate more sophisticated positivenegative and or domainspecific constructs of selfperceived uselessnessand selfperceived aging more generallyto better understand mechanisms for successful aging 1109 second we did not examine whether there is an association between changes in selfperceived uselessness and subsequent successful aging although previous studies showed that selfperceived uselessness is relatively stable 211 changes are still frequent 1 it would be interesting to investigate predictors of change over a longitudinal study period third the relationship between selfperceived uselessness and some behaviors and health are likely bidirectional like most existing studies in the field 76 we did not disentangle such bidirectional associations because it was beyond the scope of the study more sophisticated methods such as simultaneous equation modeling or structural equation modeling may shed light on this if more waves of data are available fourth in the literature coresidence has been used either as a proxy of social support or as a cultural tradition 89 90 91 92 93 94 95 that is determined by many other factors such as needs and resources 9192 in the present study we considered it as a cultural tradition which may not completely capture its broad meaning it is still a challenge to classify coresidence into a correct category and capture its meaning in the context of cultural norms fifth resource factors at the aggregated neighborhood level such as socioeconomic development and neighborhood attributes were not considered in the analysis due to lack of data because there is a documented association between these factors and selfperception of aging 45 inclusion of these interesting factors would lead to a more properly specified model much work remains to fully utilize the important concept of usefulness to intervene and improve the lives and health outcomes of older people as they age conclusions based on a unique large nationally representative dataset of older adults in contemporary china from 2005 to 2014 this study found that socioeconomic resources environments health fixed attributes and behaviors were associated with selfperceived uselessness at older ages specifically individuals who were younger men nonhan optimistic selfcontrolled healthy and with social support healthy behaviors and better resources were significantly less likely to report high frequency of selfperceived uselessness cultural factors such as coresidence with children and giving children instrumental support were also associated with lower risk of selfperceived uselessness our findings could inform the development of targeted public health programs that aim to promote positive selfperceptions about aging in china and possibly in other countries abbreviations adl activities of daily living clhls chinese longitudinal healthy longevity survey iadl instrumental activities of daily living mmse minimental state examination funding the authors declare that they have no financial support for this study authors contributions dg designed drafted and revised the text dg also supervised the data analysis yz drafted and revised the text jms revised the paper and interpreted the results lq prepared the data and performed the analyses all authors read and approved the final version of the manuscript competing interests dg is a section editor of the journal jms is an associate editor of the journal disclaimer views expressed in this paper are solely those of the authors and do not necessarily reflect the views of nanjing normal university university of the sciences or the united nations	background selfperceived uselessness is associated with poor health and high mortality among older adults in china however it is unclear which demographic psychosocial behavioral and health factors are associated with selfperceived uselessness methods data came from four waves 2005 2008 2011 and 2014 of the largest nationwide longitudinal survey of the population aged 65 and older in china 26624 individuals contributed 48476 observations this study aimed to systematically investigate factors associated with selfperceived uselessness based on the proposed rehab framework that includes resources r environments e health h fixed attributes a and behaviors b selfperceived uselessness was measured by a single item with age do you feel more useless and coded by frequency high always and often moderate sometimes and low seldom and never multinomial logistic regression models with low frequency as the reference category were employed to identify rehab risk factors associated with selfperceived uselessness results most factors in the rehab framework were associated with selfperceived uselessness although some social environmental factors in the full model were not significant specifically more socioeconomic resources were associated with reduced relative risk ratio rrr of high or moderate frequency of selfperceived uselessness relative to low frequency more environmental familysocial support was associated with lower rrr of high frequency of selfperceived uselessness cultural factors such as coresidence with children and intergenerational transfer were associated with reduced rrr of high frequency of selfperceived uselessness indicators of poor health status such as disability and loneliness were associated with greater rrr of high or moderate frequency of selfperceived uselessness fixed attributes of older age and han ethnicity were associated with increased rrr of high frequency of selfperceived uselessness whereas optimism and selfcontrol were associated with reduced rrr behaviors including regular consumption of alcohol regular exercise social participation and leisure activities were associated with reduced rrr of high frequency of selfperceived uselessness conclusions selfperceived uselessness was associated with a wide range of factors in the rehab framework the findings could have important implications for china to develop and target community health programs to improve selfperceived usefulness among older adults
introduction research has demonstrated that a risk and protective factor model is essential in conceptualizing youth behavior the presence of risk factors have been linked to negative outcomes for youth including use of alcohol and drugs delinquency homelessness suicide and mental health disorders a recent synthesis of studies by the institute of medicine also explored the developmental impact of risk factors on youth including their influence on mental emotional and behavioral health outcomes for example the presence of intensely stressful experiences in early childhood is linked to clinical anxiety later in life just as supporting early learning is linked to healthier developmental outcomes of particular interest in recent risk factor research are studies of latino populations latinos are expected to reach one quarter of the us population by the year 2050 and are at a disproportionate risk for negative behavioral health outcomes such as substance use and alcoholism sexually transmitted illnesses such as hiv and mental health concerns middleschoolaged latino youth are of particular concern with large increases in the youth population expected in the next century furthermore researchers are increasingly acknowledging that there is a dearth of knowledge on how culturally related factors such as discrimination and language difficulties impact healthy development in latino families and that increased attention is needed it is known however that latinos are experiencing a myriad of culturally based risk factors in a series of studies examining psychosocial stress and acculturation among adults and youth cervantes and colleagues found important culturally based stressors within the major life domains of latinos for example cordova and cervantes identified discrimination and racism to be key stressors that latino adolescents are exposed to on a daily basis additionally cervantes and colleagues identified eight key life domains of stress specifically related to latino youth in a sample of more than 1600 youth including stress related to family educational immigration marginalization and discrimination acculturation stress has been associated with increased risk for substance abuse alcohol consumption increased rates of cigarette smoking and family stress this increase in stress may lead to increased difficulty in the family relationships decreases in parental oversight and risky behaviors among adolescents given these unique concerns culturally informed behavioral health interventions for latinos are more effective some progress has been made in the development of evidencebased prevention programs that target racial and ethnic minority youth in a recent investigation by szapocznik and colleagues however only four randomized drug abuse preventive intervention models existed that targeted latino youth ages 1217 and included samples where 70 of participants were represented by latino youth further the substance abuse and mental health services administration recently published a report indicating that more emphasis is needed on the development of integrated behavioral health programs that address mental health substance abuse hiv and other factors associated with poor development as risk factor are linked to multiple negative outcomes prevention programs that can effectively address multiple risk factors are likely to have enhanced outcomes and potentially be more cost effective familia adelante was initially developed at the national institute of mental health funded spanish speaking mental health research center at the university of california los angeles using the stressillness paradigm as a framework for understanding risk factors the developer utilized qualitative study findings on stress and coping mechanisms as well as quantitative survey studies of hispanic adult and adolescent stress indepth qualitative interviews combined with psychometric scales including the hispanic stress inventory and the conners parent rating scale were used to evaluate program effectiveness the first version of the curriculum showed reductions in family stress and youth behavior problems enhancing academic and psychosocial coping and decreasing substance use patterns in latino youth following the development of the original curriculum for youth and parents familia adelante was again tested through the samhsafunded blythe street prevention project in 1998 the drug prevention project included youth and their parents and again demonstrated positive findings this study found significant improvements in knowledge and skills by both youth and parents for example youth reported an increase in conflict resolution skills parents participating in the fa curriculum reported an increase in gang awareness cultural pride drug knowledge and conflict resolution there was also a trend in improved emotional health across both youth and parents the current study was conducted from 2003 to 2006 and tested through six cohorts of families in a schoolbased setting prior to implementation some exercises were added to address hiv knowledge attitudes and beliefs in response to requirements set forth by the funding agency purpose of study the purpose of the current study was to test the multirisk reduction familia adelante curriculum for its effectiveness with highrisk latino youth specifically the curriculum was designed to enhance family and peer communication preventreduce substance abuse increase hiv knowledge and perceptions of harm about highrisk behavior and improve school bonding and behavior it also seeks to enhance psychosocial coping and life skills in both youth and their parents and decrease substance use and emotional problems by focusing on ways to cope with acculturative stress research suggests benefits to including families in treatment of highrisk youth currently only two evidencebased approaches exist that target multiple risk factors include families and have a high representation of latinos in their sample familias unidas and brief strategic family therapy in an effort to expand this area familia adelante was developed as a family intervention that is administered to youth and parents concurrently but separately in a group format methods procedure familia adelante consists of twelve 90minute group sessions for youth and their parents youth participants were referred to the familia adelante program as a result of their experiencing behavioral or emotional problems upon receiving a referral project staff contacted parents and an appointment was given for the first session all group sessions were held at a convenient school location and conducted during afterschool hours youth and parent group sessions were held separately and simultaneously bilingualbicultural staff were trained by the program developer each group was led by a masterslevel prevention staff and was assisted by a bachelorslevel staff member both parent and youth groups typically consisted of eight to ten individual participants the curriculum is guided by a facilitator manual which outlines each of the session topics each session in this manual includes goals leaning objectives activities and a list of materials used the activities are designed for atrisk youth and their families and cover a range of topics shown in table 1 at session 1 the participants completed pretest instruments described in further detail below the second session covered general knowledge building whereas session 3 covered feelings sessions 4 and 5 included content for both parents and families on types of stress including stress from discrimination and racism in the sixth week youth discussed stress at school as well as strategies for improving grades and communication with their teachers while parents discussed stress from work and providing for their family during week seven youth again discussed the influence of peers on decision making and strategies for making safe decisions while their parents discussed parenting including differences between parenting in the us and their home country weeks 8 and 9 provided strategies for increasing family communication and the final weeks provided gang prevention strategies and general substance use education at the final week posttest instruments were distributed and famliies participated in a graduation ceremony families were also recontacted at six months to complete followup measurement and determine longterm effectiveness of the program instruments all measures were made available in both english and spanish parents completed the measures in approximately 30 minutes this was more quickly than youth who were read the questions by the facilitator and averaged approximately 45 minutes initially demographic questionnaires were collected to gather information from youth and parents on age gender and socioeconomics these forms also included information on the participants nativity language preference and educational level other parent and youth surveys were collected during the first session at the final session and at sixmonth post intervention these instruments consisted of a number of scales from previously established and normed instruments parents and youth completed the samhsa government performance and results act participant outcome measures for discretionary programs this survey tool was used as part of samhsas national crosssite evaluation and is comprised of questions that include alcohol tobacco and other drug use and knowledge atod beliefs and perceived risk of harm from atod use future intentions to use drugs and hiv knowledge and risk perception youth also completed other sections of the gpra including school behavior school bondingattachment family bonding communication with peers communication with parents comfort level talking with parents hiv anxiety peer condom use attitudes toward condom use social norms living conditions and drugfree commitment as well as the hispanic childrens stress inventory parents also completed the conners childrens behavioral parent rating scale a subjective assessment of their youths behavior results all participants in the program completed baseline measures a total of 153 youth and 149 adult instruments were administered to six participant family cohorts a pretest occurred on the first session date a posttest was conducted at the final session and an additional measure was administered six months after baseline the overall retention rate for the youth participants at posttest was high and decreased from posttest to sixmonth followup in addition the program was able to retain a high percentage of the parents at posttest but the retention rate decreased at the sixmonth followup demographic characteristics the demographics of the participant sample can be seen in tables 2 and3 notably among parent participants the majority were female mothers as expected parents overwhelmingly identified as hispanic and most indicated their primary language was spanish almost twothirds reported their household income to be less than 25000 per year indicating a high rate of poverty and nearpoverty in the participant sample further a significant portion of parents had a high school diploma or less education unlike their parents the majority of youth participants were male slightly more than half of youth in the sample reported spanish as the primary language spoken at home the majority of youth were us born while their parent counterparts were mostly immigrants reliability analyses reliability analyses were conducted for each of the youth and parent assessment scales using cronbachs alpha as can be seen in tables 4 and5 the majority of the scales demonstrated high reliability scores a number of scales are marginally reliable for parents the highest reliabilities were found in hiv risk and the subscales from the conners scale including conduct problems while the lowest were the psychosomatic scale and anxiety for youth the highest reliability was found in comfort level talking with parents and social norms the lowest reliabilities were found in attitudes towards condom use program effects and outcomes our next step was to investigate the changes in attitudes and behaviors reported by youth and parent participants as we were particularly interested in whether the fa curriculum addressed a wide range of risk factors that are empirically linked to negative emotional and behavioral problems family communications problems school bonding and atod and unprotected sexual behaviors this was the focus of our analysis using spss 160 a repeated measures glm analysis was conducted for youth and adults youth findings analysis of the riskrelated outcomes for youth demonstrated several areas of program effects as seen in table 6 first youth communication skills appear to have been positively impacted by familia adelante specifically youth demonstrated improved communication skills with their peers and comfort talking with their parents additionally youth participants reported improved overall improved family attachment a second general area of positive change was noted with regard to youth knowledge attitudes and behaviors with regard to sexual risk specifically hivrelated anxiety and social norms regarding sexual behavior decreased across the measurement points as well as a significant increase in peer condom use at followup sexual intercourse showed a curvilinear pattern increasing at posttest but decreasing dramatically at followup the changes in the youth schoolrelated measures were not notable stress levels as measured by the latino stress inventory fell sharply at posttest and rose again at the followup table 6 also illustrates findings on perceptions and behavior change in alcohol and drug use for youth across the three measurement points use of marijuana dropped dramatically with posttest and followup reporting zero use in addition youth participants reported zero use of all other drugs at posttest including cocaine heroin methadone pcp lsd methamphetamines barbiturates and inhalants alcohol use increased slightly at posttest but dropped dramatically at followup alcohol use to intoxication dropped to zero at posttest and remained at this level in followup past 30 day sexual intercourse increased dramatically at posttest and decreased to pretest levels at followup significant and positive changes were observed in youth by their parents as well as measured by the conners parent rating scale and shown in table 7 reductions in conduct disorders learning disorders impulsivity anxiety and hyperactivity were all significant psychosomatic symptoms also decreased although not significantly parent findings table 8 shows findings from the parental measures results from the parent measures are encouraging though should be interpreted cautiously as some instruments did not meet criteria for acceptable reliability results indicate that parents knowledge of drugs and hiv rose substantially across the three measurement points the highest effect sizes for the intervention were found in parents increase in drug and hiv knowledge strong trends were also found for atod harm although not significant and to a lesser degree in hiv risk behavior discussion familia adelante is a familyoriented prevention intervention that has been developed to address the unique needs and risk factors found among latino families few prevention or early intervention programs have been available for latino families further programs that specifically address risk factors known to predispose youth to negative behavioral health outcomes often lack attention to culture and acculturation stress which has a direct impact on latino youth mental health and substance use outcomes the main objective of the intervention was to enhance family and peer communication increase substance abuse and hiv knowledge and perception of harm and improve school bonding and behavior it also sought to enhance psychosocial coping and life skills in both youth and their parents and decrease substance use and emotional problems by focusing on stress related to acculturation the evidence provided by both significance and effect size is encouraging for the use of the intervention for both youth and parents effect sizes of greater than 30 were found across a number of riskrelated factors and this level of program effect is acceptable within prevention science in this study many of the program effects were durable and lasting shown through the followup testing positive changes in communication and cognition can be expected to have longlasting effects on the dynamics of the families that participated the parents consistently reported improvements in their childrens behavior across multiple domains over the course of the intervention and months afterwards the children also presented significant improvements in communication with their parents and increases in family attachment an important factor in preventing risk in the illegal drug behavior outcomes significant positive changes were also found even though this was a young atrisk population that had low drug use at baseline the success of the study is underscored by the additional considerations of age and service exposure the research literature suggests that there are natural maturational upward trends regarding risk factors and substance use rates in this age group in young adolescents in these atrisk social conditions that marijuana and other illegal drug use decreased significantly in the youth sample and stayed this way at followup further supports the effectiveness of the curriculum while the overall changes in the young adolescents are not as dramatic as with their parents positive changes were documented in sensitive areas involving condom use and sexual norms in the case of hiv knowledge however the change in youth was greater than their parents in addition culturally based stress reduction as measured by the latino childrens stress inventory was minimal although with a positive trend since the time of this study advances have been made in measurement namely the development of the latino stress inventoryadolescent version that may prove to be a more sensitive measure of culturally based stressors in subsequent trials of the curriculum a limitation lies in the attrition of the sample in the period between the posttest and followup especially for the parents while the reasons for this drop in retention have not been systematically investigated the impression gained by the research team is that it was due in part to the high residential mobility in families future studies with latino immigrant families may need to budget in sufficient resources to include methods for locating mobile families if the validity of the results are to be strengthened and incentivizing participants may increase the response rate as well adding additional measures for parents would have also been helpful in gaining greater understanding of program benefits although knowledge measures showed promising results additionally the lack of a control group makes it difficult to say with certainty that these changes were not based on history maturation or testing however the use of multiple measurements adds additional support for the reliability of findings several of the scales fell below acceptable reliability making interpretation of these findings cautionary this is possibly due to lack of cultural appropriateness with this population a common concern with the use of existing measures addressing this concern through use of different instruments and a thorough pretest would be helpful in future research with familia adelante despite these limitations a majority of statistically significant findings were found among scales with high reliabilities this suggests that the results may be even stronger in a larger sample future research with familia adelante should strengthen the measurement instruments to increase validity and test the product with a larger randomized study of latinos and their parents lastly the rate of hiv infection in latinos is an increasing concern familia adelante seeks to impact multiple behaviors including hiv risk but found insignificant results for key prevention techniques such as condom use an important area for curriculum adaptation may be the enhancement of hiv prevention messaging and the use of condoms by youth	a comprehensive approach for providing behavioral health services to youth is becoming increasingly emphasized iom 2009 latino youth are at increased risk for substance abuse mental health concerns unsafe sexual practices and hiv prado et al 2006 and these outcomes have been empirically connected to individual family and communitybased stress iom 2009 despite this knowledge there is a lack of evidencebased approaches that target these negative outcomes by reducing stress in latino families in a culturally relevant manner cervantes kappos duenas arellano 2003 the current study examined the use of researchbased strategies for reducing multiple risk behaviors in a predominantly mexican american sample of families through a modular approach participants engaged in a psychoeducational curriculum to enhance communication and psychosocial coping increase substance abuse and hiv knowledge and perception of harm and improve school behavior over 12 sessions the curriculum aimed to achieve these outcomes through an overall decrease in family and communitybased stress by focusing on acculturative stress findings indicate that communication and perception of substance use harm were significantly enhanced while social norms regarding sexual behavior hiv anxiety and past use of marijuana and other illegal drugs were significantly reduced while many of measures were reliable α 80 further changes are necessary to improve the accuracy of future studies despite these limitations familia adelante improves many areas of participants family life and points toward the feasibility of multirisk reduction behavioral health prevention approaches
m edical doctors use medical language which does not lead to a meaningful discussion with other occupations during meetings so when i say they dominate it is more about the type of language they use such are the words of one member of the global funds country coordinating mechanism in nigeria as reported by lassa and colleagues in their case study of power dynamics in health policymaking 1 a key finding of their study was the dominance of medical professionals specifically allopathic physicians in decisionmaking spaces in nigeria who leveraged both structural power and productive power to direct efforts and determine solutions for strengthening hivaids care in health policy discussions medical dominance occurs when allopathic medicine is positioned as the sole or primary framework for understanding and responding to health problems with medical doctors correspondingly elevated as the most knowledgeable experts and decisionmakers medicalized approaches to public health are reductionist seek causes in biology rather than social or environmental factors are individualistic rather than collectively minded and focus narrowly on clinical andor technological interventions 2 the medicalization of health issues from a macro perspective and the related question of medical dominance has been examined mainly in western countries 3 however in recent years medicalized approaches to health have been increasingly understood as part of the colonial inheritance in many lowand middleincome countries 4 for example in nigeria where lassa et al report on medical dominance in hivaids policymaking the medical system continues to emphasize hospitalbased curative care benefiting the urban elite rather than building a strong and equitable primary healthcare system that draws on multiple sectors to promote health and prevent illness amongst the whole population 5 as such lassa and colleagues make a useful addition to a long tradition of public health and anthropological scholarship calling out biomedical power as detrimental to operationalizing health as a holistic sociallyembedded concept but more work is needed to draw attention to how medical dominance prevails in the high spheres of global health and how it perverts incentives results in blinkered advice and can harm rather than improve equity and effectiveness at every level global health institutions including the world health organization major multilateral bodies and global health initiatives and bilateral and private donor agencies have rarely questioned the dominance of medical professionals within their ranks and medical discourse in their strategies nor the economic thinking and costeffectiveness calculations that are used to further buttress this dominance a medicalized framing is evident across a plethora of global health issues and the goaloriented structures of global health institutions and competition between them incentivize the application of biomedical solutions 2 medical dominance exerted via structural and productive power means that global health institutions rely on narrow conceptions of knowledge to guide their responses to health issues often excluding or only superficially including lived experience social policy expertise and knowledge derived from nonpositivist paradigms such as indigenous methodologies participatory action research and even much of mainstream social science 6 these types of knowledge remain largely absent from the deliberative and decisionmaking processes of most major global health institutions as does the practical wisdom of how to implement interventions and policies 7 dismissal of nonmedical knowledge that could inform health strategies was evident in lassa and colleagues study where respondents said members of communitybased organizations and patient groups did not have the sophistication of mbbs medical doctors as a guide to decisionmaking the obsession with quantifying the impact of targeted diseasespecific medical solutionssometimes called the gates approach is much criticized 89 yet in global health spaces this narrow highly technical approach merely compounds the problems caused by the dominance of medicine with its prioritization of quantifiable knowledge rendered evermore scientific by advances in machinepowered calculation with such epistemological underpinnings it should come as no surprise when socalled solutions to complex and highly contextual health problems are in effect predetermined even in countryled collaborations such as the global funds ccms it seems they have the answers to the questions they want you to answer their system is so rigid everything is already spoon feeding a path is shaped for you to follow the words of the nigeria ccm members interviewed by lassa and colleagues indicate that a medicalized approach to hiv programming was in fact a nonchoice demonstrating how donor prerogatives drive funding allocations regardless of local priorities drawing on the combined structural and productive power of global health institutions in the process 10 in this context we can better understand the finding that nigerian medical professionals sought to advance their own power and influence in health system decisionmaking by participating in these forums and recommending medicalized solutions to public health problems despite the existence of a robust critical literature that situates healthcare as but one determinant of population health the medical professionals who make up the leadership of many global health institutions as well as in countries are not equipped by their training to work in teams to address these determinants as naidu and abimbola describe eurocentric medical and we would argue public health education as practiced around the world crowds out approaches to caring for peoples health that are more holistic peoplecentered and equityoriented such as the ife philosophy of medical and health professionals education in nigeria which trained doctors as part of multidisciplinary teams providing communitybased primary healthcare or the aboriginal communitycontrolled health services in australia 4 the oftcited barefoot doctors in china and other community health workers are frequently harkened back to in the global health discourse in fond remembrance of almaata and continuing calls for more comprehensive notions of primary healthcare 11 in the most wellendowed global health initiatives meanwhile the focus on medicalized solutions continues largely undisturbed indeed global health institutions today are arguably constitutionally incapable of producing policies and interventions that can realize the ambition of truly comprehensive primary healthcare for instance lassa and colleagues described how in the global funds ccm in nigeria social interventions were deemphasized in favor of biomedical content so as to adhere to who guidelines and pass muster with the global funds technical review panel similarly in mozambique rapid scaleup of technical hiv care with financing from the world bank the global fund the clinton foundation and presidents emergency plan for aids relief was destructive to relationships between patients and caregivers crowding out nonclinical forms of care such as prayer and motherly attention 12 in these cases and others outreach to and partnership with people and communities particularly marginalized ones was subsumed into a medicalized framework that was not only exclusionary but actively undermined critical forms of health care the dominance of biomedical cadres epistemologies and discourses in global health institutions limits the effectiveness of the interventions they propose support and finance in the case study of nigerias ccm lassa and colleagues identified a strong emerging theme of wasted antiretrovirals due to lack of uptake of the clinical hiv programming on offer with over 20 tons of expired commodities left at central medical stores and 15 tons at state level stores according to an audit report the focus on purchasing commodities exemplifies how medicalization of health creates too simplistic a view of making more modern medical treatments available to more people failing to recognize the intersecting social economic and cultural conditions that must be in place to ensure a corresponding number of patients seek to use them in the early 2010s the global fund responded to significant criticism and pressure to shift its diseasefocused and topdown approach to include health systems strengthening yielding some improvements 13 but lassa and colleagues and earlier research 14 demonstrate how the structural influence of medical power in the broader global health environs continue to shape and narrow the focus of such initiatives medicalization can result in successful outcomes when viewed from certain angles a recent evaluation of the global fund said the partnership had underperformed in building strong and resilient health systems due to its focus on diseasespecific goals while nonetheless touting the 44 million lives saved by the fund since its inception 13 this framing gives the truth of the matter despite sometimes aspiring to build durable health systems that serve populations including those traditionally excluded global health initiatives remain fundamentally defined by and focused on activities that enable quantification of disease reduction and lives saved fortyfour million lives is no small number but it should not obscure the fact that the medicalization of health issues via approaches that are focused on quantifiable technical or clinical interventions and designed without meaningful input from nonmedical stakeholders are also tightly linked to the ongoing colonial agenda of global health indeed who are these numbers designed to appeal to as scholars of indian medical history have demonstrated medicalization is not a regrettable outcome of historical contingency 15 allopathic medicine is a tool in ongoing efforts by powerful states and actors to exert control in what should be a leading site of cooperation the preservation and protection of peoples health lassa and colleagues research is a reminder that breaking the hold of medical dominance in global health institutions is necessary if we wish to make best use of limited resources to improve population health yet it will be a long row to hoe doing so will require a collective push from multiple directions including research civil society and even political pressure to overcome deeply rooted power dynamics global health bodies and the academic institutions which are so tightly linked to them can start by meaningfully engaging in a learning agenda to finance publish collate and publicize research that demonstrates the pitfalls of medicalization and the ways in which holistic approaches are superior in terms of equity justice and basic effectiveness in promoting and protecting population health direct and robust advocacy is necessary to reveal and draw attention to the workings of power in global health institutions to challenge the ongoing narrative of disinterested investment in solving technical problems and to surface conduits of power within the processes and policy agendas of such initiatives and their impacts on the broader system for their part donor agencies will need to have faith and be patient the most transformational development programs which build institutions and encourage policy reform are often those least likely to be precisely and easily measured 8 lassa and colleagues research identifies and names a power dynamic amongst a small group of actors that has had major consequences for hiv interventions in nigeria following the trail of evidence leads straight to the biggest behemoths in global health ethical issues not applicable competing interests authors declare that they have no competing interests authors affiliations 1 department of international health johns hopkins school of public health baltimore md usa 2 institute for global health university college london london uk 3 department of population health sciences spencer fox eccles school of medicine at the university of utah salt lake city ut usa 4 college of public health medical and veterinary sciences james cook university townsville qld australia	medical professionals exercised structural and productive power in the global funds country coordinating mechanism ccm in nigeria directly impacting the selection of approaches to hivaids care as described in a case study by lassa and colleagues this research contributes to a robust scholarship on how biomedical power inhibits a holistic understanding of health and prevents the adoption of solutions that are socially grounded multidisciplinary and cocreated with communities we highlight lassa and colleagues findings demonstrating the long arm of global health institutions in countrylevel health policy choices and reflect on how medical dominance within global institutions serves as a tool of control in ways that pervert incentives and undermine equity and effectiveness we call for increased research and advocacy to surface these conduits of power and begin to loosen their hold in the global health policy agenda
introduction a long tradition of sociological research has examined the effects of divorce and father absence on offsprings economic and socialemotional wellbeing throughout the life course 1 overall this work has documented a negative association between living apart from a biological father and multiple domains of offspring wellbeing including education mental health family relationships and labor market outcomes these findings are of interest to family sociologists and family demographers because of what they tell us about family structures and family processes they are also of interest to scholars of inequality and mobility because of what they tell us about the intergenerational transmission of disadvantage the literature on father absence has been criticized for its use of crosssectional data and methods that fail to account for reverse causality for omitted variable bias or for heterogeneity across time and subgroups indeed some researchers have argued that the negative association between father absence and child wellbeing is due entirely to these factors this critique is well founded because family disruption is not a random event and because the characteristics that cause father absence are likely to affect child wellbeing through other pathways similarly parents expectations about how their children will respond to father absence may affect their decision to end their relationship finally there is good evidence that father absence effects play out over time and differ across subgroups unless these factors are taken into account the socalled effects of father absence identified in these studies are likely to be biased researchers have responded to concerns about omitted variable bias and reverse causation by employing a variety of innovative research designs to identify the causal effect of father absence including designs that use longitudinal data to examine child wellbeing before and after parents separate designs that compare siblings who differ in their exposure to separation designs that use natural experiments or instrumental variables to identify exogenous sources of variation in father absence and designs that use matching techniques that compare families that are very similar except for father absence in this article we review the studies that use one or more of these designs we limit ourselves to articles that have been published in peerreviewed academic journals but we impose no restrictions with regard to publication date or with regard to the disciplinary affiliation of the journal although most articles make use of data from the united states we also include work based on data from great britain canada south africa germany sweden australia indonesia and norway using these inclusion rules we identified 47 articles that make use of one or more of these methods of causal inference to examine the effects of father absence on outcomes in one of four domains educational attainment mental health relationship formation and stability and labor force success in the next section entitled strategies for estimating causal effects with observational data we describe these strategies their strengths and weaknesses and how they have been applied to the study of father absence in the section entitled evidence for the causal effect of family structure on child outcomes we examine the findings from these studies in each of the four domains of wellbeing our goal is to see if on balance these studies tell a consistent story about the causal effects of father absence and whether this story varies across different domains and across the particular methods of causal inference that are employed within each domain we also note where the evidence base is large and where it is thin we conclude by suggesting promising avenues for future research strategies for estimating causal effects with observational data identifying causal effects with observational data is a challenging endeavor for several reasons including the threat of omitted variable bias the fact that multipleand often reciprocalcausal effects are at work the fact that the causal treatment condition may unfold over a period of time or there may be multiple treatment conditions and the fact that the effects of the treatment may change over time and across subgroups traditional approaches to estimating the effect of father absence on offspring wellbeing have relied primarily on ordinary least squares or logistic regression models that treat offspring wellbeing as a function of father absence plus a set of control variables these models are attractive because the data requirements are minimal and because they can accommodate complex specifications of the father absence effect such as differences in the timing of father absence differences in postdivorce living arrangements and differences by gender race and social class studies based on these models typically find that divorces that occur during early childhood and adolescence are associated with worse outcomes than divorces that occur during middle childhood that remarriage has mixed effects on child outcomes and that boys respond more negatively than girls for outcomes such as behavior problems interpreting these ols coefficients as causal effects requires the researcher to assume that the father absence coefficient is uncorrelated with the error term in the regression equation this assumption will be violated if a third variable influences both father absence and child wellbeing or if child wellbeing has a causal effect on father absence that is not accounted for in the model there are good reasons for believing that both of these factors might be at work and so the assumption might not hold until the late 1990s researchers who were interested in estimating the effect of father absence on child wellbeing typically tried to improve the estimation of causal effects by adding more and more control variables to their ols models including measures of family resources as well as measures of parental relationships and mental health unfortunately controlling for multiple background characteristics does not eliminate the possibility that an unmeasured variable is causing both family structure and child wellbeing nor does it address the fact that multiple causal pathways may be at work with childrens characteristics and parents relationships reciprocally influencing each other adding control variables to the model can also create new problems if the control variables are endogenous to father absence lagged dependent variable model a second approach to estimating the causal effect of father absence is the lagged dependent variable model which uses the standard ols model described above but adds a control for child wellbeing prior to parents divorce or separation this approach requires longitudinal data that measure child wellbeing at two points in timeone observation before and one after the separation the assumption behind this strategy is that the preseparation measure of child wellbeing controls for unmeasured variables that affect parents separation as well as future child wellbeing although this approach attempts to reduce omitted variable bias it also has several limitations first the model is limited with respect to the window of time when father absence effects can be examined specifically the model cannot examine the effect of absences that occur prior to the earliest measure of child wellbeing which means ldv models cannot be used to estimate the effect of a nonmarital birth or any family structure in which a child has lived since birth second if preseparation wellbeing is measured with error the variable will not fully control for omitted variables third lagged measures of wellbeing do not control for circumstances that change between the two points in time and might influence both separation and wellbeing such as a parents job loss another challenge to ldv studies is that divorceseparation is a process that begins several years before the divorceseparation is final in this case the predivorce measure of child wellbeing may be picking up part of the effect of the divorce leading to an underestimate of the negative effect of divorce alternatively childrens immediate response to divorce may be more negative than their longterm response leading to an overestimate of the negative effect of divorce both of these limitations highlight the fact that the ldv approach is highly sensitive to the timing of when child wellbeing is measured before and after the divorce in addition many of the outcomes that we care most about occur only once and the ldv strategy is not appropriate for these outcomes these advantages and limitations are evident in cherlin et als classic study employing this method drawing on longitudinal data from great britain and the united states the authors estimated how the dissolution of families that were intact at the initial survey impacted childrens behavior problems as well as their reading and math test scores at followup in ols regression models with controls the authors found that divorce increased behavior problems and lowered cognitive test scores for children in great britain and for boys in the united states however these relationships were substantially attenuated for boys and somewhat attenuated for girls once the authors adjusted for child outcomes and parental conflict measured at the initial interview prior to divorce by using data that contained repeated measurements of the same outcome these researchers argue that they were able to reduce omitted variable bias and derive more accurate estimates of the casual effect of family dissolution this approach also limited the external validity of the study however because the researchers could examine only separations that occurred after age 7 when the first measures of child wellbeing were collected growth curve model a third strategy for estimating causal effects when researchers have measures of child wellbeing at more than two points in time is the growth curve model this approach allows researchers to estimate two parameters for the effect of father absence on child wellbeing one that measures the difference in initial wellbeing among children who experience different family patterns going forward and another that measures the difference in the rate of growth in wellbeing among these groups of children researchers have typically attributed the difference in initial wellbeing to factors that affect selection into father absence and the difference in growth in wellbeing to the causal effect of father absence the gcm is extremely flexible with respect to its ability to specify father absence effects and is therefore well suited to uncovering how effects unfold over time or across subgroups for example the model can estimate agespecific effects whether effects persist or dissipate over time and whether they interact with other characteristics such as gender or raceethnicity the model also allows the researcher to conduct a placebo testto test whether father absence at time 2 affects child wellbeing prior to divorce if future divorce affects predivorce wellbeing this finding would suggest that an unmeasured variable is causing both the divorce and poor child outcomes the gcm also has limitations first it requires a minimum of three observations of wellbeing for each individual in the sample second as was true of the ldv model it can examine the effect of divorces that occur only within a particular window of timeafter the first and before the last measure of child wellbeing also like the ols model the gcm does not eliminate the possibility that unmeasured variables are causing both differences in family patterns and differences in trajectories of child wellbeing including growth or decline in wellbeing for example an unmeasured variable that causes the initial gap in wellbeing could also be causing the difference in growth rates we are more confident in the results of the gcms if they show no significant differences in predivorce intercepts but significant differences in growth rates we are also more confident in studies that include placebo or falsification tests such as using differences in future divorce to predict initial differences in wellbeing if later family disruption is significantly associated with differences in predivorce wellbeing this finding would indicate the presence of selection bias see singer willett for a more detailed technical discussion of gcms and halaby for a more detailed discussion of the assumptions and tradeoffs among the various approaches to modeling panel data magnuson bergers analysis of data from the maternal and child supplement of the national longitudinal survey of youth 1979 is illustrative of this approach these authors used gcms to examine the relationship between the proportion of time children spent in different family structures between ages 6 and 12 and scores on the peabody individual achievement test cognitive ability test and the behavioral problems index they focused on several family types intact biologicalparent families socialfather families and singleparent families they found no differences in the initial wellbeing of the children in these different family structures suggesting that controls for observable factors had successfully dealt with problems of selection in contrast they found major differences in childrens wellbeing trajectories with time spent in intact biologicalparent families leading to more favorable trajectories than time spent in other family types the combination of insignificant differences in intercepts and significant differences in slopes increases our confidence in these results however it remains possible that timevarying unobserved characteristics were driving both time spent in different family structures and changes in child behavior and achievement individual fixed effects model a fourth strategy for estimating causal effects is the individual fixed effects model in which childspecific fixed effects remove all timeconstant differences among children this model is similar to the ldv and gcm in that it uses longitudinal data with repeated measures of family structure and child wellbeing it is different in that instead of including preseparation wellbeing as a control variable it estimates the effects of father absence using only the associations between withinchild changes in family structure and withinchild changes in wellbeing plus other exogenous covariates the ife model is equivalent to either including a distinct dummy variable indicator for each child that absorbs all unobserved timeconstant differences among children or to differencing out withinchild averages from each dependent and independent variable in both of these specifications only withinchild variation is used to estimate the effects of father absence the advantage of this model is that unmeasured variables in the error term that do not change over time are swept out of the analysis and therefore do not bias the coefficient for father absence the ife model also has limitations as with ldvs and gcms ife models cannot be estimated for outcomes that occur only once such as high school graduation or a teen birth or for outcomes that can be measured only in adulthood such as earnings also as with ldvs and gcms the ife model does not control for unobserved confounders that change over time and jointly influence change in father presence and change in child wellbeing third because the model provides an estimate of the effect of a change in a childs experience of father absence it does not provide an estimate of the effect of living in a stable oneparent family or a stable twoparent family unlike the other approaches the ife model estimates the effect of father absence by comparing beforeafter experiences for only those children within the treatment group rather than comparing children in the treatment and control groups finally and perhaps most importantly the ife model is very sensitive to measurement error because estimates of the effect of a change in father absence rely heavily on withinindividual changes a good illustration of the ife approach is a study by cooper et al using data from the first four waves of the fragile families study the authors examined the link between two measures of school readinessverbal ability and behavioral problems at age 5and childrens exposure to family instability including entrances and exits from the household using an ols model they found that the number of partnership transitions was associated with lower verbal ability more externalizing behavior and more attention problems but not more internalizing behavior these relationships held for both coresidential and dating transitions and were more pronounced for boys than girls to address potential problems of omitted variable bias the authors estimated a fixed effects model and found that residential transitions but not dating transitions reduced verbal ability among all children and increased behavior problems among boys the fact that the ife estimates were consistent with the ols estimates increases our confidence in the ols results sibling fixed effects model a fifth strategy for dealing with omitted variable bias is the sibling fixed effects model this model is similar to the previous model in that unmeasured familylevel variables that are fixed are differenced out of the equation and do not bias the estimates of father absence in this case the group is the family rather than the individual and the difference that is being compared is the difference between siblings with different family experiences rather than the change in individual exposure to different family experiences the literature on father absence contains two types of sfe models one approach compares biological siblings who experience father absence at different ages in this case the estimate of the causal effect of father absence is based on the difference in siblings length of exposure for example a sibling who is age 5 at the time of a divorce or separation will experience 12 years of father absence by age 17 whereas a sibling who is age 10 when the separation occurs will experience 7 years of father absence by age 17 in some instances children may leave home before their parents divorce in which case they are treated as having no exposure a second approach compares halfsiblings in the same family where one sibling is living with two biological parents and the other is living with a biological parent and a stepparent or social father both of these strategies sweep out all unmeasured familylevel variables that differ between families and could potentially bias the estimate of the effect of divorce both approaches also have limitations the first approach assumes that the effect of divorce does not vary by the age or temperament of the child and that there is a doseresponse effect of father absence with more years of absence leading to proportionately worse outcomes whereas the second approach assumes that the benefits of the presence of both a biological mother and father are similar for children living with and without stepsiblings with respect to the first assumption as previously noted both theory and empirical evidence suggest that at least for some outcomes divorces occurring in early childhood and adolescence have more negative effects on child outcomes than divorces occurring in middle childhood moreover if siblings differ in their ability to cope with divorce and if parents take this difference into account in making their decision about when to divorce this approach will lead to an underestimate of the effect of a change in family structure the major limitation of the second approach is that it assumes that the benefits of living with two biological parents are similar for children living in blended families and children living in traditional twoparent families with respect to this assumption there is good evidence that stepparent families are less cooperative than stable twoparent families which means that living in a blended family is likely to reduce the wellbeing of all children in the household a final limitation of the sfe model is that estimates cannot be generalized to families with only one child 2withinfamily fixed effects models are employed in gennetians analysis of data on 5to 10yearold children interviewed from 1986 to 1994 for the children of the nlsy79 study gennetian examined how children in twobiologicalparent families stepfather families and singlemother families fared on the piat cognitive test as well as how children living with stepor halfsiblings compared to those with only full siblings in simple comparisons the data revealed a significant disadvantage in piat scores for children in singlemother families stepfather families and blended families relative to those in twobiologicalparent families gennetian then leveraged the data which included repeated measurements over time of family composition and outcomes for all of the mothers children to estimate models with mother and child fixed effects these analyses found very little evidence that children living in singlemother stepfather or blended families were disadvantaged on piat scores relative to children in nonblended twobiologicalparent families although they did indicate that number of years in a singlemother family had a small negative effect on piat scores finally gennetian further tested the logic of the sibling approach by comparing the wellbeing of halfsiblings one of whom was living with both biological parents and the other of whom was living with a biological parent and a stepparent the analyses showed the expected negative effect on piat scores for children living with stepfathers with this relationship remaining negative in models with mother and child fixed effects importantly these analyses also revealed a negative effect of the presence of a halfsibling on the child who was living with two biological parents natural experiments and instrumental variables a sixth strategy is to use a natural experiment to estimate the effect of divorce on child wellbeing the logic behind this strategy is to find an event or condition that strongly predicts father absence but is otherwise unrelated to the offspring outcome of interest the natural experiment may be an individuallevel variable or an aggregatelevel measure several studies use parental death as a natural experiment generally comparing outcomes for children whose parents divorced with those whose parent died the assumption behind this strategy is that experiencing parental death is a random event and can therefore be used to obtain an unbiased estimate of the effect of father absence in such analyses a significant negative relationship between child outcomes and both parental death and divorce is taken as evidence of the causal relationship of divorce on child wellbeing particularly if the divorce and death coefficients are not statistically different 3 a major challenge for these studies is that parental death is rarely random whatever is causing the death may also be causing the child outcome violent and accidentrelated deaths for example are selective of people who engage in risky behaviors similarly many illnessrelated deaths are correlated with and the other does not these analyses control for family differences that are common to both siblings however they do not control for withinsibling differences that lead one sibling to divorce and another to be stably married twin studies go one step further by comparing mz twins and dz twins allowing researchers to determine the role of genetics in accounting for the effect of divorce 3 we only include studies of the effect of parental death on child outcomes if the author uses one of the causal methods described below or explicitly uses death as a natural experiment for divorce or other types of father absence lifestyles that affect child outcomes such as smoking children of deceased parents are also treated very differently than are children of divorced parents not only by their informal support systems but also by government other studies use natural experiments to estimate instrumental variable models this strategy involves a twostep procedure in the first step the researcher uses the natural experiment to obtain a predicted father absence measure for each individual then in the second step pfa is substituted for actual divorce in a model predicting offspring wellbeing because pfa is based entirely on observed variables the coefficient for this variable cannot be correlated with unmeasured variables thereby removing the threat of omitted variable bias for this strategy to work however the researcher must make a number of strong assumptions first he or she must find a variableor instrumentthat is a strong predictor of divorce or separation but that is not correlated with the outcome of interest except through its effects on father absence or divorce the second assumption is often violated for example see besley case for a discussion of why state policies are not random with respect to child wellbeing a third limitation of the iv model is that it requires a large sample because pfa is based on predicted absence rather than actual absence it is measured with a good deal of error which results in large standard errors in the child wellbeing equation and makes it difficult to interpret results that are not statistically significant finally the iv model requires a different instrument for each independent variable which limits the researchers ability to specify different types of father absence a good example of the natural experimentiv approach and its limitations is grubers analysis of the effect of changes in divorce laws on divorce and child outcomes combining data on state differences in divorce laws with information from the 19601990 us censuses gruber found a significant positive effect of the presence of unilateral divorce lawswhich make divorce easieron the likelihood of being divorced this part of the analysis satisfied the first requirement for the iv model namely that the instrument be strongly associated with divorce he then estimated the effect of living in a state where unilateral divorce was available on a host of adult outcomes these analyses showed that unilateral divorce laws were associated with early marriage and more divorce less education lowered family income and higher rates of suicide additionally women so exposed appeared to have lower labor force attachment and lower earnings to distinguish the effect of divorce laws from other statelevel policies gruber investigated the associations between the presence of unilateral divorce laws and changes in welfare generosity and education spending during this same time period finding no associations suggestive of bias he did find however that his results were driven in large part by factors at work in california over this period most importantly gruber concluded that divorce laws did not pass the second requirement of the iv model namely that they affect child wellbeing only through their effect on parents divorce instead he argued that divorce laws are likely to affect child wellbeing by altering decisions about who marries and by altering the balance of power among married couples grubers analysis highlights the difficulty of finding a natural experiment that truly satisfies both assumptions of the iv model propensity score matching a final strategy used in the literature for obtaining estimates of the causal effect of divorce is propensity score matching based on the logic of experimental design this approach attempts to construct treatment and control groups that are similar in all respects except for the treatment condition which in this literature is father absence the strategy begins by estimating the probability of father absence for each child based on as many covariates as possible observed in the data and then uses this predicted probability to match families so that they are similar to one another in all respects except for father absence this approach has several advantages over the ols model first researchers may exclude families that do not have a good match so that we are more confident that our estimates are based on comparing apples to apples second psm analyses are more flexible than ols because they do not impose a particular functional form on how the control variables are associated with divorce psm estimation is also more efficient than ols because it uses a single variablepredicted probability of divorcethat combines the relevant predictive information from all the potential observed confounders finally it can accommodate the fact that the effects of divorce may differ across children by estimating separate effects for children in families with low and high propensities to divorce propensity scores may also be used to reweight the data so that the treatment and control groups are more similar in terms of their observed covariates the psm approach has limitations as well first the model is less flexible than the ols model in terms of the number and complexity of family structures that can be compared in a single equation second the approach does not control for unmeasured variables although it is possible to conduct sensitivity analyses to address the potential influence of such variables for this reason the approach is less satisfactory than iv models for making causal inferences finally the strategy relies heavily on the ability of the researcher to find suitable matches if there is not sufficient overlap in the kinds of people who divorce and the kinds of people who remain stably married the approach will not work similarly by limiting the sample to cases with a match the researcher also reduces sample size and more importantly the generalizability of the results see morgan winship ribar and winship morgan for a more extended technical discussion of the logic and assumptions of matching techniques the work of frisco et al serves as a useful example of the use psm models in the study of the effects of divorce drawing on the add health data the authors first estimated simple ols regressions of the relationship between the dissolution of a marital or cohabiting relationship between waves i and ii and adolescents level of mathematics coursework change in gpa and change in proportion of courses failed between the two waves these models revealed a significant negative relationship between dissolution and the measures of gpa and course failure but no link to mathematics coursework after controlling for a large number of potentially confounding variables next the authors calculated a propensity to experience dissolution as a function of parents race education income work age relationship experience and quality religiosity and health and adolescents age gender and number of siblings and then used this predicted propensity to conduct nearest neighbor matching with replacement and kernel matching regardless of matching method the estimates from the psm models accorded very well with those from the simple ols regressions as in those models there were significant negative relationships between dissolution and gpa and positive relationships with course failure and the point estimates were of a very similar magnitude across models this study also examined how large the influence of an unobserved confounder would have had to be in order to threaten the causal interpretation of the results the study had some unique and some general limitations because of data limitations the authors could not separate dissolutions stemming from divorce from those attributable to other causes such as parental death more generally because matching is limited to observable characteristics the authors could calculate only propensities of dissolution based on observable characteristics to assess the sensitivity of their results to omitted variable bias the authors conducted a simulation and discovered that an unobserved confounder that is moderately associated with dissolution and the outcomes could bias their findings evidence for the causal effect of family structure on child outcomes in this section we assess the evidence for a causal effect of father absence on different domains of offspring wellbeing empirical studies have used multiple strategies for identifying causal effects that each have unique strengths and weaknessesas we identified in the previous sectionbut we are more confident in the presence of causal effects if we identify consistent results across multiple methods many of the articles we examine used more than one analytic strategy andor examined outcomes in more than one domain consequently our unit of analysis is each separate model reported in an article rather than the article itself for instance rather than discussing an article that includes both sfe and ldv analyses of test scores and selfesteem as a single entity we discuss it as four separate cases the virtue of this approach is that it allows us to discern patterns more clearly across studies using similar analytic strategies and across studies examining similar outcomes the drawback is that some articles contribute many cases and some only one consequently if there are strong authoreffects for articles that contribute many cases then our understanding of the results produced by a given analytic strategy or for a given domain could be skewed we note when this occurs in our discussions below studies in this field measured father absence in several ways which the reader should keep in mind when interpreting and comparing results across studies some studies compared children of divorced parents with children of stably married parents others compared children whose parents married after their childs birth with those parents who never married still others simply compared twoparent to singleparent families more recently researchers have started to use even more nuanced categories to measure family structureincluding married biologicalparent families cohabiting biologicalparent families married stepparent families cohabiting stepparent families and single parents by divorce and nonmarital birthreflecting the growing diversity of family forms in society still other studies look at the number of family structure transitions the child experiences as a measure of family instability we did not identify any studies that used causal methods to study the effects of samesex unions finally we include studies of father absence that use data from a range of international samples we should note however that what it means to reside in a fatherabsent household varies a great deal crossnationally children whose parents are not married face starkly different levels of governmental and institutional support and unequal prospects for living in a stable twoparent family in different countries in fact both marital and nonmarital unions in the united states are considerably less stable than in any other industrialized nation education we begin our review of the empirical findings by looking at studies that attempted to estimate the causal effect of divorce on school success we distinguish between studies that looked at childrens test scores studies that looked at educational attainment and studies that looked at childrens attitudes engagement and school performance test scoreswe identified 31 analyses that examined the relationship between father absence and test scores including tests of verbal math and general ability the articles containing these analyses are listed and briefly described in the first section of table 1 virtually all of the test score analyses used usbased samples although the overall picture for test scores was mixed with 14 finding significant effects and 17 finding no effect there were patterns by methodology 4 first significant effects were most likely in the analyses using gcms of the gcm studies finding significant differences in slopes between children of divorced and intact families about half found no significant differences in the predivorce intercepts which made their significant results more convincing one gcm study performed a falsification test and found no evidence that subsequent divorce predicted intercepts ruling out the threat of selection bias in contrast with analyses based on the gcm design the ife and sfe analyses rarely found significant effects of family structure on childrens test scores in general standard errors tended to be larger in ife and sfe analyses than in ols analyses but in virtually all of these analyses the fixed effects coefficients were markedly reduced in size relative to the ols coefficients suggesting that the lack of significant results was not simply due to larger standard errors several factors may have limited the generalizability of the fixed effects models however first all of these analyses came from comparisons of siblings in blended families the parents in blended families differed from those in traditional married families because at least one of the parents had children from a previous relationship limiting the external validity of these results second the fatherabsent category included children of divorced parents as well as children of nevermarried mothers whereas the fatherpresent category contained both children whose mothers were married at birth and children whose mothers married after the childs birth we might expect that the benefit of moving from a singleparent household to a marriedparent household would be smaller than the benefit of being born into a stably married family given these comparisons and the small samples involved in estimation it is understandable that we found little evidence of an impact of family structure on test scores using fixed effects models although there were clear patterns in the gcm and fixed effects analyses ldv studies were a mixed bag half found effects and half did not sometimes the results were not robust even within the same paper for example both cherlin et al and sanzdegaldeano vuri found significant effects for math scores but not reading scores using the same data as sanzdegaldeano vuri sun found positive effects for both math and reading tests educational attainmentthere is stronger evidence of a causal effect of father absence on educational attainment particularly for high school graduation of nine studies examining high school graduation using multiple methodologies only one found null effects and this study used german data to compare siblings in blended families there was also robust evidence of effects when attainment was measured by years of schooling again the only studies that found no effect of father absence were those that used international samples or compared siblings in blended families finally there was weak evidence for effects on college attendance and graduation with only one of four studies finding significant results taken together the evidence for an effect of father absence on educational attainment particularly high school graduation is strong in studies using us samples perhaps because of the relatively open structure of the us educational system compared with the more rigid tracking systems within many european countries how might one explain the stronger more consistent evidence base for father absence effects on educational attainment relative to cognitive ability one explanation is that measurement error in test scores is to blame for the weak and sometimes inconsistent findings in that domain another explanation is that the methods involved in measuring attainmentsibling models and natural experimentsdo not control as rigorously for unobserved confounders as the repeatedmeasure studies of cognitive ability the lack of strong test score effects is also consistent with findings in the early education literature that suggest that cognitive test scores are more difficult to change than noncognitive skills and behaviors given that educational attainment is based on a combination of cognitive ability and behavioral skills it makes sense that we find strong evidence of effects on the likelihood of high school graduation but not on test scores attitudes performance and engagementa smaller number of analyses examined the effect of father absence on childrens school performance including gpa coursework and track placement of these analyses four found no significant effect on track placement using german data and multiple methodologies three analyses came from a study in the united states by frisco et al that found effects for gpa and courses failed but not for a third somewhat unusual measure years of math coursework completed it is difficult to draw any conclusions about the effects of family structure on school performance across these disparate samples and measures finally seven studies examined the effect of father absence on educational engagement and aspirations among teenagers in the united states five of the seven analyses found no effect on these noncognitive measures for example one study found positive effects on aspirations but the other two found no effect similarly one study found positive effects on school engagement but the other three found no effect the latter findings suggest that educational aspirations and orientations toward schooling may form at younger ages and none of these analyses examined aspirations among children younger than age 12 mental health after education the second most common outcome examined in the literature is mental health which is measured as socialemotional development when respondents are children and adolescents mental health and socialemotional development are closely related to what social scientists call noncognitive skills or soft skills to distinguish them from cognitive skills such as math and reading tests recent research shows that socialemotional skills play an important role in adult outcomes not only in influencing mental health but also in influencing educational attainment family formation and relationships and labor market success adult mental healthwe identified six studies that examined the association between parental divorce and adult mental health three of these studies were based on uk data and two were based on us data all of the empirical strategies that we discussed in the previous section were used to estimate the effects of divorce and father absence on adult mental health the findings were quite robust with four of the six analyses showing a negative effect of parental divorce on adult mental health moreover one of the two null findings was overturned in a subsequent paper by the same authors that distinguished between early and later exposure to divorce socialemotional problemssocialemotional problems in childhood are typically measured using the child behavior checklist which includes behaviors such as aggression attention anxiety and depression some researchers use the full cbcl scale whereas others use subscales that distinguish between externalizing behavior and internalizing behavior for adolescents researchers often use a delinquency scale or a measure of antisocial behavior which overlaps with some of the items on the externalizing scale a few of the studies we examined looked at other psychological outcomes such as locus of control and selfesteem and several studies looked at substance useabuse we identified 27 separate analyses that examined the association between parental divorce and some type of externalizing behavior or delinquency these analyses were based on data from four countries the united states the united kingdom canada and australia of these 19 analyses found a significant positive effect of divorce or father absence on problem behavior for at least one comparison group whereas 8 found no significant association the findings varied dramatically by method with the ldv approach yielding the most significant results and the two fixed effects approaches yielding the fewest significant findings two analyses found effects among boys but not girls and one analysis found effects among girls but not boys of the analyses reporting null findings several had characteristics that might account for the lack of significant findings one combined cohabiting parents with married parents which likely weakened the effect of father absence on child outcomes as prior research shows that disruptions of cohabiting unions are less harmful for children than are disruptions of marital unions a second controlled for family income which is partly endogenous to divorce and a third used a small schoolbased sample six analyses examined internalizing behavior in children including studies that measured loneliness and difficulty making friends three of these analyses reported significant effects of father absence whereas the other three reported no effects as was true of the externalizing analyses the internalizing analyses relied on multiple strategies also as before the analyses reporting null effects had characteristics that might account for their lack of strong findings two of the analyses that used ife models were based on lowincome samples and a third study controlled for income in addition the bachman analysis compared single mothers who married with those who remained single finally five analyses looked at low selfesteem and low selfcontrol which are sometimes treated as markers of depression or psychological distress the findings from these studies were mixed substance usewe identified six analyses that examined substance use measured as cigarette smoking and drug and alcohol use the evidence for this set of outcomes was very robust with only one analysis reporting a null effect furthermore the findings were consistent across multiple strategies including sfe models which often showed no effects for other outcomes labor force we found only a few analyses that examined the effect of father absence on childrens labor force outcomes in adulthood in part this is because earnings employment and welfare receipt in adulthood do not lend themselves to analysis using ifes gcms or ldvs which require observations before and after the divorce indeed all the analyses of this domain of outcomes used sfe models or natural experiments however in many other respects there is limited comparability between the studies although several studies used data from the united states many of these analyses were derived from estimates based on british or canadian data further the gruber and corak studies which contributed 9 of the 14 analyses differed in the ages and periods examined with gruber using data from a longer time period a wider range of ages and so a much larger set of cohorts than corak ages 2532 and births 1963corak accorded with corak insofar as they used data from the mid to late 1990s and focused on respondents in their 20s and early 30s the findings for effects of father absence were however consistent both gruber using changes in us state laws to allow for unilateral divorce and corak using parental death in canada found that divorce was associated with lower levels of employment the studies disagreed however about for whom these effects were most pronounced with grubers analyses suggesting that female children of divorce were less likely to work and corak finding that male children exposed to parental loss had lower labor force participation similarly using sfe models with british data ermisch and coauthors found evidence of higher levels of labor force inactivity among those who experienced divorce in early childhood looking at adult occupational status rather than simply employment status biblarz gottainer found that although children growing up in divorcedmother households fared worse than those growing up in stable twoparent households there was no significant disadvantage to growing up in widowmother households however these researchers did find that children growing up in stepparent households were disadvantaged regardless of whether father absence was due to divorce or widowhood the results of analyses of the effect of divorce on income and earnings were less consistent than the results for employment again gruber and corak contributed most of the analyses for these outcomes with gruber finding evidence of negative effects of divorce on income per capita and on womens earnings and corak finding negative effects of divorce on mens family income coraks result is consistent with analyses by lang zagorsky who using parental death as a natural experiment found no effect of father absence on wages and by björkland et al who using sfe models with us and swedish data found no effects on earnings corak also investigated how divorce was related to the receipt of unemployment insurance and income assistance in canada finding a higher probability of receiving income assistance but not unemployment assistance family formation and stability like the evidence base for labor force outcomes there is relatively little research on how family structure affects patterns of offsprings own family formation and relationship stability the lack of research in this domain is somewhat surprising given that these outcomes are closely related to the causal effect under consideration the dearth of studies may be because these outcomes do not lend themselves to ldv gcm or ife analyses marriage and divorcevirtually everything we know about the effects of father absence on marriage and divorce comes from just three studies all of which used a natural experiment design with the experimental variable being parental death or changes in divorce laws all three studies examined marriage as an outcome but came to different conclusions lang zagorsky found that parental death and divorce reduced the likelihood that sons will marry but found no effect on daughters using parental death as a natural experiment corak found no evidence of a causal effect of father absence on marriage for either sons or daughters finally using divorce laws as a natural experiment gruber found that growing up under the newer relaxed divorce laws actually increased the likelihood of marriage for youth the evidence for an effect of father absence on marital stability was more consistent with both corak and gruber finding evidence of a positive effect on separation but not on divorce early childbearingwe identified only two analyses that examined the effect of father absence on early childbearing these analyses were conducted by the same research team they used the same sfe model and they used the same datathe british household panel survey data in great britain both analyses found a positive association between parental absence and early childbearing with divorce in early childhood having a stronger effect than divorce in middle childhood conclusions the body of knowledge about the causal effects of father absence on child wellbeing has grown during the early twentyfirst century as researchers have increasingly adopted innovative methodological approaches to isolate causal effects we reviewed 47 such articles and find that on the whole articles that take one of the more rigorous approaches to handling the problems of omitted variable bias and reverse causality continue to document negative effects of father absence on child wellbeing though these effects are stronger during certain stages of the life course and for certain outcomes we find strong evidence that father absence negatively affects childrens socialemotional development particularly by increasing externalizing behavior these effects may be more pronounced if father absence occurs during early childhood than during middle childhood and they may be more pronounced for boys than for girls there is weaker evidence of an effect of father absence on childrens cognitive ability effects on socialemotional development persist into adolescence for which we find strong evidence that father absence increases adolescents risky behavior such as smoking or early childbearing the evidence of an effect on adolescent cognitive ability continues to be weaker but we do find strong and consistent negative effects of father absence on high school graduation the latter finding suggests that the effects on educational attainment operate by increasing problem behaviors rather than by impairing cognitive ability the research base examining the longerterm effects of father absence on adult outcomes is considerably smaller but here too we see the strongest evidence for a causal effect on adult mental health suggesting that the psychological harms of father absence experienced during childhood persist throughout the life course the evidence that father absence affects adult economic or family outcomes is much weaker a handful of studies find negative effects on employment in adulthood but there is little consistent evidence of negative effects on marriage or divorce on income or earnings or on college education despite the robust evidence that father absence affects socialemotional outcomes throughout the life course these studies also clearly show a role for selection in the relationship between family structure and child outcomes in general estimates from ife sfe and psm models are smaller than those from conventional models that do not control for selection bias similarly studies that compare parental death and divorce often find that even if both have significant effects on wellbeing the estimates of the effect of divorce are larger than those of parental death which can also be read as evidence of partial selection the virtues and limitations of the key analytic strategies although we are more confident that causal effects exist if results are robust across multiple methodological approaches it is understandable that such robustness is elusive given the wide range of strategies for addressing bias it is also the case that each of these strategies has important limitations and advantages although gcms ldv designs and psm models allow for broad external validity these approaches do less to adjust for omitted variables than do ife and sfe models yet such fixed effects models require one to assume that biological parents in blended families are just like parents in nonblended families and that the age at which children experience father absence does not affect their response in general studies that employ more stringent methods to control for unobserved confounders also limit the generalizability of their results to specific subpopulations complicating efforts to draw conclusions across methods in many ways the natural experiment strategy is appealing because it addresses concerns about omitted variable bias and reverse causality in practice however these models are difficult to implement approaches that use parental death must make assumptions about the exogeneity of parental death and the comparability of the experiences of father absence due to death and divorce similarly approaches that use instruments such as divorce law changes and incarceration rates must make a convincing case that such policies and practices affect child outcomes only through their effects on family structure some of these methodological approaches are better suited to examining one set of outcomes rather than others for instance gcm ldv and ife designs do not lend themselves to the investigation of the effects of father absence on adult outcomes in contrast although natural experiments and psm models can be used to examine a wider range of outcomes they are much less flexible in how father absence can be measured generally using dichotomous measures of absence rather than the more detailed categorical measures of family type or measures that seek to capture the degree of instability experienced by children because of these differences by method in the domains that are examined and the definitions of family structure that are used it is difficult to discern if some methods seem more apt than others to find evidence for or against the effect of father absence on children but our impression is that ldv and gcm designs tend to find stronger evidence of effects of father absence on education and particularly socialemotional health than do the other designs the evidence on the effects of father absence is more mixed in studies using ife and sfe the relatively smaller number of papers that use psm designs also return a split verdict among those studies using natural experiments there is some evidence of negative effects of father absence from changes in divorce laws weak evidence when incarceration is used as an instrument and mixed evidence from studies using parental death areas for future research looking across studies it is apparent that father absence can affect child wellbeing across the life course but within any one study there is rarely an attempt to understand how these different types of outcomes are related to one another for instance studies separately estimate the effect of father absence on externalizing behavior high school completion and employment and from these analyses we can tell that family disruption seems to have effects on each outcome but it is also plausible that the effect of father absence on high school completion operates through an effect on externalizing behavior or that the effect on employment is attributable to the effect on high school completion stated differently the articles reviewed here do a good job of attempting to estimate the causal effects of father absence on particular outcomes but they do not tell us very much about why or how these effects come about this omission reflects a fundamental tension extending beyond our particular substantive topic between the goal of estimating causal effects versus the goal of understanding the mechanisms and processes that underlie longterm outcomes few of the studies reviewed here investigate whether the effects of father absence vary by child age but those that do find important differences with effects concentrated among children who experienced family disruption in early childhood new developments in the fields of neuroscience and epigenetics are rapidly expanding our understanding of how early childhood experiences including in utero experiences have biological consequences and sociologists would benefit from a better understanding of these dynamics as they relate to a wide range of potential outcomes especially health in adulthood similarly although there has been some attention to how boys and girls may respond differently to father absence researchers should continue to be attentive to these interactions by gender we found surprisingly little work on interactions between father absence and race or class given that african american and lowincome children experience higher levels of father absence than their white and middleclass counterparts a differential response to absence could serve to mitigate or further exacerbate inequalities in childhood and adult outcomes more work particularly using the methods of causal inference discussed here remains to be done on this topic we also suggest that more research is needed to understand if the effects of father absence on child wellbeing may have changed over time we might expect that if stigma has lessened as father absence has become more common then the negative effects may have diminished alternatively diminishing social safety net support and rising workplace insecurity could have served to make the economic consequences of father absence more severe and the negative effects more pronounced finally emerging research on family complexity shows that children raised apart from their biological fathers are raised in a multitude of family formssinglemother families cohabitingparent families stepparent families blended families multigenerational familiesmany of which are often very unstable indeed stable singlemother households are quite rare at least among children born to unmarried parents which means that unstable and complex families may be the most common counterfactual to the married twobiologicalparent family thus studies of the causal impact of father absence should not treat father absence as a static condition but must distinguish between the effect of a change in family structure and the effect of a family structure itself table 1 studies of the effects of father absence on education 2050 in 1960 1970 1980 or 1990 census	the literature on father absence is frequently criticized for its use of crosssectional data and methods that fail to take account of possible omitted variable bias and reverse causality we review studies that have responded to this critique by employing a variety of innovative research designs to identify the causal effect of father absence including studies using lagged dependent variable models growth curve models individual fixed effects models sibling fixed effects models natural experiments and propensity score matching models our assessment is that studies using more rigorous designs continue to find negative effects of father absence on offspring wellbeing although the magnitude of these effects is smaller than what is found using traditional crosssectional designs the evidence is strongest and most consistent for outcomes such as high school graduation childrens socialemotional adjustment and adult mental healthdivorce single motherhood education mental health labor force child wellbeingthe authors are not aware of any affiliations memberships funding or financial holdings that might be perceived as affecting the objectivity of this review 1 we use the term father absence to refer to children who live apart from their biological father because of divorce separation from a cohabiting union or nonmarital birth we use the terms divorce and separation to talk about change in childrens coresidence with their biological fathers
background interprofessional collaboration is central to the primary care of complex chronic illnesses such as medical frailty 12 to support medically frail older patients who often have complex multimorbidity and an increased risk of mortality 3 the interprofessional team should collectively engage patients and their care partners in endoflife conversations 4 5 6 7 engaging in talk about immediate goals fears and wishes when facing a lifelimiting illness can improve qualityoflife and goalconcordant care 8 however little research has explored the forces that shape interprofessional collaboration to support eol conversations in primary care to address this knowledge gap which limits the ability to improve practice we conducted a critical ethnography to examine the structural forces shaping nurses and allied health clinicians involvement in eol conversations in the primary care of frail older adults interprofessional primary care primary care is the first point of contact with the healthcare system it provides longitudinal care and aims to prevent and manage chronic illnesses which is best achieved by an interprofessional approach that involves sharing knowledge skills and experience 9 as primary care grapples with increasingly complex multimorbid patients who are discharged from acute care quicker and sicker and require comprehensive care from a team interprofessional collaboration is essential 110 interprofessional collaboration is defined as a partnership between a team of clinicians as well as a patient in a participatory collaborative and coordinated approach to shared decisionmaking around health and social issues 11 effective collaboration requires understanding of team members roles effectively managing conflict supporting team functioning and collaboratively formulating implementing and evaluating care to enhance patient outcomes 11 in primary care the most responsible provider usually a physician or nurse practitioner is considered the medical expert within interprofessional teams the most responsible provider has an overall responsibility for directing and coordinating patients care 12 13 14 at the same time most responsible providers are expected to understand respect and support their overlapping roles and responsibilities with other clinicians on the team and be able to change from team leader to team member based on need 15 primary care exists within larger healthcare systems and social policies which in canada and other countries internationally tend to be shaped by neoliberal logics 16 that promote cost and speed efficiencies government deregulation to encourage innovation privatization of public services to lower costs for the state and individual responsibility to offload structural problems onto individuals 17 18 19 20 research shows that healthcare systems governed by neoliberalism are often characterized by interprofessional isolation and conflict as opposed to effective collaboration 162122 to date little work has explored the connection between social policies interprofessional collaboration and eol conversations endoflife conversations in primary care as patients approach their eol having a clear understanding of their wishes and values and aligning these to care becomes essential for personcentred eol care 12 this can be accomplished through eol conversations which include three types of conversations 1 advance care planning 2 goalsofcare discussions and 3 eol decisionmaking discussions 2324 the focus in this study is on the latter two types of eol conversations since research has found that advance care planning does not improve eol care influence eol decisionmaking help to align care with patient goals or improve satisfaction of care 2526 eol goalsofcare and decisionmaking discussions require providing information about the illness as well as the harms and benefits of medical interventions exploring what matters to patients and their care partners and making recommendations based on expressed goals 23 determining goalsofcare is considered the gold standard for ensuring personcentred conversations and decisionmaking 27 however research has found that physicians often do not engage patients in eol decisionmaking and goalsofcare discussions until death is imminent 428 to address this an interprofessional approach is recommended for achieving timely and highquality eol conversations in primary care 428 if physicians and nurse practitioners collaborate interprofessionally alignment between patients goals and the care provided in the last years months or weeks of life might improve 13 nursing and allied health clinicians roles in eol conversations according to the ontario palliative care competency framework it is well within the scope of nurses social workers occupational therapists physiotherapists pharmacists and many other clinicians who care for patients with lifelimiting conditions to engage patients in discussions about eol these clinicians can assess patients understanding of lifelimiting conditions recognize common illness trajectories support the expression of wishes and goalsofcare and facilitate goal setting decisionmaking and informed consent in order to support the best possible outcomes and qualityoflife an interprofessional primary care team could address unmet emotional psychological spiritual and informational needs of patients at eol more effectively than a physician or nurse practitioner alone because this approach provides wellrounded information from a variety of disciplines and improves access to timely eol conversations due to the availability of more clinicians 1229 however research examining how clinicians collaborate to support eol conversations reveals nurses and allied health clinicians are most often not engaging patients in these conversations 71230 previous studies have aimed to improve the problem of low interprofessional collaboration in serious illness conversations by improving the communication training of clinicians from multiple disciplines 728 although these interventions promoted more frequent and higher quality conversations they did not lead to earlier conversations in patients illness trajectory 728 clinicians also experienced challenges including role confusion less trust from clinicians exclusion from collaboration and the perception that eol conversations were futile 7 the social political and professional conditions that created these forms of collaboration were not examined in this research leaving gaps in understanding how social and practice structures shape collaboration as critical health scholars who are interested in the ways normative logics and social structures shape care our previous work explored how biomedical norms constrain eol conversations between physicians or nurse practitioners and frail older adults andor their care partners in an urban family health team 30 our findings suggest that attempts by patients or the most responsible provider to talk about decline death or the limits of medicine were constrained by talk and behaviour that emphasised the possibility of living longer 30 the logic of reversing or mitigating decline is reinforced by biomedical culture clinical practice guidelines and the societal expectation of longevity making it less possible for eol conversations to occur in primary care this work demonstrated the importance of examining the way broad yet often hidden forces shape eol conversations in this manuscript we build on our previous analysis of ethnographic data to critically explore how interactions within a team impact eol conversations we previously found that while the conversations were fragmented patients primary physician or nurse practitioner did engage frail older adults in goalsofcare discussions or decisionmaking yet nurses and allied health clinicians did not 30 to investigate why this pattern was observed we explore the factors that influence the quality of collaboration in the primary care team as well as policies that govern interprofessional practice more broadly methods we engaged in a critical ethnography using observations document analysis and interviews to gather indepth information about how macrostructures such as policy and normative assumptions influence how a team of clinicians collaborate around eol conversations 31 32 33 critical ethnography differs from ethnography in that it seeks not only to understand and describe the language and behaviours of a group at the micro level but also interpret how group culture is shaped by sociopolitical structures 33 to guide our investigation of characteristics shaping patterns of collaboration between clinicians from multiple disciplines we drew on the gears model of factors affecting interprofessional collaboration 34 like other investigators 35 36 37 we used this taxonomy of characteristics at the macro meso and micro levels to examine the quality of collaboration in this team to link patterns of collaboration with sociopolitical structures we also examined the governing policies of the clinic and normative assumptions within the interviews observations and policies 2038 setting and recruitment the family health team we studied is part of a larger academic teaching hospital located in ontario canada that is governed by a physician board this teaching hospital has an existing interprofessional education program including access to structured student and staff interprofessional education and dedicated resources additionally there was at least one champion within the clinic who acts as a representative for the institutional interests in effective collaboration the clinicians also received professional development on eol conversations the clinic is comprised of over 20 staff family medicine physicians and several nurse practitioners who are nurses with extended class meaning they have received graduate university education allowing them to order tests diagnose and prescribe the clinic also includes nurses and allied health clinicians such as social workers an occupational therapist physiotherapist pharmacists and dieticians this team works with patients of all ages including frail older adults and patients from diverse socioeconomic and racialized backgrounds we used purposeful sampling which allowed for recruitment of participants who could provide rich information about the topic of inquiry and allowed for indepth understanding of an issue with the results being transferable rather than generalizable 39 to participate clinicians had to care for patients who they considered to be mildly to severely frail on the clinical frailty scale 40 a senior physician at the clinic facilitated clinician recruitment clinician participants we employ certain terminology to refer to the clinicians in our study the term allied health clinician refers to a social worker physiotherapist and occupational therapist the term nurse refers to registered and registered practical nurses who share similar scopes of practice as opposed to nurse practitioners whose scope of practice resembles family medicine physicians medical professionals refers to both nurse practitioners and physicians who act as the most responsible provider to patients in the clinic grouping participants together is important to protect anonymity twenty clinicians participated in this study 10 medical professionals 4 nurses 4 allied health clinicians and 2 medical students one clinician who was approached declined to participate and one clinician withdrew after being observed due to increasing work demands all participants involved in the study provided informed written consent prior to their engagement in the research process and assent was obtained during each research encounter data production we utilized several data production strategies observations of clinicians in their daytoday activities onetoone semistructured interviews and document analysis data were produced from february october 2019 resulting in 17 interviews with clinicians each lasting 60 minutes on average and over 100 hours of structured observations of clinicians daytoday activities excluding direct patient care on average each clinician was observed for 67 hours an observation guide was used to focus the first authors attention in the field on people communication collaboration conflict and talk of frailty or eol cc wrote reflexive notes about initial impressions decisions about what to observe and when how participants responded to her and ethical dilemmas such as being shown patient records that were not part of the research protocol interviews were conducted by cc in person at the clinic using a semistructured interview script interviews were recorded and transcribed verbatim by a transcription service cc listened to audio recordings to check the accuracy of the transcription transcripts were then deidentified and audio recordings deleted the remaining data will be retained on a password protected secure server for 5 years and then deleted to increase rigor the team held routine meetings to discuss data production strategies such as note taking techniques examine decisions in the field and explore initial analytic ideas 41 to produce data about the structural level policies that shape primary care practice in ontario canada we conducted searches of policies and documents and consulted with experts including the association of family health teams of ontario some governing policies such as annual funding agreements between the family health team and the ontario ministry of health and longterm care were not publicly available the documents we analyzed include 1 the ontario palliative care competency framework 2 primary care performance measurement framework for ontario 2014 3 physician service agreement 2012 4 health quality ontario primary care performance in ontario 2019 and 5 family health team accountability reform application package 20142015 these policies were included because of their central role in governing primary care through the enforcement of practice competencies funding priorities performance measures and clinical accountabilities data analysis our analysis began with data simplification using the gears model 34 this framework was used as a coding structure to code observation notes interview transcripts and document data to draw our attention to factors in the data such as beliefs and formal information structures that shape collaboration 3442 we then examined how the characteristics captured by each of the code impacted the way nurses and allied health clinicians collaborate in eol conversations these codes were then sorted by characteristics that support eol conversations such as knowledge and by barriers to eol conversations such as prioritizing biomedical assessments secondly we critically examined the coded data to understand the assumptions and logics influencing collaboration we accomplished this by paying attention to patterns of language and actions that revealed the underlying assumptions 20 this final progression of coding resulted in the creation of a number of themes which we present in our findings results our findings suggest that nurses and allied health clinicians including a social worker physiotherapist and occupational therapist have the knowledge skills and willingness to facilitate eol goalsofcare and decisionmaking discussions with frail older adults however most of these clinicians did not engage in eol conversations within this setting we argue that forces at the practice organizational and structural levels constrain nurses and allied health clinicians practice these constraints can be traced to neoliberalbiomedical ideas that normalize and prioritize biomedical effectiveness and efficiency these ideas converge to impact team collaboration in particular ways that limit nurses and allied health clinicians involvement in eol conversations a culture governed by neoliberalbiomedicine primary care performance measures in ontario assess access patientcentredness integration effectiveness focus on population health efficiency safety and appropriate resources from our examination of these measures we suggest the governance of primary care in ontario at the time of the study is shaped by neoliberalbiomedical logics neoliberalbiomedicine refers to the way pervasive social norms such as efficiency and cost containment are intertwined to produce certain effects on care we observed how efficiency relating to cost and speed as well as individualism promotes individual responsibility for health and construes freedom as choice performance indicators for access mostly emphasize quantity of and speed at which patients are seen by a physician or nurse practitioner while also assessing the reduction of costly acute care services for example one measure evaluates the percentage of patients who report that they were able to see their physician or nurse practitioner on the same or next day performance indicators for integration tend to emphasize cost containment by discouraging duplication of services and the prevention of hospitalizations with little emphasis on nonmedical social or community care indicators for population health tend to promote individual responsibility for the prevention of illness by evaluating the percentage of patients who have engaged in health screenings and certain lifestyle choices for example one measure evaluates the percentage of female gradeeight students who have completed vaccination against human papillomavirus efficiency logic intersects with biomedicine particularly through the promotion of evidencebased practice that not only justifies the use of public funds but promotes costsaving health prevention initiatives when we refer to biomedicine in this context we are most interested in biomedical dominance and the control over what constitutes legitimate healthcare and who can practice it within the performance measures we found indicators for effectiveness often promote the appropriate screening and treatment of chronic illness emphasizing that illnesses can and should be treated an objective of the performance measure is to assess patient centredness a systemwide objective of patient centredness based on best practice should encourage collaborative relationships between clinicians and patients that prioritize patients values goals beliefs and needs however patientcentred care is measured by access to biomedical care and individual choice thereby reproducing logics of biomedical effectiveness and individualism not patientcentredness for example measures evaluated spending enough time with involvement in decisionmaking and an opportunity to ask questions our overall analysis of performance measures suggests that neoliberalbiomedicine particularly the logics of biomedical effectiveness and efficiency are evident at the structural level we also found this ideology exerts to various degrees influence on beliefs and actions at the organizational and practice levels shaping team collaboration nursing and allied health knowledge and skills to support eol conversations nurses and allied health clinicians had consistent and clear beliefs about when to initiate eol conversations what to discuss and how to discuss it to describe when it is appropriate to start having eol conversations the nurses and allied health clinicians spoke of conditions that signify the body is deteriorating such as being frail getting a diagnosis of a terminal illness or a decrease in health status a clinic nurse explains the the nurses and allied health clinicians also spoke about the importance of personcentredness during eol conversations which extends beyond offering and exploring choice about eol care these participants believe it is important to elicit patients goals and wishes at the eol including what is important to them and what they are hoping to accomplish before they die they emphasized how the personhood of the patient should be discussed not just their physical body a nurse explains we might think the focus is physically what you want done but for some people the focus maybe more of like a spiritual aspect … so just in sharing or asking them what was the goal of your loved one what was their desire for death … anything they wanted to do or accomplish … just figuring out how they can live in their last days live and die with dignity … just kind of identifying what are their wishes what are their desires and yeah and ensuring that we can support them in that sense many of the nurses and allied health clinicians also drew on personcentredness to emphasis the role rapport plays in eol conversations for example many believe eol conversations should be initiated by someone with an existing relationship who knows the patients values and has their trust which is usually their primary physician or nurse practitioner usually its the physician that initiates it it should be someone who the patient has a trusting relationship with too yeah someone that theyve built a rapport with i think like a healthcare professional who is understanding … who knows their situation a little bit and theyre able to have honest open trusting communication with them the nurses and allied health clinicians descriptions of eol conversations highlights their overall knowledge of this complex practice despite this knowledge there was agreement that nurses and allied health clinicians are not generally involved in eol conversations yet it could be beneficial if they played a bigger role some medical professionals in the team suggested the value of nurses and allied health clinicians taking on more responsibilities … c ertainly nurses and you know nurses ask my patients about their sex history … they ask them about all like all kinds of … taboo topics … so i have no concerns about them being able to address like end of life in a you know a sensitive sort of openended…manner … the social worker or the counsellors yeah i think anyone could … but yeah … i dont think in ten years ive ever like i remember anybody coming to me and being like oh you know like im the nurse i took their blood pressure i was talking to them about their hospitalisation and you know i asked a bit about whos going to make decisions for them thats never happened nurses and allied health clinicians hold practice knowledge about eol conversations that supports them to engage frail older adults in eol conversations yet this group rarely enacts this dimension of care part of the reason for this appears to be a culture characterized by certain patterns of collaboration that make it difficult for nurses and allied health clinicians to initiate and sustain eol goalsofcare and decisionmaking discussions biomedical dominance and efficiency constraints to nurses and allied health clinicians practice when examining interprofessional collaboration at the clinic biomedical dominance is noticeable in which profession is most central to patients care at the clinic practice is structured so that nurses and allied health clinicians are positioned to provide episodic taskbased care which limits their knowledge of and rapport with patients making it less possible for them to support eol goalsofcare and decisionmaking discussions additionally influenced by efficiency logic the clinical team works to maintain fastpaced care which leads to a particular pattern of relating between disciplines making it less possible for nurses and allied health clinicians to engage in eol conversations our findings of how biomedical dominance and efficiency constrain collaboration in eol conversations beyond physicians and nurse practitioners are organized into three sections 1 lack of longitudinal relationships 2 lack of collaborative decisionmaking and 3 undervaluing nurses practice lack of longitudinal relationships biomedical dominance is reproduced in the way nurses and allied health clinicians roles are organized in the clinic whereas these clinicians are relegated to shortterm care physicians and nurse practitioners foster longitudinal relationships with patients over time which supports the facilitation of eol goalsofcare and decisionmaking conservation because of their understanding of patients medical history and values one of the medical professionals explains how longitudinal relationships support eol conversations having a conversation is really important but just in kind of understanding what their a patients past behaviour is like and having conversations about their life about their childhood about whats going on now … i get a sense of who they are and im not suggesting that that should replace a good goalsofcare conversation where you allow that person the opportunity to actually say it but its a really rich in an area where you get to know people over a longitudinal thing its a very rich environment to understand peoples values wishes … what they define as quality longterm relationships make it easier to engage in eol goalsofcare and decisionmaking discussions with patients another medical professional agrees and elaborates that it can be challenging for nurse practitioners and physicians to find the time to support eol conversations and that it would be helpful if nurses and allied health clinicians could assist in this work however a lack of close relationships with patients makes this difficult j ust putting those first few questions out philosophic or valuebased discussions you cant just walk out of the room like it turns into a longer appointment and then youre behind … it would be nice to have … people to be able to talk through this kind of thing more social workers but if they dont have that longterm relationship with the patient its not going to go anywhere right so it comes back to the same people who have the longterm relationship who are busy and have lots of patients like it just is not its not great at all the way roles are designed physicians and nurse practitioners are central to patient care as they develop continuous relationships with their patients this is in contrast to nurses and allied health clinicians who often have longer appointments with patients yet they generally do not know the patients well thereby making it more difficult to engage in eol goalsofcare and decisionmaking discussions a nurse discusses how the organization of their role as taskbased limits the possibility of eol conversations the thing is with the clinic its like more episodic and focus on one single issues so like just sometimes in the clinic we just do blood pressure or dressing change or just specific task its hard for me to kind of make just a decision oh the patient needs advanced care planning … just because i feel like i dont see the whole picture of their health because of biomedical dominance the established pattern of collaboration is to involve nurses and allied health clinicians in taskbased care which limits what these clinicians know about patients and how they contribute to their care without longitudinal relationships and knowledge of patients health history it becomes more difficult and less likely for these clinicians to engage in eol goalsofcare and decisionmaking discussions lack of collaborative decisionmaking nurses and allied health clinicians are most often involved in patient care because of a request or referral from the patients physician or nurse practitioner nurses are most often involved in patient care with inthemoment taskbased requests whereas allied health clinicians often receive an electronic referral requesting specific types of support in describing the organization of their role an allied health clinician states im mandated to see each patient only once im in a consultant role another allied health clinician further explains the care they provide and how they communicate with physicians and nurse practitioners i see people two to three times and then discharge them to services that can be longerterm i always write to the referring provider with a note about history clinical presentation and plan and goals i usually get a note back and we dialogue this way when requested to provide care nurses and allied health clinicians use their specialized knowledge to support patients through assessments and access to other services as opposed to providing longterm therapy planning or followup care the biomedical dominance that shapes the organization of allied health clinicians work also leads some of these clinicians to feel excluded from shared decisionmaking and collaboration in patient care an allied health clinician explains some physicians do not referral at all they maybe dont know what i do or they might have myopic focus on medicine and pay less attention to the psychosocial issues and ways we can help … its not as collaborative and cohesive as could be … theres no mechanism for that collaboration really nurses and allied health clinicians occupy a supportive if not marginalized position in the clinic biomedical dominance makes the work and knowledge of physicians and nurse practitioners central to patient care with there being few opportunities to include nurses and allied health clinicians in shaping patient care to a similar extent additionally by design of the clinical workflow and the allocation of clinical responsibilities nurses and allied health clinicians provide episodic referralbased care which has consequences for their ability to engage in eol goalsofcare and decisionmaking discussions undervaluing nurses practice observation notes by first author cc detail the constant work done by the team to provide efficient fastpaced care an example of this is the way it was noted that team members are friendly and polite but walk quickly around the clinic going from one task to another rarely stopping an excerpt of observation notes exemplifies this observing a physician … he comes out of his room walking towards the nursing station a nurse is there and gives an update about a blood pressure reading thats great thank you name he says and puts a piece of paper in a mailbox he turns back to his room quickly sits down at the computer pulls something up on the screen skims it and then walks quickly to the waiting room to get his next patient efficiency logic is also reproduced in the way some clinicians speak about their roles this is particularly true for physicians who see their time as a resource that needs to be used efficiently and fairly consider the following two comments of medical professionals on the culture of efficiency its realizing that as much as you want to spend 90 minutes with a patient that comes at the expense of your other patients so you have to balance that time in the room with this patient against the patients that are outside in the waiting room who you also need to see we think of our time as a resource and you know if i spend an hour with a patient that means theres three other patients i dont see so my job is to create access efficiency logic influences the collaboration between nurses and physicians in such a way that limits nurses involvement in eol conversations at the heart of this efficient primary care clinic is the 15min appointment with a physician with 3045 min appointments for some complex frail patients for physicians to see a new patient every 1530 min they often require help from nurses a participant explains i admit our physicians think about their practice their population how can you help me with x … they just think about getting through their day with these patients and this problem in front of them because theyre too busy to think any other way so theyre like i want a nurse to help me with all these people the expectation for efficiency shapes the role of nurses to help physicians with their patient care rather than cultivate their own forms of practice with patients nursing roles at this clinic most often include giving immunizations measuring vital signs assessing infants doing wound care administrative tasks and healthcare or team organization a nurse comments on their role and collaboration with physicians i feel as a nursing scope of practice … we have wellbaby assessments developmental and safety screening for infants and toddlers or help with physicals dressing change those kinds of things … it just really depends on the need of the clinic if … the family doctor … maybe they are too busy with medical care … its important for a nurse … then to help the doctors physicians often request inthemoment support from nurses which would catch them midtask in their clinical care this form of collaboration prioritizes efficient biomedicine but leads to interruptions of nursing work interruptions indicate an undervaluing of nursing practice as a cultural norm and makes it less possible for nurses to have eol goalsofcare and decisionmaking discussions because they are less likely than other clinicians to have uninterrupted time a nurse explains ive worked really hard on if my doors closed then theres a reason for that and my colleagues know that … i would hope that…my colleagues and management would see it as a worthwhile time for me to spend time with these people whoever needs to have that eol conversation and would respect that … but i do have interruptions at times and it does complicate that conversation … interruption is a big one so even though we went we just had that big spew about what i try to set the tone for i still get interrupted while this pattern of relating is normalized due to neoliberalbiomedical logics some nurses at this clinic resist it a group of the nurses worked with management to stop interruptions to their work management announced a written nursing request system that the team is meant to use instead of interrupting a medical professional explains why this is important as captured in the following observation note a physician said he had to take a lengthy history and i author cc asked if he often would ask a nurse to do it he said thats a good question and shut the door he said were in a difficult time there has been the introduction of the medical communication form that just happened … he said its been years in the making … the nurses do not want to do menial tasks workload is high and they want to practice to their full scope it is not okay to ask nurses to do histories or prescreening because they have other more important work to do he says if hes behind he can ask nurses to help him out but that should not be a regular thing however despite this new communication system interruptions continued this was captured in author ccs observation notes a medical resident comes out of his room in a hurry asking where is nursing im author cc the only person there and say they all seem occupied and gesture to the closed doors of the nursing offices he looks around at all the doors and then a nurse comes out of her room with a blood pressure machine putting it back where it is stored the resident tells her he needs help with vaccinations the nurse pauses seeming unsure of what to do she turns back to her room saying she is with a patient right now and instructs him to write a communication note he pops into another nurses office and asks for help neoliberalbiomedical logics normalizes a particular way of collaborating in this clinic that prioritizes efficient fastpaced medical care this logic leads to the organization of nurses and their work to be taskoriented and driven to meet the needs of the clinic but undervalues nurses independent practice and expertise this context and culture of collaboration is one of the ways nurses are constrained in their ability to engage in eol goalsofcare and decisionmaking discussions discussion our analysis suggests that the distribution of tasks and roles in this family health teamis shaped by neoliberalbiomedical logics that normalize and prioritize biomedical effectiveness biomedical dominance and efficiency thereby limiting interprofessional collaboration for eol goalsofcare and decisionmaking discussions biomedical effectiveness and dominance prioritize the role of biomedicine in sustaining patients physical health preventing decline and death and controlling what counts as healthcare and who can practice it 214344 efficiency prioritizes speed and minimizing costs 162245 together these logics create a culture that prioritizes the work of physicians and nurse practitioners while normalizing limited collaboration with nurses and allied health clinicians and restricting their practice to providing episodic taskbased care that supports biomedical efficiency rather than drawing on their own professional expertise this culture and its patterns of relating limit the possibility of nurses and allied health clinicians engagement in eol conversations our findings align with a small but growing body of work that draws attention to the way relationships of power operate on interprofessional collaboration 46 however we are the first to apply this type of critical analysis to ethnographic data to explicate the way relationships of power limits collaboration for eol goalsofcare and decisionmaking discussions in primary care our findings suggest the barriers to nurses and allied health clinicians involvement in eol conversations are less related to skills and knowledge and more rooted in normative logics that shape the way primary care service delivery is structured and evaluated while we recommend strategies to improve interprofessional collaboration for eol conversations be targeted at the structural level our data does highlight some possible gaps in knowledge about eol conversations for nurses and allied health clinicians for example when asked about what to discuss during eol conversations nurses and allied health clinicians rarely mentioned the importance of exploring patients understanding of their illness and using patients goals to guide decisionmaking some resources could be directed at clarifying scopes of practice in relation to eol conversations and providing instruction on how to engage in robust eol goalsofcare and decisionmaking discussions in primary care neoliberalbiomedical logics are present in the way clinicians roles and responsibilities are governed in primary care with the work of physicians and nurse practitioners being organized as central to all patient care and nurses and allied health clinicians being mandated to provide episodic care with little longterm relationship development with patients structuring care this way supports biomedical effectiveness and efficiency neoliberalbiomedical logics are also present at the practice level with nurses and allied health clinicians being less involved in decisionmaking about patient care and ownership of care hierarchies between clinicians from different disciplines is well documented especially between nurses and physicians 47 there is a long history of medicine expecting obedience from nursing with nurses being expected to act as physicians eyes and hands 4748 nurses have often been treated as physicians assistants who perform manual labour at the direction of physicians rather than having their own practice forms of knowledge and expertise 4849 a similar disregard for the expertise of social work and occupational therapy exists with their knowledge base and clinical effectiveness often being questioned within interprofessional medical teams 50 despite policy shifts towards interprofessional collaboration in the provision of primary care physicians often remain the de facto leaders of these teams a trend that disrupts collaboration with little evidence to support this hierarchy 44 to curb biomedical dominance in primary care foster collaboration and embrace overlapping roles changes to funding and governance are needed 5152 we argue that for primary care nurses and allied health clinicians to become involved in eol conversations their expertise needs to be valued they need to be equal members of the team who share in decisionmaking about what care is needed have professional autonomy and be able to develop longitudinal trusting relationships with patients other research outside of primary care supports our findings research has found that to support eol conversations nurses and allied health clinicians should be integral members of the team who share responsibility for making decisions about patients care 5354 a lack of shared decisionmaking disrupts the ability of nurses and allied health clinicians to use their expertise which often involves a more holistic approach that can be helpful during eol conversations 8 53 54 55 our analysis is also consistent with research that suggests nurses and allied health clinicians need to form trusting and ongoing clinicianpatient relationships to facilitate personcentred eol conversations 853 this was not possible at our study site due to the organization of work that inhibited participation in longitudinal care without sufficient knowledge of the patients clinicians are less equipped to engage in eol conversations because of a lack of understanding of patients illness history and trajectory and needs around eol 2755 all patients do not require an interprofessional approach but complex older patients do we recommend primary care teams clarify nurses and allied health clinicians roles in eol conversations and ensure teams are aware of and supportive of these roles to facilitate involvement in this practice and potentially increase the quality of care for these patients 275455 however we also argue that without addressing the influence of neoliberalbiomedical logics on the organization and delivery of care nurses and allied health clinicians will likely continue to be excluded from this practice most studies examining interprofessional collaboration have done so at the micro interpersonal level ignoring the structurallevel characteristics that impact collaboration 4651 our findings underscore the importance of analysis of structural characteristics as well as dominant ideologies and their influence on collaboration while there may be strategies at the practice level to support team collaboration in primary care such as regular team meetings sharing responsibility for patient care role clarity and nonhierarchical team building 3756 we believe these strategies are less impactful if governing logics are left unexamined and unchanged bourgeault mulvale 51 suggest the caring work of nonmedical primary care clinicians such as nurses social workers and occupational therapists who promote wellbeing fulfilling occupations and coping among other things is less valued because its outcomes are more challenging to quantify than biomedical work 182144 we found this marginalization and devaluing of the work of nurses and allied health clinicians in our study in the way the clinic was organized to allow physicians and nurse practitioners to control who provides care and how which resulted in nurses and allied health clinicians having limited involvement in patient care including in eol conversations these findings point to the importance of examining and modifying primary care quality indicators in ways that value the work of all team members and patientcentred care another reason biomedical dominance remains entrenched in primary care includes funding models shaped by neoliberalism 2257 within neoliberal reforms funding priorities are often focused on managing chronic illness reducing cost by reducing hospital admissions and supporting physicianowned primary care practices 17182257 primary care clinics funding is often controlled by incorporated businesses governed by a physicianboard that makes organizational and service delivery decisions 58 research from ontario where our study took place has linked funding agreements such as those of family health teams to decreased interprofessional collaboration and minimal delegation of tasks to nurses and allied health clinicians 52 we recommend primary care teams interested in cultivating team collaboration examine the influence of funding models and work to make meaningful changes that support more collaboration for complex patient care including eol conversations in canada and internationally research has examined how neoliberalbiomedical logics govern healthcare policy institutional governance and direct care in a variety of areas such as eol care maternal care womens health addiction care public health emergency services and primary care 1722 59 60 61 what our study adds to this scholarship is the way neoliberalbiomedical logics limit collaboration in interprofessional primary care teams specifically in the area of eol conversations this is a novel and important finding because it helps to explain why taking an individuallevel approach to addressing the challenge of delayed or avoided eol conversations specifically by educating nurses and allied health clinicians about how to facilitate eol conversations 132862 is unlikely to result in practice change this is because nurses and other allied health clinicians are embedded in a biomedical culture that prioritizes biomedical effectiveness biomedical dominance and efficiency until and unless these are addressed individuallevel solutions will fall short of achieving real change limitations to protect anonymity data from nurse practitioners and physicians were grouped together while these two types of clinicians have similar roles at the study site there are differences in the organization of their work that is not captured in our findings future research could focus on nurse practitioner led clinics to further explore this groups experience facilitating eol conversations additionally we were unable to determine the participants level of training in eol since clinicians attended schooling at various times in various geographical locations making it impractical to review the curriculum each participant received in eol care and interprofessional collaboration finally our study site was an urban academic medicare funded primary care team located within a health science centre while not generalizable our detailed description of the setting participants and interactions support transferability to other contexts conclusion our findings suggest primary care nurses a social worker occupational therapist and physiotherapist have the knowledge skills and inclination to engage frail older adults in eol conversations however they are constrained in their ability to do this by specific patterns of relating that are shaped by neoliberalbiomedical logics operating at the structural organizational and practice level our study highlights the way these governing logics restricts interprofessional collaboration in primary care by shaping the distribution of tasks and roles in such a way that limits nurses and allied health clinicians engagement in eol conversations it is our hope that this study inspires future practice change research to improve interprofessional collaboration and eol conversations by reimagining funding models and performance indicators in primary care that fully support meaningful interprofessional personcentred care for complex frail patients abbreviation eol endoflife authors information this research study is one part of dr carters doctoral dissertation competing interests the authors declare no competing interests	context interprofessional collaboration is recommended in caring for frail older adults in primary care yet little is known about how interprofessional teams approach endoflife eol conversations with these patients objective to understand the factors shaping nurses and allied health clinicians involvement or lack of involvement in eol conversations in the primary care of frail older adults methodssetting a critical ethnography of a large interprofessional urban family health team in ontario canada data production included observations of clinicians in their daytoday activities excluding direct patient care onetoone semistructured interviews with clinicians and document review analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice participants interprofessional clinicians n 20 who cared for mildly to severely frail patients clinical frailty scale at the family health teamfindings suggest primary care nurses and allied health clinicians have the knowledge skills and inclination to engage frail older adults in eol conversations however the culture of the clinic prioritizes biomedical care and normalizes nurses and allied health clinicians providing episodic taskbased care which limits the possibility for these clinicians engagement in eol conversations the barriers to nurses and allied health clinicians involvement in eol conversations are rooted in neoliberalbiomedical ideologies that shapes the way primary care is governed and practicedour findings help to explain why taking an individuallevel approach to addressing the challenge of delayed or avoided eol conversations is unlikely to result in practice change instead primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients including eol conversations
introduction for some decades ageing in europe causes serious political concerns on wellbeing and social participation of old citizens as well as on care for the old and personnel to take care for them these concerns increased due to the economic crisis of 2008 and are related health and need for care affect wellbeing and social participation and vice versa 1 2 3 4 therefore in most european countries policy measures were proposed and taken to influence consequences of the economic crisis and ageing 56 measures included new pension regulations changing arrangements for longterm care and for access to social services but the effects of such measures on society and life of citizens are unknown this study explores which societal measures related to the economic crisis and ageing may have affected the life satisfaction of older citizens understanding the effect of such measures on life satisfaction of older citizens could inform policymakers about future measures to get a better life for old citizens 7 research on quality of life and life satisfaction focuses mainly on individual determinants such as age income marital status health status physical limitations social contacts and social participation of citizens whose determinants mostly show a statistically significant relationship with life satisfaction 8 9 10 11 12 besides individual characteristics the context in which people live should be taken into account because life satisfaction is strongly context related and also depends on social comparison 1314 therefore some researchers argue to use vignettes to assess life satisfaction to correct for the socalled differential item functioning a bias in selfreports caused by differences in personal and sociocultural context 15 although a useful method it does not take into account societal changes over time including cohort effects affecting life satisfaction 1617 societal changes may have a wide effect that is influencing the life of many people in various countries while others have an effect on people living in specific regions or countries comparative studies between countries have shown the influence of specific factors such as national income age composition life expectancy and welfare provisions on life satisfaction at societal national level 18 19 20 21 such studies may show how data on wellbeing can help policymakers identify the groups and countries that are bearing the brunt of the economic crisis as well as those that are holding out better than expected and provides a new layer of evidence to aid policy decisions 20 comparative research on life satisfaction worldwide shows a ushape between life satisfaction and age supposing a major influence of ageing itself young age groups show relatively high life satisfaction which decreases in middle age groups but increases again in older age groups 122223 such ushape is found to be rather consistent 24 but it does not apply to all countries 32526 indicating that specific events or societal changes may affect it in different ways this may also apply to the economic crisis starting in 2008 therefore our premise is that this economic crisis has affected the ushape relationship between age and life satisfaction in european countries the first research question is has this ushape changed and if so in which direction and in which european countries the second research question is which societal conditions changed by measures due to the economic crisis of 2008 are related to life satisfaction of older citizens in europe we focus on older citizens because these citizens may be more vulnerable to such societal changes and therefore are an important target group for policy measures 3 to answer the second question one has to look at differences in changes between countries 20 analyses on life satisfaction at nationalcountry level use standardised national data age dependency ratio or life expectancy and aggregate individual data a comparative study of 27 european countries describing changes in a full range of subjective wellbeing between 2007 and 2011 in all adult citizens shows that gdp and percentage of people with disabilities are related to wellbeing however subjective wellbeing over time increased marginally and did not apply to all countries indicating that national policy or culture may make a difference 20 although it was expected that the economic crisis of 2008 would show some effect on life satisfaction one may argue that the time frame was too short to see such effects a recently published study analyses changes in life satisfaction in 24 european countries between 2002 and 2012 also taking into account recent mainly income related societal changes including the economic crisis of 2008 21 income related indicators do affect life satisfaction mostly but their effects are not uniform over european countries however it was stated that economic crises tend to be followed by crises in happiness our study focuses on more detailed changes like change in life expectancy pension health status and quality of care that is especially on changes important for older people methods to see effects of policy measures related to the 2008 crisis on life satisfaction one has to wait till such measures are implemented in practice and experienced by citizens therefore we use the time frame between 2006 and 2014 and assessed indicators two years before the crisis was started and two years after the measures taken were fully implemented based on former mentioned studies we selected societal indicators on demography on welfare and on health the research design combines changes in societal indicators over time with a comparison between countries to analyse which changes in national indicators affect life satisfaction of old citizens in 2013 the data are based on representative samples in each country like the data on life satisfaction or subjective health or on official national statistics collected by eurostat or oecd life satisfaction is assessed as the degree to which an individual judges the overall quality of his life to be scored on a 10point scale between not satisfied at all and fully satisfied using data of the eusilc ahm 2013 study 12 to answer the first research question life satisfaction of different age groups in 31 european countries is compared to answer the second research question we selected the following indicators to measure societal conditions as independent variables demographic indicators old dependency ratio 27 and life expectancy at birth 28 welfare indicators of gdp for social protection 29 of gdp for longterm care 30 and aggregate replacement ratio an indication for gross pension for 6574 years old as compared to gross earnings of 5059 years old 31 health indicators people with very good subjective health 32 of longstanding illnesses 33 and of selfreported unmet needs in health care 34 spss 23 is used for data storage and analysis analysis first we present the average life satisfaction of adult citizens in 31 european countries in 2007 and 2013 next the relationship between age and life satisfaction in 31 european countries in 2013 is described that is is a ushape present the relationship between mean life satisfaction and age in 2014 is described for the following age categories 1624 2534 3549 5064 6574 and 75 and over we ranged countries in four figures next the existence of statistically significant differences in mean life satisfaction of older citizens as compared to adult citizens will be tested for 2007 and 2013 mean paired sample test for analysis of variance is used to test the difference in life satisfaction between adult citizens till 65 years and citizens 65 years and over before answering the second question do changes in demographic welfare and health indicators between 2006 and 2014 affect life satisfaction in older citizens in 2013 we present the data of the eight independent indicators 234 next bivariate pearson correlations between differences in mean life satisfaction of citizens between 16 and 65 years versus 65 years and older and the independent indicators in 2014 are described the mean differences of the eight indicators for 2006 and 2014 are calculated per country and tested on statistical significance significant differences are described in the last analysis step the influence of these mean differences in indicators on life satisfaction of older citizens in 2013 is assessed using linear regression analysis and enter method with collinearity tested results the mean life satisfaction scores for all citizens in 2007 and 2013 in the 31 countries are about the same 70 and 71 respectively overall the tendency is that life satisfaction decreased in western european countries and increased in centraleastern european countries however some considerable differences exist between countries mean life satisfaction decreased with at least 05 points in cyprus denmark estonia and malta but increased with at least 05 points in austria hungary latvia and romania the relationship between age categories and mean life satisfaction per country shows that a ushape does not dominate in 2013 the majority of countries show a declining line in life satisfaction from young citizens to old citizens twelve countries show more or less a ushape the declining gradient between age and life satisfaction is most notable in bulgaria croatia greece latvia portugal and romania in denmark switzerland sweden norway and ireland citizens in the age group 6574 score highest in life satisfaction where score declines in the 75 years and over age group with the exception of switzerland an increase in life satisfaction at 75 years and over is only found in iceland no statistically significant difference in mean life satisfaction is found between the two age groups in 2007 the mean score on life satisfaction in 2007 applies for both age groups that is 70 the mean life satisfaction for citizens till 65 years is 72 in 2013 and for citizens of 65 years and over 69 analysis of variance of mean life satisfaction scores between adult citizens of 16 to 65 years and those 65 years and over in 2013 shows a statistically significant difference that is for old citizens the mean life satisfaction is significantly lower in 2013 in 2013 mean differences in life satisfaction are strongly decreased in older citizens in romania bulgaria croatia greece lithuania portugal slovenia and slovakia as compared to not old citizens increase of mean life satisfaction in current gerontology and geriatrics research older citizens as compared to young ones is rare but occurs in denmark and ireland the difference in mean life satisfaction between 2007 and 2013 is due to lower life satisfaction in older citizens in 2013 before answering the second research question we present the mean or proportional scores for each indicator of societal change per country the demographic indicators show an increase in the old age dependency ratio in all countries as well as in life expectancy at birth between 2006 and 2014 the welfare indicator of gdp on social protection increased in all but two countries this increase was relatively strong in cyprus denmark finland greece ireland netherlands and spain the welfare indicator gdp on longterm care expenditure stayed on average the same in 2006 compared to 2014 the only decrease was in romania a strong increase occurred in finland and norway the aggregate replacement ratio increased slightly between 2006 and 2014 in most european countries but not in austria estonia germany italy and sweden a quarter of citizens in the 31 european countries reported very good health in 2006 and in 2014 on average there is a slight decrease between 2006 and 2014 the score of this health indicator varies strongly between countries with low scores in estonia latvia lithuania and portugal and high scores in cyprus greece iceland and ireland a strong decrease in subjective health is reported in denmark and finland the average proportion of longstanding illnesshealth problems stayed about the same between 2006 and 2014 in the 31 countries as did the proportion of selfreported unmet needs for they were too expensive longstanding illnesshealth problems were more frequently reported between 2006 and 2014 in austria cyprus greece malta and portugal and less reported in bulgaria and luxembourg selfreported unmet needs in 20062014 increased strongly in greece ireland iceland and italy and decreased strongly in bulgaria germany lithuania poland and romania the relationship between the mean scores of the eight societal indicators in 2014 and difference in life satisfaction between both age groups in 2013 is explored by pearsons correlations older citizens with higher life satisfaction as compared to younger ones live in countries which have a high life expectancy at birth which spend a high percentage of their gdp on social protection and longterm care in 2014 and have a high percentage of citizens in very good health next it is analysed which societal indicators changed significantly between 2006 and 2014 the following indicators show significant mean changes between 2006 and 2013 old dependency ratio life expectancy at birth gdp social protection and longstanding illnesses in 31 european countries the old dependency ratio increases on average with 3 points between 2006 and 2014 the life expectancy over 2 years on average the percentage of gdp spent on social protection with 3 and the percentage of longstanding illnesses increased with almost 2 no significant mean differences between 2006 and 2014 are found for of gdp spent in longterm care aggregate replacement ratio the of very good subjective health and of unmet needs in health care regression analysis with life satisfaction of older citizens in 2013 as dependent variable and mean differences in the eight indicators as independent variables shows that four indicators statistically significantly contribute to explaining the level of life satisfaction in older citizens explaining 38 of the variance low life satisfaction of older citizens in 2013 occurs in countries where life expectancy decreased as well as financial means for social protection and longterm care in countries where the percentage of unmet needs in health care between 2006 and 2014 increased older citizens show low life satisfaction in 2013 discussion life satisfaction of older citizens in europe is significantly decreased in 2013 as compared to younger age groups such a difference has not been found before that is in 2007 or 2003 2035 it is interesting to note the overall tendency that life satisfaction decreased in western european countries and increased in centraleastern european countries but it seems that in the later countries younger age groups are more satisfied as compared to older ones the former found that 1 therefore it is important to look for the dynamics of these conditions on aggregate level to investigate the influence of policy measures on life satisfaction as stated in the third quality of life survey in europe 20 our study shows that significant changes in societal indicators related to the ageing of the population in combination with the economic crisis occurred in european countries between 2006 and 2014 relatively less investment in social protection and longterm care affected negatively life satisfaction of older citizens as did decline in quality of care the second quality of life survey in europe showed that material deprivation and health status were the most important influences on life satisfaction at individual level 35 our outcomes suggest that also policy measures taken at national level affect life satisfaction of the most vulnerable citizens like old citizens directly however this applies especially in countries which already have a backlog in economics and welfare many centraleastern european countries have arrears in social protection and quality of care as compared to more prosperous northwestern european countries with longstanding social welfare provisions therefore in these countries older citizens show more frequently a lower life satisfaction as compared to young and middle aged citizens as all studies our study has shortcomings most evident is that not all theoretically possible indicators for societal changes could be included because of the limited indicators in international data bases the same goes for the time period the time period is partly determined by the available data in specific years nevertheless we have argued that the chosen years 2006 and 2014 are adequate in 2006 a financial crisis was not discussed or visible in 2014 the policy measures were implemented and people were confronted with the consequences especially older citizens because of intervention in welfare and care facilities a strong point of the study is that the collected data are comparative not only in time but also in method of data collection and in validity of the measurements for international comparative research data from eurostat or oecd are reliable valid and free available most studies on life satisfaction and ageing use individual indicators as explaining factors to understand variance in life satisfaction 2035 rather innovative is that we use aggregate indicators on national level including 31 european countries to understand changes in life satisfaction in older citizens based on this study we conclude that life satisfaction of old citizens deteriorated related to policy measures taken because of the economic crisis of 2008 and ageing of the population in europe these measures have changed various societal conditions negatively nevertheless some societal indicators show that social conditions clearly improved in some countries but others got worse for example the percentage of reported unmet needs decreased significantly in bulgaria lithuania romania poland and estonia between 2006 and 2014 but it is not said that old citizens profited most in ireland greece italy iceland and belgium unmet needs in health care were more often reported based on our analysis we believe that the rudimentary structure of health and welfare provisions in various centraleastern european countries still were too vulnerable to cope with the imposed policy measures and not because of attitudes or belief systems 18 at the same time it should be stated that knowledge and understanding on how societal processes and policy measures affect quality of life of citizens are limited theoretical development is still poor especially when it comes to the interaction between policy measures societal changes and individual preferences and behaviour international comparative research based on sound theoretical concepts is strongly needed conflicts of interest the authors declare that there are no conflicts of interest submit your manuscripts at stem cells international hindawi	objectives ageing of societies causes serious political concerns on wellbeing of old citizens and care for the frail old these concerns increased with the economic crisis of 2008 in european countries policy measures were taken to deal with the consequences of this crisis this study explores the possible effects of these measures on life satisfaction of older citizens methods life satisfaction was assessed through international surveys in 2007 and 2013 and changes in societal conditions using eight indicators on demography welfare and health are assessed in 31 european countries in 2006 and in 2014 data are standardised and based on official national surveys and statistics results the former found that ushape relationship between age and life satisfaction disappeared after the crisis negative changes in social protection and care arrangements taken after the economic crisis are related to low life satisfaction in old citizens conclusions various societal conditions deteriorated in 2014 as compared to 2006 policy measures taken due to the 2008 economic crisis have changed societal conditions and affected life satisfaction of older citizens negatively in countries with a rudimentary structure of health and welfare provisions old citizens could not cope with the imposed policy measures
background socioeconomic position throughout life is usually inversely associated with morbidity and mortality from cardiovascular disease although the underlying biological pathway is not entirely clear 12 cardiovascular disease has been associated with higher levels of inflammatory molecules perhaps as a consequence of exposure to pathogenic organisms 3 although it is unclear whether pathogen burden mediates sep differences in cardiovascular risk 34 poor early life conditions are usually associated with higher levels of inflammatory markers 5 6 7 8 9 10 11 and poorer adult immune function 1213 these associations are less clear however amongst men from middle income countries 10 furthermore little is known about the association of sep across the life course with immune function the duration or number of exposures across the life course may be most important 14 alternatively the timing of exposure to poor socioeconomic conditions may be crucial as a number of sensitive periods or simply as a single critical period it is also possible that either interor intragenerational social mobility plays a part developmental tradeoffs between growth maintenance and reproduction may occur when there are competing demands for energy resources between biological systems 131516 potentially at the expense of immune function in resourcepoor environments alternatively intergenerationally and environmentally driven upregulation of the gonadotropic axis with economic development may obscure some of the normally protective effects of social advantage in the first few generations of men to experience better living conditions 1718 thus generating epidemiologically stage specific associations between sep and immunerelated functions such as proinflammatory states among men 1819 rapidly developing megacities of china may provide a sentinel for the changes in noncommunicable diseases expected with economic development and inform effective interventions to reduce the disease burden in a large sample of older residents from one of the most developed megacities in china guangzhou in southern china we assessed the association of sep at four life stages with proxies of inflammation and compared models representing the accumulation sensitive periods and critical period hypotheses additionally we hypothesise that 1 higher life course sep is protective for adult inflammation 2 the normal protective effect of social advantage is obscured in men experiencing rapid socioeconomic development methods sources of data the guangzhou biobank cohort study is a collaboration between the guangzhou no 12 hospital and the universities of hong kong and birmingham the study has been described previously in detail 20 participants were drawn from the guangzhou health and happiness association for the respectable elders a community social and welfare association unofficially aligned with the municipal government where membership is open to anyone aged 50 years or older for a nominal monthly fee of 4 yuan approximately 7 percent of permanent guangzhou residents aged 50 years or more are members of the ghhare eleven percent of the members were included in this study who were capable of consenting were ambulatory and were not receiving treatments which if discontinued might have resulted in immediate lifethreatening risk such as chemotherapy radiotherapy or dialysis those with less serious chronic illnesses or with acute illnesses were not specifically excluded from the study though they may have been less likely to attend participants were recruited in three phases and this study includes participants recruited in phase 3 only because only phase 3 has detailed information on childhood socioeconomic position and inflammatory markers participants underwent a detailed halfday medical interview as well as a physical examination with fasting blood being sampled quantitative haematological analysis was performed using a sysmex kx21 haematology analyser the guangzhou medical ethics committee of the chinese medical association approved the study and all participants gave written informed consent prior to participation socioeconomic position across the life course we used indicators of sep at four life stages childhood early adult late adult and current sep childhood sep was measured by an index of notable parental possessions that were appropriate to china in the mid20th century based on sociologic accounts of life in southern china at that time 17 the items selected were a watch a sewing machine and a bicycle these items were categorized as previously as none or at least one 21 as in other similar studies we used education and longestheld occupation as proxies for early and late adult sep 22 early adult sep was assessed from the highest level of education occupation was categorised as manual or nonmanual current sep was assessed from household income per head household income was recorded in six categories household income per head was estimated using the midpoint of each income category and assuming that those in the highest category had an annual income of 75000 yuan the median household income per head was used as the cutoff point between low and high sep outcome measures the primary outcome was total white blood cell count used as in other studies as a marker of a proinflammatory state 5 and less well functioning immune system as we do not have a detailed breakdown of different white blood cell types such as macrophages we also considered granulocyte and lymphocyte counts as outcomes because these immune cell subpopulations largely relate to innate and adaptive immunity respectively they have previously been used as markers of inflammation 2324 other measures of inflammation were not available statistical analysis multivariable linear regression was used to assess the adjusted associations of sep with the outcomes following mishra et al 25 we determined the most parsimonious representation of life course sep by comparing models for three different life course hypotheses to a fully saturated model which represents all possible life course sep trajectories as in previous work 26 the accumulation hypothesis was represented by a model representing the number of life stages with high socioeconomic position and the sensitive periods hypothesis by a model in which all four measures of sep were considered as separate items in one model adjusted for all four measures of sep the critical period hypothesis was represented by models in which only one sep exposure was included 25 we used the akaike information criterion to compare models 27 a smaller aic indicates a better model we examined whether the outcomes had different associations with sep by sex or age from the heterogeneity across subgroups and the significance of an interaction term obtained from a model including all interaction terms with age or sex all models were adjusted for age and sex a second set of models was additionally adjusted for lifestyle factors as potential mediators and a third set of models additionally adjusted for body mass index as a potential mediator proxies of sep were unavailable or unclassifiable for 287 of the participants mainly because information on household income or the longestheld occupation was missing alcohol use or smoking was not available for 2 of participants we used multiple imputation for missing data 2829 socioeconomic position at any stage alcohol use and smoking were predicted based on a flexible additive regression model with predictive mean matching incorporating age sex leg length seated height alcohol use smoking status physical activity and sep at the other three stages 28 we imputed missing values 10 times and analysed each complete dataset separately then summarized estimates with confidence intervals adjusted for missing data uncertainty 30 as a sensitivity analysis a complete case analysis without imputation was performed we used stata version 100 and r version 2122 for analysis imputation and model estimation results of the 10088 phase 3 participants examined 11 had missing data for total white blood cell granulocyte or lymphocyte counts analysis was based on the remaining 9981 participants there were more women than men and the women were younger mean age 592 years than the men mean age 631 years overall the mean white blood cell and granulocyte counts were lower in women than men the associations of sep with white blood cell granulocyte or lymphocyte counts did not vary with age however associations of sep with lymphocyte count varied with sex so only sex stratified results have been presented for this outcome for white blood cell count and granulocyte count the sensitive periods model performed better than the fully saturated model accumulation or critical period models the sensitive periods model shows that some life stages had stronger negative associations than others with white blood cell count and granulocyte count the early adult stage had the strongest association for both outcomes the pattern for lymphocyte cell count was somewhat different associations varied by sex table 3 shows that for both sexes the accumulation and sensitive periods models did not perform as well as critical period models the early adult life stage was a critical period for women with a negative association between sep and lymphocyte cell count by contrast for men all estimates of association between sep and lymphocyte cell count were positive although all confidence intervals included zero additional adjustment for lifestyle factors attenuated estimates slightly but the pattern of associations generally remained the same smoking among men is associated with both low sep and higher lymphocyte count hence adjustment for smoking strengthened the positive association of sep with lymphocyte count further adjustment for bmi produced very similar results estimates of association were little changed all results were similar in a complete case analysis discussion consistent with other studies in developed and developing settings examining the association between sep and inflammation 5 6 7 8 9 10 11 we found that sep was negatively associated with adult immune cell numbers particularly among women consistent with the only other study from a developing country setting the advantage of higher sep for adult inflammation was less marked among men 10 in general considering sep at all four life stages was better than considering individual life stages except for lymphocyte cell counts this study has a number of strengths to our knowledge it is the first study to investigate the role of life course sep in later adulthood inflammation in a nonwestern developing setting moreover we explicitly determined the most parsimonious representation of life course sep the large sample size allowed sexspecific analysis nevertheless there are limitations first it is a crosssectional study with recalled sep which may be imprecise although most likely nondifferential second in a crosssectional design reverse causality must be considered although it is unlikely that inflammation has a causal effect on life course sep third there may have been gender bias in the allocation of resources within families most likely favouring boys and men which may have mitigated the disadvantages of low sep however it is unclear why this should have mitigated the effect of sep for lymphocytes but not for white blood cells and granulocytes fourth our cohort may not be fully population representative however prevalence of certain morbidities such as diabetes were similar to those in a representative sample of urban chinese 31 fifth survivor bias is possible which may have limited participants socioeconomic and health diversity biasing results towards the null if survivorship were an issue we would have expected differences in associations by age of which there was no evidence sixth we did not explicitly consider the life course effects of social mobility since these are particularly hard to define and test clearly interand intragenerational mobility upward and downward mobility are all potential risk factors seventh a single measurement of white blood cells and differential cell counts may not accurately reflect longterm immune function or inflammation however white blood cell count is used as a marker of immune status in clinical settings and is a wellestablished and routinelyused marker of systemic inflammation 32 white blood cell count is associated with disease risk and predicts disease outcome 3334 eighth although we report associations between sep and differential white blood cell counts clinical significance remains to be determined within the normal range elevated white blood cell counts are associated with risk factors for chronic diseases such as cardiovascular disease 3235 white blood cell counts can be conceptualised as a mixed marker of exposure and response even a relatively small shift towards a healthier inflammationimmunological profile might have significant public health benefits at the population level 3334 ninth acute infection trauma and underlying chronic disease or medication could be mediators there is no evidence to suggest that participants were experiencing infection during the assessment process nor significant trauma although only those with lifethreatening illness were specifically excluded those experiencing significant acute infection or trauma were less likely to attend this study which should have minimized any bias from this source we also performed descriptive analysis of the data to detect and exclude outliers which may have resulted from unknown underlying disease medication or recording error one possible explanation for the association of low sep with inflammation is via current health behaviour linked to inflammation 5 36 37 38 although we did not perform formal tests of mediation we did adjust for smoking alcohol consumption physical activity and bmi in separate models which had little effect among women but among men this attenuated the negative association of early adult sep with white blood cell and granulocyte counts and strengthened the positive association of early adult sep with lymphocyte counts this suggests that any associations are unlikely to be driven by adult health behaviour in women though these may obscure negative associations of early adult sep with inflammatory markers in men low sep may increase exposure to proinflammatory agents such as microbial pathogens pollutants or adverse work conditions mechanisms for increased exposure or vulnerability to pathogens in low sep groups include earlier andor greater lifetime exposure due to adverse living conditions such as overcrowding and increased susceptibility to primary infection through nutritional deficiencies or stressrelated immune dysfunction 3 a gender bias may have protected low sep men from such exposures and adverse work conditions although it is not clear why the effects should be most obvious for lymphocytes lower birth weight amongst those with low childhood sep is another possible explanation but birth weight is not available for our participants birth weight is inversely associated with inflammatory markers 639 however birth weight appears to be less relevant in developing country settings such as ours 40 and there is no reason why birth weight should have sexspecific effects on some white cell subtypes an alternative explanation is that better early life conditions would be expected to promote development of the adaptive immune system particularly of the thymus 41 whose development takes place in early life 41 and which is sensitive to malnutrition micronutrient deficiencies and infections during growth and development 42 43 44 moreover the same exposure would also allow upregulation of the gonadotropic axis resulting in sexspecific effects on some immune cell subpopulations 45 46 47 particularly those relating to adaptive immunity consistent with this mechanism we have previously observed similar sexspecific associations in the guangzhou biobank cohort study of childhood stress with white cell count 48 and of childhood diet with lymphocytes but not granulocytes 19 however we do not have measurements that would allow proof of this mechanism conclusions socioeconomic position was inversely associated with white blood cell differential counts as a marker of inflammation with a clearer and more consistent association among women than men environmentally and intergenerationally driven changes to the gonadotropic axis may obscure the normally protective effect of social advantage in the first few generations of men but not women to experience better living conditions given the links between the immune system inflammation and chronic disease this provides a biological mechanism between sep and the pathophysiological genesis of chronic disease understanding such mechanisms for populations experiencing the epidemiological transition is of public health significance competing interests the authors declare that they have no competing interests	background socioeconomic position sep throughout life is associated with cardiovascular disease though the mechanisms linking these two are unclear it is also unclear whether there are critical periods in the life course when exposure to better socioeconomic conditions confers advantages or whether sep exposures accumulate across the whole life course inflammation may be a mechanism linking socioeconomic position sep with cardiovascular disease in a large sample of older residents of guangzhou in southern china we examined the association of life course sep with inflammation methods in baseline data on 9981 adults ≥ 50 years old from the guangzhou biobank cohort study 200608 we used multivariable linear regression and model fit to assess the associations of life course sep at four stages childhood early adult late adult and current with white blood granulocyte and lymphocyte cell counts results a model including sep at all four life stages best explained the association of life course sep with white blood and granulocyte cell count for men and women with early adult sep education making the largest contribution a critical period model best explained the association of life course sep with lymphocyte count with sexspecific associations early adult sep was negatively associated with lymphocytes for women conclusions low sep throughout life may negatively impact late adult immuneinflammatory status however some aspects of immuneinflammatory status may be sensitive to earlier exposures with sexspecific associations the findings were compatible with the hypothesis that in a developing population upregulation of the gonadotropic axis with economic development may obscure the normally protective effects of social advantage for men
introduction south african today remains a nation torn by violence and racial inequity one of major challenges for its people is to create new futures across historically constituted racial divides by finding ways to engage with each other across difference in this regard multilingualism holds out the promise of offering a way of bridging difference and opening spaces for engagement and empathy with others however our point in this paper is that multilingualism has always been and remains today an epistemic site for managing constructed racialized diversity contemporary constructs of multilingualism both in policy and everyday practice continue to reinforce racialized divisions inherited from historical uses of language as a tool of colonialism and a mechanism of governmentality in apartheid the system of exploitation and state sanctioned institutional racism in order to illustrate this we trace in section 2 the ways in which constructs of multilingualism are entwined with racialization as a building block of south african imaginary in section 3 we focus particularly on present day constructs practices of multilingualism that centre decoloniality social transformation equitable education and livelihoods and that encapsulate a dynamics of a society in transformation in this context we discuss tensions in racialized multilingualism as well as the limitations inherent in inherited constructs of multilingualism for new modes of coexistence across racialized differences we suggest that at the present time there a few opportunities for scoping a more constructive understanding of multilingualism within the prevailing discourses of liberal enlightenment views of language and race by way of conclusion we suggest that alternative linguistic orders require a decolonial rethinking of the role of language in epistemic social and political life senses of multilingualism the current official account of multilingualism in south africa since the democratic dispensation in 1996 delimits 11 official languages among a population of 56 million this representation of multilingualism is the democratic states recognition and repatriation of the indigenous languages that were not accorded official recognition by apartheid but relegated to bantustans however it is one conceptualization of multilingualism among a multitude as the south african multilingual landscape has been construed and represented variously at different historical moments as diverse representations and values of languages and their relationships have emerged out of turbulent moments of social and political change in particular it is an attempt to linguistically articulate the image of the rainbow nation different multilingualisms reflect the complex sociopolitics of colonialism and apartheid the state sanctioned and institutionalized system of racial segregation as well as the countrys postapartheid democratic dispensation since 1994 above all multilingualism has been part of the many attempts of the state and its institutions throughout history to manage racialization a foundational pillar of its design marx remarks on how the state emerges as a central actor in racemaking as it is the subject of contestation and responds to various challenges from the society in which is is embedded and that racial identities … do not quickly fade even if the conditions that reinforced them changed in south africa as the nationstate has engaged with the turbulence of change different notions of race have superseded each other rasool remarks on the south african peoples long histories of racialization of enracement deracement and retracement across all of these conjunctures reorganizations and turbulent shifts of state and race multilingualism has served as the epistemic space and semiotic articulation of different racialized normative orders we can distinguish 4 distinct periods reflected in ideologies of multilingualism that roughly correspond to major shifts in the politics and economy of the country colonialism apartheid the negotiated settlement and the democratic dispensation we trace underlying structuralideological similarities across seemingly different constructs of multilingualism and attempt to identify the subtext of parallel emerging ideologies of multilingualism yet to be clearly articulated colonialism colonial understandings of languages and their speakers were an integral part of managing the colonialimperial encounter in all essentials european constructs of language and linguistic diversity were mapped onto the linguistic space of colonized africa the historian © stroud richardson and cmdr 2021 patrick harries notes with respect to missionary linguistic activity with the language tsonga in the transvaal province in the north east that many of the linguistic givens and truths believed by the swiss missionaries to be scientifically incontrovertible were in fact social constructs whose roots may be traced to nineteenthcentury european codes of thought one such truth was the mapping of languages onto bounded units of organization such as tribes and clans these were european prefeudal notions of social organization that allowed the missionaries to categorize and efficiently manage people on terms they themselves were best acquainted with from their own contexts similarly colonizers used european paradigms models of historical migration and mixture of peoples and their languages to account for what they understood to be unbridled linguistic hybridity and chaotic diversity of the african linguistic ecology the missionaries found ready categorizations of the cultural traits and spirit of their tribes by mapping them onto a francogerman rivalries model where for example zulus were likened to germans as ferocious but industrious one consequence of this was the production of an imaginary of shared ancestral languages across tribes made distinct through separation and warfare but possible to reclaim through tools of historical reconstruction veronelli refers to the notion of the coloniality of language as the coloniality of power in its linguistic form a process of dehumanization through racialization at the level of communication coloniality refers to the patterns of power control and hegemonic systems of knowledge that continue to determine forms of control and meaning across social orders even subsequent to colonialism as a social military or economic order the other axis of coloniality is modernity the specific organization of relationships of domination the colonialitymodernity nexus that undergirds south african policies and practices of racialized multilingualism from colonialism until today apartheid building from earlier institutional and structural conditions2 racial segregation as an allencompassing design of south african society was formally introduced with the election of the national party in 1945 apartheid was about structural and institutionalised racism through the implementation of judicially upheld racially discriminatory policies for example the prohibition of mixed marriages act 1949 from the 60s to the 80s apartheid was best known in its guise of the group areas act which reserved prime land for whites and forcibly removed other races to peripheral areas the apartheid idea of racial purity and national homogeneity found a potent resonance in the politically engineered cultivation of language and multilingualism as racial bordering a massive investment in distinguishing people and languages following the european nationstate principle of one volk one nation one language because of the aversion of afrikaners to entertaining a conceptualization of afrikaans as the result of a cross between the speech of the early settlers and the prattle of their black slaves language planning of afrikaans was organized around three principles diachronic purism that is the idea that afrikaans is as multilingualism as racialization © stroud richardson and cmdr 2021 white and pure as the race albocentrism the stance that only the versions of the language spoken by whites could be an object of study and compartimentage where different varieties of afrikaans were studied as distinct phenomena with then contemporary forms of standard afrikaans seen as a direct and linear descendant of dutch and subject to systemic change through internal factors alone the apartheid emphasis on bordering workand its embrace of the eighteenth century idea that single languages were constitutive of the nationstate justified the artificial creation of territories for ethnolinguistically defined groups and a balkanized state all previous attempts at socalled harmonization of african languages to a few orthographically unified clusters as a way to counteract the colonially engineered linguistic divisiveness were quashed by the apartheid formation of separate language committees in 1957 negotiated settlement the negotiated settlement in the twilight years of the apartheid state had as its overriding goal the construction of a nonracial order the government in waiting the african national congress embraced nonracialism as a founding principle of the new democracy in exile this had translated ideologically into the wide use of english as the language of the liberation movement and as a perceived neutral language and a medium for equality aspiration and national development albert luthuli one of the founding leaders of the party had always been explicitly in favour of english as a language of unification and had earlier vehemently rejected education in african languages as a strategic ruse on behalf of the apartheid state to divide and dispossess africans in line with this the national english language project was formed in 1985 on the initiative of neville alexander the nelp put forward the idea of english as the link language together with a small number of secondary languages as regional languages alexander subsequently also suggested harmonization to two language clusters in order to unify the nation 3 given the lacklustre experiences among newly independent colonies that had chosen the languages of the former colonial metropole it was inevitable that the nelps promotion of english would be critically questioned in 1987 following contributions by kathleen heugh in particular multilingualism in african languages was recognized as an essential condition in the broader struggle for a free democratic and united south africa as a result the nelp was reconceptualized in 1987 as the the national language project in particular the nlp emphasized the importance of the educational use of african languages for democratic and equitable development and access the period prior to the inauguration of a democratic south africa was one of intense work on sketching the contours of a multilingual language policy for the new state to be the historical landmark conference under the auspices of the nlp on the cusp of democracy entitled democratic approaches to language planning and standardization introduced an unprecedented range © stroud richardson and cmdr 2021 and complexity of understandings of multilingualism into political debate besides reopening discussions around african language harmonization from the 1920s and 40s the conference put forward notions of multilingualism as more than the sum of discrete languages and linguistic balkanization and as a complex ecology of language practices … ranging over grassroots and fluid practices of languages to a more conventional and hierarchical language construct what heugh termed functional multilingualism during the period of 19921995 a resource view of language came to complement the initial discourses on language rights perhaps most importantly although less noted was the challenge to the exclusivity of the state in language planning and the emphasis put on the necessary involvement of nongovernment bodies regrettably very few of these many insights were followed through in the concrete roll out of the democratic state in retrospect it is remarkable that little attention was paid to the racial underpinnings of the linguistic order that the language planners inherited witz et al note how the idea of discrete races and ethnic groups was somehow present in the politics of accommodation and reconciliation that gave birth to postapartheid south africa in 1994 with south africans framed as a rainbow nation marked by diversity and many cultures rasool notes how as much as race was made through structures and systems of rule it was also produced through articulations and contests within different sections of the broad liberation movement notwithstanding their avowed antiracism the idea of nonracialism defaulted to a liberal enlightenment idea of equal treatment of blacks and whites of recognition parity of treatment and legislative incorporation into state structures and public spaces it did not mean the dismantling as such of the idea of race however recognition of indigenous languages and their speakers did not equate to the recognition of the deeply racialized colonial subjectivities layered into african languages neither did it offer strategic interruption of the historical mechanisms of multilingualism in the continued reproduction of these subjectivities as one more mode of racialization multilingualism would become apparent in the rollout of the postracial state the democratic dispensation formal transition to democracy came with the general election of the anc to government in 1994 and the writing of the constitution 1996 the new language policy became a central part of the structural replacement of the apartheid state alexander noted that unless linguistic human rights and the equal status and usage of african languages were translated into practice the democratization of south africa the country will remain in the realm of mere rhetoric not surprisingly the implementation of the language policy came to focus on institutional structures such as legalization to encourage the promotion and use of african languages in all public spaces the belief in multilingualism as an instrument of social and epistemological justice became embedded in national policy state institutions and socalled chapter 9 institutions such as the pan south african language board the brief of which was to protect the rights of all languages and their speakers through recognition and institutional accommodation of diversity a once divided nation would be unified by multilingualism as racialization © stroud richardson and cmdr 2021 maximizing the democratic potential of social formations within which south africans lived the tension identified in the conference democratic approaches to language planning and standardization between a multilingualism of state institutions and a more fluid and bottomup construct came to a head in conjunction with the implementation of the language in education policy the wording of the document is replete with radical wordings such as fluidity and the recognition of a spectrum of multilingual practices and engagements with pupils repertoires however when the proposals were inserted into the practicalities of everyday institutionalized schooling what was an expansive generous and complex construct of multilingualism defaulted to a traditional hierarchical relationship between englishafrikaans and african languages even more insidiously the policy overtime has undergirded an increasing monolingualization as modus operandi in the school system and increasingly so in catchment areas of great diversity it is beyond the scope of this essay to delve into the concrete details of these developments nevertheless defaulting to monolingual english schooling is likely one part of a much wider capture or repopulation of state and private structures by elites for whom english is a capital investment in increasingly transnational markets of whiteness in other words state institutions have despite the good intentions of their architects defaulted to an increasing monolingual whitening as a motor of elite privilege postracial south africa the tension identified in the conference between state management of language and bottomup initiatives has come to characterize developments around multilingualism in south africa in the last 5 years explicitly more generally complex strands of historical debate continue to resurface in different configurations and with different stakeholders and contemporary ideological constructs of multilingualism are best seen as kaleidoscopes of inherited fragments of past multilingualisms and contemporary subtexts or responses to these as noted above education has been and remains one of the key sites for the production and circulation of ideologies on multilingualism the school is where the complex interweaving of subjectivities bodies and aesthetics with different languages created under colonialism and apartheid are most visible it is a space in the south african context where interracial and interlingual relationships are played out on a daily basis and where tensions in differently racialized constructs of language and multilingualism as well as tensions between grassroots and institutions are increasingly taking centre stage and finding their most explicit articulations on the one hand the school is a prototypical force for integration segregation and disciplining on the other it is also an institution rich with potential for change school policies and practices reflect the weight given to english in south african society generally and the belief that african languages constitute a hinder for learning it colonial and apartheid values of the inferiority of african languages and the superiority © stroud richardson and cmdr 2021 of metropolitan languages remain strong the equation of english with intelligence and academic ability and streaming according to english language ability serve to reinforce the indexical weights and values given to english and african languages and perpetuate a monolingual mindset the variety of english valued in schools is white south african english and ethnolinguistic repertoires of whiteness more generally while township accents or black englishesare delegitimized teachers step out of teaching content subjects to produce disciplinary asides in order to correct learners on for example points of english pronunciation makoe and mckinney note how despite their multilingual proficiencies african language speakers are seen as deficient monolinguals and schools produce dominant ideologies of linguistic homogeneity and inequity former elite schools are taking african languages off the curriculum in accordance with the basic education departments new curriculum policy that only one first additional language should be offered and less time is given in the curriculum for any other language than english and afrikaans in fact african language parents have also voiced unhappiness with their perception that the variety of the african language taught is debased schools teach kitchen zulu this then is not just a monolingual bias but a particular white language bias a situation that reproduces apartheid language hierarchiesregimes such a predominant white positionality on language matters is nicely captured in the words of one member of a prominent governing body foundation who publicly stated in 2017 that afrikaans is a much easier language to master there are no clicks the vocabulary and the structure are part of the same family of languages as english and therefore easier to pick up… one reaction to the racialization of language that incidentally also clearly illustrates bodily invasive features of language ideology comes from a cape town elite girls school the school habitually penalized the children for speaking isixhosa on the school premises formally noting the transgression in a special book the language prohibition was one part of a more extensive black disciplinary discourse formalized in the code of conduct that stipulated that learners must keep their hair tidy students were literally chastised to the very fibres of their black body and took widely to social media in attempts to change antiquated codes of conduct and propriety modelled on whiteness beyond the more institutionalized use of named languages is the way in which school children us multiple languages to circumvent official racial categories kerfoots important study of primary school learners in a lowincome neighbourhood in cape town showed how students strategic use of repertoires in encounters across difference contributed new identitybuilding resources among other things they used multiple languages also as as a means of shaping new interaction orders restructuring hierarchies of value and subverting racial indexicalities and sometimes even resignifiying the very meanings of racial categories conclusion any singular notion of multilingualism obscures the centuries long shifting idea of language and conceals the de facto complexity and multiplicity of multilingualism as plural responses to moments of turbulent transition throughout south african history state structures policies and institutions have engaged with constructs of the nationstate that are deeply racialized with either the goal of constructing separating and disempowering nonwhite races or in order to further social transformation through addressing historically racebased inequalities in both cases the default is a celebration of whiteness itself an everchanging construct deeply entangled with transnational neoliberal marketization constructs of multilingualism have been central as epistemological and strategic sites for the play of racialized state dynamics they have been heavily determined by racial bordering from the early beginnings of first colonial contact until today as part of a larger discursive regime or battery of historical procedures and institutionalized discourses they have helped either to invisibilize or discipline the black body or attempted to restylize it and its relationships to whiteness we have touched on how fragments of institutionally racialized ideologies of multilingualism appear in the contemporary thoughts and practices of the everyday highlighting specifically how speakers deploy and attempt to circumvent these constructs of language in their everyday practice by way of brief conclusion there is clearly a need to rethink multilingualism as a semiotics of relationality the articulation in language of relationships between individuals groups andor institutions and its role as a site for racial contestation a rethought multilingualism can provide one necessary space to interrogate the unmaking of race notes 1	south african today remains a nation torn by violence and racial inequity one of major challenges for its people is to create new futures across historically constituted racial divides by finding ways to engage with each other across difference in this regard multilingualism holds out the promise of offering a way of bridging difference and opening spaces for engagement and empathy with others today contemporary constructs of multilingualism both in policy and everyday practice continue to reinforce racialized divisions inherited from historical uses of language as a tool of colonialism and a mechanism of governmentality in apartheid the system of exploitation and state sanctioned institutional racism in this paper we seek to demonstrate how multilingualism has always been and remains today an epistemic site for managing constructed racialized diversity in order to do so we trace periods of south africas history by way of conclusion we suggest that alternative linguistic orders require a decolonial rethinking of the role of language s in epistemic social and political life
introduction indonesia is the worlds 4 th most populous country where 433 of its population lives in rural areas and smoking remains as a health problem in this nation 1 according to the 2018 basic health research tobacco prevalence was predominant among the age of 15 years and above and majority are male smokers 2 a study among the us adults shows that it is more common in their rural areas compared with that in the urban settlements 3 similar findings in indonesia also recorded the same result 4 tobacco addiction is an indonesian public health issue with a steady rising of the incidence and also the increasing mortality rate because cardiovascular diseases are associated with the high prevalence addiction of tobacco smoking 5 aditama observed that most of the male participants were heavy smokers with an average of 76 cigarettes per day 6 while a different study showed 214 7 several studies have outlined the causes of smoking behaviour such as lack of knowledge socioeconomic factors information through media and stress or negative liferelated events 8 9 10 11 however majority of those studies were conducted in urban areas erefore this study aims to analyze the determinants of tobacco smoking addiction in rural areas methods is was a crosssectional study conducted on february 2020 at songgon district banyuwangi residence east java it lies among the border of bondowoso and jember residence which are dominated by madurese javanese and osing ethnicities ese represent those of the rural east java which is the 2 nd province with the highest number of populations in indonesia 1 e respondents were male local villagers aged 15 year old and above it was conducted under the community medicine education training program and organized by the faculty of medicine universitas airlangga on a oneweek period using sample size calculation the minimum requirement was 75 responses 12 consecutive samplings were carried out until the minimum number is fulfilled e authors had provided standardized training programs for all interviewers prior to the survey administration e respondents were requested to complete three questionnaires consisting of tobacco addiction determinants perceived stress scale10 and who assist v30 questionnaire for tobacco all were given in indonesian language e first question list consisted of three sections as follows health risk awareness social control and mass media role in tobacco smoking with each statement the respondents response were placed on a 4point likert scale where 1 and 4 indicated strongly disagree and agree respectively each section had a maximum score of 60 points for the first section and 40 points for the second and third sections is questionnaire has been prevalidated and tested for reliability with alpha � 0908 e indonesian version of the pss10 was adapted from the previous studies with r � 0632 and alpha � 0857 13 while the who assist v30 questionnaire was from the indonesian ministry of healths booklet statistical analysis e acquired data were analyzed using ibm spss statistics for windows ver 230 which were expressed as mean ± standard deviation correlation between demographic and addiction risk was measured using both the spearmans rankorder and fishers exact test while those between the scores obtained from tobacco addiction determinant questionnaire and pss10 based on who assist v30 questionnaire were measured using spearmans rankorder only a p value of 005 was considered as statistically significant ethical clearance is study followed the principles of helsinkis declaration and also received the permission from the faculty of medicine universitas airlangga before it began all respondents had presented their signed consents prior to their inclusion in the study details that might disclose the identity of the respondents were omitted results demographic data a total of 75 responses were collected and validated e mean age of the respondents was 4404 ± 1310 most of them worked as a selfemployee subsistence regarding the education level most respondents were of senior high school levels or higher it was also observed that most of them were married and living with 46 persons in their homes e demographic data were presented in table 1 determinants of tobacco smoking behavior in the first section respondents were asked about their views on a tobacco smoker the introducer the place and its health effects a higher score showed that they were more aware of the health risks of tobacco smoking e mean point obtained was 4293 ± 703 while 58 and 27 were the maximum and minimum achieved scores respectively in the second section the respondents opinions were enquired based on smoking in social settings a higher score signifies that they could maintain good social control regarding tobacco smoking e mean point was 2953 ± 49 while 40 and 15 were the highest and lowest scores respectively while the third sections were enquired about the mass media role against smoking behaviour a higher score means that they were more aware of the media reporting the dangers of tobacco smoking e mean point recorded was 3020 ± 471 while the maximum and minimum obtained scores were 40 and 15 respectively e pss10 is a questionnaire used to measure the perception of stress a higher score indicates that the respondent is having a high level of stress smoking was considered one of the behavioural responses during stressful conditions e mean score acquired was 1496 ± 567 while the highest and lowest acquired points 26 and 0 respectively addiction risk and demographic data e who assist v30 is used to measure the addiction risk toward smoking e scores were categorized into three namely low moderate and high and the number of respondents on each class was recorded as 45 23 and 7 respectively table 1 describes the correlation between demographical data and tobacco addiction danger it was observed that the risk did not significantly correlate with age occupation education level marital status and number of persons in each home addiction risk and determinants of smoking behavior e scores of each questionnaire sections and pss10 were compared based on the respondents addiction risk we observed that those in the lower group scored the highest point in all the three sections respondents in the moderate group got the lowest on the first section with an average of 4030 ± 549 scores while those on the high category got the least in the second and third sections spearmans rank showed an inverse correlation between score achieved on the questionnaire and addiction risk and those in all the three sections on the pss10 those in the lower group had a low score compared with those in the moderate and higher groups however this study shows that there is no significant relationship between the pss10 score and the risk of tobacco addiction discussion currently only one study that had been conducted to analyze the determinants of tobacco smoking addiction in rural areas of indonesia 14 previous studies show that smoking is more prevalent among men than women in rural areas 215 e preliminary survey also found out that no female smoker was recorded in songgon district therefore only male respondents were recruited to participate a better awareness of tobacco health dangers is associated with a lower addiction risk and a desire to quit smoking 1617 is is due to the high awareness level of the dangers which sabotages the victims experience making it a worse exposure and as a result indirectly reducing the risk of addiction 18 several studies reported that social environments and stigmatization from smoking behaviours have led to decreased smoking rates 919 maintaining a good social control means that a person is capable of inhibiting smoking while maintaining an ethical interaction with others in indonesia especially in rural areas a cigarette is usually offered during social meetings and occasionally as a sign of friendship another cultural aspect is the politeness rejection of a hosts offer which is considered impolite and may offend them 6 erefore the smoking rate is unsurprisingly high but its addiction is a different matter as it is multifactorial and often depends on personal experiences e authors assumed that social meetings contributed to smoking addiction for those that socialize however further study is needed to investigate this assumption it was presumed that social control might be a better determinant of the addiction risk e mass and social media campaigns were thought to be effective in changing smoking behaviour among adults 2021 in contrast it was also assumed that smoking advertisements have been enhancing their habits toward tobacco 8 in indonesia campaigns to stop smoking or sensitization on its dangers is rarely carried out but tobacco advertisement is always seen everywhere 2223 again it must be emphasized that tobacco addiction is multifactorial and depend on the respondents perception it is argued that a persons awareness of mass media reporting the danger of smoking may be a better determinant is research made some findings different from those of the previous studies that the stress level were not significantly related to addiction risk 2425 since the stress level in rural areas is lower than that in the urban settlements it was also observed that the urban settlements experienced more distress compared with the rural areas 26 besides environmental and socioeconomic aspects rural areas tend to support each other through gotong royong a term which encompasses communal service and mutual assistance without hesitancy to those in need 27 erefore it is assumed that the lower stress levels may lead to a stressrelated smoking behaviour which has not been considered in this research is study has several limitations firstly the limited time which restricted the sample size and method however the authors managed to reach the minimum sample required secondly using only a single district may not represent rural areas in other provinces or islands in indonesia irdly the authors did not study the smoking behaviour and the social background that lead to addiction erefore further study is recommended with more sample sizes in several other rural areas conclusion tobacco smoking remains a nationwide problem in indonesia results show that high perceived stress has no correlation with the increased addiction risk in rural areas however the increased awareness of its health dangers good social control and mass media campaign is significantly in relationship with its decrease erefore this study could be a recommendation of the smoking prevention program to address more of the issues rather than focusing on stress management for the population 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 of this article declared no potential conflicts of interest authors contributions jps sulistiawati and ak were involved in the conception and design of this research revision of the article and the final approval of the version to be published jps was responsible for the acquisition of data analysis and interpretation of data and drafting the article	to analyze the determinants of tobacco smoking addiction in rural areas methods a crosssectional study was conducted on february 2020 e selfadministered questionnaire α � 0908 and perceived stress scale10 were used as tobacco smoking determinants and the who assist questionnaire v30 to determine its addiction risk eir correlations were analyzed by spearmans rankorder approach using the spss version 230 results among 75 male respondents that participated in this study those on low moderate and high addiction risk were 45 6000 23 3067 and 7 933 respectively and significantly correlated with the research questionnaire that consisted three parts 1 awareness toward the health risk 2 social control 3 mass media role in tobacco smoking p � 0014 0004 and 0009 respectively but there was no significant correlation with the stress level p � 0287 conclusion increased awareness toward the health risk good social control and mass media reporting the danger of tobacco smoking is significantly in correlation with the decreased addiction in rural areas however the high perceived stress has no correlation with its increase
any discussion on the environmental dimension of the quality of life in the city should be preceded by clarifying the meaning ascribed to the term environment as used in this paper the notion of the environment carries so many meanings and encompasses so much that omitting a definition here would trigger a multitude of ambiguities and misconceptions the tradition and evolution of the scope covered by the notion of the environment is particularly long and rich in geographical research a canonical order of the terminology related to the environment was introduced into polish geographical studies by tadeusz bartkowski in this paper the term environment is understood as the natural environment already transformed by human presence and activity while still providing elements of nature in the urban habitat in the paper we intend to start a discussion on the growing significance of the environmental dimension when assessing the quality of life in cities we refer to theoretical reflections that stand in opposition to the modernist planning paradigm which for years consolidated the strong tendency to consider nature alone excluding society and society alone without nature the trend was developed and boosted by a number of factors such as the industrialisation of production new technologies rapid urbanisation globalisation expansive and uncontrolled exploitation and the quality of the natural environment the dynamically developing research on quality of life has been continuously reversing the order of the modernist discourse evidencing the importance of the relations between physical social and cultural matter in spite of the variety of approaches and concepts on how to define quality of life it is commonly agreed that the notion of quality of life is made up of two mutually intertwined dimensions psychological and environmental the factors related to inner mental mechanisms determine the sense of personal satisfaction and satisfaction with life the factors related to external environmental conditions on the other hand determine internal impressions and views terms such as the individualpersonal quality of life a subjective sense of wellbeing or the level of satisfaction with life are used to identify the group of the internal factors the external factors refer to various levels and categories of the quality of life and describe such concepts as the quality of life in cities the quality of community life the quality of the place or the environmental quality of life the variety of factors taken into account in order to assess the quality of life is immense it is assumed that each of the measures reflects in a sense the impact and importance of the specific component in the comprehensive general sense and view of the quality of life meanwhile the same assumption suggests that the notion of quality of life can be disintegrated to form a set of factors or dimensions if the correct set of factors is compiled it will be possible to use it to obtain a credible comprehensive assessment of the quality of life in the city the key lies in defining each factor in such a way as to enable its measurement and consequently assess its quality and durability what is important in practice is that each measure must be clearly defined operationally in terms of its structure so that research findings are repeatable and comparable initially researchers dealing in measuring quality of life focused primarily on social and economic indices and attempted to develop then accumulate statistics of various aspects of social life the need to develop a consistent list of objective social indices has led to the emergence of an entire stream of research called the social indices movement which concentrates on the accumulation and analysis of statistics depicting various spheres of life introduction © 2023 authors published by sciendo this work is licensed under the creative commons attributionnoncommercialnoderivs 30 license research and analyses based on subjective indicators on the other hand have focused on the individual assessment of daily experience and form the other extreme according to august campbell studies of quality of life cannot be conducted without referring to the subjective sense of satisfaction and wellbeing in research of this type the quality of life of an individual can only be determined based on the persons own assessment bearing in mind such mental processes as perception comparison evaluation and assessment paul harwood for instance defines quality of life as an individuals sense of wellbeing or their satisfaction with various spheres of life robert gillingham and william reece state that the individuals quality of life is the level of satisfaction they gain consuming goods and services purchased in the market and public goods for empirical studies one should adopt a possibly broad interpretation of the notion that the quality of life is the ratio between the degree of the values present at a specific place and their desirable level taking into account both the resources at an individuals disposal and their personal evaluations and feelings whereas the selection of specific indices depends on the context of the surveys and the adopted assumptions the purpose and methodology of the survey the authors of this paper held a qualityoflife survey of the inhabitants of gdańsk in june 2021 using the indices of the citys spatial correlations the survey was conducted based on a partnership contract between the university of gdańsk and the municipality of gdańsk the main purpose of the research project was to monitor changes in the values of the qualityoflife indicators among the residents of gdańsk in both territorial and sociodemographic perspectives the field research was carried out on a representative sample of 1509 adult residents of gdańsk using the penandpaper personal interview method the sample reflected the structure of the adult population of gdańsk in terms of sex age education and district of residence1 in the conducted surveys the respondents could assess and score several dimensions of life in their closest neighbourhood using a sixpoint rating scale where 1 represented the worst and 6 the best evaluation in the paper we present only a section thereof narrowed down to the dimension of the quality of life of interest to us and its environmental component at the place of residence the qualitative analysis of the obtained results was performed under descriptive and statistical methods which enabled the significance of the relationships between the variables to be identified the dependent variable took the form of an index made up of five detailed indices the quality of the air the quality of potable water the intensity of noise the accessibility of green areas and the condition of the green areas the sostructured index enabled the presentation of several variables with a single result which facilitated data analysis and increased measurement reliability the mannwhitneywilcoxon test was employed in comparisons of the dichotomous variables and the kruskalwallis htest for more than two groups whenever a statistically significant result of multiple comparisons was obtained the dunns post hoc tests were performed with holms correction the significance level accepted for analyses was p 005 the environmental aspects of quality of life as viewed by the inhabitants the weight and significance of the factors making up the sphere of the environment are growing dynamically when assessing the quality of life due to public attitudes the issue of the environment is becoming increasingly prominent in urban policies a new approach to the urban environment and the necessity to calculate the risks posed by climatic changes have triggered a change in the approach to the qualityoflife indicators the over the entire city and reflected the demographic crosssection of the whole population in effect the structure of the sample in terms of social and demographic features was as follows sex female male age 1824 2539 4059 59 education primary basic vocational lower secondary 105 secondary 429 higher 464 environmental diagnosis which consists in broadly construed attempts at describing the environment and its components utilises the measurements classified as objective indices namely the environmental quality index the indices themselves are nothing more than objective physical measurements and the quality term suggests subjective evaluation considering that the aim does not always come down to discovering the presence of a physical component of the environment but rather to capturing the perceived quality of the environment in this paper we shall refer to the subjective evaluation of the quality of the environment therefore with the intertwining social and environmental phenomena the conceptualisation of the quality of life as a category comprising various sets of elements requires the adoption of objective and subjective views the surveys held in 2015 in gdańsk reveal that nearly half the population believe that gdańsk stands out among other large cities in poland in terms of the values of its natural environment and this represents one of the vital components of the citys identity the fact that the main axis of the citys historical development runs between the coastline of the bay of gdańsk and the edge zone of the wooded moraine uplands gives gdańsk the advantage of the continuum of sea beaches on one end and the tricity landscape park on the other and that creates a unique potential for the development of the leisure and recreation function the linear layout of the citys downtown areas puts the benefits of nature within the reach of a substantial part of the population the status of both belts is that of spaces rooted in the physical environment and the features of their significance are comprehended without any effort or special reflection wooded land accounts for 18 of gdańsks entire area and plays not only a protective role but also a recreation and leisure function there are five nature reserves set up in the woodlands on top of that there are 448 ha in total of cultivated green within the city itself including 300 ha that comprise 18 city parks and numerous green areas and squares that add up to 148 ha hence not surprisingly accessibility of green areas is evaluated highest by the city dwellers though their condition in terms of cleanliness and aesthetics is assessed slightly lower gdańsk offers relatively good conditions concerning water management particularly the supply of potable water to the inhabitants potable water is supplied from 10 intakes including 8 of the deep type and 2 of the surface type all meeting the high eu standards water evaluated at 414 is hence along with green areas a major environmental value of gdańsk the picture is unfortunately poorer for the two other environmental elements the quality of the air and noise intensity the main contributors to air pollution are manufacturing plants traffic and indoor air pollution for years on end too intense and intolerable smells from the waste processing plant in gdańskszadółki have remained a major airrelated issue the environmental conditions are further determined by the intensity of noise although noise falls below the permissible threshold over a major part of the city there are areas exposed to the risk of excessive noise levels including the neighbourhoods around the main traffic routes the airport and the vicinities of the port and the industrial estates the environmental issue which is of significance in the inhabitants subjective perception is reflected in the gdańsk development strategy this transpires in the conducted empirical studies which reveal evident relationships between natural values and the identity dimension of experiencing the city as well as high scores given to individual components of the environmental conditions in the latter respect however the city of gdańsk is not a uniform organism with the superimposed territorial diversity expressed as a subdivision into districts differences transpired between individual subareas in their subjective evaluation of the environmental conditions evaluation of the environmental conditions in the citys territorial structure the environmentally friendly city captured in the slogan of the green city comes down to the project of shaping the city so as to follow the line of development deemed desirable by most inhabitants however the methods used to implement the green city idea means that not all inhabitants can benefit equally from the effects of the needed and anticipated policy of creating green public spaces and maintaining elements of the green infrastructure inhabitants access to green areas green facilities or waterfront areas is ever more frequently disputed as a factor of social segregation and injustice in the city space while some districts benefit from green projects and the introduction of greenery into urban development others remain neglected and deprived of easy access this access to open public spaces the existential significance of which was revealed during the pandemic should be common in all residential districts instead of being confined to privileged downtown areas currently however the gentrification of districts subject to the process of revitalisation and restoration is an issue of far more social weight the process includes making districts much more attractive to live in thanks to hence analysis of the locations and their access to green areas and waterfronts in the spatial structure of the city is of paramount importance in assessing the citys policy in the context of the inhabitants quality of life in order to arrive at a more complete evaluation of the environmental dimension of the quality of gdańsk residents lives an attempt was made to estimate the distribution of the inhabitants opinions according to their place of residence the results obtained in individual city districts were arranged under the frequency distribution procedure and based thereon three equal intervals were identified the borders of which being the difference between the maximum and minimum values then three zones were identified in the city the districts where the result fell in the high interval districts with the result falling into the medium range and districts falling in the low interval an analysis of the average score distribution indicates a deep polarisation of the citys territorial structure in terms of the environmental conditions on one extreme we have areas that scored highest for their environmental conditions namely the districts located in the coastal belt that comprise a large number of city parks such as przymorze żabianka zaspa and the districts directly beside tricity landscape park such as oliwa and vii dwór thanks to their location the abovenamed areas share the features of relatively low noise and fairly clean air at the other extreme are the areas where the environmental conditions were assessed lowest these are the districts located either in the city centre where the builtup development is highly concentrated and the traffic intense and where the main traffic junctions are located or they are the old districts neighbouring on industrial or storage estates intended for revitalisation at a later date the social and demographic determinants of the evaluation of the environmental conditions in the survey it was assumed that demographic variables such as sex and age would be the vital predictors determining the evaluation of the environmental values of gdańsk followed by the variables defining social status namely education and income yet another variable taken into account was the length of residence in gdańsk and variables of psychosocial nature such as the respondents selfassessment in terms of their sense of happiness and their selfassessed opportunities to attain their own life goals the analysis performed revealed that there is no statistically significant correlation between social features such as education or income and the overall evaluation of environmental conditions a relation of this kind does exist however in the case of demographic features the environmental conditions at the place of residence are slightly better perceived by men than by women and by younger versus older people the best views of the environmental conditions at the place of residence are shared by people residing in gdańsk for a period shorter than three years the worst assessments on the other hand come from those who have lived here for more than ten years interestingly the environmental conditions are valued higher by those who perceive their potential to attain their life goals well and believe they are happy contrary to those who do not share any such the conducted survey reveals that the subjective perception of various aspects of the city including the environmental conditions changes along with the inhabitants individual experiences the best evaluation of the environmental conditions in the city came from the dwellers of gdańsk representing the younger age groups and those living in gdańsk for a relatively short time prevailingly the latter are young settlers or people who came to gdańsk in search of a more attractive job or to take up studies after which they decided to stay relying on common knowledge one could assume that criticism of the city should decline as years go by however in this case one should consider cognitive dissonance the decision an individual makes to migrate and settle in the city results in the need to cherish a high view of its values to justify the reasonableness of the choice made when interpreting the evaluation of the living conditions in the city one should also refer to the fact that in the course of experiencing space one can identify elements which will not be forgotten or which gain particular weight the issue gains in importance considering that what we face in the contemporary world is the dynamically advancing process of population ageing similar trends are observed in poland gdańsk included this makes it even more necessary to take this fact into account in the processes of planning and developing the city space conclusions the task of urban policy is to mitigate any negative effects occurring in the city tissue and counteract excessively stark disproportions between individual dimensions of the quality of life including in terms of environmental conditions from the perspective of the paradigm of sustainable development the revitalisation of the most neglected areas is of high significance where such areas are found in districts of fewer environmental values the conducted survey reveals farreaching differences in the spatial structure of the city when it comes to the residents perception of the values of the natural environment in the city space extremes that create a peculiar continuum can be identified one extreme covers the districts located in the vicinities of woodlands and the coastline the other extreme represents the older districts located in the neighbourhood of industrial and storage estates moreover the results of the survey presented in the paper indicate that the perception and evaluation of the environmental values at the place of residence are determined by demographic factors such as sex and age the survey shows that lower satisfaction with the environmental values at their place of residence is shared by women and people in the oldest age group even though one might presume that town planning is by no means sexrelated and the city space is for everyone the conducted survey points to the fact that women men the the higher the mean the higher the evaluation the significant difference between categories up to 3 years and longer than 10 years source own elaboration young and the elderly use the city in different ways and have different expectations of it assuming that the quality of life is the ratio between the existing dwelling conditions and the aspirations of the city dwellers one can conclude that environmental values such as accessibility of green areas quality of the air and noise intensity rank higher in the hierarchy of needs shared by women and the elderly and result in their more critical views the realisation of the ambitious goal of attaining a higher balance between spatial structures will not be an easy process this is because looming on the horizon are the longexistent risks related to the process of spatial planning these can include insufficient municipalityowned land the drive shared by private investors to generate maximum profit by increasing the intensity of builtup development at the expense of the natural environment low environmental awareness among the decision makers and the continually changing law which constricts the longterm policy of protecting the public interest as the urban population grows the expected improvement of life quality in cities will grow too considering control of the climatic risk and managing it all city users will need to be engaged in the process	the purpose of this paper is to attempt an analysis of the environmental dimension of the quality of life using quantitative surveys conducted among residents of gdańsk in the paper we make reference to the theoretical assumptions ensuing from the concept of a comprehensive and integrated approach to the development of the urban environment whilst noting the profound impact humans bring to their evaluation of the environmental components the paper focuses primarily on the inhabitants attitudes to the environmental values of their place of residence in relation to things such as the condition and accessibility of green areas air quality potable water quality and noise intensity the surveys indicate that views on the citys environmental values are determined by numerous factors such as the citys territorial structure districts and its demographic structure sex age and psychosocial features such as a subjective sense of mental wellbeing
introduction on march 11 2022 the world health organization declared covid19 as a pandemic as a result the vulnerability of atrisk populations heightened worldwide and health inequalities for many vulnerable people and their communities have worsened one such vulnerable group is people who are deprived of their liberty in a variety of detention settings the impact of covid19 within such detention settings as described in developed countries and indeed in africa and south africa is the focus of our viewpoint historical barriers to health in closed settings such as overcrowding poor hygiene facilities and resources as well as poor ventilation all of which intersecting with already poor menstrual health management conditions within detention facilities will undoubtedly exacerbate the vulnerability of incarcerated women to covid19 with such environments conducive to spread of disease understanding the intersectional vulnerabilities that exist within detention settings the united nations has called for various measures to be initiated to ensure a decreased risk to public health within these facilities including the early release of vulnerable incarcerated persons due to issues of overcrowding and having to eat shower and toilet in communal areas such measures are congruent to the normative un standards of detention for example the united nations standard minimum rules for the treatment of prisoners the united nations rules for the treatment of women prisoners and noncustodial measures for women offenders the united nations standard minimum rules for noncustodial measures in addition to the african charter on human and peoples rights and the nonbinding robben island guidelines for the prohibition and prevention of torture in africa at the global level both before and since the covid19 there is a wealth of evidence indicating continued health inequity of women in prisons with their specific health needs routinely neglected and deprioritised this is especially the case regarding their sexual and reproductive health lack of access to menstrual health products in prison such as sanitary towels is known as period poverty our viewpoint concerns the right to menstrual hygiene management in detention settings with a focus on the african context and specifically south africa globally of the 115 million people deprived of their liberty 741000 are women over 1 million are detained in africa and in south africa women are a minority prison population with 3 453 women incarcerated in the country menstruation health management cultural dimensions disparities and covid19 impacts menstruation is an integral function of ciswomens trans and gendernonconforming peoples health throughout their reproductive lifespan defined as the hygienic menstrual management of menstrual blood through the safe and hygienic use of and disposal of menstrual management materials mhm has become an emerging public health endeavour affecting approximately 50 of the worlds population who menstruate according to the united nations international childrens emergency fund approximately 800million women menstruate daily and of the 18 billion females nonbinary transgender men that menstruate millions are unable to manage their menses hygienically and at their own discretion due to broader socioeconomic disparities juxtaposed against cultural misconceptions and taboos poor mhm is generally a consequence of poverty and deprivation the impact of the covid19 pandemic on mhm remains largely unexplored beyond the covid19 devastations we suspect that millions of women around the world have suffered and continue to suffer an accelerated untold erosion of basic human rights bodily integrity and dignity due to the lack of access to adequate mhm the vulnerability of economically and socially atrisk girls women trans and gendernonconforming people who menstruate is potentially heightened during covid19 as a scarcity in sanitary products and adequate water sanitation and hygiene facilities disproportionately hampers their agency in managing their menstrual health hygienically at their own discretion globally the impact of poor mhm remains largely unknown due to the deeply historical and cultural construction of menstruation as an individual health concern framed within the private realm as an individual and private concern the solution for poor or inadequate mhm is framed as the responsibility of the individual irrespective of socioeconomic circumstances and despite very serious health consequences over the past decade menstrual health has increasingly become a global public health concern that has been adopted as a human rights endeavour because of the social political and economic disparities associated with mhm understanding the harmful gendered effects that women endure during times of pandemic and crisis the world bank unicef and who together with other health and gender advocacy agencies have sounded the alarm by issuing briefs and recommendations aimed at assisting governments in creating gender conscientized health policies during the covid19 pandemic refrains such as periods dont stop for pandemics and world can pause but periods cannot highlight the urgency that is needed in managing mhm particularly within contexts already lacking sustainable resources this is echoed by the world bank and their movement to end period poverty and period stigma by 2030 however slow progress in development efforts hamper mhm in middle to lowincome countries in addition to povertystricken contexts in high income countries 75 of households in low and middleincome countries have inadequate access to handwashing with soap which is salient both to mhm and in stopping the transmission of the covid19 pandemic progress in within the african context as in many other developmental contexts have been hampered complexities of ensuing menstrual hygiene management in african prisons pre and beyond covid19 menstruation and other reproductive functions have been historically stigmatized as a mechanism of othering women through its signification of difference between men and women within the african context social stigmatisations and cultural misunderstandings of menstruation have resulted in negative attitudes and experiences for women researcher findings of such have been evidenced in mali and ghana as well as within the south african context framed as a political silence menstruation in contexts outside detention facilities are hushed because of the social and cultural stigmas associated with menstruation yet much like women living on the outside women within the carceral contexts face issues of menstrual equity at the intersection of discrimination within detention spaces globally women lack autonomy over their own bodies as they are reliant on the state to provide for their basic mhm needs indeed the bangkok rules acknowledge menstrual health specifically in rule 5 which states that carceral centres are responsible for the provision of hygienic facilities and mhp free from cost to women unfortunately there is a lack of literature currently within the african and south africa context that explores how the impact of social and cultural stigmatisations as well as the lack of bodily autonomy manifest themselves in the menstruating experience within carceral facilities even prior to the covid19 pandemic the general and gendered health disparities faced by the incarcerated have largely escaped the priorities of global and african prison health agendas for example a systematic review which explored incarcerated females experiences of carceral health care in subsaharan africa over the past two decades uncovered not only a dearth on incarcerated female experiences but also violations of human rights coupled with poor healthcare provision including lack of prisons system resourcing of sanitary products the marginalized vulnerabilities of incarcerated women though grossly unexplored are expected to have exponentially heightened since the advent of the pandemic harsh and unexpected covid19 lockdown restrictions disrupting the supply of menstrual hygiene supplies combined with pandemic induced economic strain on families we suspect have invariably affected the mhm of incarcerated women leaving this already atrisk cohort at the mercy of overburdened state resources in detention settings deliberate or unintended restricted access to mhp and the inferior quality of mhp mean that incarcerated women may not have a sufficient supply of mhp per cycle yet just as the prepandemic silence the absence of scholarly work that critically engages with menstruation internationally and locally in detention facilities is distressing equally concerning are the immense barriers to access of researchers into prisons in africa an opinion piece published in the lancet titled what are the greatest health challenges facing people who are incarcerated we need to ask them summarises the strides that need to be achieved in prioritising menstruation in detention facilities when the only reference to gendered issues was listed as genderaffirming care it is within such narratives that the gross realities of women experience are neatly glossed over the covid19 pandemic draws parallels to poor mhm one a global catastrophic pandemic one a seemingly hidden gendered issue find commonality in that they both are symptomatic and at the same time aggravated by ailing healthcare infrastructures both are an infringement on basic human rights to accessible and equitable health care heightened by preexisting global health disparities it is therefore unsurprising that the covid19 pandemic may amplify the politics of health and health provision of incarcerated women who are already marginalised and silenced within their contexts of restraint this holds significance within most carceral contexts for example as documented in south africa where females remain a forgotten minority south africa women in detention spaces and right to menstrual health prisons in ssa have seen an increase in the incarcerated female population in recent years south africa has one of the largest prison populations on the african continent with the latest department of correctional services report for 20202021 indicating that there are currently 140948 individuals incarcerated in south africa of this total 137 495 are men and 3453 are women making up a small percentage of 245 as one of the countries who are a signatory for the united nations standard minimum rules for noncustodial measures the dcs in south africa follows the delegated guidelines and minimum standards for the provision of health care services of the men and women remanded to their custody recognition of these rights and responsibilities are protected through local regulations as well and include the correctional services act and the white paper on corrections in south africa yet there are long standing concerns surrounding the incarcerated populations wellbeing including overcrowding poor nutrition and deteriorating facilities all of which impact the physical and mental health of incarcerated populations there is a resounding silence within the south african context in highlighting and prioritizing menstrual health equity within incarcerated contexts despite the advances that have been made in prioritizing gender the mhm within correctional facilities remains largely unexplored within the south africa context the veiled secrecy that envelopes most carceral contexts in south africa means that deliberate menstrual discrimination based on multiple intersectionalities goes unchallenged as reported by van hout and wessels the longstanding and precarious situation of women in detention settings in south africa since postapartheid timeframes needs to be highlighted with the visibility of women enhanced particularly with regards to poor living conditions reasonable and safe accommodation and protection from custodial violence it is therefore unsurprising that the covid19 pandemic would raise the alarm as a correctional health crisis particularly when considering the devastation that hivaids and tuberculosis has wrought on the south african carceral community despite this media coverage and academic attention surrounding covid19 in corrections has been framed as genderneutral with incarcerated women all but invisible and the impact of the pandemic on their lives ignored the unique health needs of incarcerated female population in an alreadyoverburdened system that is overcrowded and unhygienic places women at great risk of having their health needs relegated and neglected gendered impacts of covid19 for incarcerated south african womens menstrual hygiene management unfortunately as the female population comprise only a fraction of the general incarcerated population in south africa there exists a research vacuum and narrative silence around the unique situation posed for incarcerated women before and during the advent of the covid19 pandemic to date only one study has addressed the menstrual health narratives of a portion of the incarcerated in south africa in the context of a broader study of lived experience agboola explicates the narratives of 10 previously incarcerated women who discussed the conditions of their carceral mhm their accounts corroborate previous findings from research in south african correctional facilities where access to healthcare services is limited as are necessary general hygiene provisors such as like soap and water all of which are exacerbated by high levels of overcrowding for women the situation is far more dire it is evident that the incarcerated female population have complex health needs with disproportionate rates of underlying health conditions when compared to women in general and so necessitates the understanding that they often have greater genderspecific primary healthcare needs in comparison to their male counterparts a reality that is particularly evident with regards to menstruation both local and international research studies indicates that on average incarcerated women are issued with two sanitary pads for each day that they are menstruating at the cost of the state however this resulted in a policing of periods where women were forced to provide evidence of soiled sanitary towels to correctional staff before replacements were issued even in ordinary circumstances incarcerated womens healthcare needs necessitate unique undertakings in the male dominated carceral environment but when resources are diverted into emergency health provisions for covid19 it is not unlikely that access to reproductive health services behind bars will be impacted women have special hygiene requirements which correctional facility authorities are obliged to provide for along with hygienic menstrual material disposal reports during the pandemic have been that globally lockdown efforts have resulted in limited delivery and access to sanitary products women in correctional facilities have had to go without sanitary products during covid19 crisis management lockdowns as mhp such as tampons or menstrual cups are often provided by external support networks like charities or family members who are no longer able to visit as access to prisons by external visitors has been prohibited although tampons and other vital mhp may be available from the correctional commissary they are often sold at inflated prices which can be costprohibitive family and friends visiting prisoners are in many ways the lifeblood of the prison bringing not only human interaction and contact with the outside world but also resources such as cash food bedding toiletries and so forth for vulnerable and marginalized women including the incarcerated population the pandemic crisis may result in menstruation becoming a time of deprivation and stigma when faced shortages and reduced privacy under lockdown a new normal and incarcerated women agency in menstrual hygiene management as stated within the detention space mhm becomes a public matter rather than occupying its usual space in the private lives of women whereas prior to incarceration they were in the sole care of their menstruation and menstrual symptoms once in a correctional facility this fundamental aspect of the women experience becomes a public affair of course this impacts their embodied agency within the constraints of their carceral surroundings which form part of a penal system designed with the male body in mind a space where womens bodies and needs are invisible the conceptualisation of such experiences is manifested in the term period poverty which bostock denotes as a form of biopower where menstrual inequality in corrections and the restriction of sanitary products is used to gain control of women through their biology in response to social and physical distancing measures and lockdowns to manage the covid19 pandemic issues of carceral accountability and oversight increase as do concerns with incarcerated womens agency privacy autonomy hygiene and selfsufficiency the new restrictions allow for less accountability and more isolation than we have seen in decades to complicate matters further incarcerated women usually come from marginalized and disadvantaged backgrounds characterized by histories of substance abuse violence physical and sexual abuse all of which exacerbate physical and mental health problems even prior to the challenges imposed by the covid19 pandemic incarcerated women found monthly menstrual management as well as accompanying myths and taboos led to high levels of menstrual distress particularly prevalent within the south african cultural milieu many vulnerable women state that they have a lack of understanding of the menstrual cycle and are unable to function normally as they are physically and mentally weaker during menstruation experiencing issues with bodily cleanliness feeling dirty during their menstrual period as well as vulnerable as they believed it was a time of openness of the body with a susceptibility to infection and illness the sexual and disgust connotations of menstruation coupled its secretive demeanour mean that poor menstrual management resources and misinformation result in its monthly onset ensuing a fraught and anxious time for women therefore raising awareness regarding menstruation and hygienic practices as largely a neglected area in terms of research is imperative to dignified menstrual health practices for vulnerable women the persistence of shame and stigma regarding menstruation requires far more than the provision of sanitary products it requires the sustained effort and intervention in developing the incarcerated women selfesteem and agency concerning their bodies in order to improve their menstrual health practices unfortunately such bodily empowerment seems unlikely in a carceral environment in the grips of covid19 where basic health interventions of sanitation and social distancing are hampered by lacking resources and failing infrastructure moreover the withdrawal or lapse of incarcerated womens reproductive health care and its diversion into covid19 crisis health care treats menstruation as a commodity rather than a basic human right further exacerbating period poverty in female correctional centres the serious dearth of information on the experience of menstruation and of menstrual symptoms of the south african incarcerated community necessitates the undertaking of academic interest and research to better understand the nature of their menstrual health management and its impact on their lives both inside and outside of correctional facilities even before the advent of covid19 there was an increasing need to understand the incarcerated communitys mhm and period poverty alongside studies concerning the unique experiences of transgender and nonbinary menstruating people in corrections it is essential to understand the unique and diverse oppressions faced surrounding period poverty to ensure appropriate and proportionate activism legislation and improvements for menstruating people in prisons south africa was the first african country to adopt a constitution that explicitly prohibits discrimination on the basis of gender sex and sexual orientation the equality court judgement of september v subramoney was the first of its kind in south africa by tackling the equality rights of transgender prisoners and rights to dignified detention and reasonable accommodation by analogy this case could leverage for greater rights assurances of menstruating women and women in general in south africas prisons additionally the 2020 judgement of sonke gender justice nps v president of the republic of south africa is of further relevance to the situation of women menstruating in prison and held that section 7 of the constitution required the state to take reasonable steps to protect the rights of incarcerated persons to this end the covid19 pandemic offers an opportunity for the dcs to fully integrate an empathetic and rightsbased approach that is more in line with the south african governments department of womens sanitary dignity implementation framework for the provision of sanitary dignity minister ronald lamola issued a press release assuring the united nations that south africa would adhere more closely to the mandela rules following the pandemic if our new normal during and after the covid19 pandemic can be orientated towards reducing inequalities and increasing empowerment for women particularly vulnerable and women like those incarcerated then mhm must be part of that conversation any new practices adopted in light of the pandemic should be sustainable and instituted long term setting a precedent going forward and becoming entrenched practice although enabling every women in south african to manage their menstruation safely and comfortably is not a simple undertaking especially in the carceral environment establishing menstrual health management as an actionable public health issue is imperative such adopted practises and policies can do much to establish and maintain meaningful development around menstruation and empowerment in the post covid19 era to come concluding remarks our viewpoint highlights the potential equality and basic human rights violations of menstruating women in south african prisons precovid and beyond extant jurisprudence can be leveraged to support strategic public litigation along with various efforts to sensitise government promote civil society activism and encourage further research to inform policy and practice which sufficiently uphold the rights of women south africa has ratified the optional protocol to the un convention against torture and national preventive mechanisms are advised to fully consider inspections regarding menstrual management provisions in south africans prison system going forward structural inequalities in various contexts around the world have exacerbated covid19 and mhm disparities within historical contexts of deprivation this has very real continuing health consequences for the girls women nonbinary and transgender men who lack access to the resources and facilities needed to safely manage their monthly cycle at their own discretion mhm disparities require multisectoral collaboration between public heath legal human rights and carceral contexts for menstrual equity and human rights issues to advance it is essential for governments big businesses and development organisations and projects to find innovative and costeffective strategies for meeting the crisis response to the covid19 pandemic but also in achieving a sustainable supply of mhm to those inside and outside of carceral facilities within the prison context in south africa women face multiple layers of discrimination and punishment that draw attention to the historical discourses of correctional facilities as a site of punishment surveillance and discipline too often the voices of those most vulnerable are missing from commentaries and activism on menstrual health issues there is a growing need for transparency within carceral facilities that research can provide by exploring the lived experiences of women and corrections officers in managing mhm the covid19 pandemic presents unique challenges to access to carceral facilities that need to be confronted restricted research access to carceral facilities could signify that any unequitable and in humane retreatment of incarcerated women may go unopposed additionally the absence in menstrual health literature particularly within the african context means that the intersection of health disparities and racial discrimination that the covid19 pandemic has highlighted remains unknown and therefore unchallenged with carceral contexts indicating the need for future research prioritisation finally in this viewpoint we acknowledge that menstruation is not an exclusive feature of the female body since nonbinary and transgender men may also menstruate there is currently a punishing silence in international and national literature that seeks to understand the lived menstrual experiences of nonbinary and transgender men both inside and outside of carceral facilities the structural restrictions of their menstrual bodies go unchallenged in contexts where historical constructions of masculinity pervade the is a necessary area of social legal ethical and research development in mhm further reading united nations united nations standard minimum rules for noncustodial measures united nations 2 april available at minimumrulesfornoncustodialmeasurestokyorulespdf united nations international childrens emergency fund and united nations population fund periods in the pandemic 9 things we need to know covid19 is having a global impact on menstrual health and hygiene unicef and unfpa 31 august available at about the authors janice kathleen moodley is a psychological practitioner and senior lecturer in the department of psychology at the university of south africa her research is critically orientated and challenges the discursive interactions between psychology health gender racial inequalities and politics within the global south janice kathleen moodley is the corresponding author and can be contacted at bianca rochelle parry has been a lecturer and a postdoctoral fellow at the department of psychology and the chief albert luthuli research chair at the university of south africa muckleneuk campus since 2016 her main research focus is on the lived experiences of marginalized communities in south african society with a particular concentration on women and gender this application extends to her teaching interests which include community psychology qualitative research methodologies and online teaching methods specifically within the correctional context for instructions on how to order reprints of this article please visit our website or contact us for further details	purpose the menstrual health and menstrual hygiene management mhm of incarcerated women remains relatively low on the agenda of public health interventions globally widening the inequitable access of incarcerated women to safe and readily available menstrual health products mhp the covid19 pandemic has adversely impacted on the mhm gains made in various development sectors in the global north and south through its amplification of vulnerability for already atrisk populations this is especially significant to developing countries such as south africa where the incarcerated female population are an oftenforgotten minority designmethodologyapproach this viewpoint highlights the ignominious silence of research and policy attention within the south african carceral context in addressing mhm the ethical and political implications of such silences are unpacked by reviewing international and local literature that confront issues of inequality and equitable access to mhp and mhm resources within incarcerated contexts findings structural inequalities in various contexts around the world have exacerbated covid19 and mhm within the prison context in south africa women face multiple layers of discrimination and punishment that draw attention to the historical discourses of correctional facilities as a site of surveillance and discipline research limitationsimplications this study acknowledges that while this viewpoint is essential in rising awareness about gaps in literature it is not empirical in nature practical implications the authors believe that this viewpoint is essential in raising critical awareness on mhm in carceral facilities in south africa the authors hope to use this publication as the theoretical argument to pursue empirical research on mhm within carceral facilities in south africa the authors hope that this publication would provide the context for international and local funders to assist in the empirical research which aims to roll out sustainable mhp to incarcerated women in south africa social implications the authors believe that this viewpoint is the starting point in accelerating the roll out of sustainable mhp to incarcerated females in south africa these are females who are on the periphery of society that are in need of practical interventions publishing this viewpoint would provide the team with the credibility to apply for international and national funding to roll out sustainable solutions originalityvalue it is hoped that the gaps in literature and nodes for social and human rights activism highlighted within this viewpoint establish the need for further participatory research human rights advocacy and informed civic engagement to ensure the voices of these women and their basic human rights are upheld
introduction education is generally regarded as a fundamental human right of all citizens across the globe this is because it equips individuals with the desired knowledge skills and training which can help them attain selfreliance in decision making and to succeed in all the spheres of life based on the provisions of article 21a of the constitution of the federal republic of nigeria the state shall provide free and compulsory education to all children from the age of six to 14 years as the state may determine by law 1 2 besides section 18 also states that the government shall direct its policy towards ensuring that there are equal and adequate educational opportunities at all levels while section 18 shows that the government shall strive to eradicate illiteracy and to this end government shall as and when practicable provide free compulsory and universal primary education free secondary education free university education and free adult literacy programme 3 furthermore nigeria takes part in major conventions geared towards bridging gender imbalance and for the protection of rights of children the organization of african unity charter declared that every child shall have the right to education and full realization of this right shall in particular ensure equal access to education in respect of males females gifted and disadvantaged children for all section of the community 4 the provision of free education to citizens especially children and women was also concretized by the convention on the rights of the child in 1991 in which nigeria with the support of unicef took bold steps to domesticate the convention into national law the bill was passed by the national assembly in july 2003 and by september 2003 it was promulgated as the childs rights act of 2003 after the assent of the president 3 despite the available laws and conventions as cited many children especially the girl child find it extremely difficult to have access to free and quality education particularly in the northern part of nigeria due to poverty cultural belief systems restrictions stereotyping and gender discrimination for these reasons the challenges affecting girl child education in nigeria become major concerns in academic discourses because of their seeming vulnerability amidst sociocultural and economic barriers the more the girl child is rendered illiterate the more the society collapses this is so because even without the universal basic education the girl child may one day become a mother to be shouldered with the responsibility of training her children which can be catastrophic to the future of the society 5 this issue according to robert limlim the unicef deputy president educating girls is known to be the basis for sound economic and social development educated mothers will in turn educate their children better care for their families and provide their children with adequate nutrition 6 in nigeria especially in muslim dominated northern states girl child education is conspicuously lagging behind despite policies made to ensure equitable access to education maikudi 7 argues that the problem of girl child education in the northern region could be traced back to the colonial era when the british educational policy placed more emphasis on coeducation the system was not appealing to the predominantly northern muslim communities not until 1929 when the first girls school was established in the northern province even during that time there was low spending on girls education to a large extent therefore the introduction of formal education for the girl child in northern nigeria by the british at that time could be seen as a manifestation of their interest to control womens education within the context of minimal literacy and numerous skills maikudi 7 further observes that formal education at that time also gives currency to domestic roles as envisaged by the british to train a class of northern upper class girls as housewives to the growing up of male nigerian bureaucrats in addition to socialization of their children along the same line in this regard therefore the problem of girl child education stems largely from cultural and religious beliefs the nature of the british coeducation as well as gender discrimination in northern nigeria this paper therefore attempts a crossexamination of the challenges debilitating against girl child education in ungogo local government area of kano state nigeria the choice of ungogo is largely informed by the fact that it is one of the most populous local government areas located within the kano metropolis with the largest number of girls that cannot access simple universal basic education within the state the specific objectives of the paper however are to find out the roles played by religiocultural beliefs in depriving girl child education to determine whether poverty leads to deprivation of girl child education to assess the problems of gender discrimination which also leads to denial of girl child education literature review previous findings reveal that girl child education has recently got the attention of scholars because of its importance to the development of society and its adverse effects on the girls that are denied access to education fapohunda 8 observes that persistent presence of illiteracy among girl child creates unfavorable environment for meaningful development gender discrimination in terms of education exacerbates backwardness especially in northern nigeria by preventing majority of females from obtaining rightful education needed to improve their prospects in addition unicef 9 states that when girls are denied their full rights to education it affects the society in its entirety as no society is sure of its future when the girl child is denied her right to education on the other hand ojimadu 10 argues that the fundamental rights of a girl can only be developed through sound education and realizing that all other rights of the girl be it economic social or political lay on catering for her right to education many other scholars submit that girl child education reduces social ills including unemployment disruption of family values widespread of diseases and insecurity 11 furthermore oresile 12 maintains that there is a clear linkage between girls education and sustainable development of a country this according to him is realized through their roles as future mothers and peace educators as they inculcate in their children the norms values and ethics of society maimuna 13 posits that education provides the girl child to fit properly into different social roles in the society as she acquires both mental and physical skills to develop her mindset and to contribute meaningfully to her society on the same vain stephen 14 observes that the acquisition of education by the girl child lays the foundation for socioeconomic improvements of nations the federal ministry of women affairs 15 also avers that educational attainment is no doubt the most fundamental prerequisite for empowering girls in all spheres of life this report makes it clear that without quality education girls will be unable to participate and be represented in government a broad range of empirical data also shows that girl child education reduces mortality rates of children because knowledge and awareness ensure the increase of healthy and hygienic maternity based on the literature reviewed it is clear that there is a direct linkage between girl child education and societal development it is equally established that the denial of girl child education has adverse effects on the girl which by extension paved the way for other societal problems in spite of these efforts the girl child remains in critical socioeconomic and political conditions which largely stemmed from several factors contributing to the backward state of her education especially in northern nigeria despite the relevance of the literature reviewed it is observed that there is the dearth of sources highlighting the plights of girl child education from a micro level and especially in the rural or semirural areas which is a gap this present study attempts to bridge although the colonial period arguably witnessed a lot of educational activities in northern nigeria especially in the 1920s and 1940s boys education received greater attention it was only from the 1930s that girl child education received attention in the northern province on this basis therefore girl child education in northern nigeria was first hindered by the unevenness in terms of equal access to educational irrespective of gender categories 16 17 18 19 maikudi 7 establishes that the problem of girl child education in northern part of nigeria in general could be traced back to the colonial era when the british educational policy placed more emphasis on coeducation that system was however not appealing to the predominantly northern muslim communities until 1929 when the first girls school was established in northern nigeria even with the establishment of the school there was low funding on girls education for this simple reason kurfi 5 and dauda 20 also posit that the problem of girl child education in the northern region largely stems from the introduction of western education by the british colonial government which laid emphasis on the education of both girls and boys attending the same schools apart from the stated religious dimension muslims of northern nigeria were culturally uncomfortable with the western system of education especially that of girl child which they believe could cause some disasters to them this development therefore served as a barrier to the smooth development and acceptance of girl child education in northern nigeria okpani 21 further concludes that the problem of girl child education has its roots in skepticisms held by the present northern states in nigeria about western education which was introduced by colonialists and christian missionaries with emphasis on attendance of both boys and girls it should however be noted that the rejection of western education by northern muslims emerged at the beginning of its introduction but was later embraced by the majority even with the recent bokoharam insurrections claiming to question the legality of western education mainstream muslims have not subscribed to their baseless ideology methodology this paper is built on both primary and secondary data while the administration of questionnaires formed the primary aspect of the data the secondary sources include published and unpublished works ranging from books journal articles to theses and dissertations the target population of the study constitutes the youth between ages 1535 years which include both male and female who reside in ungogo local government area these categories of people were chosen because they fall within age bracket of youth and they have firsthand information about the problem under study sample size due to time limitation and resource constraint this study could not cover the total population and as such the sample size is relatively small a total of 120 respondents formed the sample size across five political wards that are purposively selected within the local government area sampling technique this paper utilized multistage clustered sampling technique the rational for this sampling technique is to have equal representation of units it is also supported with a purposive sampling technique where necessary thus the following stages were followed stage the researchers also identified 6 locations out of the 6 political wards selected in stage one the locations were selected using purposive sampling technique that is augmented with a survey method this selection was however informed by the fact that the areas happened to be the most populous within the already identified 6 locations these 6 locations are rijiyar zaki ungogo panisau rimin zakara kurna rimin gata stage 3 4 major streets were equally selected by the researchers in each of the 6 locations selected in stage 2 stage 4 at this stage 5 households were selected from each streets selected in stage 3 stage 5 this is the last stage in the sampling technique within which the researchers administered the instrument of data collection to respondents from each household selected in stage four and thereby amounting to a total of 120 respondents method of data collection primary data was collected through the administration of questionnaires while the secondary data was largely gathered from the libraries at bayero university kano and ahmadu bello university zaria as well as from the internet the primary source of data collection is also called a firsthand data collection in which a selfadministered questionnaire strategy was adopted and designed to be the instrument of data collection in so doing a total number of 120 questionnaires were administered to obtain information from respondents there was also an introductory letter in the questionnaire to the respondents which clearly specified the intention of the researchers the questionnaire comprises of both close and openended questions which gives respondents the opportunity to express their opinions the questionnaire was divided into 3 parts part one contains the biodata of the respondents while part two and three contained the main questions of the research the responses obtained form the basis of analysis presented thereafter published and unpublished works such as books journal articles theses and dissertations relevant to the research work served as secondary source of data collection method of data analysis a qualitative method of data analysis is used in this paper in this regard data obtained from the questionnaire is logically arranged using frequency and tabular representation finding and discussion finding in this paper a total of 120 questionnaires were administered but only 105 questionnaires were retrieved in the course of doing the analysis the questionnaire responses were critically analyzed this section therefore presents the interpretation of the data collected and analysed in the course of the study table 1 shows that 905 respondents agreed with the fact that poverty is a factor denying girl child education when asked to explain their position respondents argued that most families find themselves in poor conditions where they cannot afford to cater for their basic needs in life as well as the education of their girls they also added that the cost of education is high which is not compatible with the poverty situation of most families within the local government area respondents further opined that while enrolling children into school parents are expected to buy uniforms learning materials and transport fees which they cannot afford due their poor state 95 of the respondents however did not agree that poverty is a major factor affecting girl child education this indicates that poverty serves as a factor of denying girl child education within the local government area as expressed by many respondents from the table 2 it is clear that 838 respondents agreed that poverty causes parents to send their girl child to street hawking respondents with such stand provided reasons to justify their position based on the fact that poverty curbs parents demand for education and therefore send their girl child to street hawking to generate income for the family in some instances parents send their children to various low paid works such as domestic helping serving as nannies to younger children especially in urban areas162 of respondents revealed that poverty does not cause parents to send their girl child to street hawking because whatever they earned from street hawking is too little to sustain the family needs and as such poverty is not a casual factor for sending girl child to street hawking thus from these responses it can be deduced that poverty forced many parents to send their girl child to street hawking items such as kolanuts groundnuts pure water and food are used for the hawking table 3 indicates that 714 of respondents do not agree with the notion that street hawking helps sustain income for the family stating that the income earned in the street hawking is a meagre one and therefore it is too little to sustain the family needs in some instances girls usually return home with the items without selling them others provided that parents have no choice rather than to send their girl child to street hawking because the condition they often find themselves in forces them to do so 286 of respondents however agreed that street hawking for girl child sustains income for the family stating the fact that some parents are not employed or in some cases fathers have divorced mothers and the children are under the latters care as such they have no source of income to cater for themselves most of such families totally depend on income earned from street hawking which is used to provide food for the family and maintain a substantial capital for the hawking business this indicates that the income earned from the street hawking does not adequately sustain the family sometimes children go to bed without eating and drinking despite the street hawking activity table 4 indicates that 914 of the respondents considered the cost of education to be a factor denying girl child education stating the fact that cost of education nowadays is very high while parents are expected to pay school fees buy learning materials uniforms and also pay for transport and feeding most parents cannot afford to pay such fees continuously even if they start paying when the due payment is over the girl child is sent back home for the nonpayment of fees such as pta examination fees or lack of good uniforms or books on the other hand 86 of respondents revealed that the cost of education is not a factor of denying girl child education from the foregoing therefore it can be concluded that the cost of education is no doubt a factor denying girl child education in the community table 5 shows that 762 of respondents agreed that religiocultural beliefs are directly linked to the denial of girl child education in ungogo local government area when asked to explain their position respondents argued that cultural practices such as early marriage serve as major barriers to accessing education for girls in the local government area it has always been part of the peoples tradition to marry girls out at an early age and once they are married they have no access to education most parents hold certain religiocultural views about girl child education which stem from their outright distrust for formal schooling because of its emphasis on coeducation they believe that coeducation can affect the morality of the girl child 238 of respondents do not agree that cultural belief is a factor leading to the denial of girl child such respondents also argued that some harmful cultural practices such as early marriage are no longer practiced by many families as parents are not capable of making arrangement for ceremonial wedding because of the financial burden associated with it from the above findings it should be concluded that there is compatibility between religiocultural beliefs and denial of girl child education this is because marriage is viewed as a protective mechanism against unwanted pregnancy shielding girls honor from potential shame table 6 shows that 961 of respondents maintained that gender discrimination is a factor affecting girl child education this is because while boys are competing in getting admissions into the universities girls are left behind struggling with primary or secondary education more often than not girls are married out and thus they cannot continue with their education on the other hand 380 said that gender discrimination is not a factor because in some instances girls attend school more than boys and performed higher academically table 7 indicates that 3904 of respondents believe that poverty is the major factor debilitating against girl child education this is followed by 2857 of respondents who consider cultural practices to be the reason denying girl child education while 1428 of respondents argue that the cost of education hinders girl child education 1142 of respondents however consider gender discrimination to be the major problem affecting girl child education and 666 of respondents consider low government effort to be the challenge of girl child education in the community table 8 indicates that 3333 of respondents are of the opinion that the government must be involved in order to tackle the problem of girl child education although the government has made several efforts to curtail the problem much needs to be done 28 57 of respondents on the other hand argue that parents should be involved in tackling the problem of girl child education while 1428 of respondents believe that the problem of girl child education can be reduced when community leaders and community on based organizations are involved so that they can play a significant role in terms of enlightenment and empowerment besides 952 of respondents are of the view that nongovernmental organizations should be involved in tackling the problem of girl child education hence it can be deduced from the table that government should be the primary agent for addressing the problems of girl child education discussion having presented all the necessary data in tabular form indicating facts and findings about the challenges of girl child education in ungogo local government area it became apparent that the challenges facing girl child education in the community cannot be overemphasized this is because the research indicated that the denial of girl child education is linked to certain religiocultural beliefs such as coeducation and early marriage the research also revealed that although figures have shown that only 952 of respondents agreed that girls marry between the ages 1719 years the situation seems to be worse when such girls are married out without attaining a primary or secondary school certificate as practiced by many families in the community many respondents are of the view that the emphasis on coeducation by the western schools since its introduction by the british colonial government discouraged many parents from sending their girl child to school this is simply because it is alien to their religious and cultural practices to support these findings marope et al 22 states that cultural restrictions militate against girl child education in northern nigeria concluding that …in some cultures girls are restricted in the kind of role they can play education inclusive eresimadu 23 okwara 24 okpani 21 unicef 25 and maimuna 13 opine that there are three important cultural belief systems which militate against girl child education thus early marriage condemnation of coeducation and preference of educating the male child furthermore the research equally showed that poverty is a major factor affecting the state of girl child education in ungogo local government area of kano state it also revealed that because of the failure to properly fund the girl child to go to school many parents resorted to sending them to street hawking with the intention of sustaining the family economically in some instances girls are sent to engage in domestic helping or to serve as nannies to younger children especially in the urban areas the meagre income generated from such activities however cannot sustain the family to support this assertion okpani 21 and ojimadu 10 argue that girls engage in street hawking practices to generate income for the family by selling foodstuffs on the street while the girls miss the opportunity of going to school meanwhile birmingham 26 mamman 27 ojimadu 10 ikwen 28 abolarin 29 kurfi 5 and maimuna 13 also state that poverty always challenge the state of girl child education in northern nigeria the research also showed that the cost of education serves as a major barrier to girl child education taking into consideration that parents are expected to pay school fees buy uniforms learning materials transport and feeding costs and examination fees many poor families cannot bear the demand for such cost and as such they pay little attention to the education of their girls this finding is supported by unicef 25 who argue that most parents do not consider education of the girl child a priority because they have little or no disposable income to supplement the cost of education moreover this research found out that gender discrimination affects the state of girl child education as many parents prefer to educate their boys than girls this is because many girls are denied access to education by virtue of their gender and due to the common believ that at some point in time a girl is to be married out this reason further justifies parents preference for educating boys than girls to support this afigbo 30 opines that girls inadequate access to education is largely informed by the gender discrimination they face in line with this finding unicef concludes that more than 100 million children had no primary education in africa and out of this number 60 million were girls the effect of this inequality makes the girl child vulnerable and prone to abuse sexual harassment and maternal mortality which are directly related to the lack of qualitative education for girls conclusion this paper revealed that the challenges of girl child education are still evident and therefore hamper on girls access to education factors such as religiocultural beliefs parental level of education and income play a significant role in determining the possibility of girls having access to education in ungogo local government area of kano state as critical as these two factors are scholars pay little attention to them as they tend to focus more on government policies towards girl child education though this paper has traced the origin of northern nigerian muslims abhorrence to western education to the insistence of the british colonial government to promote coeducation and the fact that the type of education they introduced was seen as christian in both content and outlook it is observed that poverty religiocultural beliefs and negligence on the side of the government further exacerbated the problems militating against girl child education in the region in line with this current reality this paper found out that a lot of efforts have to be put in place so as to properly curb out the problems of girl child education in ungogo local government area in particular and northern nigeria in general these efforts are also manifold in nature because of the fact that the government parents community leaders nongovernmental organisations and the international community have to be involved so as to address the problems within the shortest possible time	since the introduction of western education to northern nigeria especially in the 1920s many muslims in the region found it objectionable as it tempered with their religiocultural values including for instance coeducation in light of this therefore this paper identifies and examines the major challenges affecting girl child education in ungogo local government area of kano state nigeria using both primary and secondary sources that are augmented with a qualitative data analysis the researchers administered a total number of 120 questionnaires across five 5 political wards of ungogo local government area that were purposively sampled out of the 120 questionnaires administered only 105 were retrieved representing 875 response rate data collected is analyzed using descriptive statistics results revealed that religiocultural reasons poverty lack of viable government educational policies and parental preference to educate the male child are the major factors curtailing the chances of the girl child to have access to western education in the area of study
offer opportunities to sharpen our understanding of specific problems participatory approaches are confronted with seen from an insiders point of view at the same time some contributions to this issue may stimulate discussion on the role and limitations of pta in the light of outside experiences such as those against the backdrop of bottomup civil engagement or participatory experiments in technology design taking a more relaxed point of view may help redefine the role of pta as one specific element in the wider context of technology governance this does not mean that questions of legitimation or impact are of less importance in the future they could rather open our eyes to new perspectives such as moving away from purely participatory events to more comprehensive approaches participation being one element among others one of the case studies presented in this issue demonstrates that the role pta is able to play within a specific political setting very much depends on the institutional arrangements and different national styles of policymaking other case studies dealing with new procedural developments in the field impressively show how practitioners of pta try to react to upcoming requirements overcome apparent problems and provide some valuable insights into thesometimes puzzlingworld of technology policy the first paper by thomas saretzki reminds us that it is of decisive importance to distinguish between technology assessment and technology policy when legitimation problems of participatory approaches are at stake in contrast to technology policy the core function of any modern ta is to mediate between three institutionally and functionally differentiated systems science politics and the public according to saretzki legitimation problems indicate first of all that attempts to justify participation in a given case have not been entirely successful in the eyes of the relevant groups of sponsors participants organizers or observers to deal with legitimation problems in a constructive way saretzki proposes the development of a multidimensional selfreflective and selfcritical approach to ta which is able to serve as a system of reference for legitimating their own new roles especially in the context of participatory procedures in ta leo hennen responds to recent criticism regarding practical experiments with pta according to this strand of literature pta shows a number of crucial problems in many cases such public deliberation processes have only marginal impact on political decisions they also run the risk of being instrumentalized by influential interests groups while showing serious deficits regarding the production of new and authentic layperson expertise in reference to these main lines of reasoning hennen argues in the paper that these criticisms insufficiently take into account the context of participatory ta as an element of policy consulting taking into account the specific nature of pta as a strategy to stimulate public deliberation and collect attitudes interests and patterns of argumentation used by laypersons it is able to improve the responsiveness of the political system and to give a voice to perspectives that are not or only poorly represented in political debates and decisionmaking processes against the background of civil society engagement in the fields of biomedicine and nanotechnology peter wehling explores the potential of the socalled uninvited forms of participation and discusses possible consequences for more institutionalized formats of pta similar to several other authors wehling refers to recently discussed practical problems and structural limitations with invited forms of pta and contrasts these experiences with interestbased civil society interventions by patient associations and environmental and consumer organizations he shows how uninvited initiatives in science and technology build up democratic legitimacy and manage to gain impact on decisionmaking processes wehling comes up with a number of recommendations to rethink and improve existing pta approaches and methods and discusses new strategies to combine invited and uninvited forms of participation based on two national case studies dealing with the governance of xenotransplantation in switzerland and austria erich griessler explores the influence of structural conditions and national styles of policymaking on the role and effectiveness of pta griessler shows that experiences with pta differ fundamentally between the two countries in switzerland the number of public dialogue exercises on xenotransplantation is much higher than in austria and the possible impacts of these deliberations on policymaking seem to be much more effective griessler discusses a number of important similarities and differences regarding political institutions and practices of policymaking in both countries he suggests that the most important factor for explaining the prominent role of pta in switzerland is the extraordinary veto power of the swiss citizenry which calls for dialogue formats to avoid potential resistance from the public michael decker and torsten fleischer report on recent experiences with as they call it big style participation in germany both authors have been involved in a stillongoing series of citizens dialogues on future technologies initiated and led by the german federal ministry of education and research at least in the german context these dialogues are to be valued as a unique experiment on the one hand several thousand citizens will be involved in the whole procedure on the other hand the strong position of the ministry which is responsible for the entire process and heavily involved in its planning organization and communication constitutes an unusual feature in the paper the authors allow some firsthand insights into the political background associated expectations and practical restrictions those procedural innovations are confronted with based on first evaluations and internal reflections on the process they tentatively conclude that the high efforts to guarantee a kind of statistical representativeness are still contested by participants as well as a variety of incumbent political actors the next paper also deals with new methodological directions in the field of pta niklas gudowsky walter peissl mahshid sotoudeh and ulrike bechtold describe a recently developed method that allows for comprehensive participatory forwardlooking activities this method called civisti brings together expert stakeholder and lay knowledge in a wellbalanced way preparing longterm oriented recommendations for decisionmaking in issues related to science technology and innovation it comprises three phases in an initial phase the invited citizens produce future visions in a bottomup process experts translate these visions into practical recommendations in a consecutive phase finally the same groups of citizens validate and rank the outcome the authors not only report on first experiences with this new approach they also address a number of practical challenges and discuss some options for improvement diego compagna draws our attention to the problems of translation between design and use in participatory technology development projects his empirical material stems from a recently finished 3year project on service robots in elderly care using some analytical concepts taken from classical social constructivist approaches and actornetwork theory compagna unrolls step by step and reflects on experiences made in the project he addresses scenarios as developed by designers developers and future users involved as translation tools and epistemic objects that are able to mediate between diverse expectations and experiences however as the process continues scenarios gain a kind of agency and each participating group is forced to align itself to the scenarios on a more general level and with regard to similar situations in pta exercises compagna concludes that participatory methods such as scenario exercises must be understood as active translators with the intrinsic ability to recompile and reconfigure the whole process in an unexpected way in the final paper michael zschiesche offers the opportunity to reflect on pta in a similar way by providing insights from a related but quite different field of infrastructure projects in germany formal public participation is required in authorization processes according to the federal immission control act for the approval of industrial facilities as well as in the planning permission procedure for infrastructure projects empirical data on those approval procedures show that the right of the concerned publics to be involved in the procedures is not at all made use of in many cases in particular procedures according to the immission control act show extremely low rates of participation here only one out of three authorization processes is met by public engagement based on secondary sources zschiesche also shows that even in cases where public participation takes place the actual influence on the outcome remains marginal to improve the formalized procedure in the future the author discusses options to combine formal and informal methodsas widely used in ptaand calls for participatory interventions at much earlier stages of a planning process the various papers hence cover a wide range of positions and empirical case studies they also allow for some tentative conclusions in line with recent scholarly discussion as long as ta positions itself as a mediator between science politics and the public it has to cope with the multiplicity of participatory methods and strategies in addition it must be able to master specific qualities and the limitations of pta as well as being prepared to adapt methods and methodologies to changing sociopolitical environments public discourses on emerging technologies and their possible consequences for society and the environment need not be restricted to policy advice as typically provided by ta institutions forms of civic expertise with a special focus on societal impacts may play a stronger role both in technology policy and in technology design ta may profit from such outreach as these other fields may profit from the procedural and methodological expertise ta has developed during the last 30 years the papers in this special issue once more contribute to this stock of knowledge and clearly offer some fruitful ideas about promising future directions of pta theory and practice open access this article is distributed under the terms of the creative commons attribution license which permits any use distribution and reproduction in any medium provided the original author and the source are credited	discussions on the role of participatory approaches in technology assessment and technology policy have a long history while in the beginning this subject was handled mainly as a theoretical requirement for democratic governance of technology active involvement of stakeholders and laypeople became popular in ta exercises throughout the 1980s since then a variety of participatory ta pta methods and strategies have been developed and widely used raising further farreaching expectations it has been argued that participatory approaches might broaden and hence enrich the knowledge and value base in ongoing technological discourses and eventually improve the factual as well as democratic legitimacy of technologyrelated decisions joss and bellucci 2002 moreover a stronger integration of diverse actors and stakeholders was linked to the promise of better socially embedded solutions an increased acceptance and enhanced diffusion of technology as well as technology policy however practical experiences with pta have shown that under realworld conditions it is difficult to meet all these expectations eg abels and bora 2004 despite a continuing and widespread interest in pta empirical evidence and theoretical positions on the practical performance of pta have remained ambiguous the papers selected for this special issue refer to this ambiguity from different angles and aim to contribute to the ongoing discussion on theoretical foundations as well as practical experiences and critical appraisals of various forms of pta most ideas experiences and findings covered by this collection had first been presented and discussed at the yearly conference on technology assessment at the austrian academy of sciences in 2011 1 in a similar vein the papers in this special issue m ornetzeder á k
introduction managing a spinal cord injury is challenging even in usual circumstances it is a medically complex condition that requires timely care support and diligent selfmanagement to promote wellbeing and prevent serious secondary complications undoubtedly system disruptions created by the covid19 pandemic have substantially exacerbated the challenges of living with sci tis study explores the experiences and perspectives of people with spinal cord injury and critical stakeholders to identify secondary complications access concerns and potential solutions in the context of the pandemic health systems have been experiencing severe stress as they redistribute resources to manage covid19 outbreaks 45 for people with sci this has curtailed routine healthcare rehabilitation and outpatient services with earlier discharge from inpatient rehabilitation for people who are covidnegative and suspended or temporarily reduced admissions 467 te use of telemedicinetelerehabilitation and home care has increased to support people at home 48 but further evidence is required to assess comparability with inperson consultations across a range of clinical interactions 910 additionally changes in service delivery and system capacity have negatively impacted on social and mental wellbeing of staf and the social contact between people with sci their families and health professionals 4 unsurprisingly in this scenario scs are occurring in physical psychosocial and occupational domains for people living with sci tis includes increased vulnerability to infection and respiratory complications 57 signifcantly decreased physical activity including recreational and occupational pursuits 11 and markedly increased spasticity pain and discomfort 71213 tese scs were attributed to pandemicrelated social restrictions resulting in reduced walking extended sitting in wheelchairs or confnement to bed and insomniarelated pain or discomfort symptom reemergence and increased spasticity were also attributed to the postponement of treatments such as botulinum toxin type a injections 12 in the psychosocial domain lost access to personal supports such as family personal networks and formal support workers increased social isolation and complicated access to healthcare information 47 13 14 lower resilience and quality of life have also been reported with increased depression and anxiety particularly around accessing services 61415 in the occupational domain social restrictions have reduced access to recreational activities 11 it is also more difcult to access essential assistive technology other necessary equipment repairs routine medical supplies groceries and transport for healthcare appointments 5614 te fnancial concerns and impacts have also been substantial 14 while australia limited the spread of covid19 in the frst two years of the pandemic through widespread lockdowns covid19 mandates leave payments and jobkeeper supports health and social care system functionality was still significantly compromised impacting on all members of the community including people with sci and other disability since restrictions began to ease in late 2021 including reopening of international borders in february 2022 covid19 has spread rapidly by july 2022 australia had recorded 9235014 cases and 11387 deaths 16 queensland initially minimised the spread of covid19 through border closures strict isolationquarantine mandates societal restrictions and lockdowns te state only returned to a close to normal situation when achieving a 90 vaccination rate 17 practical guidelines were published to protect the rights of australians with disability under pandemicrelated restricted access to health services including mobility aids communication options visitor and family access and involuntary hospital discharge 18 implementing some of these strategies potentially placed additional demand on already limited service resources thus challenging service delivery for providers and recipients across primary secondary and tertiary healthcare sectors severe pandemicrelated disruption to sci services warrants investigation of the personal impacts and how the disruptions are managed by people living with sci health professionals and services and identifcation of system enhancements to better protect people with sci and other disability from future pandemic waves or other causes of system disruption tis study is part of a larger program of research which examines the impact of health system stress caused by the covid19 pandemic on scs and access to health and rehabilitation services by comparing people with sci discharged prior to and during the pandemic in queensland australia using data linkage and survey data te aim of this component of the research was to examine the perspectives of a sample of people with sci and sci expert stakeholders regarding disruptions in their access to health and rehabilitation services impact on scs and examples of problem solving and innovation in response to service disruption and personal impacts for people with sci it was assumed that study participants would report reduced health service capacity and increased scs due to the pandemic particularly in the frst several months of the pandemic method 21 design te present study utilised a multimethods qualitative design comprised of a qualitative online survey of people living with sci and expert stakeholder forums with experienced sci clinicians as well as representatives from communitybased sci consumer organisations and other community services providing services to people with sci such as compensation agencies examining multiple perspectives enabled a comprehensive understanding of the impacts from all critical stakeholders in the sci rehabilitation journey to be gained te survey identifed issues of importance to respondents living with sci and the forums enabled key issues to be explored indepth to generate insights of value to all concerned te study setting was the queensland spinal cord injuries service which provides statewide specialist sci services along a lifelong continuum of care that comprises of 2 health social care in the community acute management and primary rehabilitation outpatient followup as well as transitional and community rehabilitation and outreach services participants data analysis descriptive analyses were used to summarise the demographic characteristics of survey respondents qualitative content analysis 19 was used to summarise the information provided in the survey responses to the question topics tis enabled the development of a comprehensive and coherent summary of respondents views regarding the topics of interest frequency distributions were used to provide an overview of responses structured to align with the openended survey questions te analysis was conducted independently by two team members followed by a meeting to progress the fndings minor diferences were identifed and resolved through discussion to ensure consistency te forum transcripts were analysed thematically 20 following fve key steps familiarisation with the data identifying a coding framework indexing the data charting to identify patterns and mapping and interpretation a framework approach was adopted to enable prespecifed questions to be addressed 2122 tus the key themes were structured deductively from the four question topics and inductively from the comments of participants two forum participants agreed to read the fndings and both confrmed that they accurately represented what was discussed results te survey was completed by 34 people with sci no information was available regarding nonrespondents or their reasons for nonparticipation te mean time since injury was approximately 20 years a total of 16 sci expert stakeholders participated in one of two forums and all but two opted to attend in person participants comprised ten clinicians representing specialist inpatient and community sci services as well as representatives from three key consumer organisations and one compensation agency te duration of esfs was 90 minutes and 120 minutes respectively due to the complementarity of fndings from the online survey and esf the results are presented as a single unifed narrative regarding the impact of the covid19 pandemic on physical and mental wellbeing access to services and supplies and the use of workarounds to mitigate adversity table 2 summarises the survey results comments were selected from the survey responses and forum transcripts to shed light on the study results in this section respondent refers to a person who completed the survey and participant refers to a person who participated in the forum discussion impact on physical and psychosocial wellbeing unwanted physical impacts were a common concern for sci survey respondents early in the pandemic with only two reporting no physical impact te most frequently reported problems were a lack of physiotherapy and no hydrotherapy followed by lack of exercise and gym access since facilities were shut down or respondents were confned to their home another commonly reported concern was muscle stifness linked to reduced physical activity te impact on physical wellbeing was discouraging as one forum participant observed when you know what theyre capable of and how hard theyve worked to get there and then youre watching that just go backwards and then losing independence and function that was tough to watch esf1 p1 another participant noted some just stopped services altogether and we found some reluctant to go to doctors to physios to whatever services other services they might need and yes its just been that when they get to a point where they absolutely have to go theyre dealing then with a pressure wound or something that is a whole lot worse than it needed to be had they gone out early esf1 p5 a forum participant explained that a lot of the community services that people relied on were gone almost very quickly esf2 p6 undesirable impacts on mental health were reported by most sci survey respondents te majority identifed isolation as a mental health issue and nine reported experiencing isolation and mental health issues anxiety worry or stress were reported by a substantial minority others identifed fear boredom frustration and a lack of concentration as a concern only six respondents reported no impact on their mental health for example one reported being very bored and we all became depressed due to lack of human contact r2 one individual living with sci described impacts in terms of injury immense stress pain and exhaustion r12 for his wife who had become his sole caregiver in contrast however another respondent noted liv ing rurally so nothing much changed r20 esf participants had noted signifcant increases for the majority in dass depression anxiety and stress scores esf1 p1 and reduced mental wellbeing we know that social connection is such a protective factor and it completely dropped of for a lot of people mental health has been the big issue and big concern esf1 p6 one sci survey respondent reported a relationship breakdown and the partner of another was diagnosed with mental illness a participant noted that it is not surprising that there would be signifcant impacts on family given that access to professional support workers was often challenging and that even getting support te number of people with sci who experienced diffculties was marginally lower by a year later although several reported no impact on their usual services almost half reported difculty in general and more than a third reported that no support was available or that it was difcult to fnd a similar number reported restricted community access 6 health social care in the community specialist sci inpatient and ambulatory services were variably impacted through the course of the pandemic survey respondents noted that they were unable to access gp hospital and specialist care r17 or attend my regular sci rehabilitation sessions r22 in the early stages the need to create hospital inpatient capacity resulted in very rapid discharge planning for existing patients and consequently increased responsibility and stress on specialist sci community services i think the early discharges whether they are by the health system wanting people to be discharged or people wanting to be discharged themselves the fallout is just that were seeing bigger problems at home esf2 p6 later as all community services were increasingly curtailed discharge from inpatient services was often delayed for example by inability to get home modifcations completed by community service providers in a timely manner if were all on lockdown or there are restrictions then you dont get your home mod ifcations started you cant discharge you have a backlog for people coming in the front door if people cant get home esf2 p2 one of the forum participants noted that delayed discharges also meant that others needing specialist spinal rehabilitation were placed in acute wards or other hospitals esf2 p3 another remarked that a downside of being able to go out into the community again after a longdelayed discharge from the spinal injuries unit was that for people with sci who have been in a cocoon for six months twelve months this freedom also generated fear around how vulnerable am i esf1 p4 a minority of sci survey respondents experienced lack of fexibility in their interactions with government agencies such as centrelink and the national disability insurance scheme and one had to pay a fee for cancellation of support during a snap lockdown lack of access to therapy surgery consultations and exercise remained a problem as the pandemic continued one sci survey respondent reported difculty accessing vaccinations while two were concerned about challenges accessing clear information around the limits of covid19 vaccination including effcacy another reported that it was helpful that supermarkets had disabledonly times r18 and access was easier with less road trafc r18 but such benefts were not experienced by those unable to access shopping and chemist r7 in contrast almost a quarter of respondents reported no problems with obtaining personal or home support or community access during the entire pandemic impact on equipment consumables and repairs for some sci survey respondents the cost of consumables was a problem and an equal number reported difculties with delays and deliveries access to equipment and parts was difcult for almost a quarter of respondents for example one respondent waited 9 months for parts for an essential item to be repaired r9 while others had problems from almost day 1 with continence supplies r29 or being unable to purchase examination gloves or to attend massage fortnightly and hydro therapy twice a week r21 in contrast six identifed no problems with equipment or consumables one esf participant provided further insight into such disruptions w e had to get special permission for all of our suppliers to come in to provide equipment we had to keep communicating and highlighting that as it impacted on peoples rehab ilitation and potentially length of stay to ensure that the expectation was understood that things couldnt move as quickly as we would normally move them esf1 p9 another forum participant noted tats been a massive problem getting equipment and aids getting allied health to the people getting equipment to the people ordering the equipment and that goes with telehealth as well with getting suddenly ipads computers technology esf2 p6 a minority of sci survey respondents identifed no problems with technology despite its potential advantages technology was problematic for several respondents who struggled with virtual communication in contrast some esf participants found telehealth to be a nice escalation pathway now esf1 p2 positive impacts were also identifed including easier disabilityfriendly access to shops because at times less road trafc allow ed safer short distance travel easier access at shopping centres r16 secondary complications a substantial minority of survey respondents reported a diverse range of physical complications due to pandemicrelated restricted access to services including muscular deterioration skin problems weight gain neurological problems and hypertension for example physiotherapy services shut and my legs ended up becoming very tight r28 consistent with these reports an esf participant described seeing s ituations where the person has not been able to come to get the acute treatment necessary postinjury tey have been remotely hospitalised and very quickly they developed utis pressure injuries sepsis they lack expertise in managing sci by the time they get to the spinal injuries unit theyve got to get extended medical treatment which delays rehabilitation esf2 p1 te diversity of experience with covid19 or servicerelated complications is reinforced by the absence of complications for a substantial number of respondents in contrast with the sci respondent who disclosed suicidal thoughts and another who lost employment for one respondent the covidimposed isolation was intensifed by marriage breakdown and separation r17 solutions and workarounds to mitigate negative impact almost a quarter of respondents were unable to identify any solutions and three had resigned themselves to their circumstances six sci respondents regarded technology as a solution and a similar number reported that shopping less frequently and shopping online were solutions six respondents tried a selfdirected approach to exercise eight planned for and sourced alternative supports four restored or developed new work or home routines and seven used or developed new personal strategies including avoiding watching the news relaxation techniques and increased hobby activities for some respondents workarounds were not necessarily positive as one had to move into a tense living arrangement with my expartner r7 and another reported confusion about access to medical services unrelated to my sci r6 while acknowledging that phone consultations and telehealth were most welcome r6 solutions were also constrained by undercurrents of fnancial concerns such as having lost my job and hav ing no personal income r7 or concerns about personal choice regarding vaccination mandates with no supplies in our area r5 or the mandate to have our health workforce vaccinated and staf leaving r22 esf participants were more positive in recognising the opportunities and challenges of imposed change its changing everybodys expectations weve all come along the journey and had to learn we cant get everything we want now although we need it we cant get all the services we want we cant get it the way we want it i think the balance of learning that this is new and we all have to accept it and also learning that everybody emotionally and mentally are heightened balancing that as well has been difcult but that includes everybody tats the service users the service providers who are also humans with a family in this pandemic esf2 p6 discussion to our knowledge this is one of the frst australian studies to examine the impact of covid19 pandemicrelated health system stress on a sample of people with sci it also reveals how service providers and people living with sci in the community have innovated in attempts to mitigate the impact of pandemicrelated disruptions te survey and forum results together contribute to our understanding of these impacts for people living with sci in three ways firstly people with sci experienced service disruption particularly to health and community services and personal supports secondly the impacts of the disruptions were measured by secondary complications in physical health and psychosocial domains lastly people with sci and those who support them accommodated and generated change to try to fnd solutions for ensuring access to care during the pandemic tese impacts were evident in the beginning of the pandemic and stayed relatively stable over the prolonged period created by widespread restrictions lockdowns and other pandemic responses te scale complexity and duration of disruption to healthcare rehabilitation and community support services and to the supply of equipment and consumables has been unprecedented and is consistent with international research 462324 as is the fnding of disrupted inhome personal support 5 in addition to closed delayed or rationed services participants were confronted with their own selfpreservation instincts of not wanting to interact with services for fear of contracting covid19 7 although intended to alleviate concerns about loss of facetoface interactions the rapid growth in telehealth consultations was found to generate new challenges related to unfamiliar or unreliable technology as well as safety concerns for example when undertaking physical therapy virtually 458 service users and providers were challenged by the scarcity and higher cost of supplies and by uncertain service accessibility and safety disruption led to multiple concurrent and intersecting impacts isolation was implicated as a key contributor to scs in physical and psychosocial domains particularly poor mental health supporting previous research 61415 respondents reported increased anxiety worry and stress and one disclosed suicidal ideation te impact also extended to quality of life and wellbeing with respondents reporting increased fear boredom frustration poor concentration relationship breakdowns and increased burden on family memberssupport workers it was almost inevitable that hardwon levels of physical health sufered because of pandemicrelated disruption with the reporting of increased muscle stifness loss of strength and mobility increased paindiscomfort and other medical complications consistent with previous research 7 11 12 13 15 tese results all support the study assumptions coupled with the pressure of ongoing needs the large number of impacts compelled people to respond however it is noteworthy that for more than three quarters of respondents attempts to innovate were unsuccessful which seems consistent with their reported frame of mind despite working in survival mode providers continued to explore and test alternatives to ensure adequate support was reaching those who needed it with some success including increased use of telehealth te limitations of technology as an alternative means of communication are not new especially for inexperienced users 4 taken as a whole the results of this study demonstrated resilience in people with sci and in the health professionals who care for them tey were confronted by new largescale challenges and at least attempted to resolve them in ways to preserve quality of life and progress with rehabilitation nonetheless some respondents clearly experienced unwanted physical and mental health impacts reduced or disrupted access to usual services and community increased scs and difculty accessing support and equipment in contrast to many natural disasters the covid19 pandemic is a marathon which adds endurance as a further need tis has implications for all concerned including those who may have used alternative sources of support to mitigate or delay the development of scs implications since some issues arising early in the pandemic failed to resolve new and collaborative approaches are needed to manage complex issues that resist or overwhelm usual strategies te pandemic provides a new opportunity to develop and evaluate crisis management plans and strategies and to add them to standard resources as valuable actionready backup plans in any future disruptions to the supply chain and coordination of health care and support if online solutions become standard options work is needed to improve the low efectiveness of technological solutions reported by the study participants and to now shift the focus of education and training away from health professionals and service providers to the end users we suggest that this population who prize their independence and resilience 2526 would welcome training initiatives to improve their technological capacity training in telehealth and technology for delivering care and rehabilitation would require signifcant investment in materials hardware and training for both people living with sci and healthcare personnel while some facetoface attendance is nonnegotiable due to the handson nature of physical rehabilitation the integration of technology in healthrelated care could have great benefts for this population in many other aspects particularly those with limited mobility a key priority is to conserve and consolidate the team of specialised health care and support workers who carry the burden of bridging gaps between needs and resources tere is opportunity to build on the peer support and crosspollination that exists within this network exchanging ideas can contribute practically to what is being learned te composition of partnerships could be explored in a brief that enables new thinking to enter the process in summary forward planning is needed on multiple levels statewide planning for service delivery during prolonged periods of disruption is needed to safeguard the availability of resources as well as specialised healthcare and support workers able to care for vulnerable populations centralised planning is needed to enable consumables to be stockpiled with simpler access to products and equipment decentralised planning is needed to proactively ensure local backup plans are in place finally multilevel advocacy and planning is needed to protect the capacity and availability of healthcare and support workers and to maintain cohesion between these workers and community organisations te core implication is that we must work together to avoid the scenario in which vulnerable people who depend on specialised health care and support fail to receive them only to inadvertently develop complications that isolate them further from the quality of life that is their right and increase the need for access to the very services which are restricted strengths and limitations tis small study provides rich insights into the daily realities of pandemicrelated disruptions to specialised services that are needed longterm by people with sci te results identify and explore the complexity of multiple interconnected factors that have afected the health and wellbeing of people with sci tey also highlight the motivation that generates important strategies to protect and sustain adequate care under unprecedented ongoing conditions that interrupt the timely delivery of needed services tese initiatives reveal exceptional use of human characteristics such as resilience autonomy and resourcefulness in seeking to close gaps that can lead to adversity for people with sci however the study is limited by convenience sampling and small sample sizes which may have resulted in some potential bias for example the proportion of female respondents does not match the gender distribution in the sci population additionally the timing of the study meant that covid had not yet spread widely throughout the community due to the pandemicrelated restrictions and vaccination mandates terefore the fndings may relate to the impact of the lockdown restrictions themselves versus the impact of the rapid spread of the virus data saturation is unlikely to have been reached although there were common themes from both esfs terefore it is important to note that these study results provide insights from one small population of people with sci who are linked to services provided by one tertiary hospital and the network of community services that continue to support people with sci beyond discharge from hospital while some results will be generalisable the experiences of provider and user groups in other geographic settings and health systems may vary leading to diferent implications conclusions tis multilevel multimethods qualitative study provides valuable insights that a survey or singlelevel qualitative inquiry alone could not provide te results present the nature of pandemicrelated disruption its impact solutions and implications which may inform future rehabilitation practice and research in the study setting and elsewhere while the research was conducted during the early stages of the pandemic in queensland australia when covid19 cases were relatively low future research should examine the disruptions and implications of the pandemic in more recent times now that lockdowns are a thing of the past and almost all pandemicrelated restrictions have been lifted but where covid19 is widespread in the community to ascertain if the impacts vary in type or signifcance for people who depend on services and support for people who care for them for people who provide services and support opportunities and challenges of alternative modes of service delivery and personal support tinking now about alternative ways to provide services and support data availability te deidentifed survey and forum data used to support the fndings of this study are available upon request from prof timothy geraghty appendix a online survey demographic questions other points tat brings us to the end of our prepared questions but there may be other issues that need to be discussed have we missed anything conflicts of interest te authors declare that they have no conficts of interest	as part of a larger study examining the perceived impacts of health system stress in queensland australia caused by the covid19 pandemic this study explored the experiences and perspectives of a sample of people with spinal cord injury sci and critical stakeholders to identify secondary complications access concerns and potential solutions in the context of the pandemic tis study utilised a multimethods qualitative design tirtyfour people with sci completed an online survey between august and november 2021 recruited from an online spinal life australia peer support group sixteen sci expert stakeholders recruited from the queensland spinal cord injuries services consumer support organisations and funding agencies participated in one of two expert stakeholder forums in september 2021 focusing on impacts of the pandemic on the services they provided survey and forum results were analysed thematically results highlighted service disruption wherein people with sci faced difculty accessing health and community services including rehabilitation and personal supports reduced access led to secondary complications in physical health psychosocial and occupational domains solutions for safeguarding access to care including actionready backup plans efective technology and training collaboration of service networks and forward planning for system disruption consumables access staf support and advocacy are required to best support vulnerable populations and the supporting staf in times of crisis in conclusion covid19 disrupted access to specialist sci and mainstream health rehabilitation and social care services resulting in functional decline and physical and psychosocial complications while people with sci and their service providers attempted to innovate and solve problems to overcome service access barriers this is not possible in all situations improved planning and preparation for future system disruptions mitigates risks and better protects vulnerable populations and service providers in times of severe system stress
introduction continuing care retirement communities provide a variety of residential options for older adults offering a unique setting with a range of services that are responsive to changing care needs as one ages since the 1990s there has been a rapid growth in the construction of ccrcs and there are now approximately 1900 nationwide ccrcs represent a unique setting for aginginplace and provide residents the ability to stay at one facility even as their health needs change these facilities offer a single source for longterm care needs including independent housing assisted living and nursing services with convenient access to alcohol drinking may be commonplace for the majority of residents of ccrcs yet even with the rapid growth of ccrcs in recent years little research has focused on alcohol use in these settings instead much of the extant research has focused on residential retirement communities such as leisure world rather than ccrcs in some instances the drinking quantity and frequency of drinking were found to be higher in these semistructured communities than within general populationbased samples other research has focused on assisted living programs for example castle wagner fergusonrome smith and handler surveyed nurses aides who worked in assisted living programs in pennsylvania the aides reported that they believed that a majority of residents drank alcohol and that 34 drank daily aides in the study believed that 28 of residents made poor choices for alcohol consumption and 11 had alcohol abuse problems although study findings are somewhat limited in their reliability due to collateral reporting and poorly defined measures of alcohol use they remain compelling further investigation of alcohol use within different types of retirement communities is needed to better understand whether there are unique patterns of and motives for alcohol use enabling optimal design of interventions for these settings alcohol and health among older adults to understand the importance of alcohol use in ccrcs it is important to recognize the relationship between alcohol use and aging alcohol consumption tends to decrease as people age however compared to younger adults older adults may be at higher risk even while consuming less alcohol because they have higher blood alcohol levels for a given dose of alcohol and have increased brain sensitivity to the effects of alcohol because of these risk factors recommended drinking limits for persons aged 65 years and older are lower than for younger individuals guidelines suggest no more than seven drinks per week and no more than three drinks on a given day individuals who cross that threshold are considered atrisk older adults also have greater medical comorbidity and take more medications that may increase risks associated with alcohol use compared with other age groups using this broader definition of risk moore et al identified 18 of men and 5 of women in a nationally representative sample as atrisk drinkers conversely there are known health benefits of drinking among individuals who do not drink heavily and for whom alcohol is not contraindicated low to moderate use of alcohol can lead to positive health outcomes related to cardiovascular disease cognitive functioning andmortality alcohol use at moderate levels is also linked to decreased functional impairment for older adults although research has focused on the health effects of alcohol use among older drinkers less is known about alcohol use among older adult residents of ccrcs and similar independent living settings more indepth approaches are necessary to investigate drinking among older adults in these living situations psychosocial factors such as drinking motives may be important as these may influence the extent to which alcohol use is an unhealthy response to psychosocial issues such as depression conversely alcohol use may be important as a means of socialization a core component of successful aging older adults drinking motives and affective states drinking motives theory focuses on proximal reasons people drink which may help us understand alcohol consumption among ccrc residents these motives can be categorized as a positive reinforcement such as drinking for social and enhancement reasons or as a negative reinforcement such as coping and conformity reasons these motives are seen as a result of the direct pharmacological effects of drinking andor the instrumental effects of drinking if individuals have expectations about the effects of drinking then their motives will reflect those expectancies for instance if alcohol is perceived as a method of decreasing tension an individual will drink to reduce tension alternatively beliefs about the enhancement or social effects of alcohol will be consistent with drinking motives focused on attaining positive experiences although much of the research on drinking motives has focused on adolescents and young adults coopers theory provides a broader conceptualization of the proximal factors associated with alcohol use in drinking motives theory negative affective states are central to understanding alcohol use alcohol use among older adults is theorized as a means of coping with painful life experiences and other forms of psychological distress overall findings in this area vary by the cause of the affective state ones coping repertoire drinking history and measurement of alcohol use much less attention has been focused on positive reinforcement motives and drinking among older adults or the notion that alcohol use among older drinkers is motivated by social or enhancement motives rather than coping motives using drinking motives theory as a conceptual framework we explored alcohol use among older adults in a ccrc first we investigated relations between drinking motives and context of drinking such as whether a person drank alone or drank outside of their home second we hypothesized that negative affect and coping motives would be associated with increased drinking and that positive mood and social motives would be associated with lower levels of consumption in this study drinking motives are stable characteristics of the individual that may influence drinking habits negative and positive affect are conceptualized as time varying factors that impact the likelihood that one will consume alcohol together we conceived of drinking motives interacting with affective states to influence consumption such as individuals with high coping motives being particularly likely to drink as a result of negative affectivity and conversely people with social motives being more likely to drink for social or enhancement reasons we endeavored to explore these associations of drinking motives in light of the dynamic nature of mood and affect by measuring daily variations in affective states method study design and sample this was a descriptive pilot study conducted at one ccrc located in the washington dc suburban area with participants who resided within the independent living level of care the ccrc has more than 2500 residents with most in independent living 8 in assisted living and 4 in a nursing home there are multiple venues where alcohol is served participants were recruited for this study via flyers pamphlets and informational videos inclusion criteria included being a current drinker residing independently within the ccrc english fluency and the ability to communicate over the telephone we focused on independent living as residents at this level of care likely had less disability and greater access to alcohol individuals were excluded from the study if they displayed clinically significant cognitive decline as measured by the minicog screen of the 81 people who expressed an interest in participating 77 were eligible among eligible participants 72 consented to participate 3 refused and 2 were lost to follow up before consenting to participate 71 of those who consented to participate completed all aspects of the study one individual did not complete the eight days reporting that the protocol was too burdensome procedures data were collected from participants in three phases by research assistants an initial facetoface interview on day 1 daily surveys administered via telephone on days 28 and a final daily survey and telephone interview on day 9 the initial facetoface interview consisted of a minicog test used for eligibility the consent process and a structured survey instrument participants were called every day for eight days beginning the day after the initial interview during these telephone calls participants were surveyed about their activities emotions and drinking behaviors from the day previous to the call the final telephone interview included questions about drinking motives atrisk use of alcohol and alcohol history we opted for oneday retrospective phone calls based on pilot research conducted at a different ccrc where handheld devices or written diaries were perceived as being too burdensome among individuals in this age group and that a morning phone call asking about the previous day was the most feasible option for older adults four research assistants and the lead author collected daily diary information in a total of 569 phone contacts two doctoral level research assistants were responsible for 70 of the daily phone contacts with the lead author personally making 20 of calls and two masters level trainees conducting the final 10 all interviewers were trained by the primary author on scripted phone surveys and inperson interviews the lead author observed each research assistant conducting inperson and phonebased interviews on multiple occasions initial facetoface interview measures sociodemographic variables included education age gender marital status and length of residence at the ccrc sf12v2® was used as a general health screening tool to measure dimensions of health disability over the past four weeks the sf12v2® is designed to yield a populationbased norm of 50 on a scale of 1100 with a standard deviation of 10 and contains two major subscales the physical component scale and the mental component scale the sf12v2® is a valid and reliable measure of health status for older adults health disabilitythe medical outcomes study depressive symptomsthe patient health questionnaire9 was used to measure the presence and severity of depressive symptoms the phq9 contains nine items that ask about the frequency of dsmiv based depression symptoms over the past two weeks response options range from 0 to 3 levels of depressive symptoms can be derived from the sum of the nine items minimal symptoms mild symptoms moderate symptoms and moderately severe symptoms and severe symptoms the phq9 displays good reliability and is a valid measure c of depressive symptoms among older adults in primary care internal consistency for the current study was acceptable daily telephone call measures alcohol consumptionparticipants were queried regarding drink consumption on the previous day using a standard drink graphic from the niaaa provided to them during the inperson interview in the united states a standard drink is 06 ounces or 14 grams of pure alcohol this is roughly equivalent to 12 ounces of beer 89 ounces of malt liquor 46 ounces of wine 34 ounces of fortified wine 23 ounces of liqueur or aperitif or 15 ounces of brandy or spirits they were also asked about where they were when they drank and whether they drank alone positive and negative affectthe positive and negative affect schedule shortform was administered daily the panas shortform scale is made up of 10 items including 5 positive and 5 negative adjectives that represent dimensions of subjective wellbeing the respondents rated their level on these items from 1 to 5 with the previous day as the timeframe scores were averaged for both the positive and negative subscales internal consistency values for this study were acceptable at α 70 for positive affect and α 76 for negative affect following curran and bauer panas positive and negative affect scales were recoded to create individual mean positive and negative affect scores and deviation scores from each persons mean on each day the within person variable represents the level of variation from his or her average positive and negative affect each day the between person variation quantifies each individuals mean level of positive and negative affect across the eight days data were collected final telephone interview measures drinking motivesdrinking motives were assessed using the drinking motives questionnaire revised shortform based on the measure originally developed by cooper the dmq measures four types of drinking motives enhancement social conformity and coping enhancement motives refer to drinking to enhance positive mood and social motives refer to drinking for social reasons coping refers to drinking to manage negative emotional states and conformity motives are focused on drinking to fit in a specific group in the dmq items relate to the frequency of drinking for specific reasons over a 12month timeframe in the short form of the dmq 12 questions are asked with 3 response options we created and scores using the mean values for each subscale the dmq measure displays acceptable validity in older adults internal consistency for the coping and social subscales was acceptable in this study at 74 and 79 respectively however internal consistency reliability for the enhancement and conformity subscales was problematic in this study with values well below the acceptable range for cronbachs α therefore these subscales were not included in analyses atrisk and unhealthy alcohol usethe alcohol use disorders identification test and the comorbidityalcohol risk evaluation tool were used to screen for unhealthy drinking measured over a 12month timeframe the audit is a 10item measure designed to identify hazardous and harmful drinking in the general population a score of 8 or higher on the audit indicates hazardous or atrisk use the audit is a broad alcohol screening measure designed for general population use conversely the caret was used to assess areas of unhealthy alcohol use specific to older drinkers the caret includes quantity and frequency variables and other indicators from the audit but goes beyond them by assessing for alcohol consumption along with comorbid medical conditions alcohol use with medications that are contraindicated exceeding recommended consumption guidelines specific to older adults and driving after drinking the caret like the audit measures atrisk drinking but evaluates consumption and health specific to older adults because the caret measures drinking risks across a continuum of use and sets guidelines that are elder specific it is an appropriate measure to use specifically with ccrc residents four dichotomous indicators of alcohol related risk were derived from this measure exceeding alcohol consumption guidelines hazardous alcohol and medication couse hazardous alcohol with comorbidities and driving while under the influence data analysis data analysis was conducted in three steps first univariate and bivariate statistics were generated to describe the sample sociodemographic and person level drinking characteristics next we analyzed the context of drinking specifically drinking alone and drinking outside ones home two logistic regression models were used to examine sociodemographic affective and motivational influences on drinking alone and drinking outside of the home independent variables in these models included sociodemographic variables panas positive and negative affect and drinking motives finally we estimated two poisson regression models to predict the number of drinks consumed in a given day in the first model sociodemographic variables and panas variables were included to examine the role of positive and negative affect on the number of drinks consumed in the second model social and coping drinking motives were added generalized estimating equations with a firstorder autoregressive correlation structure were estimated for all regression models due the nesting of days within persons gee is a regression method that addresses violations to the assumption of independence in gee within person errors are allowed to correlate over time model estimates and standard errors adjust for these correlations the autoregressive correlation structure estimates correlated errors that are symmetrical and strongest on observations closest to each other and less correlated as they are farther apart results sociodemographic characteristics in the final sample the average age of participants was over 80 years old and almost twothirds were women the vast majority of participants were white and college educated the sample was primarily currently married or widowed mean participant sf12v2® health scores were 4687 indicating the sample had somewhat poorer health than the general population of adults sample demographic characteristics were similar to those of independent living residents at the ccrc however the study sample was slightly younger lived at the site for slightly shorter durations and contained lower percentages of women and married persons than the ccrc population as a whole differences between the sample and the overall census of the ccrc were likely a result of two factors we recruited individuals who were current drinkers a distinct subpopulation that are more likely to be male and younger from population studies of older adults also all participants resided within independent living meaning they were healthier and likely younger than nursing home and assisted living participants in this sense the study is generalizable to current drinking older adults in ccrcs alcoholrelated characteristics the average percentage of drinking days among participants was 57 and the average number of drinks per drinking day was 128 people drank when they were alone 43 of the time on average with variability among individuals people drank most commonly in their apartments or somewhere else in the facility the lowest proportion of drinking occurred offsite hazardous alcohol use based on audit scores was uncommon in the sample the caret identified larger percentages of atrisk drinkers 4 to 62 of participants endorsed specific atrisk drinking patterns such as drinking above niaaa drinking guidelines and drinking with comorbid conditions or medication that may interact with alcohol over 60 of participants endorsed a medication interaction atrisk drinking pattern making it the most common type of atrisk drinking within the sample social motives showed the highest mean values but copingrelated drinking were weaker motives for drinking in this sample mood and depressive symptoms table 3 shows the mean scores for positive and negative affect on the panas short form participants displayed higher mean levels of positive affect than negative affect based on the phq9 84 of the sample did not endorse any depressive symptoms 8 endorsed minimal depressive symptoms and only 6 endorsed mild symptoms or greater similarly the mcs of the sf12v2® indicated 9 at risk of depression but mcs scores were above the norm of 50 for the general population gee models results from the gee models examining sociodemographic factors affect and drinking motives in predicting the context of drinking are presented in table 4 current marital status and social drinking motives emerged as significant predictors of drinking alone for married individuals the odds of drinking by themselves were 85 lower than for those who were not married social drinking motives were inversely associated with drinking alone with each onepoint increase in social motives associated with a 27 decrease in the odds of drinking alone all other predictors in the model were not associated with drinking alone only one factor predicted drinking outside ones home within person negative affect which was associated with a decreased likelihood of drinking outside of ones home in the ccrc or in the community on average a onepoint increase in deviation from ones negative mean value on a given day was associated with a 16 decrease in the odds of drinking outside ones home results from the two models exploring the extent to which sociodemographic factors positive and negative affect and drinking motives influence the amount people drank on a given day are reported in table 5 adjusting for sociodemographic factors higher levels of between person positive affect were associated with less drinking a onepoint increase in ones average panas positive affect scale was associated with 10 lower drinking when drinking motives were included in the model the role of positive affect persisted although there was some decrease in model fit overall based on quasilikelihood information criterion indices both coping and social drinking motives were significant predictors with each onepoint increase in coping drinking motives associated with a 17 increase and each onepoint increase in social motives associated with a 16 increase in drinking in addition we found that lower sf12v2® pcs disability was associated with greater drinking with each 10point increase in the sf12v2® associated with a 10 greater count of drinks on a given day we were interested in exploring the extent to which motivational effects of alcohol use varied based on the affective makeup of the individual to see if coping motives affected consumption among those with higher negative affectivity and social motives among those with higher positive affectivity we added two interaction terms neither interaction term was significant suggesting that the influence of drinking motives was relatively uniform across the levels of negative and positive affect discussion individuals reporting higher levels of positive affect drank less than those with lower levels of positive affect and although coping and social motives were associated with greater consumption drinking to cope did not confer a specific risk in this sample within person variations both positive and negative affect were not associated with differences in drinking behavior negative or positive affect on a given day was not associated with increased drinking for that day independent living and drinking behavior our findings suggest that auditdefined hazardous drinking is rare in this sample but alcohol use with symptom and disease comorbidities andor use with contraindicated medications are more common than heavy drinking or problem drinking findings suggest potential program development opportunities for ccrcs to increase awareness and education around drinking with specific disease comorbidities or medication contraindications despite these identified comorbidities and that nearly half of respondents in the study drank over the recommendations set by niaaa few older adults endorsed specific alcoholrelated problems these findings mirror national studies that have found low prevalence of problem or disordered drinking among adults over age 65 but higher prevalence of atrisk drinking due to consumption levels above guidelines among older adults the relationship of elder specific drinking guidelines to later health consequences remains uncertain with some studies demonstrating mortality effects and other studies more equivocal about elder specific drinking limits given the proportion of drinking alone it would appear that context specific factors such as peer influence and alcohol availability may be less important in influencing drinking among older adults than younger groups unlike in adolescent populations alcohol availability may not affect use and older adults may not be as influenced by peer behavior in the same way as younger populations are it is possible that peer influences among older adults are a function of social networks more than context specific effects older adults who consume alcohol at higher levels may have different social networks than those who drink less or who abstain completely the peer effect in older adult drinking may also be different for heavy or problem drinkers than for low risk drinkers nonetheless our qualitative research suggests that older adults themselves perceive that their drinking is influenced by their peers because much of the work in this area is retrospective and crosssectional further research is needed to unpack complex relationships between alcohol use social networks contextual specific factors and drinking drinking motives and older adults interestingly although a large proportion of drinking was done alone this sample endorsed social motives at the highest levels and coping motives at much lower levels in contrast to the notion that drinking is a means of coping among older adults our finding is consistent with other research on older adults that has identified much higher endorsement rates for social motives than for coping motives in our study social motives were negatively associated with drinking alone suggesting that stated drinking motivation is consistent with behavior both social and coping motives were associated with the amount consumed during a given day one other published study has identified associations between coping motives and alcoholrelated problems among older adults as well as between social motives and quantity frequency and binge drinking although relatively little is known about the motives for using substances among older adults it has been proposed that older adults primarily use substances to cope with life changes or transitions loss depression and loneliness aspects thought of as unique to late life this literature however has focused on older adults substance problems and more research is needed on motives for drinking among older adults with less severe or no drinking problems positive and negative affect and alcohol consumption much research has focused on approaches to drinking that emphasize alcohol use as a form of tension reduction among older adults including the stress and coping and selfmedication models the underlying premise of this research is that negative affectivity in the form of stress or stressful events precipitates drinking much of the research in this area has tended to focus on either crosssectional analysis or longer term longitudinal assessment of the role of stress and coping on use and consequences we did not find temporal relationships between negative affect or positive affect and the amount consumed on a given drinking day residents with higher mean levels of positive affect drank less there are a number of factors that may explain this finding older adults living in the context of a ccrc may experience less mood variability than younger age groups in the absence of marked affective variability reactive drinking may be less common the relationship between positive and negative affect is also more complex in older adults than it is among younger groups in that positive and negative emotions may coexist more readily also the study sample was made up of older drinkers who did not report alcoholrelated problems drinking to cope with negative affect may be unique to younger populations of older adults or those with problem drinking histories future research could explore motivational models of drinking among older adults to discern whether daily positive and negative affect influences consumption among problem drinkers this study suggests that negative affect does not impact consumption but that those with more positive affect drink less limitations although this study provides novel insights into drinking patterns specific to older adults our findings should be interpreted in light of specific limitations our sample of older adults was recruited from a single ccrc potentially limiting generalizability to the general population of older adults or to those with identified problem drinking however findings may be relevant to a population of current drinking older adults living in ccrcs and other congregate forms of living a larger number of more representative studies are needed to understand affective and motivational factors that can be generalized to the older adult population living in ccrcs because data collection occurred one time per day we did not explore the impact of within day variation in affect similarly older adults were asked about the previous day rather than momentary affect recall bias under this protocol was likely less than using methods that require recall over a longer timeframe but the potential for recall bias was still present the intensive longitudinal approaches used in this study may induce reactivity among participants but the use of a daily response schedule may be associated with less reactivity due to habituation drinking motives were treated as time invariant but it is possible that motivations for drinking could vary over time in a given individual conclusions alcohol use among older adults living in ccrc settings is largely motivated by the desire for socialization although residents also report drinking to cope harmful drinking may be rare among older adults in these settings but hazardous drinking based on comorbidities concurrent medication use and other agingspecific factors may be common future research on drinking among those in ccrcs should consider the extent to which hazardous use broadly defined leads to harmful outcomes in considering the role of mood affect and drinking among older adults future research should further explore the relationship between drinking and context with an emphasis on identifying factors that are associated with unhealthy drinking data collection process table 1 risk indicators in the caret item acknowledgments a n 324 for this analysis based on subsamples of drinking days only b or only presented for significant effects a n 563 based on data from 66 participants over 8 days and 5 participants with data over 7 days	objectivesthe purpose of this pilot study was to describe patterns of alcohol consumption among continuing care retirement community ccrc residents and to explore the role of drinking motives and affective states on drinking context and consumption methodwe utilized a phonebased daily diary approach to survey older adults about their daily alcohol consumption context of drinking eg drinking alone positive and negative affect and their motives for drinking data were analyzed descriptively and regression models were developed to examine associations between sociodemographic factors affect drinking context and motives and alcohol consumption resultsccrc residents drank most frequently at home and were alone almost half of drinking days on average although the context of drinking varied considerably by participant problem alcohol use was rare but hazardous use due to specific comorbidities symptoms and medications and the amount of alcohol consumption was common respondents endorsed higher social motives for drinking and lower coping motives social motives were associated with decreased likelihood of drinking alone but negative affect was associated with decreased likelihood of drinking outside ones home coping and social motives were associated with greater consumption and higher positive affect was associated with lower consumption
introduction care is intrinsic to the human condition although the term is frequently used in discussions about comprehensiveness and humanization of health practices its definition is still imprecise due to the complexity inherent to it in general care can be understood as the interaction between two or more people for the purpose of alleviating suffering and achieving wellness mediated by knowledge focused on this end it is often carried out through normative actions reduced to procedures prescriptions and regulations to the detriment of a type of care that values the life projects of the other the perspective of care as a daily construction in interactions that involve relationships of power makes the person the main focus such a perspective broadens the understanding of different ways of caring and the various factors that influence practices consequently it helps diminish the barrier that separates professionals and researchers from users therefore care is linked to social and cultural issues and may differ from person to person in distinct contexts thus it is pertinent to the present study especially for its connection with homeless people the number of homeless or street people is rising in brazil and various countries illustrating the extremes of inequality and social exclusion in the world the context of the street is where numerous people seek to be welcomed supported and sheltered although they are constantly subjected to unhealthy conditions and human conglomerations as well as deprivation of food and water exposure to climatic variations and situations of violence in the street context many get entangled with alcohol and other drugs and are vulnerable to chronic psychiatric and infectious diseases such as skin conditions lice infestations tuberculosis and sexually transmitted diseases the specificities of life in the street associated with the complexity of factors renders people susceptible to various social and health problems that challenge different professionals such as nurses nursing technicians physicians social workers dentists and oral health technicians psychologists community health agents occupational therapists and social agents from diverse sectors and services in society according to data from the national survey on homeless people it is common for them to go to emergency hospitals when they are sick as well as seek to perform hygiene habits and maintain food intake the data shows that these people adopt healthcare measures aligned with the context in which they are inserted these aspects lead to the concept of social representations which understands them as a type of knowledge that produces and determines behaviors and shows that something absent can be added and something present can be modified therefore it is important to explore the meanings attributed to health care by this segment of the population since social representations can be reflected in practices and behaviors of the social group and thus have a close relationship with nursing and health teams the analysis of these representations makes it possible to rethink healthcare practices as well as implement policies to promote the access of homeless people to health services with a decrease in the various forms of prejudice violence and vulnerability to which they are subject this contextualization gave rise to the following question how do homeless people represent health care practices the representation of an object can reveal its multiple facets and make it possible to understand specificities of the individual andor group in relation to the object represented in this sense the theory of social representations in its structural approach focused the cognitive processes of social representations endeavors to study the influence of social factors on thought processes through the identification and characterization of relational structures the purpose of this study was to identify and analyze the structure and content of the social representations of homeless people in relation to health care method this was a qualitative study and the empirical data was produced from may to august 2016 seventytwo homeless people registered in two institutional shelters located in the city of salvador bahia brazil participated in the study the shelters were founded in 2014 and are part of the municipal network of the unified social welfare system in order to provide temporary shelter and the means for people 18 years of age or older to have a place to stay social interaction and a reference address these two shelters can accommodate between 33 and 51 people respectively the group investigated was chosen according to the following criteria be 18 years of age or older and appear to be able to interact with the researcher for data production the freeassociation test an instrument widely used in social representations theorybased studies was used due to the possibility it provides for spontaneously capturing mental projections and implicit or latent content that may be hidden in discursive and reified content the instrument was comprised of two sections the first involved the data identification and health characterization of the participants the second the test itself composed of the prompting phrase taking care of your health means where each participant was requested to state up to five words or short expressions that immediately come to mind then the participants chose from among the terms cited the one considered the most important justifying the choice the test was applied individually in a reserved room and lasted 10 minutes on average two software for processing qualitative data were used one to identify the combination of the frequencies of evoked words with the average order of evocation and the other for building a word cloud this in turn was used to confirm the centrality of the elements that made up the probable central core the justifications for the terms considered most important were transcribed in their entirety and used as the basis for the fourquadrant chart which facilitated comprehending the meanings assigned to the terms evoked the study was assessed and approved by the research ethics committee of the school of nursing of the universidade federal da bahia under opinion no 14778002016 the rules and guidelines for conducting studies involving human beings were respected in compliance with resolution no 46612 of the national health council in conducting the study the confidentiality and anonymity of the homeless people were ensured through using the letter p in reference to participant followed by the number in order of occurrence as well as their privacy and freedom to participate or not in the study and to withdraw at any time results in the group that was studied most were women predominantly 21 to 31 years of age in conjugal relationships black in terms of racecolor belonged to a religion reported not having completed elementary school and were informally employed as for length of time being homeless a period of less than five years was the most common in relation to health conditions most reported not having any comorbidities but among those who did the most prevalent ones were hypertension syphilis hivseropositivity and renal lithiasis most said they use health services primarily in hospitals in terms of health needs they said they went to health units for prevention and orientation medical treatment tests and to get medication most reported having used some type of psychoactive substance in their lives the most prevalent being alcohol followed by marijuana the analysis of the corpus revealed that in response to the stimulus taking care of your health means the investigated group evoked 327 words of which 47 were distinct the minimum frequency was 5 and any terms with a lower frequency were excluded from the composition the average frequency was 15 and the average order of evocation was 29 the necessary processing calculations were done through the software itself based on zipf s law which enabled expressing the content and structure of the social representation as shown in chart 1 chart 1 fourquadrant chart in reference to the stimulus taking care of your health means salvador ba brazil 2017 elements from the central core frequency ≥ 15 average order of evocations 29 elements from the 1 st periphery frequency ≥ 15 average order of evocations 29 element freq the upper lefthand quadrant called the central core contains the terms which obtained a higher frequency and lower average order of evocation in the present study the central core was comprised of the term doctor which had a higher frequency and was the most readily evoked this is confirmed by the justifications of the participants for this term the doctor will look at you consult with you and see what you need the doctor knows more hell do all the tests see whether your pressure is high or low and check how youre doing the other terms that made up the central core were taking care of yourself and eating which is an intersubjective and functional dimension the justifications for these terms when defined as being more important underscored the fact that health care involves a personal commitment prioritizing on health and nutrition as illustrated in the following excerpts if we dont take care of our bodies who will first you have to take care of yourself and have selfesteem to be healthy women need to take care of themselves and take preventive measures always go to the doctor and take care of their intimate parts right apply vaginal cream in my first pregnancy i didnt social representations of health care by homeless people rev esc enferm usp • 201852e03314 even know how to apply vaginal cream my motherinlaw taught me try to go to the doctor eat healthy food no one can live without food drugs are not healthy alcohol is not healthy you have to eat healthy things that give your body energy in the upper righthand quadrant also called the first periphery are found the most important peripheral elements of the representation since they had the highest frequencies even though they had been evoked later on and include the terms taking preventive measures hygiene and happiness in the hierarchization process taking preventive measures was referred to 17 times in the justifications demonstrating the importance of the maintenance of hygienic care for the group studied in order not to harm yourself or others through hygiene you do not contract bacteria which avoids having to go to the doctor or taking medication if you dont keep yourself clean youre susceptible to catching a disease the term happiness introduces an affective and subjective dimension in relation to the object investigated five of the participants indicated and justified this term as being the most relevant as shown in the following narratives happiness is when the body and mind are in equilibrium and health is also balanced happiness is the ultimate goal of life your achievements in life dont matter if youre not happy theyre not worth anything when youre happy its much easier to work things out in life its much easier to solve things i think that happiness comes first in everything the lower righthand quadrant called the second periphery contains the least frequent and most belatedly evoked elements which have pertinence in the representational field due to their significant participation in reference to daily practices this quadrant was composed of six terms physical activity test treat beauty healthy and body as illustrated in the following segments checkups are important for avoiding diseases whats important in life is health peace and freedom when i engage in physical activity i feel very good lighter and my breathing improves if we dont take care of our bodies who will first you have to take care of yourself and have selfesteem to be healthy if you dont treat the disease how is it going to be cured you have to take preventive measures against disease have greater joy in the lower lefthand quadrant technically referred to as the contrast zone the elements are low in frequency and readily evoked by the participants it is composed of seven terms good medication important life sickness responsibility and love these aspects reinforce the elements arranged in the central core ten participants assigned greater importance to the terms when you have selfesteem you generally take care of your health if you dont get treated you arent living without health you wont live for a long time because love is what drives everything i am love an insurmountable love i believe in this love immeasurable free of charge in simplicity in the word cloud which randomly groups and organizes the terms taking frequency into account it can be seen that the word doctor appeared the most in the corpus followed by the term taking preventive measures and taking care of yourself as well as the terms hygiene and eating discussion the set of words prompted by the stimulus taking care of your health means and its distribution in the fourquadrant chart reveals that the social investigation of the group was anchored in habits and actions disseminated over the years by the biomedical model and permeated with specificities inherent to the context in which these individuals are inserted the conception that health care has evolved from strictly healing and individualized techniques to comprehensive and collective practices appears to be reflected in the terms contained in the central and peripheral system of the fourquadrant chart in general the terms embody technical aspects related to the treatment and cure of diseases with intersubjective and attitudinal elements that reveal the involvement of the person in the healthcare process according to the principles in the structural approach of the social representations theory the words arranged in the upper lefthand quadrant characterize the possible central core of the representation since they were evoked more readily and due to their high frequency it is worth noting that the central core is the most stable part of the social representation with fewer possibilities of change in this study the elements that composed it were doctor taking care of yourself and eating although the participants referred to a concept of care still rooted in the biomedical model in which physicians play a central role they indicated coresponsibility based on selfcare ie care which depends on the person as expected the holding of power and knowledge to prescribe tests and drugs for treating and curing diseases was attributed to physicians this conception may explain the fact that the doctor element had a higher frequency and was the one most readily evoked by the group the other terms from the central core taking care of yourself and eating as well as the others that made up the fourquadrant chart confirm the idea of the person as the main care focus and its daily construction in the peripheral system there are various terms related to the groups understanding of an expanded definition of the concept of health and consequently of health care the first periphery upper righthand quadrant consists of elements which due to their importance often reinforce the central elements in this study the terms taking preventive measures hygiene and happiness implicate the person in the healthcare process and have attitudinal dimensions related to practices or actions that permeate caring for ones own health in the group investigated prevention is a daily task that is not only limited to measures against catching diseases but also encompasses protection against situations of violence and injuries that can damage physical and mental health such situations are linked to the reality of the context in which they are inserted as expected the main synonyms of hygiene are healthy and fragrance the conditions of homeless people associated with dirt and poor hygiene are factors that prevent andor hinder access to health services and increase social exclusion in brazil the hygienic mentality was propagated between the second half of the 1940s until the mid1960s to address commercial issues of the industrial era the production and commercialization of new and varied products related to health and hygiene were widely covered by the press disseminating a new modern and healthy way to live this production and commercialization of new products and their dissemination in the media is still the case today and imposes upon the society a concept of hygiene associated with aromatic products while at the same time condemning the natural smells of the human body the presence of the term happiness refers to a subjective dimension of the social representation of the investigated group in relation to health care although many intellectuals have devoted themselves to the study of happiness there is no still consensus as to what this feeling is feelings of happiness are unique to each person and may be individually or collectively associated with physical social affective or other factors satisfaction with ones health is an extremely important feeling for increasing the likelihood a person will say they are happy this satisfaction does not depend on social relationships but on peoples feelings toward themselves since their health may be affected by a sickness but they are nevertheless happy a feeling of satisfaction is very important for people to claim they are happy it is possible to have a life that is not based on prescriptive happiness ie a life whose objects of desire break away from historically and socially established criteria for example graduation success at work marriage family from this perspective wanderers migrants homeless people and individuals living in diverse cultural contexts will not view themselves as disadvantaged within the broader narrative on happiness as strange as it might seem being homeless may also be a form of feeling happy distant from socially formatted contexts and that constitute an element that triggers generates a disease cycle the street often becomes a place of refuge liberation and for establishing new relationships the elements that make up the second periphery lower righthand quadrant formed by words less readily and frequently evoked had a lower significance or importance for the group examined in this study physical activity test treat beauty healthy and body also had characteristics with a positive connotation for the object represented in an attitudinal and imagerelated dimension these terms are complementary and indicate that taking care of ones health helps ensure better quality of life guided by the biomedical model in an intimate association with the term doctor found in the central core this association reveals a more pragmatic and procedural need for this care the terms physical activity beauty and body complement each other and disclose an imagerelated dimension of the social representation of the object investigated these terms also denote positive aspects in relation to health care and the involvement of the individual physical activity was inherent to the daily lives of the participants in their attempts to find ways to maintain hygiene habits and obtain food and an adequate place to sleep and rest however the appearance of this term in the second periphery may be rooted in the idea that has been propagated that engaging in physical activities helps maintain a healthy life beauty and the body and prevents health problems it is clear that for the social group health is related to the body and beauty regardless of the location where they are it is worth noting that beauty is relative despite standards socially disseminated by the media in any case the concern about beauty and ones body involves actions focused on the complex process of health care revealing the implication of selfcare the set of words that make up the contrast zone lower lefthand quadrant contains elements that obtained a low frequency and average order of evocation but were considered important for the group that was investigated the set of words that comprise the contrast zone are good medication important life sickness responsibility and love and also point to an imagerelated intersubjective and functional dimension of the representation some terms make reference to the biomedical model but promote the individuals involvement in health care and love as an element of this care a predominance of terms with a positive connotation was also noted the term important refers to the symbolic value associated with the object and indicates involvement in the development of control strategies and responsibility for ones personal health the love element deals with an affective dimension and is associated with the term happiness placed in the second periphery reinforcing the expanded concept of health this term denotes that care involves the participants need for selfesteem in order to take better care of themselves and others the social representation also fulfills a function in relation to familiarity with the group and the affective dimension is presented on the basis of this transit supported by individual and collective memory and by daily experiences and situations according to the principles of the structural approach of the theory the peripheral system is linked to daily reality encompasses elements of transition and is responsible for updating the central core this dynamicity promotes transformation of the social reality and helps modify behaviors conducts and actions related to their health as homeless people with respect to the word cloud the terms more emphatically expressed are represented by the expressions doctor taking preventive measures taking care of yourself hygiene and eating where two of the terms belong to the first periphery of the fourquadrant chart this therefore illustrates the centrality of the terms in the central core and reinforces how the rules of medical knowledge are important for the group that was studied and at the same time shares and appropriates knowledge based on expanded health care using notions of prevention and promotion of complications as well as individual practices for taking care of health conclusion in studying the social representations of a group of homeless people in relation to health care the centrality of cultural elements in regard to health and specificities in the daily lives of the investigated group were noted and that warrant being considered in professional care practices the predominance of the term doctor in the central core reflects the idea of health care linked to diagnosis treatment and at times cure of a certain disease and at the same time reveals one of the problems faced by homeless people which is access to health services the set of evoked words represents health care as a daily construction rooted in actions for meeting basic human needs established by the context of the street coresponsibility for health care is inherent to this context the terms evoked reveal aspects of the imagerelated cultural and biological dimensions of health care the data produced cannot be generalized due to the limitation of the group studied and the dynamicity of social representations its originality and unprecedented nature permit reflection on the formulation of professional practices aligned with the needs and realities of homeless people in addition to indicating the need for further studies on the topic in this sense it is believed that the data can be used in initiatives to train health professionals especially nurses in order to reduce conflicts in the care provided and decrease health complications in the homeless population resumo objetivo identificar e analisar a estrutura e o conteúdo das representações sociais de pessoas em situação de rua sobre cuidados em saúde método pesquisa qualitativa fundamentada na abordagem estrutural da teoria das representações sociais com pessoas em situação de rua vinculadas a duas unidades de acolhimento institucional para a produção dos dados foi utilizado o teste de associação livre de palavras cujos dados foram processados por dois software e analisados à luz da referida teoria resultados participara da pesquisa 72 pessoas o conjunto de evocações do quadro de quatro casas remete a ações individuais sociais e culturais os termos médico cuidar de si e alimentação compuseram o núcleo central da representação sinalizando dimensões imagética e funcional do objeto investigado a nuvem de palavras confirmou a centralidade dos termos conclusão o grupo investigado representa o cuidado em saúde como uma ação dinâmica vinculado à pessoa e ao contexto e ancorado em elementos da concepção higienista descritores pessoas em situação de rua assistência à saúde autocuidado enfermagem em saúde pública enfermagem de atenção primária resumen objetivo identificar y analizar la estructura y el contenido de las representaciones sociales de personas en situación de calle acerca de los cuidados sanitarios método investigación cualitativa fundamentada en el abordaje estructural de la teoría de las representaciones sociales con personas en situación de calle vinculadas a dos unidades de acogimiento institucional para la producción de los datos se utilizó la prueba de asociación libre de palabras cuyos datos fueron procesados por dos softwares y analizados a la luz de la mencionada teoría resultados participaron en la investigación 72 personas el conjunto de evocaciones del cuadro de cuatro casas remite a acciones individuales sociales y culturales los términos médico cuidar de sí y alimentación compusieron el núcleo central de la representación señalando la dimensión de imágenes y la funcional del objeto investigado la nube de palabras confirmó la centralidad de los términos conclusión el grupo investigado representa el cuidado sanitario como una acción dinámica vinculado con la persona y el contexto y anclado en elementos de la concepción higienista descriptores personas sin hogar prestación de atención de salud autocuidado enfermería de salud pública enfermería de atención primaria erratum social representations of health care by homeless people in the article social representations of health care by homeless people doi published by the journal revista da escola de enfermagem da usp volume 52 de 2018 elocation e03314 on page 1 where was written dejeane de oliveira silva 1 1 universidade federal da bahia salvador ba brazil now read dejeane de oliveira silva 12 1 universidade federal da bahia salvador ba brazil 2 universidade estadual de santa cruz ilhéus ba brazil	objective identify and analyze the structure and content of the social representations of homeless people in relation to health care method qualitative study based on the structural approach of the theory of social representations conducted with homeless people linked to two institutional shelters to produce the data the freeassociation test was used the resulting data was processed by two software and analyzed according to the theory above results seventytwo people participated in the study the set of evocations from the fourquadrant chart refers to individual social and cultural actions the terms doctor taking care of yourself and eating composed the central core of the representation indicating imagerelated and functional dimensions of the object investigated the word cloud confirmed the centrality of the terms conclusion the investigated group represents health care as a dynamic action linked to the person and context and is anchored in elements of the hygienist conception
introduction conspiracy theories are nothing new in human history scholarly research on conspiracy theories began in the 1930s and it has been a field that is highly multidisciplinary and diverse various researchers have proposed definitions for conspiracy theories keeley defines conspiracy theory as a proposed explanation of some historical event in terms of the significant causal agency of a relatively small group of personsthe conspiratorsacting in secret a more general definition of conspiracy theory is provided by wood douglas and sutton as a proposed plot by powerful people or organizations working together in secret to accomplish some goal conspiracy is sometimes considered a form of misinformation misinformation is commonly defined as false or inaccurate information that spread regardless of an intention to deceive this suggests that any malicious intent of the content creator is not a necessary condition of misinformation but incorrectness of information is thus there is a stark difference between conspiracy and misinformation the intent of powerful people is crucial for the definition of conspiracy this difference proves the need for indepth research on conspiracies that should be differentiated from those on misinformation a belief in conspiracy often correlates with anomia lack of interpersonal trust and having political beliefs at extreme ends of the political spectrum conspiracy theories in contrast to nonconspiracy views tend to be more attractive as they satisfy ones epistemic existential and social desires this results in undesirable outcomes like decreased institutional trust and social engagement political disengagement prejudice environmental inaction and an increased tendency towards everyday crime additionally conspiracy theories can form a worldview in which believers of a type of conspiracy tend to approve of other conspiracies as well polls have also shown that everyone believes in at least one or a few conspiracy theories hence a holistic understanding of conspiracy theories cannot be achieved in isolation from a specific type of conspiracy in todays context conspiracy theories are widely propagated on social media conspiracy narratives are nourished by information cascades on social media and reach a larger audience consequently these false narratives tend to outperform real news in terms of popularity and audience engagement within online environments enders et al show that usage of 4chan8kun has the highest correlation with the number of conspiracy beliefs followed by reddit twitter and youtube among the social media services youtube is one of the most influential sources of news and entertainment it has 2562 million monthly active users and it is the second most popular social network worldwide as of january 2022 contributing to a billion hours of video viewed daily audit studies show that video recommendations on youtube can lead to the formation of filter bubbles on misinformation topics similarly exposure to conspiracy videos might result in undesirable outcomes for example the belief that the 5g cellular network caused covid19 has resulted in more than 200 reports of attacks against telecom workers in the united kingdom the belief in white genocide conspiracies resulted in the death of 51 individuals in new zealand the belief in conspiracy theories is no doubt an issue of concern however most existing research focuses only on specific types of conspiracy theories and not all datasets are available for research communities in this work we build younicon a curated dataset of youtube videos from channels identified as producing conspiracy content by recfluence we aim to help researchers to study the patterns of production and consumption of conspiracy videos such as how individuals interact with those videos from an aggregated or individual level 1 younicon comprises the following information • metadata of all 596967 videos from 1912 channels that produced conspiracy identified by recfluence • a list of 3161 videos manually labeled as being about conspiracy or not • 37199252 comment ids of comments in all videos with basic metadata and scores from the perspective api 1 • 100 videos manually labeled for the type of conspiracy younicon will be a valuable resource for studying youtube as a medium of conspiracy theory production and consumption the contributions of this paper are as follows • curate a largescale dataset of videos with conspiracy content • perform exploratory analyses on the dataset to understand its key properties • discuss potential uses for the dataset related work and datasets conspiracy detection table 1 highlights several existing datasets that have been used for conspiracy theory detection research existing literature often focuses on misinformation or specific conspiracy theories related to covid19 alien visitation antivaccination white genocide climate change or jeffery epstein most works focus mainly on tweets as the unit of the study for example galende et al study tweets explicitly containing the word conspiracy phillips ng and carley conspiracy taxonomy mahl zeng and schäfer used network analysis of cooccurring hashtags in tweets to assign hashtags into topic groups qualitatively based on their thematic relationship this resulted in the 10 most visible conspiracies which include agenda 21 antivaccination chemtrails climate change denial directed energy weapons flat earth illuminati pizzagate reptilians and 911 conspiracies while cooccurring patterns of hashtags reveal a partial taxonomy of conspiracy a more comprehensive one is found on wikipedia on wikipedia a list of conspiracy theories is constantly being updated upon closer inspection of the list of conspiracy topics from wikipedia we found that it covers well the conspiracies in mahl zeng and schäfer hence we will use the taxonomy of wikipedia for younicon data collection on youtube interactions between content creators and consumers occur as follows a content creator posts a video with a title description and tags a content consumer views likes or comments on a video a view represents a playback of a video a like is positive feedback to the video by users and a comment is the way in which online collective debates grow around the video a comment can be a reply to a video or a reply to other comments youtube channels about conspiracy ledwich and zaitsev curated a list of usbased political channels in the recfluece project they classify each channel based on its political leaning channel type and topical category we downloaded an entire list of youtube channels from recfluence on 25 february 2022 and extracted only channels with the conspiracy label we then used the youtube data api2 to collect the basic information about these channels out of the 2365 channels with the conspiracy label 1912 channels were accessible by the youtube api the rest of the channels were deleted from youtube and thus excluded from the following analysis while recfluence provides a quite extensive list of usbased political channels the resulting list could be improved with more channels however all the pipelines used in this work will still be valid video metadata in contrast to recfluence that provide channellevel conspiracy information younicon focuses on videolevel conspiracy for the extracted conspiracyrelated channels from recfluence we collect the metadata of every video published on those channels the metadata includes the title description tags number of likes number of views duration and published date we twitter conversations dataset of conversations with more than 1000 tweets that contain the word conspiracy manually labeled by research assistants collect these metadata for 1049413 videos in total to get a better sense of the content that was presented in the videos we also collect transcripts or subtitles of the videos using a pypi package youtubetranscriptapi 3 we only consider those videos with english transcripts which are 761565 videos in total more than 4500 conversations semiautomatic we further filter out nonenglish videos by detecting the language of the videos based on their titles which often summarizes the gist of the video in particular we use the fasttext language identification model which can recognize 176 languages with a threshold of 05 to determine the language with the highest probability for a video between the two fasttext language identification models we used the larger and more accurate one as a rule of thumb channels with less than 80 percent of their videos that are in english are excluded from the rest of the analysis for all textual metadata we apply common preprocessing techniques then we filter out videos that do not have all the metadata this results in a collection of 596967 videos with all metadata which are title 3 description tag and transcript additionally we collect toplevel comments as a part of the videos features we filter out comments authors if 1 their comments detected as english are less than 80 or 2 they leave only one comment we also eliminate the toplevel comments written by the same video creator to focus on the behavior of the viewers as a result we obtain 37199252 comments for these comments we use the perspective api to perform scoring for toxicity identity attack and threat4 dataset construction figure 1 is a flowchart that summarises the dataset construction proposed in this paper the following sections will explain the proposed method in detail table 2 summarises the variables available in the younicon video labeling the procedure of manual annotation is done in accordance with the institutional review board guidelines under we use amazon mechanical turk for data labeling our labeling task known as human intelligence task in amt asks an amt worker whether a given video contains conspiracy or not the title description tags and the first 1000 characters of the transcript of each video are given to amt workers we select workers located in the us with a past hit approval rate of greater than 98 and 5000 hits approved and compensated them at a rate of 005 usd per hit for each video we recruit three workers and determined a label based on the majority vote in contrast to misinformation where there is a clearcut answer determining whether a video contains conspiracy can be more challenging as an individuals political or religious belief might affect their decision about conspiracy videos thus we follow a majority voting scheme for each videos label labeling is conducted in two stages in the first stage we sample 2200 videos after labeling we find that this dataset is somewhat imbalanced only around 20 contain conspiracy theories although 20 may seem like a relatively large proportion of the videos with conspiracy theories we note that all these videos are from the channels that are categorized as conspiracy in recfluence to make younicon a betterbalanced dataset of conspiracy and nonconspiracy videos we use machine learning models to get pseudolabels first we finetune the robertalarge model by using the sampled videos we split the data into train validation and test sets and use the concatenated texts as features for the model this model attained an accuracy of 074 with a positive f1 of 05273 and a negative f1 of 08207 we used this trained model to assign conspiracy or nonconspiracy pseudolabels to all the videos in the full dataset then we sample 1000 videos with conspiracy pseudolabels and manually labeled them in the same manner after these 2 rounds of labeling we obtain a dataset of 3161 videos fleiss kappa an extension of cohens kappa is used to measure interrater reliability a score of 04111 is calculated implying that there is a moderate agreement between raters in the dataset topic classification going beyond whether a video is about conspiracy or not we also assign a conspiracy topic to a video based on conspiracy taxonomy compiled on wikipedia in doing so we first parse the text of the list of conspiracy theories page on wikipedia this wikipedia page contains summaries of the popular conspiracy theories which include aviation business and industry deaths and disappearances economics and society espionage ethnicity race and religion extraterrestrials and ufos government politics and conflict medicine science and technology outer space and sports we exclude the category of sports because our dataset based on recfluence is unlikely to contain sportsrelated conspiracies the topic fandom celebrity relationships and shipping a new topic added on 18 may 2022 which is after our wikipedia data collection is also not included in this analysis the topic classification consists of two stages 1 keyword extraction and 2 topic inference for keyword extraction we identify representative words of each topic using logodds ratios with informative dirichlet priors which is a widely used technique for a largescale comparative text analysis it estimates the logodds ratio of each word between two corpora i and j given the prior frequencies obtained from a background corpus we rank the words based on their logodds scores and obtain a list of representative words for each of the conspiracy theories the background corpus used in this analysis is the google 1gram extended with the counts of the vocabulary used in the list of conspiracy theories wikipedia page for each conspiracy topic we compare the corpus of one topic against the concatenated corpus of all other topics for each topic we use the top ten keywords as the preliminary keywords for topic inference we also add the subtopic names listed in wikipedia to the keywords of each topic we then convert 21 keywords to bigrams or trigrams to be more distinguishable and remove 62 keywords related to countries or locations or those that are generic having the representative keywords for topics at hand we infer the topic of the video by simply using a keywordmatching method we match the keywords in each topic to the videos features by using spacys phrasematcher we assign a topic by choosing one with the highest frequency of exploratory data analysis to provide a brief overview of the dataset we conduct an exploratory analysis we first compare the difference in engagement of videos with conspiracy theories and those without conspiracy theories results conspiracy detection we use the annotated data of 3161 videos to build a classifier that detects whether a video is about conspiracy or not since our data is slightly unbalanced we perform undersampling to balance the classes for the training for testing we use the holdout test set sampled from the initial 2200 annotated videos as a feature we use all videos textual meta information including title tags description and transcript since the deep learning models can take 512 tokens at maximum we truncate the video description and transcript using the first 200 tokens the feature input called combined is created by concatenating the first 200 tokens or words for both the video description and transcript followed by the title and tags in order to compare the performance of the models other than simply accuracy recall or precision we use the f1score f 1 2 × precision × recall precision recall which is calculated for both the positive and negative classes to account for class imbalance f1 weighted which is the f1 score weighted by the support is also used table 5 summarizes the prediction results of various models dummy classifier predicts all videos as negative yielding an accuracy of 08 which is the same as the proportion of nonconspiracy videos in the test set traditional machine learning models including naive bayes logistics regression and support vector machine with linear kernel are also tested all three models naive bayes logistics and svm slightly outperform the dummy classifier obtaining a weighted f1 of 07141 07930 and 07863 respectively we also explore pretrained language models such as robertalarge the training set is further split into 8020 trainvalidation split for finetuning of the pretrained model the learning rate of 1e5 is used with a batch size of 4 with random seed 13 for finetuning our results in table 5 show that the pretrained models result in better performance in all metrics but recall obtaining an accuracy of 08575 and weighted f1 of 08624 in table 5 we also show the prediction results based on individual features by comparing the weighted f1 of models built based on each feature we observe that the tags are best among the individual features followed by video description titles and transcript zero shot and few shot classification we further conduct experiments to examine if it is possible to detect conspiracy theories via zero and fewshot learning zero and fewshot learning are techniques that aim to make predictions for new classes with limited labeled data we test pretrained natural language inference and natural language generation models on zero and fewshot settings we use all the features of videos as the input for those models for the nlg models we test on both autoregressive generation and sequence to sequence models5 however we find that the generated results of zeroshot and most fewshot models are simply a repeat of the given text from which we cannot infer the classification labels the model could generate clear classification indicators only for the fewshot settings with 128 finetuning data instances however it predicts all inputs as nonconspiracy as for the nli models we apply the top three most popular finetuned zeroshot inference models from the huggingface website6 considering the nli is not a binary classification task we neglect the score of neutral prediction and activate the scores of entailment and contradiction predictions as the final binary output to help the nli models better understand the objective of detecting the conspiracy from short texts we concatenate the input text with the assumption statement the model would then give out the answer about whether the assumption statement entails or contradicts the given text the contradicting answer means that the model predicts the given text as nonconspiracy the zeroshot test results are in table 6 the best positive f1score of 057 still does not outperform our proposed conspiracy detection method yet we demonstrate the possibility of those nli models for the conspiracy detection task topic classification we perform topic inference to understand the type of conspiracy theory of a video published on youtube for the groundtruth dataset we randomly sample 100 videos and label them by the first author based on table 3 in figure 2 we investigate how sensitive our topic inference method is the method has two parameters dominance and the minimum number of words matched dominance is a metric that is commonly used to study the diversity of a community a higher dominance score suggests a higher percentage of the words matched with one topic hence having a threshold for dominance to be higher will ensure that the matched topic will have higher accuracy but lesser videos are likely to be matched the number of words matched also interplays with the retrieval and accuracy figure 2 shows this relationship for example when we consider a match of the topic to be that it requires at least one word matched 76 videos are matched with a topic but the accuracy of matching is 0789 if we increase the threshold to at least 10 words and the dominance score to be greater than 06 only 14 videos are matched with a topic but all matching is correct when there are at least 2 words matched and a dominance threshold of greater than 05 the accuracy is 0842 and 57 videos are matched with a topic we explore the topics covered by conspiracy videos using the method outlined above by using the parameters of at least 2 words matched and a dominance threshold of greater than 05 we apply the matching to all the videos with conspiracy theories in our dataset to understand the distribution of the conspiracy topics out of the 1144 conspiracy videos in the dataset 770 videos have been matched with a topic figure 3 shows the distribution of the detected topics topics are relatively well distributed and the top four topics are ethnicity race and religion government politics and conflict science and technology and extraterrestrials and ufos discussion in this paper we propose a new dataset younicon for the detection of conspiracy theories on youtube over various topics while conspiracy theories have been studied for decades across different disciplines a largescale dataset of videos on popular social media services will accelerate research on the production and consumption of conspiracy theories on online platforms younicon offers a plethora of opportunities to study the subject of conspiracy theories from the text data first we hope that the automatic detection of conspiracy theories can be deeply explored by the machine learning community and potentially result in realworld tools to assist and facilitate the work of factcheckers our study gives a first step in this direction by exploring standard classification techniques providing the first assessment of the potential of automated detection of conspiracy theories and also a baseline for future comparisons second we hope researchers can use the dataset to study the dynamics of conspiracy theories on systems like youtube as this dataset contains all videos 00 04 05 06 07 09 dominance that are available in the channels lifetime we are able to study how these content creators have evolved their production strategies over time for example do channels focus on a particular type of conspiracy over time or do they adopt a more generalist approach and produce a variety of content are there relationships between engagement and topics of conspiracy the dataset has the potential to answer such questions similarly for the content consumers the comments included in the dataset can act as a peephole for us to analyze the behaviour of their consumption of conspiracy theories in other words researchers can potentially trace a conspiracy pathway and look at how people can get involved in the echo chambers of conspiracy theories future works can include looking for better ways to perform topic classification while wikipedias list of conspiracy theories is used here this classification can serve as a starting point for a better taxonomy to be developed given the advances of large language models it would be worth exploring the prompting approach with recent llms or the incontext learning approach with prompt tuning for the conspiracy detection task fair consideration the proposed dataset follows the fair principles of findability accessibility interoperability and reuseability the dataset can be found and accessed through zenodo at the doi keywords for the topics of conspiracy theories are also shared as a csv file for the use of other researchers for works related to conspiracy theories hence the data satisfies reusability and interoperability ethical consideration we carefully designed our dataset from the data collection period we collect only publicly available data on youtube with the use of youtubes data api also our approach is approved by the institutional review board of singapore management university to safeguard the interests of our labelers on amazon mechanical turks they are informed that the content that the conspiracy theories are not true and that withdrawal from the study is without penalty helplines are also provided to the participants in the event of any negative emotions	conspiracy theories are widely propagated on social media among various social media services youtube is one of the most influential sources of news and entertainment this paper seeks to develop a dataset younicon to enable researchers to perform conspiracy theory detection as well as classification of videos with conspiracy theories into different topics younicon is a dataset with a large collection of videos from suspicious channels that were identified to contain conspiracy theories in a previous study ledwich and zaitsev 2020 overall younicon will enable researchers to study trends in conspiracy theories and understand how individuals can interact with the conspiracy theory producing community or channel
background women in prison have poor selfreported health and high levels of social disadvantage experience of trauma and mental health problems 1 2 3 4 in australia women are usually in prison for less than 6 months reincarceration is common and the majority report problematic substance misuse 3 4 5 6 approximately 8 of people in prison in australia are women and the imprisonment rate for women is increasing currently standing at 33 prisoners per 100000 female adult population 7 aboriginal and torres strait islander women are over represented in prison related to historical and systemic disadvantage and these women are even more likely to experience serial incarcerations with short sentences or on remand 5 poor access to health care is common for women in contact with the criminal justice system substance misuse and struggles related to accommodation socioeconomic disadvantage and family needs can mean health is neglected in the community 89 in a national survey of people in prison in australia in 2015 10 48 of women reported they did not access the health care they needed when they were in the community additionally 15 said they did not access needed care in prison the main reason reported for men and women not accessing care in either setting were reported to relate to choosing not to and lacking motivation to seek care additional barriers in the community were reported to be cost substance misuse and competing priorities while in prison waiting times and health care not being available when needed were the other major barriers although prison is often a time of compromised wellbeing due to the deprivation and loss of choice and control inherent to incarceration 11 it can also be a window of opportunity to improve health through access to overdue health care 1213 furthermore the importance of managing health well across the interface of prison and community is clear leaving prison is a time of vulnerability associated with high morbidity and mortality 14 15 16 health problems at release decrease the likelihood of successful community reentry 15 however the ideal of postrelease continuity of care can be disrupted by complex health and social support needs relapse to substance misuse poor health information transfer and difficulty in establishing connections with community healthcare providers 17 18 19 in this study we examined the ways in which women in contact with the prison system experience access to health care particularly those with histories of problematic substance misuse we focused on women who were exiting prison and aiming to reestablish their lives in the community and explored their experiences of both prison and community health systems through understanding their experiences of healthcare access healthcare providers and health services may be better enabled to provide equitable care for this marginalised group theoretical framework we used the conceptual framework of candidacy as described by dixonwoods and colleagues 20 to examine the womens healthcare access the framework was first developed to examine equity of access to the united kingdom national health service thus providing a useful lens on how access is determined and enabled for people in disadvantaged situations it emphasizes that healthcare access is contingent and subject to constant negotiation candidacy has been applied to healthcare access in diverse situations including people with intellectual disability 21 mental health problems 22 multiple sclerosis 23 young people seeking sexual health care 24 women who were sex workers needing primary care 25 and children with asthma 26 it has not yet been applied to people in contact with the criminal justice system and people with histories of substance misuse in the research literature as explained by the candidacy framework potential service users identify a health need and seek care after care has been requested providers are seen as adjudicating the claims deciding whether and in what way care will be delivered providers judgements can be based on how deserving potential service users are and how well they will do if given treatment which can disadvantage those in more deprived circumstances 20 limited resources such as in prisons and hospitals may increase adjudications of ineligibility by raising thresholds for what is thought to be a legitimate need the candidacy framework also considers the navigation and permeability of services to navigate services potential users must be aware of them and have adequate resources such as transport and time permeability refers to the ease with which people can use services including through feeling comfortable and having the capabilities to access the service for example services which align with user cultural values are more permeable and services with complex or rigid referral and appointment systems are less permeable methods given the ethical and practical challenges of recruiting people in prison as research participants we report our methods in detail according to the standards of reporting qualitative research guidelines 27 the principal researcher who undertook all interviews was employed as a parttime general practitioner in the prison health service and also worked as a gp in the community setting this study took place in 3 womenonly correctional centres in new south wales australia health care for women in nsw prisons is delivered predominantly in stateowned correctional centres through a boardgoverned network under the nsw ministry of health 28 health care is primarily delivered by general and specialist nurses 629 women see gps and other medical practitioners after being triaged by nurses to waiting lists this differs from the community model where gps provide most primary health care and are directly accessible under universal health insurance sampling and data collection we invited women who were within 6 weeks of release to participate in two interviews firstly in prison and then 16 months after release women were eligible if they had been in prison at least 1 month could be interviewed in english without an interpreter and if they had not received health care from pa beyond treatment for minor selflimited problems we identified potential participants through selfresponse to flyers custodial lists and nursing and correctional staff knowledge of pending release dates women were invited by staff to meet with the researcher initially all eligible participants who responded to flyers were recruited to ensure maximum variation nursing staff subsequently identified participants who varied in age ethnicity custodial history health status healthcare utilisation and engagement in transitional support programs 30 pa undertook the consent process with all participants emphasising the voluntary and confidential nature of the research and that decisions to participate would have no effect on their health care or relationships with healthcare providers interviews in prison were conducted in prison health clinics or general visitor areas under general surveillance of correctional officers outside the interview rooms postrelease interviews in the community were by telephone participants received a payment of 10 aud into their inprison account consistent with usual research practice in nsw prisons or a 50 aud supermarket voucher if in the community interviews were semistructured and questions explored needs expectations and experiences of health care with participantled content encouraged focused questions were added to explore themes identified in the emerging analysis 31 interviews were audiotaped and transcribed verbatim data analysis given that many participants spoke of experiences in multiple incarcerations we analyzed womens pre and postrelease interviews together as continuing narratives of their experiences of health care we used inductive thematic analysis informed by constructivist grounded theory 31 the constructivist approach was considered appropriate for this research as it is encourages recognition of and ongoing reflection on how researcher perspectives position and privilege influence the analysis pa undertook open coding on all transcripts concurrently with data collection wh and jd independently coded a third of selected informationrich transcripts to enhance rigor and jd also provided interpretations arising from her aboriginal cultural expertise focused coding and analysis proceeded with repeated reference back to the data memowriting checking of the emerging analysis in new interviews with participants and research team discussions we further reviewed the findings using the theoretical lens of candidacy to generate additional insights on healthcare access results we interviewed 40 women prior to release and 29 of these women in a second interview their characteristics are described in table 1 the majority of women had problematic substance misuse the average duration of prerelease interviews was 28 min and second interviews 22 min the location of interviews and reasons for not participating in a second interview are shown in fig 1 seven women returned to prison within 6 months of release one woman died of an overdose due to commonality of experiences across prison and in the community findings from both settings are presented together womens experiences pertained largely to primary health care delivered by prisonbased nurses and doctors and by community gps but also to hospitalbased providers including emergency departments the major themes related to the opportunity to access health care in prison and the constraints in that environment being seen as legitimate seekers of care the experience and fear of being blocked from care and the services and personal capabilities which promoted access to care these are explored below with illustrative quotes prison as a health care opportunity despite the many disadvantages of being in prison women also believed it to be an opportunity to seek overdue care for preventive health and neglected health problems although good health was seen as desirable in the community it could be difficult to achieve increased focus on health in prison was possible because of decreased substance misuse mental health treatment time on their hands fewer competing priorities and a desire to make positive life changes when you come in here is when you really are straight and you really want to know if youve got anything … your head becomes clearer and then you do think about your health as youre getting older some women moved in and out of prison so frequently that they saw prison health services as their main provider the only time i i literally see doctors and that is in gaol… im not out long enough to get that appointment for some health care in prison was better aligned with their needs than care they had experienced in the community due to prison clinicians understanding of addiction and its comorbidities women believed community gps lacked interest and skills in substance misuse management and therefore women were more likely to disclose and seek care for this in prison hepatitis c treatment in prison was often mentioned as a healthcare opportunity and one which could create personal meaning out of being in prison i wanted to take something positive out of this experience cause its been an ordeal … to address whatever i could to make the most of this time rather than to have it dead time constraints in prison care the waiting game however prison could also be experienced as a missed opportunity the key systemic constraint was long and unpredictable waits for care several women referred to this as the waiting game preventive health care delivered by nurses was effective and valued but if women required access to a gp secondary care or specialized investigations waiting times could be substantial some women saw the waits as acceptable because care was ultimately delivered particularly during longer sentences other women strongly felt waiting put them at risk of health complications and waiting could be interpreted as a judgement that their problems werent important or as withholding of care their frustration was magnified by wanting to have care completed while in prison as they believed they would not follow up in the community women with shorter sentences reported deflection of health care requests because investigations or specialist care could not realistically be achieved before release some women did not seek care while in prison because of previous experiences of waiting in community n 20 in corrective service transitional housing n2 in drug rehabilitation centre n1 died post release fig 1 participant outcomes have been so much easier than out there like my lifes fullon out there another constraint was the limited range of care compared to the community usual medications alternative therapies dietary preferences and preferred healthcare options were not always available youve got more options out there youve got counsellors um youve got groups that you can go to legitimacy and stigma in prison and the community women perceived they were frequently judged not to have health problems worthy of receiving care and were denied health care both in prison and in the community they described this as a battle to be seen as legitimate patients and experienced this as personal rejection linked to the dual stigmas of substance misuse and imprisonment the drug user could be having a leg hanging off and the community gp thinks oh well she just got released from gaol shesshe looks like a user so couldnt harm her to wait another 10 min 5 minutes whatever ill just see this family being refused care at gp practices in the community could be experienced as a profound and traumatizing rejection this could occur because of past behaviours leading to permanent barring from practices or when gps suspected prescription drug misuse some women believed that their requests for mental health care were misinterpreted by community gps as drug seeking due to stigma and lack of gp skills waiting room signs aimed at deterring prescription drug misuse could reinforce perceptions of lower status and women reported a heightened sensitivity to the inclusion of past medical opinions in their health records community gps treat you like you know youre nobody really… it has to be something in my file that someones put in there that straightaway discriminating against me participants who did not have a history of substance misuse perceived prison healthcare providers to be accustomed to managing women with addictions and the system to be set up accordingly such that they also experienced lack of credibility in their claims to care while their access to community providers was satisfactory in prison they felt a need to differentiate themselves from other prisoners with substance misuse histories at times this appeared to relate to their own negative attitudes to addiction they reported that women with substance misuse problems took excessive healthcare provider attention with providers disbelieving their own more legitimate claims to care the ones that are not druggies theyre the ones that really need help some women felt that healthcare providers both in and outside the prison didnt believe them when they discussed their medical histories and particularly their reported medications requiring proof before instituting treatment they considered this to be emblematic of their ongoing struggle to be seen as legit one participant expected community gps to be suspicious of any information she gave them even official paperbased test results which needed follow up maybe theyll think the test result its not legit or something… they would think it was fake… because its got to do with prisons and criminals with such experiences over time some women chose not to seek care in prison or the community because they assumed providers would not be receptive or the care they would receive would be substandard in the community women could choose not to disclose their incarceration to avoid differential treatment the doctors outside dont know that youve been to gaol you dont have to tell them anything you know what i mean so theres no real stigma when youre out conversely access was facilitated by having a health condition which was prioritized by healthcare providers such as hiv or schizophrenia when seeking healthcare access these otherwise stigmatising conditions could reinforce womens status as legitimate patients both in prison and the community increasing their ability to access services and receive continuity of care some health services were considered inclusive of people with histories of substance misuse or incarceration such as sexual health services and services which catered for marginalised members of the community in aboriginal medical services women reported there was usually no stigma related to their status as exprisoners however substance misuse could still be a source of stigma i go to aboriginal medical centres cause not many discriminate i dont think i dont know well theres some do i reckon and some dont really when you say youre a drug user and they blurt huh you know what i mean despite anger at not being seen as legitimate when they believed care was needed some women also acknowledged the complexity of prescription drug misuse the danger this posed to them and the prescribers role in accurately judging the legitimacy of requests for medications you get the doctor to write it for you anyway which is not the doctors fault its the persons fault for lying being let down and blocked from care women related experiences of feeling uncared for and let down by providers in prison and in the community women commonly reported not being called up to the prison clinic or contacted by community providers despite their attempts to seek care interpreting this as withholding of care and a judgement they were not important i want to be treated like a normal patient you know that wants to get something done… its just gaol it makes you feel like a number you know but um yeah i guess when you get out you just yeah noone reallynoone cares for when you get out differential treatment was seen to have serious implications women feared the possibility of being blocked from care despite a serious health problem fearing misdiagnosis uncontrolled pain or life threatening illness this was seen as a risk both when in prison for accessing hospital emergency departments whilst a prisoner and when accessing gps and hospitals in the community i said oh no i dont use drugs anymore but what the community gp wrote was reflecting on me as a druguser and i was treated differently yeah especially when i went to hospital for my gallstones one time they wouldnt medicate me because they thought i was a morphine seeker… i wouldnt even know how to seek morphine capabilities selfefficacy and supporting access capabilities for accessing both prison and communitybased health systems related to family support selfefficacy assertiveness and knowledge of and compliance with the rules of different systems those who did not successfully meet formal requirements for example by carrying their medical benefits cards or attending appointments were likely to conflict with providers some women described being vocal and determined in seeking care changing providers when necessary until they received the care they needed women who lacked confidence in their ability to manage their health often invoked their previous lack of success mental health problems addiction social isolation and poor life experiences and circumstances decreased their sense of selfefficacy selfefficacy was reported to be increased by existing personality traits and resilience personal growth and overcoming addiction if i cant look after myself whos going to look after me … ive always known how to get help some believed the passive role they assumed in prison decreased their confidence in accessing care after release others reported increased selfconfidence at release related to overcoming preincarceration health problems or to positive healthcare experiences while in prison healthcare providers could be important in supporting womens selfconfidence ive addressed more issues since coming to gaol than i ever did … ive taken a good look at all that has affected me in my life so its been quite transitional programs care coordinators or mentors were seen to be effective facilitators to care on leaving prison they were valued for practical and emotional support particularly for women who had little family support linkages with community healthcare providers were also enhanced by transitional case managers who also acted as advocates and communication brokers if youre unsure and if youre not very good at speaking or whatever like to go to the doctors or communicatingor anywhere that you need to go the care coordinators you know theyll help you with that discussion women in our study experienced significant barriers to healthcare access both in prison and in the community particularly related to their histories of substance misuse many sensed that they were not perceived to be legitimate patients with legitimate healthcare needs which created a fear of being blocked from care when it was urgently needed candidacy for health care the candidacy framework can be used to uncover vulnerabilities in access 20 in our study of women in contact with the criminal justice system concepts related to making claims to care and judging of eligibility by providers were illuminating claims to care dixonwoods and colleagues note that marginalised groups may be more likely to identify themselves as candidates for care through a series of crises rather than planned health care resulting in high uptake of emergency care compared to preventive care 20 this accords with findings from a large survey of australian prisoners in 2009 who reported high uptake of hospital emergency department care in the community 34 the increased helpseeking behaviour seen in prison 10 has been suggested as linked to increased distress caused by incarceration 32 however in our study the main motivator for seeking care was greater selfidentification of candidacy due to decreased substance misuse fewer competing priorities and a desire for positive life change women wanted to address overdue healthcare needs prison was seen as a healthcare opportunity however one which could be missed due to system constraints in our research prison health services were seen to perform well in providing preventive health care but were less able to deliver complete investigation or management of more complex health needs within the confines of a prison sentence in prison care is delivered within a correctional system which is illdesigned for healthcare delivery there are timelimited windows of access within a regulated daily schedule and a transient prison population serving sentences which may be short or include frequent movements between prisons 6 after women identified a healthcare need and appeared to the prison health service the rest of the prison sentence could be spent waiting for the health management plans made in those consultations to be implemented waiting had a negative effect on relationships with prison healthcare providers and could be interpreted as providers withholding care or judging womens claims as unimportant relationships with healthcare providers women describe a struggle to establish their legitimate access to care both in prison and in the community because of negative provider adjudications prescription drug misuse affects therapeutic relationships both in prison and the community prison doctors perceive one of their key tasks is judging patient credibility 32 and the challenge in being considered a legitimate patient in prison has been described 3334 in the community stigma is compounded by healthcare provider discomfort and lack of skills in managing exprisoners or substance misuse problems 1835 which the women in our study readily identified mental illness is a known source of stigma within primary care which can hinder help seeking 36 in our study the stigma of mental illness was not seen to impede healthcare access rather women perceived their mental health care was suboptimal because they were not taken seriously by providers who suspected exaggeration related to their addictions provider adjudication had a profound emotional meaning for many women in this study imbued with expectations and experiences of rejection and withholding of care in other studies of access using candidacy theory service users could feel devalued by negative interactions with providers 23 and frustrated by delays in diagnoses 26 or ineligibility for programs 21 however the fear of being denied future care for serious illness illustrates the heightened significance of provider adjudications to women with substance misuse and in contact with the criminal justice system overcoming stigma may require women to be articulate and persistent both in and out of prison consistent with the candidacy concept that negotiation between providers and users is a key factor in accessing care the power imbalance between providers and patients can make negotiations challenging for patients in many healthcare situations but even more so for prisoners who have controls and limits on their choices in prison although prisons may aim to release more empowered individuals with control over their lives agency may decrease in prison and persist after release as part of the institutionalization that can be fostered by serial incarcerations 37 experiencing medical homelessness a key aim of primary care is to reduce health inequalities by providing coordinated wholeperson care also an underlying principle behind the recent emergence of patientcentered medical homes 38 however in the same way that womens lives are destabilized by lack of accommodation on leaving prison 39 our research also shows that they are destabilized by a lack of access to trusted and reliable medical care furthermore women can be caught in an ongoing state of waiting and exclusion during cycles of prison and communitybased health care leading to a persistent state of transition and medical homelessness their medical homelessness is characterized by ineffectual attempts to access care transient relationships with healthcare providers disrupted medical management and a profound sense of exclusion from health care health system constraints provider judgements that their claims to care are not legitimate and experiences of poor provider skills in managing addiction and its comorbidities contribute to a sense that they have no place in either prison or communitybased health care experiences of rejection contributed to an ongoing state of inadequate care by engendering avoidance and helplessness in our participants at a practical level women in contact with the prison system are a transient population women may frequently move between prison and community on multiple short sentences a particular problem for aboriginal and torres strait islander women custodial decisions may lead to them being placed in different prisons or in unfamiliar community locations on release developing trusting therapeutic relationships with providers when displaced from familiar settings is difficult and even more so if the basis for trust is eroded by providers who assume drug seeking regardless of the presenting health problem although control in the prison environment led to some women being more able to seek care their custodial situation also created barriers which meant women could leave prison feeling their needs were not met women on remand are not eligible for all prisonbased health programs and not all services available in the community are accessible in prison if health care is not completed prior to release initial efforts may be wasted by failures of continuity due to disconnected systems of care 919 or by choices to not to disclose incarceration after release 18 women who have been in contact with the criminal justice system have often had poor life experiences including trauma abuse and violence our participants sense of personal rejection and of falling between the cracks of health care are likely to be based both on experienced events as well as on psychological vulnerability related to life trauma and experiences of being let down throughout their lives their deep and often lifelong disadvantage is perpetuated in the personal and structural barriers they face in accessing health care both in prison and the community overcoming barriers to care skilled and empathic healthcare providers assist in overcoming barriers to care women in contact with the prison system value community gp acknowledgement of and assistance with the broad issues that have an impact on their wellbeing as well as skilled management of substance misuse and a nonjudgemental patientcentred approach 18 exposure of students and trainees to people in prison or with substance misuse problems may decrease stigma and promote more effective health care for these people 4041 this should include training in traumainformed health care so that healthcare providers are aware of the psychological dynamics that may impact on the development of therapeutic relationships with people in contact with the custodial system 42 this may assist providers to avoid retraumatizing vulnerable patients for example through words and actions which reinforce the sense of withholding care family and other advocates can greatly assist access to care 21 however women leaving prison often lack social connectedness and support in the community 43 access may be facilitated by prison and community providers working together prior to women leaving prison to plan for care following release 44 care navigation through reentry programs can provide instrumental and relational support to promote health care access 93045 given the risk of medical homelessness our study reinforces the importance of resourcing transitional programs to assist women to link with skilled nonjudgmental community care on release limitations the participants in this study had high reported health problems and needs particularly related to substance misuse although our participants also reported mental and physical health problems their primary focus when reporting barriers to healthcare access revolved around current or past histories of substance misuse our findings are likely to be more transferable to other people who struggle with substance misuse both inside and outside prisons although our participants were reflecting on their experiences as women within the australian prison and community health system the applicability of candidacy concepts suggests wider relevance for marginalised groups particularly those caught in a pattern of serial incarcerations or of substance misuse the roles of the primary researcher and interviewer as a visiting gp within the prison health service and as a community gp were made known to the participants although this may have enhanced the research through shared understandings of complex health systems it may also have inhibited participants from expressing their views completely and led to lack of identification of findings which may be novel to an outsider however the fact that the women freely shared in their experiences of suboptimal care suggests that they did not feel constrained by a fear of further impacting on their access to care the inclusion of researchers who are not involved in delivery of prison health services and a cultural adviser assisted in ensuring the analysis was comprehensive and inclusive of multiple perspectives and interpretations conclusion women in contact with the criminal justice system and particularly those with histories of substance misuse can face difficulties in accessing health care both in prison and in the community for those women who cycle in and out of prison healthcare access can be conceived as an ongoing state of medical homelessness their experiences of poor community provider skills in managing addiction and provider judgements both in prison and in the community that their claims to care are not credible may contribute to a persistent state of waiting and exclusion during cycles of prison and communitybased care consideration of the vulnerabilities and points of exclusion for women caught in this cycle will assist in determining how to ensure healthcare access for this marginalised population authors contributions pa led study conceptualization and design data acquisition and analysis and drafting the manuscript jd contributed to data analysis and cultural mentorship pm contributed to study conceptualization data analysis and manuscript revision wh contributed to study conceptualization and design data analysis and manuscript development all authors read and approved the final manuscript consent for publication not applicable competing interests pa is a visiting general practitioner and member of the board of justice health forensic mental health network	background women in contact with the prison system have high health needs short periods in prison and serial incarcerations are common examination of their experiences of health care both in prison and in the community may assist in better supporting their wellbeing and ultimately decrease their risk of returning to prison methods we interviewed women in prisons in sydney australia using prerelease and postrelease interviews we undertook thematic analysis of the combined interviews considering them as continuing narratives of their healthcare experiences we further reviewed the findings using the theoretical lens of candidacy to generate additional insights on healthcare access results sixtynine interviews were conducted with 40 women prerelease and 29 of these postrelease most had histories of substance misuse women saw prison as an opportunity to address neglected health problems but long waiting lists impeded healthcare delivery both in prison and in the community the dual stigmas of substance misuse and being a prisoner could lead to provider judgements that their claims to care were not legitimate they feared they would be blocked from care even if seriously ill family support selfefficacy assertiveness overcoming substance misuse compliance with health system rules and transitional care programs increased their personal capacity to access health care conclusions for women in transition between prison and community healthcare access could be experienced as medical homelessness in which women felt caught in a perpetual state of waiting and exclusion during cycles of prisonand communitybased care their healthcare experiences were characterized by ineffectual attempts to access care transient relationships with healthcare providers disrupted medical management and a fear that stigma would prevent candidacy to health care even in the event of serious illness consideration of the vulnerabilities and likely points of exclusion for women in contact with the criminal justice system will assist in increasing healthcare access for this marginalised population
introduction the improvement of womens sexual and reproductive health and rights remains important in the fight to reduce child and maternal mortality lowand middleincome countries often have maternal mortality ratios due to childbirthrelated complications estimates show that the subsaharan africa region has a soaring mmr of 542 per 100000 live births 1 three countries made the largest contribution to the mmr in the region these include south sudan chad and sierra leone 1 these high rates are partially due to various challenges which tend to intensify them such as lack of access to and provision of healthcare services lack of or inadequate use of family planning services malnutrition and other issues 2 3 4 5 many countries have made significant strides toward meeting their millennium development goals targets especially when it comes to the use of maternal health services 6 however the progress made at the national level tends to hide the inequalities that still exist at lower levels of geography the level of maternal health service use differs between different socioeconomic groups within a country it remains to be seen if the sustainable development goals will build on the mdgs in increasing the use of maternal health services while reducing inequalities between socioeconomic groups sierra leone has had challenges trying to reduce the mmr and improve maternal health service provision after years of struggles in dealing with high maternal mortality levels and poor uptake and provision of maternal health services due to unaffordability the government introduced the free health care initiative around 2010 as a way of improving the use of maternal and child healthcare 78 in poor communities outofpocket expenditure on health becomes unrealistic the fhci removed user fees for women and young children needing to use healthcare services 9 this led to some improvements in the update of lifesaving maternal health services the percentage of births that were delivered at home decreased over time in the country from 718 in 2008 244 in 2013 and 164 in 2019 10 11 12 high financial costs often become a barrier to healthcare use especially in rural areas where women are expected to travel long distance and pay more for transport to reach health services especially in rural areas 13 14 15 however there is evidence of the existence of health inequalities in the country despite many improvements in maternal healthcare use studies show the existence of wealthbased health inequalities in some parts of the country 1617 to analyse inequalities in maternal healthcare we adopted the framework developed by the commission on social determinants of health the csdh framework argues that social position is an important determinant of health inequities 18 the framework considers different elements of inequality such as socioeconomic status education race and geographic location as well as other elements 18 19 20 in this study we included maternal education and household wealth index as the structural determinants of health we also include the place of residence in the analysis the structural determinants are part of the social and economic context of individuals and these are often regarded as the actual social determinants of health 18 inequalities in healthcare especially in lmic have drawn a lot of attention in recent times 21 addressing the health needs of the populations in lower socioeconomic positions is crucial in improving the overall health of the entire population although a few studies on healthcare inequalities have been conducted in sierra leone many have focused on different aspects of healthcare inequality and have used other measures and datasets than those considered in this study 16172223 this study aims to explore the extent of health inequalities in maternal healthcare as well as possible changes in these inequalities in sierra leone methods data sources we used crosssectional data from the 2008 2013 and 2019 demographic and health surveys the dhs collects nationally representative data on various healthrelated interventions this data is publicly available for download upon request the dhs data are among the widely used sources of data for analysis of healthrelated inequalities the dhs conducted in sierra leone sampled 7 758 households in 2008 13 006 households in 2013 and 13 793 households in 2019 with a response rate of 976 993 and 995 respectively 10 11 12 for all data collection points women of reproductive age who were either usual household members or women present in the household on the night before the survey were eligible for interviews we indicate the study sample in table 1 maternal health indicators this section presents the maternal health indicators used in the study we selected the following indicators four or more antenatal visits skilled antenatal care providers births assisted by a skilled birth attendant and births delivered in a facility we defined four or more antenatal care visits as women who had at least four or more antenatal care visits for their most recent pregnancy this definition has been used elsewhere 2425 we defined skilled antenatal care providers as women whose antenatal visits were attended by a skilled provider we defined births delivered in a facility as births that were delivered in a health facility the health facilities included a government hospital government health centre government health post other public sector private hospitalclinic and other private sector we also defined births assisted by a skilled birth attendant as births that were assisted by a skilled birth attendant a skilled provider included a doctor nursemidwife or auxiliary midwife we dichotomised the selected indicator variables and we coded them as 0 no and 1 yes inequality stratifiers and measures this study used three stratifiers to measure healthrelated inequality the household wealth index was computed for each household using the principal components analysis method to disaggregate the sample into equalsized quintiles 26 we measured the prevalence of four maternal health indicators for each of the data points considered in this study we used rate ratios to measure absolute differences in inequalities using the selected inequality stratifiers the rate ratios provide a general description of the extent of inequalities the rate ratios for the wealth index were measured in terms of highest versus lowest household wealth quintile the rate ratios for maternal education were measured in terms of highest versus none the rate ratios for residence were measured in terms of urban vs rural the main limitation of the measures above is that they provide a basic picture of inequalities and ignore the differentials that often exist between all the categories of the inequality stratifier for instance in computing the rate ratios for the household wealth index only two extremes are considered and not the rest of the quintiles to remedy this we used the concentration index the concentration index is the most used measure of health inequalities in public health studies it shows the magnitude of healthrelated inequalities and whether these inequalities are concentrated among those with low socioeconomic status or those with high socioeconomic status the index value becomes negative when the health intervention is concentrated among the poor and positive when it is concentrated among the rich 27 if the concentration index is negative then the health indicator is said to be concentrated among individuals with low socioeconomic status while a positive concentration index shows that the health indicator is concentrated among individuals with a high socioeconomic status 28 therefore to further quantify inequalities in the selected indicators we employed the concentration index specifically we employed the erreygers corrected concentration index eðhþ ¼ 4 m ðb h à a h þ �cðhþ where b h and a h refer to the maximum and minimum bounds of the binary health indicator μ refers to the mean of the health indicator and c refers to the concentration index 29 the erreygers corrected concentration index is recommended for use when the variable is binary 30 the concentration curve is used to visualise the extent of inequalities in terms of the concentration index and the inequality stratifier is ranked across the xaxis and the cumulated fraction of the health intervention is plotted on the yaxis and a diagonal line represents the line of equality 27 where the health intervention lies below the equity line then it is said that there are prorich inequalities in that society and when it lies above the equity line then it is said there are propoor inequalities we used the conindex command in stata to estimate the corrected concentration index 31 various studies have used dhs data and applied similar methods to analyse the trends determinants and inequalities in maternal child and reproductive health interventions as well as service coverage 428 32 33 34 complex samples for all the data points the sldhs used a twostage cluster sampling approach to select respondents for the surveys 10 11 12 as such we needed to adjust for data representation in our analysis therefore we used the stata svyset command to account for the underand oversampling of certain enumeration areas an alpha level of 005 was considered statistically significant we used stata version 142 35 and microsoft excel for all analyses of this study ethical considerations we conducted all analyses using publicly available data from the sldhs the institutional review board of macro international inc reviewed and approved the collection of data for all periods of the sldhs data used in this study permission was granted to the authors by the dhs program to use this data for this study for more information on the ethical review processes used by the dhs program see more details on the ethical considerations in dhs data here results prevalence and rate ratios table 2 shows the ratios of educationrelated inequalities among wra between those with no education and those with higher levels of education there was an increase in the use of maternal health services over the three periods the use of delivery care services doubled between 2008 and 2019 the ratios for the selected maternal health indicators indicate the existence of inequalities that favour women with higher levels of education moreover there was a decrease in inequalities between women with no education and those with higher levels of education from 2008 to 2019 as shown by the decrease in ratios table 3 examines the prevalence of maternal healthcare use as well as the wealthbased inequality ratios for the selected maternal health indicators the use of maternal health services increased with socioeconomic status where there was a higher use of these services among women from the richest households in terms of the ratios the findings showed that inequalities favoured women from the richest households the ratios showed a decline between 2008 and 2019 indicating a decrease in prorich maternal health inequalities table 4 shows the prevalence of maternal healthcare use by urbanrural residence and ratios of urban to rural inequalities the use of maternal health services was higher among women from urban areas than those from rural areas except for the use of antenatal services in 2019 the ratios for antenatal services in 2019 indicated that inequalities slightly favoured women from rural areas in general the ratios in 2008 and 2013 showed that inequalities favoured women from urban areas for all indicators concentration curves the concentration curves show that there are inequalities in the use of maternal health services favouring those with a higher socioeconomic position there is a higher use of maternal health interventions by wealthier women than by poorer women the inequalities decreased over time as portrayed by the narrowing of the curves particularly in the use of antenatal services figs 1 and2 shows that the inequality gap has decreased over time moreover by 2013 and 2019 the inequality gap had almost closed in terms of the use of antenatal services furthermore the findings show that there is high inequality in the use of health facilities for delivery and skilled birth attendants as shown by the wide curves concentration indices the wealthbased and maternaleducationbased concentration indices show that there have been improvements in inequality in the use of maternal healthcare use for about eleven years from 20082019 the biggest decrease in the concentration index was for the use of births assisted by a skilled birth attendant which decreased from 0330 to 0113 for wealthbased inequalities and 0230 to 0095 for educationbased inequalities conversely there was high inequality in the use of delivery care services in both 2008 and 2013 discussion this study aimed to explore health inequalities in maternal healthcare in sierra leone the findings show that considerable progress has been made in the use of maternal health services the measures employed in the study show that inequalities in maternal healthcare use have declined since 2008 our findings suggest that maternal health inequalities favour women from wealthy households educated women as well as women from urban areas this could be because women with better socioeconomic status tend to live in urban areas and can better pay for use and the available health services compared to their counterparts 3637 moreover improvements in wealth and educationbased inequality were evident in 2013 and 2019 for the use of antenatal services although inequality declined over time the use of delivery care services remained highly unequal our findings are similar to other studies which found substantial inequalities in the use of delivery services similar studies show that inequalities in delivery care services tend to favour wealthier and more educated women 3343738 a study in sierra leone also found that maternal education made a considerable contribution to inequalities in institutional delivery 16 the cultural aspects of the population as well as their perceptions of modern medicine and related health provision are critical in understanding the use of maternal healthcare services 1639 additionally the findings show that there is some degree of inequality favouring populations in urban areas this supports the literature which argues women in urban areas tend to have greater access to maternal health services compared to women in rural areas 4041 these findings speak to the ruralurban gap in the provision of healthcare services between rural and urban areas as well as the related barriers such as costs and distance disproportionally faced by women in rural areas 13 14 15 42 the introduction of the fhci and the removal of user fees might have contributed to the increase in the use of maternal health services as well as the reduction of inequality in the use of these services witter and colleagues have conducted numerous studies which monitored and evaluated the main pillars of the fhci concerning how these pillars have been implemented on the ground 4344 the authors argue that the use of maternal health services in the country has increased and this increase could be attributed to the implementation of the fhci 434546 it is difficult to pinpoint the exact contribution of the fhci to increasing the use of health services since some of these health services had high uptake rates before the implementation of the fhci 46 although the fhci may have contributed to an increase in the use of maternal healthcare services there is still some level of inequality that exists in the use of maternal healthcare services in the period highlighted in this study a comprehensive analysis of the impact of this initiative on the use of maternal health services and related inequalities in the country will be important for future research strengths and limitations the main strength of this study is that we used nationally representative datasets from three collection periods to better estimate inequalities in maternal healthcare use the study uses crosssectional data as such the data cannot serve as the basis for establishing causality among variables there may be recall bias because of the longer recall time where respondents are required to report on past occurrences of the use of certain healthcare services conclusion our findings show that despite efforts by the government to increase the use of maternal healthcare services among women with a lower socioeconomic status the use of these services remains favourable to those with a higher socioeconomic status to ensure balance among the different socioeconomic groups policy initiatives need to prioritise women with lower socioeconomic status through projects aimed at reducing poverty and increasing their educational levels especially among women from rural areas moreover further studies are necessary to study the specific impact of the fhci and similar initiatives on the use of maternal healthcare services in the country and what impact these initiatives have had on the reduction of health inequalities the dataset is freely available for download and use upon registration on the demographic and health survey program website data curation mluleki tsawe formal analysis mluleki tsawe investigation a sathiya susuman methodology mluleki tsawe software mluleki tsawe supervision a sathiya susuman writing original draft mluleki tsawe a sathiya susuman writing review editing mluleki tsawe a sathiya susuman	sierra leone is one of the countries with poor health outcomes the country has made some progress in the uptake of maternal health services despite improvements in the national coverage rates there is no evidence of how equal these improvements have been
social networks much progress has been made both on obtaining and analyzing empirical data 2 5 and mathematical modeling 6 9 in a more recent set of extensions scientists have begun studying the simultaneous propagation of multiple memes in which not only the interaction between nodes in the network but also the interplay of multiple memes plays an important role in determining the systems dynamical behaviors these two forms of interactions together add complexity and research value to the multimeme propagation model this paper proposed a series of mathematical models on the propagation of competing products three key elements the interpersonal network the individuals and the competing products are modeled respectively as a graph with fixed topology the nodes on the graph and the states of nodes our models are based on the characterization of individuals decision making behaviors under the social pressure two factors determine individuals choices on which product to adopt the endogenous factor and the exogenous factor the endogenous factor is the social contact between nodes via social links which forms a tendency of imitation referred to as social pressure in this paper the exogenous factor is what is unrelated to the network eg the products quality in the microscopic level we model the endogenous and exogenous factors respectively as two types of productadoption processes the social conversion and the self conversion in social conversion any node randomly picks one of its neighbors and follows that neighbors state with some given probability characterizing how openminded the node is in the self conversion each node independently converts from one product to another with some given probability depending on the two products involved although individuals exhibit subjective preferences when they are choosing the products statistics on a large scale of different individuals behaviors often reveal that the relative qualities of the competing products are objective for example although some people may have special affections on feature phones the fact that more people have converted from feature phones to smart phones rather than the other way around indicates that the latter is relatively better we assume that the transit probabilities between the competing products are determined by their relative qualities and thus homogeneous among the individuals b literature review various models have been proposed to describe the propagation on networks such as the percolation model on random graphs 10 11 the independent cascade model 12 14 the linear threshold model 15 17 and the epidemiclike meanfield model 18 20 as extensions to the propagation of a single meme some recent papers have discussed the propagation of multiple memes eg see 21 32 some of these papers adopt a susceptibleinfectedsusceptible epidemiclike model and discuss the longterm coexistence of multiple memes in singlemultiplelayer networks eg see 25 27 some papers focus instead on the strategy of initial seeding to maximize or prevent the propagation of one specific meme in the presence of adversaries 29 32 among all these papers mentioned in this paragraph our model is most closely related to the work by stanoev et al 28 but the social contagion process in 28 is different from our model and theoretical analysis on the general model is not included c contribution firstly we propose a generalized and novel model for the competitive propagation on social networks by taking into account both the endogenous and exogenous factors and considering the individual variance as well as the interplay of the competing products our model is general enough to describe a large class of multimeme propagation processes moreover many existing models have difficulty in dealing with the simultaneous contagions of multiple memes and have to avoid the problem by adding an additional assumption of the infinitesimal step length that only allows the occurrence of a single contagion at every step differently from these models the problem of multiple contagions does not occur in our model since we model the contagion process as the individuals initiative choice under the social pressure which is more suitable for the productadoption process in addition compared with the independent cascade model in which individuals choices are irreversible our models adopt a more realistic assumption that conversions from one product to another are reversible and occur persistently secondly we propose a new concept the productconversion graph to characterize the interplay between the products there are two graphs in our model the social network describing the interpersonal connections and the productconversion graph defining the transitions between the products in self conversion which in turn reflect the products relative quality thirdly starting from the description of individuals behavior we develop two markovchain competitive propagation models different in the chronological order of the social conversion and the self conversion processes applying the independence approximation we propose two corresponding network competitive propagation models which are difference equations systems such that the dimension of our problem is reduced and some theorems in the area of dynamical systems can be applied to the analysis of the approximation models fourthly both theoretical analysis and simulation results are presented on the dynamical properties of the network competitive propagation models we discuss the existence uniqueness and stability of the fixed point as well as how the systems asymptotic state probability distribution is determined by the social network structure the individuals openmindedness the initial condition and most importantly the structure of the productconversion graph we find that if the productconversion graph contains only one absorbing strongly connected component then the self conversion dominates the systems asymptotic behavior with multiple absorbing strongly connected components in the productconversion graph the systems asymptotic state probability distribution also depends on the initial condition the network topology and the individual openmindedness in addition simulation results are presented to show the high accuracy of the independence approximation and reveal that the original markovchain model also exhibits the same asymptotic behavior at last based on the network competitive propagation model we propose two classes of noncooperative games in both games the players are the competing companies with bounded investment budgets on seeding eg advertisement and promotion and improving their products quality the first model is a infinitely repeated oneshot game in which the players myopically maximize their nextstep payoff we investigate the unique nash equilibrium at each stage theoretical analysis also reveals some strategic and realistic insights on the seedingquality tradeoff and the allocation of seeding resources among the individuals the second model is a dynamic game with infinite horizon in which the players aim to maximize their discounted accumulated payoffs the existence of nash equilibrium for the twoplayer case is proved and numerical analysis is given on the comparison with the oneshot game d organization the rest of this paper is organized as follows section ii give the assumptions for two markovchain propagation models section iii and iv discuss the approximation of these two models respectively in section v we discuss the two classes of games section vi is the conclusion e is always assumed connected and there is no self loop ie ãii 0 for any i ∈ v ii model description n×n with a ij 1 if ∈ e and a ij 0 if ∈ e the rownormalized adjacency matrix is denoted by ã n×n where ãij 1 ni a ij with n i n j1 a ij the graph g v b competing products and the states of nodes suppose there are r competing products denoted by h 1 h 2 h r propagating in the network we consider a discretetime model ie t ∈ n and assume the products are mutually exclusive we do not specify the state of adopting no product and collectively refer to all the states as products denote by d i the state of node i after time step t for any t ∈ n d i ∈ h 1 h 2 h r for simplicity let θ 1 2 r ie the set of the product indexes c nodes production adoption behavior two mechanisms define the individuals behavior the social conversion and the self conversion the following two assumptions propose respectively two models different in the chronological order of the social and self conversions assumption 1 consider the competitive propagation of r products in the network g at time step t 1 for any t ∈ n suppose the previous state of any node i is d i h r node i first randomly pick one of its neighbor j and following js previous state ie d i d j with probability α i if node i does not follow js state in the social conversion with probability 1α i then node i converts to product h s with probability δ rs for any s r or stay in h r with probability δ rr assumption 2 at any time step t 1 any node i with d i h r converts to h s with probability δ rs for any s r or stay in the state h r with probability δ rr if node i stays in h r in the process above then node i randomly picks a neighbor j and following d j with probability α i or still stay in h r with probability 1α i assumptions 1 and 2 are illustrated by figure 1 and figure 2 respectively by introducing the parameters δ rs we define a directed and weighted graph with the adjacency matrix ∆ r×r referred to as the productconversion graph figure 3 gives an example of the productconversion graph for different smart phone operation systems based on either of the two assumptions ∆ is rowstochastic in this paper we discuss several types of structures of the productconversion graph eg the case when it is strongly connected or consists of a transient subgraph and some isolated absorbing subgraphs the parameter α i characterizes node is inclination to be influenced by social pressure define α as the individual openmindedness vector assume 0 α i 1 for any i ∈ v d problem description according to either assumption 1 or assumption 2 at any time step t 1 the probability distribution of any nodes states depends on its own state as well as the states of all its neighbors at time t therefore the collective evolution of nodes states is a r n state discretetime markov chain define p ir as the probability that node i is in state h r after time step t ie p ir p d i h r we aim to understand the dynamics of p ir since the markov chain models have exponential dimensions and are difficult to analyze we approximate it with lowerdimension difference equations systems and analyze instead the dynamical properties of the approximation systems e notations before proceeding to the next section we introduce some frequently used notations in table i the rth column vector of the matrix x ∈ r n×m x the ith row vector of the matrix x ∈ r n×m x the ith row vector of the matrix ãx ∈ r n×m ie x where x ir n j1 ãij x jr g the graph with the adjacency matrix a iii network competitive propagation model with socialself conversion this section is based on assumption 1 we first derive an approximation model for the time evolution of p ir referred to as the socialself conversion network competitive propagation model and then analyze the asymptotic behavior of the approximation model and its relation to the social network topology the productconversion graph the initial condition and the individuals openmindedness further simulation work is presented in the end of this section a derivation of the socialself ncpm some notations are used in this section notation 3 for the competitive propagation of products h 1 h 2 h r on the network g define the random variable x r i by x r i 1 if d i h r x r i 0 if d i h r due to the mutual exclusiveness of the products for any i ∈ v if x r i 1 then x s i 0 for any s r define the n 1 tuple d i d i1 d i1 d n ie the states of all the nodes except node i after time step t define the following notations for simplicity p rs ij p x r i 1 x s j 1 p r i p x r i 1 d i γ r i p x r i 1 x s i 1 d i in the derivation of the network competitive propagation model the following approximation is adopted approximation 4 for the competitive propagation of r products on the network g approximate the conditional probability p ms ij by its corresponding total probability p im for any m s ∈ θ and any i j ∈ v with the independence approximation the socialself ncpm is presented in the theorem below theorem 5 consider the competitive propagation based on assumption 1 with the social network and the productconversion graph represented by their adjacency matrices ã n×n and ∆ r×r respectively the probability p ir satisfies p ir p ir s r α i n j1 ãij p sr ij p jr p rs ij p js s r δ rs p ir for any i ∈ v and r ∈ θ applying the independence approximation the approximation model for equation ie the socialself ncpm is p ir α i n j1 ãij p jr r s1 δ sr p is proof by definition p ir p ir e e x r i x r i d i where the conditional expectation is given by e x r i x r i d i s r γ r i p s i γ s i p r i according to assumption 1 γ r i p s i α i j ãij x r j p s i δ sr p s i therefore e γ r i p s i α i j ãij e x r j p s i δ sr e p s i one the righthand side of the equation above e p s i p is moreover e x r j p s i dij p x s i 1 x r j 1 d ij d ij p sr ij p jr apply the same computation to e γ s i p r i and then we obtain equation replace p sr ij and p rs ij by p is and p ir respectively and according to the equations s r p is 1p ir and s r δ rs 1δ rr we obtain equation the derivation of theorem 5 is equivalent to the widely adopted meanfield approximation in the modeling of the network epidemic spreading 19 33 34 notice that the independence approximation neither neglects the correlation between any two nodes states nor destroys the network topology since p jr p js and ãij all appear in the dynamics of p ir b asymptotic behavior of the socialself ncpm define the map f r n×r → r n×r by f diag ãx x∆ according to equation the matrix form of the socialself ncpm is written as p f p where p n×r we analyze how the asymptotic behavior of system ie the existence uniqueness and stability of the fixed point of the map f is determined by the two graphs introduced in our model the social network with the adjacency matrix ã and the productconversion graph with the adjacency matrix ∆ 1 structures of the social network and the productconversion graph assume that the social network g has a globally reachable node as for the productconversion graph we consider the more general case suppose that the productconversion graph g has m absorbing strongly connected components and a transient subgraph reindex the products such that the product index set for any lth absorbing sccs is given by θ 1 1 2 k 1 and θ l l1 u1 k u 1 l1 u1 k u 2 l u1 k u for any l ∈ 2 3 m and the index set for the transient subgraph is λ m l1 k l 1 m l1 k l 2 r then the adjacency matrix ∆ of the productconversion graph takes the following form ∆ ∆ 0 ×k0 b k0× ∆ 0 where ∆ diag ∆ 1 ∆ 2 ∆ m and b b 1 b 2 b m with b l ∈ r k0×k1 for any l ∈ 1 2 m is nonzero and entrywise nonnegative matrix ∆ l k l ×k l with δ θ1 rs δ rs and δ θ l rs δ l1 u1 kur l1 u1 kus for any l ∈ 2 3 m is the adjacency matrix of the lth absorbing scc and is thus irreducible and rowstochastic the following definition classifies four types of structures of g definition 6 based on whether the productconversion graph g 2 stability analysis of the socialself ncpm the following theorem states the distinct asymptotic behaviors of the socialself ncpm with different structures of the productconversion graph theorem 7 consider the socialself ncpm on a strongly connected social network g with the productconversion graph g assume that each absorbing scc g of g is aperiodic for any ∆ l l ∈ 1 2 m as least one column of ∆ l is entrywise strictly positive for any r ∈ λ s∈λ δ rs 1 ie ∆ 0 1 k0 ≺ 1 k0 then for any p ∈ s nr the solution p to equation has the following properties depending upon the structure of ∆ in case 1 p converges to p 1 n ∆ exponentially fast where p is the unique fixed point in s nr for the map f defined by equation moreover the convergence rate is α max ζ where α max max i α i and ζ 1 r r1 min s δ sr in case 2 for any i ∈ v lim t→∞ p ir 0 for any r ∈ λ w r for any r ∈ θ 1 in case 3 for any l ∈ 1 2 m and i ∈ v lim t→∞ p θ l w p θ l 1 k l w where m diag ãi diag α and p θ l p θ l ir n×k l with p θ l ir p i l1 u1 kur and p θ l being the ith row of p θ l in case 4 for any l ∈ 1 2 m and i ∈ v lim t→∞ p ir 0 for any r ∈ λ γ l w r for any r ∈ θ l where γ l depends on ã b l p θ l p λ and satisfies m l1 γ l 1 before proving the theorem above a useful and wellknown lemma is stated without the proof lemma 8 let m ∈ r n×n be rowstochastic suppose the graph g is aperiodic and has a globally reachable node then the nonsingular matrix 1 moreover m red is discretetime exponentially stable q      1 1 1 1 1n 1n 1n      satisfies qm q 1 m red 0 n1 c 1 for some c ∈ r n1 and m red ∈ r × n proof of theorem 7 case 1 since matrix ∆ is rowstochastic irreducible and aperiodic according to the perronfrobenius theorem w ∈ r r is welldefined by substituting p defined by p w for any i ∈ v into equation we verify that p is a fixed point of f for any x and y ∈ r n×r define the distance d by d x y ∞ then d is a complete metric space for any x ∈ s nr it is easy to check that f 0 n×r and f 1 r diag ãx1 r x1 r 1 n therefore f maps s nr to s nr for any x ∈ s nr according to equation f f 1 ≤ α i x p 1 p ∆ 1 the first term of the righthand side of satisfies x p 1 ≤ r r1 n j1 ãij x jr w r ≤ x p ∞ the second term of the righthand side of satisfies p ∆ 1 r r1 r s1 x is w s δ sr if x p then f f 1 ≤ α i x p ∞ if x p since x 1 r p 1 r 1 both the set θ 1 s x is ≥ w s and the set θ 2 s x is w s are nonempty and s∈θ1 x is w s s∈θ2 w s x is 1 2 r s1 x is w s therefore p ∆ 1 r r1 r s1 x is w s δ sr 2 r r1 min s∈θ1 δ sr s∈θ2 x is δ sr where min s∈θ1 δ sr s∈θ2 x is δ sr ≥ 1 2 min s δ sr x p 1 substituting the inequality above into we obtain p ∆ 1 ≤ 1 r r1 min s δ sr x p 1 since r r1 δ sr 1 for any s r r1 min s δ sr is no larger than 1 in addition since at least one column of ∆ is strictly positive r r1 min s δ sr 0 therefore 0 ≤ ζ 1 r r1 min s δ sr 1 and f p 1 ≤ α i ζ x p ∞ this leads to f f ∞ ≤ x p ∞ for any x ∈ s nr and 0 1 this concludes the proof for case 1 case 2 for the transient subset λ define p λ p λ ir n×k0 with p λ ir p irk1 for any i ∈ v and r ∈ 1 2 k 0 then p λ diag ãp λ p λ ∆ 0 according to assumption of theorem 7 c max r∈ 12k0 k0 s1 δ λ rs 1 and ∆ 0 1 k0 ≤ c1 k0 therefore p λ 1 k0 diag ã c i diag p λ 1 k0 since ρ diag ã c i diag 1 for any p λ ∈ snk0 p λ → 0 n×k0 exponentially fast define p θ1 n×k1 then we have p θ1 diag ãp θ1 i diag p θ1 ∆ 1 i diag p λ b since p λ converges to 0 n×k0 exponentially fast we have 1 there exists c 0 and 0 ξ 1 such that i diagp λ b ∞ ≤ cξ t 2 p θ1 1 k1 1 k1 ∞ → 0 exponentially fast which implies d p θ1 s nk1 → 0 exponentially fast for any x ∈ snk1 define map f by f diag ãx i diag x∆ 1 according to the proof for case 1 there exists a unique fixed point p for the map f in s nk1 given by p ir w r moreover there exists 0 1 such that for any x ∈ s nk1 f p ∞ ≤ x p ∞ since the function f p ∞ xp ∞ is continuous in snk1 p and d p θ1 s nk1 → 0 there exists t 0 and 0 η 1 such that for any t t f p θ1 p ∞ ≤ η p θ1 p ∞ for t ∈ n much larger than t p θ1 p ∞ ≤ η tt p θ1 p ∞ c ξ t η tt ξ t ηξ since 0 η 1 0 ξ 1 as t → ∞ p θ1 p ∞ → 0 this concludes the proof for case 2 case 3 for any l ∈ 1 2 m p θ l f p θ l i diag p θ l ∆ l diag ãp θ l where ∆ l 1 k l 1 k l since θ l is absorbing and strongly connected therefore p θ l 1 k l m p θ l 1 k l where m idiag diag ã is rowstochastic and aperiodic moreover the graph g has a globally reachable node and therefore the matrix m has a normalized dominant left eigenvector w applying the perronfrobenius theorem lim t→∞ p θ l 1 k l w p θ l 1 k l 1 n let c l w p θ l 1 k l following the same line of argument in the proof for case 2 f maps s nk l to s nk l and maps snk l to snk l moreover p ∈ r n×k l with p c l w for any i ∈ v is the unique fixed point of the map f in s nk l in addition there exists 0 1 such that for any x ∈ s nk l f p ∞ ≤ x p ∞ the function ĥ f p ∞ xp ∞ is continuous in snk l p since for any p θ l ∈ snk l p we have p θ l 1 k l → c l 1 k l which implies d p θ l s nk l → 0 as t → 0 therefore there exists 0 η 1 and t 0 such that for any t t f p θ l p ∞ ≤ η p θ l p ∞ therefore p θ l → p as t → ∞ case 4 p θ l diag ãp θ l i diag p θ l ∆ l i diag p λ b l for any l ∈ 1 2 m therefore p θ l 1 k l m p θ l 1 k l φ where m diag ã idiag is rowstochastic and primitive the vector φ is a vanishing perturbation according to the proof for case 2 let x p θ l 1 k l and y qx with q defined in lemma 8 let y err y 2 y n1 where y i x i1 x i for any i 1 2 n 1 then we have y qm q 1 y qφ let ϕ ϕ 1 ϕ 2 ϕ n1 with ϕ i j q ij φ j ϕ is also a vanishing perturbation and y err m red y err ϕ the equation above is an exponentially stable linear system with a vanishing perturbation since ρ 1 y err → 0 n1 as t → ∞ which implies that p θ l 1 k l → γ1 n and γ l depends on m b l p θ l and p λ moreover l γ l 1 since p 1 r 1 n following the same argument in the proof for case 3 we obtain lim t→∞ p θ l γ l w 3 interpretations of theorem 7 analysis on case 1 to 4 leads to the following conclusions 1 the probability of adopting any product in the transient subgraph eventually decays to zero 2 for the productconversion graph with only one absorbing scc g the systems asymptotic productadoption probability distribution only depends on w in this case the self conversion dominates the competitive propagation ∆   ∆ 1 0 0 0 ∆ 2 0 b 1 b 2 ∆ 0       06 04 0 0 03 07 0 0 0 0 1 0 0 08 0 02     the markovchin solution is computed by the monte carlo method in each sampling a α and p are randomly generated and set identical for the markov chain and the ncpm the probability p 12 is plotted for both models on different types of social networks such as the complete graph the erdősrényi graph the powerlaw graph and the star graph as shown in figure 4 and figure 5 the solution to the socialself ncpm nearly overlaps with the markovchain solution in every plot due to the iid self conversion process b asymptotic behavior of the markov chain model in figure 6 and figure 7 all the trajectories p ir for the markovchain model on an erdősrényi graph with n 5 p 04 and randomly generated α are computed by the monte carlo method figure 6 corresponds to the structure of the productconversion graph defined by ∆ ∆ 1 0 0 ∆ 2 ∆ 1 06 04 03 07 ∆ 2 05 05 01 09 the simulation results shows that in these two cases the markovchain solutions converge exactly to the values indicated by the socialself ncpm regardless of the initial condition the matrix ∆ used in figure 7 is given by equation as illustrated by figure 7 the asymptotic adoption probabilities vary with the initial condition in the markovchain model in consistence with the results of theorem 7 iv analysis on the selfsocial network competitive propagation model in this section we discuss the network competitive propagation model based on assumption 2 ie the case in which self conversion occurs before social conversion at each time step firstly we propose an approximation model referred to as the selfsocial network competitive propagation model and then analyze the dynamical properties of this approximation model theorem 9 consider the competitive propagation model based on assumption 2 with the social network and the productconversion graph represented by their adjacency matrices ã and ∆ respectively the probability p ir satisfies p ir p ir s r δ sr p is δ rs p ir s r δ ss α i n j1 ãij p is p rs ji s r δ rr α i n j1 ãij p ir p sr ji for any i ∈ v and r ∈ θ applying the independence assumption the matrix form of the selfsocial ncpm is p p ∆ diag diag p δ ãp diagp diag with p n×r and δ it is straightforward to check that for any p ∈ s nr p is still in s nr according to the brower fixed point theorem there exists at least one fixed point for the system in s nr since the nonlinearity of equation add much difficulty to the analysis of it in the remaining part of this section we discuss the special case when r 2 for simplicity in this section let p p 2 p 12 p 22 p n2 without loss of generality assume δ 22 ≥ δ 11 define the map h r n → r n by h δ 12 1 n x δ 11 diag ãx δ 22 diagx diag diag ãx then the selfsocial ncpm for r 2 is written as p h and p 1 is computed by p 1 1 np we present below the main theorem of this section theorem 10 consider the twoproduct selfsocial ncpm given by equations and with the parameters δ 11 δ 12 δ 21 δ 22 α 1 α n all in the interval and δ 22 ≥ δ 11 we conclude that system p i p i ≤ 1 1 2 α i α i δ 22 δ 11 δ 22 δ 11 α i δ 22 δ 11 3δ 22 δ 11 for any i ∈ v then p is globally exponentially stable moreover the convergence rate is upper bounded by max i max i k i i k i 1 where i and k i are defined as i α i k i and k i δ 12 δ 21 δ 22 α i respectively proof we start the proof by establishing that h is a continuous map from 0 1 n to 0 1 n itself firstly since h δ 12 δ 11 diag ãx x δ 22 diagx diag diag ãx and x δ 22 diagx x 0 n the righthand side of the expression of h is nonnegative therefore for any x ∈ 0 1 n h 0 n secondly recall that x i i j ãij x j that is x i is the weighted average of all the x j s except x i and the value of x i does not depend on x i since ãii 0 moreover since j ãij 1 for any i ∈ v x i is also in the interval 0 1 according to equation rewrite the ith entry of h as h i δ 12 δ 11 α i x i η i x i where η i 1δ 12 δ 21 δ 22 α i α i x i the maximum value of η i is 1δ 12δ 21δ 11 α i obtained when x i 1 therefore η i x i ≤ max then we have h i ≤ δ 12 δ 11 α i max max 1 the inequality above leads to h 1 n for any x ∈ 0 1 n since h maps 0 1 n to 0 1 n itself according to the brower fixed point theorem there exists p such that h p this concludes the proof of the existence of a fixed point any fixed point of h should satisfy h p ie 0 n δ 12 1 n δ 11 diag ãp diag diag ãp p δ 22 diagp therefore p δ 12 k 1 1 n δ 11 k 1 diag ãp k 1 diag diag ãp where k i δ 22 diag is a positive diagonal matrix define a map t r n → r n by t δ 12 k 1 1 n δ 11 k 1 diag ãx k 1 diag diag ãx we have that map h has a unique fixed point if and only if map t has a unique fixed point for any x and y ∈ 0 1 n define the distance d xy ∞ then is a complete metric space according to equation since k 1 diag ã δ 22δ 11 and diag are all nonnegative for any x y ∈ 0 1 n and x y we have t t moreover t δ 12 k 1 1 n 0 n and t δ 12 k 1 1 n δ 11 k 1 α k 1 α δ 12 k 1 1 n δ 22 k 1 α since t i δ 12 δ 22 α i δ 12 δ 21 δ 22 α i 1 we have t ≺ 1 n therefore t maps 0 1 n to 0 1 n for any x y ∈ 0 1 n t i t i δ 11 α i k i α i k i moreover x i y i ≤ max j x j y j x y ∞ and x i x i y i y i ≤ max max i y 2 i min i x 2 i max i x 2 i min i y 2 i ≤ 2 x y ∞ therefore t i t i ≤ i x y ∞ where i αi δ12δ21δ22αi one can check that i 1 for any i ∈ v and i does not depend on the x and y let max i i then for any x y ∈ 0 1 n t t ∞ ≤ x y ∞ with 1 applying the banach fixed point theorem we know that the map t possesses a unique fixed point p in 0 1 n in addition for any p the sequence p t∈n defined by p t p satisfies lim t→∞ p p this concludes the proof of statement for statement one can check that t maps s x ∈ r n 1 2 1 n x δ12 δ12δ21 1 n to s itself since t is a contraction map the unique fixed point p is in s the concludes the proof for equation according to equation we have c i p i c i p i δ 12 δ 12 p i where c i δ 21 δ 22 α i and c i δ 11 α i α i p i firstly we point out that c i c i since c i c i δ 21 α i 0 moreover p i p i δ 12 δ 12 δ 21 α i p i δ 11 α i α i p i the righthand side of the equation above with 1 2 ≤ p i ≤ δ12 δ12δ21 achieves its maximum value 11 2 αi αi δ22δ11 δ22δ11 at p i 1 2 this concludes the proof for equation now we prove statement with δ 11 δ 22 h x x δ 12 1 n 2δ 12 x δ 11 diag ãx x one can check that p 1 2 1 n is a fixed point according to statement the fixed point is unique let p y 1 2 1 n then the twoproduct selfsocial ncpm becomes y m y where m i δ 11 diag ã δ 11 diag for any i ∈ v if 1 2δ 12 δ 11 α i ≥ 0 then n j1 m ij 1 2δ 12 δ 11 α i δ 11 α i 1 2δ 12 1 and if 1 2δ 12 δ 11 α i 0 then n j1 m ij 2δ 12 δ 11 α i δ 11 α i 1 1 since ρ ≤ m ∞ max i n j1 m ij the spectral radius of m is strictly less than 1 therefore the fixed point p 1 2 1 n is globally exponentially stable now consider the case when δ 22 δ 11 let p y p then system becomes y m y diag diag ãy the righthand side of the equation above is a linear term m y with a constant matrix m plus a quadratic term the matrix m can be decomposed as m m δ 12 i and m m m is further decomposed as a diagonal matrix m plus a matrix m in which all the diagonal entries are 0 since m i δ 22 diag diag diag is a positive diagonal matrix and m δ 11 diag ã diag diag ã is a matrix with all the diagonal entries being zero and all the offdiagonal entries being nonnegative the matrix m m m is nonnegative since ã diag 1 n1 1 n2 1 nn a the matrix m can be written in the form da e where a is symmetric and d e are positive diagonal matrix one can easily prove that all the eigenvalues of any matrix in the form m da e are real since m is similar to the symmetric matrix d 1 2 d 1 2 the local stability of p is equivalent to the inequality ρ 1 which is in turn equivalent to the intersection of the following two conditions λ max 1 δ 12 and λ min 1 δ 12 first we prove λ max 1 δ 12 since a is irreducible and α 0 n p 0 n we have mij 0 if and only if a ij 0 for any i j in addition mii 0 for any i ∈ v therefore m is irreducible aperiodic and thus primitive according to the perronfrobenius theorem λ max ρ we have ρ ≤ m ∞ and for any i ∈ v j mij 1 δ 21 α i α i according to equation for any i ∈ v 1δ 21 ≤ j mij ≤ 1δ 21 2 δ 12 δ 21 α i 1δ 12 therefore λ max ≤ 1 δ 21 2 δ 12 δ 21 α i 1 δ 12 now we prove λ min 1 δ 12 according to the gershgorin circle theorem λ min ≥ min i for any i ∈ v mii j i mij 1 δ 21 α i α i according to equation p i p i ≤ 1 1 2 α i α i δ 22 δ 11 δ 22 δ 11 moreover inequality is necessary and sufficient to 1 1 2 α i α i δ 22 δ 11 δ 22 δ 11 1 α i α i δ 22 δ 11 δ 22 δ 11 therefore mii j i mij 1 δ 21 α i 1 δ 12 for any i ∈ v that is to say the inequality is sufficient for ρ 1 ie the local stability of p this concludes the proof for statement for statement observe that the maps h and t satisfy the following relation h kt x for any x ∈ 0 1 n where k i δ 22 diag for any x y ∈ 0 1 n h i h i k i t i t i we estimate the upper bound of h i h i in terms of xy ∞ in two cases case 1 δ 12 δ 21 δ 22 α i 1 for any i firstly δ 11 δ 22 1 1 δ 22 δ 11 δ 22 3δ 22 δ 11 always holds as long as δ 11 δ 22 then recall that for any x y ∈ 0 1 n t i t i ≤ i x y ∞ where i αi ki 1 therefore h i h i ≤ x y ∞ for any i ∈ v the coefficient k i i 1 k i is always strictly less than 1 because it is a convex combination of i 1 and 1 therefore h is a contraction map case 2 there exists some i such that δ 12 δ 21 δ 22 α i ≥ 1 in this case for any such i h i h i ≤ x y ∞ if α i δ11δ22 3δ22δ11 then we have k i i k i 1 α i δ 12 δ 21 1 δ 11 δ 22 δ 12 δ 21 1 1 therefore h is also a contraction map combining case 1 and case 2 we conclude that if α i δ11δ22 3δ22δ11 for any i ∈ v then h is a contraction map according to the proof for statement h maps 0 1 n to 0 1 n therefore according to the banach fixed point theorem for any initial condition p ∈ 0 1 n the solution p converges to p exponentially fast and the convergence rate is upper bounded by max i max the rest of this section are some remarks of theorem 10 firstly equation has a meaningful interpretation the condition δ 22 ≥ δ 11 implies that product h 2 is advantageous to h 1 in the sense that the nodes in state h 1 have a higher or equal tendency of converting to h 2 than the other way around as the result the fixed point is in favor of h 2 ie p ≥ 1 2 1 n from the proof of statement we know that around the unique fixed point the linearized system is y m y where m is a metzler matrix and is hurwitz stable usually the metzler matrices are presented in continuoustime network dynamics models eg the epidemic spreading model 35 36 in the proof of theorem 10 we provide an example of the metzler matrix in a stable discretetime system figure 8 plots the righthand sides of inequalities and respectively as functions of the ratio δ11 δ22 for the case when 0 δ11 δ22 1 one can observe that for a large range of δ11 δ22 the sufficient condition we propose for the global stability is more conservative than the sufficient condition for the local stability one major difference between the selfsocial and the socialself ncpm in the asymptotic property is that in the selfsocial ncpm every individuals state probability distribution is not necessarily identical moreover distinct from the socialself ncpm for any of the four cases of g defined in definition 6 the asymptotic behavior of the selfsocial ncpm depends on not only the structure of g but also the structure of the social network g and the individual openmindedness α v noncooperative qualityseeding games based on the socialself ncpm given by equation we propose two noncooperative multiplayer games distinct in the payoff functions and analyze their nash equilibria these two games share the common idea that companies benefit from the adoption of their products and thereby invest on both improving their products quality and seeding eg advertisement and promotion to maximize their products adoption probabilities all the notations in table i and the previous sections still apply and in table ii we introduce some additional notations and functions exclusively for this section → r ≥0 defined by ψr γ x ir 1 r γ with model parameter γ 0 gr gr r r×1 ≥0 → r ≥0 defined by gr 1 r where ς ∈ r r 0 βr βr β 1r βnr ãpr ur singlestage reward for player r with system state p ur 1 n pr a repeated oneshot qualityseeding game 1 game setup and analysis in this subsection we consider the scenario in which the companies allocate their investments aiming to maximize their instant payoffs the game is referred to as the repeated oneshot qualityseeding game and is formalized as follows players the players are the r companies each company r has a product h r competing on the network players actions at each stage t each company r has two types of investments the investment on seeding ie x r and the investment on quality ie w r the total investment is bounded by a fixed budget c r ie 1 n x r w r ≤ c r rules the investment on seeding changes the individuals productadoption probability in the social conversion process for any individual i ∈ v each company rs investment x ir creates a virtual node in the network who is always adopting the product h r in the social conversion process the probability that individual i picks company rs virtual node is ψ r x γ for any i ∈ v and r ∈ θ the probability that individual i picks individual j in the social conversion process is then given by 1 r s1 ψ s x γ ãij the investment on quality ie w r influences the productconversion graph we assume that the productconversion graph is associated with a rankone adjacency matrix δ 1 1 n δ 2 1 n δ r 1 n and δ r g r ς is determined by all the companies investments on product quality and the products preset qualities ς 0 r with each company rs action y r x r w r at time t the dynamics of the productadoption probabilities p ∈ r n×r ≥0 is given by p h p y 1 y r where the map h is defined by h py 1 y r ir α i γ x 1 r γ n k1 ãik p kr α i ψ r x γ g r w ς for any p ∈ s nr i ∈ v and r ∈ θ payoffs and goals at each stage t each player r chooses its action y r in order to maximize the payoff u r 1 n p r ie the total adoption probability of product h r at the next stage the following theorem gives a closedform expression of the nash equilibrium at each stage and the systems asymptotic behavior when every player is adopting the policy at the nash equilibrium theorem 11 consider the rplayer qualityseeding game described in this subsection further assume that the budget limit c r for any company r satisfies c r ≥ max γ ς r 1 n α n 1 n α ς r 20 then we have the following conclusions i for each t there exists a unique purestrategy nash equilibrium y x w given by x ir α i n c r α i γ n 1 n β r α i n ς r β ir γ w r 1 1 n α n c r 1 n β r γ 1 n α n ς r and x ir ≥ 0 w r ≥ 0 for any i ∈ v r ∈ θ ii if x w x w for any t ∈ n and p ∈ s nr then p obeys the following iteration equations p r c r ς r 1 n ãp r γ 1 r c 1 r ς nγ 1 n for any r ∈ θ t ∈ n as the result p r converges to 1 r exponentially fast with the rate nγ 1 r nγ proof since we only discuss the actions at stage t in this proof for simplicity of notations and without causing any confusion we use x ir for x ir x ir w r resp if company r knows the actions of all the other companies at time step t ie y s for any s r the optimal response for company r is the solution to the following optimization problem minimize ∈ωr 1 n p r subject to 1 n x w c r ≤ 0 24 let xir x ir β ir γ wr w r ς r and l r 1 n p r µ r 1 n x r µ r w rµ r c r for any i ∈ v and r ∈ θ the solution to the optimization problem satisfies ∂l r ∂x ir α i s r xis 2 µ r 0 ∂l r ∂w r 1 n s r ws 2 µ r 0 ∂l r ∂µ r 1 n x r w r c r 0 according to the definition of nash equilibrium solves the optimization problem with for any s r one immediate result is that 1 n x r w rc r 0 for any r ∈ θ moreover equation leads to 1 √ µ r 1 n k1 α k s r x ks r s1 c s w s 1 n β s γ and therefore α i s r x is n k1 α k s r x ks r s1 x is r s1 c s w s 1 n β s γ the righthand side of the equation above does not depend on the product index r therefore for any r ∈ θ therefore x ir α i 1 n α c r w r 1 n β r γ 29 combining equation and we obtain c r w r 1 n β r γ w r c τ w τ 1 n β τ γ w τ η for any r τ ∈ θ and some constant η substitute the equation above into equation we solve that η 1 n α1 n therefore we obtain equation and by substituting equation into equation we obtain equation the uniqueness of the purestrategy nash equilibrium is implied from the computation moreover equation guarantees x ir ≥ 0 and w r ≥ 0 for any i ∈ v and r ∈ θ substituting euqation and into the dynamical system after simplification we obtain equation and thereby all the results in conclusion ii 2 interpretations and remarks the basic idea of seedingquality tradeoff in the competitive seedingquality game is similar to the work by fazeli et al 32 but in our model players take actions at every step instead of just at the beginning of the game moreover our model is based on a different propagation model theorem 11 reveals the behavior of the competitive propagation dynamics under the players rational but myopic actions and provides some strategic insights on the investment decisions and the seedingquality tradeoff for shortterm reward maximization interpretation of β ir by definition β ir is the average probability among all the neighbors of individual i of adopting product h r at time step t the larger β ir the more individual i is inclined to adopt h r via social conversion therefore β ir characterizes the current social attraction of h r for individual i and 1 n β r n characterizes the current overall social attraction of product h r in the network seedingquality tradeoff according to equation at the nash equilibrium the investment on h r s product quality monotonically decreases with 1 n αn and increases with 1 n β r this observation implies that 1 in a society with relatively low openmindedness the competing companies should relatively emphasize more on improving their products quality rather than seeding and vice versa 2 for products which do not have much social attraction seeding is more efficient than improving the products quality allocation of seeding resources among the individuals according to equation nash equilibrium on the boundary without equation the righthand sides of equation and could be nonpositive in this case the nash equilibrium would be on the boundary of the feasible action set ie some of the x ir or w r might be 0 b dynamic qualityseeding game with infinitehorizon in this subsection we introduce a multistage game among more farsighted players than in the previous subsection the players aim to maximize the accumulated payoffs of all the stages we refer to this game as the dynamic qualityseeding game the model setup is the same with the game defined in the previous subsection except for the following two modifications players policies denote by y r the set of functions mapping s nr to ω r each player rs policy is a sequence of maps denoted by y r y rt t∈n where y rt ∈ y r for any t player rs action at each stage t is thus given by y t y rt p we refer to y r y rt t∈n as stationary policy if y rt y rτ for any t τ and simply use y r for the map at each stage payoffs and goals denote by v r the payoff of player r with initial condition p p and each player s adopting the policy y s the payoff v r is given by the accumulated step payoffs with discount that is v r ∞ t0 ε t u r where p p and p h p y 1 y r for any t ∈ n this model setup defines a multistage noncooperative dynamic game with infinite horizon one interpretation of the discounted accumulated payoff is that people tend to value the immediate profit more than the future profit an alternative explanation is that the discount factor ε characterizes the interest rate 1ε 1 when the players deposit their current payoff to the banks or use them for some other investments the rtuple is a nash equilibrium if for any p ∈ s nr and r ∈ θ v r ≥ v r for any y r ∈ y ∞ r y r × y r × in this subsection we limit our discussion to the case of two players the following theorem presents some results on the stationary nash equilibrium and the equilibrium payoff function for this dynamic qualityseeding game theorem 12 consider the dynamic qualityseeding game defined in this subsection with r 2 define the subset of continuously differentiable functions v v 0 1 n → r v satisfies properties p 1 and p 2 where p 1 p p ⇒ v ≤ v for any p p ∈ 0 1 n p 2 v is convex in p we conclude that there exists a nash equilibrium where y 1 and y 2 are both stationary policies the total payoff for player 2 at this nash equilibrium is given by v 2 p y 1 y 2 v where e 2 is the second standard basis vector of r 2 and v is the unique fixed point of the map t v → v defined by before proving the theorem above we summarize theorem 44 and property 41 in 37 on the twoplayer zerosum continuous games into the following lemma t v 1 n p ε sup y2∈ω2 inf y1∈ω1 v he 2 where p 1 n p p ∈ r n×2 as a result v 1 n v 2 p y 1 y lemma 13 consider the twoplayer zerosum continuous game with player 1 as the minimizer and player 2 as the maximizer suppose the action sets of player 1 and 2 denoted by ω 1 and ω 2 respectively are both compact and convex subsets of finitedimension euclidean spaces if the cost function v ω 1 × ω 2 → r is continuously differentiable convex in y 1 and concave in y 2 then the game admits at least one saddlepoint nash equilibrium in pure strategies if there are multiple saddle points the saddle points satisfy the ordered interchangeability property that is if and are saddle points so are and proof of theorem 12 in this proof for simplicity denote by p the second column of the matrix p ie p 1 np p and correspondingly p 1 np p since ω 1 and ω 2 are compact subsets of r n1 for any v ∈ v there exists such that t v 1 n p εv he 2 moreover from the expression of map h one can deduce that h satisfies p p ⇒ he 2 he 2 for any ∈ ω 1 × ω 2 and p p ∈ 0 1 n this leads to the conclusion that t v also satisfies property p 1 moreover by definition h is linear in p since v is convex in p one can check that t v is also convex in p therefore t satisfies property p according to the expression of the map h is a nash equilibrium of the dynamics game this concludes the proof theorem 12 provides an iteration algorithm to compute the stationary nash policy and the players respective payoffs at the nash equilibrium a comparison by simulation is given in figure 9 between the nash policies for the dynamic game discussed in this subsection and the repeated oneshot game in the previous subsection the model parameters are set as n 3 α γ 5 ς 1 ς 2 1 c 1 30 c 2 60 ε 08 and ã such that ã13 ã23 1 ã31 ã32 05 and ãij 0 otherwise simulation results show that with the same initial condition for the two types of games the players total payoffs at the respective nash equilibria are very close to each other moreover from figure 9 we can observe that for each of the two games the players payoffs are almost linear to the initial average probability of adopting h 2 vi conclusion this paper discusses a class of competitive propagation models based on two productadoption mechanisms the social conversion and the self conversion applying the independence approximation we propose two difference equations systems referred to as the socialself ncpm and the selfsocial ncpm respectively theoretical analysis reveals that the structure of the productconversion graph plays an important role in determining the nodes asymptotic state probability distributions simulation results reveal the high accuracy of the independence approximation and the asymptotic behavior of the original socialself markov chain model based on the socialself ncpm we propose twotypes of competitive propagation games and discuss their nash equilibria as well as the tradeoff between seeding and quality for the repeated oneshot game one possible future work is the deliberative investigation on the nash equilibrium on the boundary it is also of research value to explore the extension of the analysis in section vb to the case of multipleplayer dynamic games another open problem is the stability analysis of the selfsocial ncpm with r 2 simulation results support the claim that for the case when r 2 there also exists a unique fixed point p and for any initial condition p ∈ s nr the solution p to equation converges to p we leave this statement as a conjecture	in this paper we propose a class of propagation models for multiple competing products over a social network we consider two propagation mechanisms social conversion and self conversion corresponding respectively to endogenous and exogenous factors a novel concept the productconversion graph is proposed to characterize the interplay among competing products according to the chronological order of social and self conversions we develop two markovchain models and based on the independence approximation we approximate them with two corresponding difference equations systems our theoretical analysis on these two approximated models reveals the dependency of their asymptotic behavior on the structures of both the productconversion graph and the social network as well as the initial condition in addition to the theoretical work we investigate via numerical analysis the accuracy of the independence approximation and the asymptotic behavior of the markovchain model for the case where social conversion occurs before self conversion finally we propose two classes of games based on the competitive propagation model the repeated oneshot game and the dynamic infinitehorizon game we characterize the qualityseeding tradeoff for the first game and the nash equilibrium in both games